Objective

To determine whether the Department of Health’s eMedNY system reasonably ensured that Medicaid claims were submitted by approved providers, were processed in accordance with Medicaid requirements, and resulted in correct payments to providers. The audit covered the period from October 2024 through March 2025, and certain findings included claims with dates of service as far back as January 2022 or as recent as April 2025.

About the Program

The Department of Health (DOH) administers the State’s Medicaid program. DOH’s eMedNY computer system processes claims submitted by providers for services rendered to Medicaid-eligible members and generates payments to reimburse the providers for their claims. During the 6-month period ended March 31, 2025, eMedNY processed over 328 million Medicaid claims, resulting in payments to providers of over $46 billion. The claims are processed and paid in weekly cycles, which averaged about 12.6 million claims and $1.8 billion in payments to providers.

Key Findings

The audit determined eMedNY reasonably ensured Medicaid claims were submitted by approved providers, were processed in accordance with requirements, and resulted in correct payments to providers. However, we also identified the need for improvement in the processing of certain types of claims. The audit identified over $13.8 million in improper Medicaid payments, as follows:

• $6.4 million was paid for managed care premiums on behalf of Medicaid members who should not have had managed care coverage because they had other concurrent comprehensive third-party health insurance.
• $4.1 million was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that members had.
• $2.4 million was paid for fee-for-service inpatient claims that should have been paid by managed care.
• $742,804 was paid for managed care newborn birth and maternity claims that contained inaccurate information, such as low newborn birth weight, which caused increased payments.
• $252,777 was paid for inpatient, clinic, referred ambulatory, and eye care claims that did not comply with Medicaid policies.

As a result of the audit, more than $3.4 million of the improper payments was recovered. We also identified 14 Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs. In response to these findings, DOH removed 13 providers from the Medicaid program and was reviewing the ownership status of the remaining provider.

Key Recommendations

We made eight recommendations to DOH to recover the remaining inappropriate Medicaid payments and improve controls.