Objective

To determine whether UnitedHealthcare Insurance Company of New York properly reimbursed surgical claims involving multiple providers. The audit covered the period from January 2019 through June 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 covers 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.

Civil Service contracts with various carriers to administer the Empire Plan. UnitedHealthcare Insurance Company of New York (United) administers the medical/surgical benefit, which covers a range of services, including office visits, diagnostic testing, and surgical procedures. Surgical procedures sometimes require the involvement of multiple medical providers, such as co-surgeons or surgical assistants. Co-surgeons are two or more physicians who work together as primary surgeons, usually with different specialties, performing distinct parts of a surgical procedure. A surgical assistant is either a physician or other qualified health care professional who assists the physician performing the surgical procedure.

United’s reimbursement policies require co-surgeons and surgical assistants to report their roles during a surgical procedure to ensure claims are paid appropriately. United has various controls, including electronic edit checks and a medical claim review process, to ensure that claims comply with United’s reimbursement policies.

Key Findings

The audit identified nearly $12.5 million in potential overpayments for surgical procedures involving co-surgeons or surgical assistants. About $11.5 million of the potential overpayments were for procedures performed by multiple providers, with at least one provider failing to bill with the appropriate information to identify their role during the procedure. The remaining $988,314 in potential overpayments were at risk of being paid inappropriately because of non-compliance with United’s reimbursement policy or other billing issues. United has already reviewed and recovered almost $2.9 million of the nearly $12.5 million.

Key Recommendations

• Review the $9.6 million in potential overpayments for surgical procedures involving co-surgeons or surgical assistants and for other billing issues, and recover as warranted.
• Evaluate the effectiveness of existing claim review processes and revise as warranted to detect inappropriate payments to providers who billed incorrectly, as identified in this audit.