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 April 2025 through September 2025, and certain claims going back to August 2024 or as recent as December 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 September 30, 2025, eMedNY processed almost 331 million claims, resulting in payments to providers of nearly $55 billion. The claims are processed and paid in weekly cycles, which average about 13 million claims and $2 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 $12.1 million in improper Medicaid payments, as follows:

• $6.3 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;
• $5.2 million was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that members had;
• $342,115 was paid for managed care newborn birth and maternity claims that contained inaccurate information, such as low newborn birth weight, which caused increased payments; and
• $276,436 was paid for inpatient and clinic claims that did not comply with Medicaid policies.

As a result of the audit, nearly $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. We advised DOH officials of these providers, and by the end of the audit fieldwork, DOH had removed 12 providers from the Medicaid program. The Office of the Medicaid Inspector General referred one of the remaining two providers to the New York State Education Department’s Office of Professions and the other provider to DOH’s Office of Professional Medical Conduct.

Key Recommendations

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