Objective

To determine whether sufficient controls are in place to prevent multiple payments for the same services related to the Center of Excellence for Cancer Program (Cancer Program). The audit covered claims with a date of service during the period from January 2019 through December 2024.

About the Program

The New York State Health Insurance Program (NYSHIP), administered by the Department of Civil Service (Civil Service), is one of the nation’s largest public sector health insurance programs. NYSHIP provides coverage for about 1.2 million active and retired State, participating local government, and school district employees, and their dependents. The Empire Plan is the primary health benefits plan for NYSHIP, covering over 1 million members.

Anthem Blue Cross (Anthem) administers the Empire Plan’s Hospital Program, which provides coverage for inpatient and outpatient services provided by a hospital, skilled nursing facility, or hospice. UnitedHealthcare Insurance Company of New York (United) administers the Medical/Surgical Program, which covers a range of services, including but not limited to, office visits and diagnostic testing.

United also administers the Center of Excellence for Cancer Program (Cancer Program), a select group of providers recognized as leaders in the field of cancer treatment, which provides paid-in-full benefits for covered services with no copayment for enrolled members. United is responsible for paying cancer-related expenses under the Cancer Program, including hospital services typically paid by Anthem.

Key Findings

We found that inadequate controls led Anthem and United to make multiple payments to health care providers for the same services related to the Cancer Program. Consequently, we identified $18.1 million in Anthem payments for services also paid for by United on behalf of members enrolled in the Cancer Program. Of this amount, $8.7 million has been remitted to Civil Service; $7.1 million in payments still require a review to determine which payment (Anthem’s or United’s) should be remitted to Civil Service; and $2.3 million has not been remitted to Civil Service despite providers reporting refunding the improper payments.

As a result of our audit, Civil Service issued a directive stating that United will process all claims related to the Cancer Program, regardless of the reported medical condition, for services provided after December 31, 2025.

Key Recommendations

• Review the nearly $9.4 million in improper payments identified by this audit, make recoveries, and remit them to Civil Service as appropriate.
• Implement the Civil Service directive so that only United processes claims related to the Cancer Program.