Objective

To determine whether the Department of Health provided adequate oversight of electronic transmitter identification numbers used for Medicaid billings. This audit examined fee-for-service claims from January 2020 through December 2024.

About the Program

The Department of Health (DOH) administers the Medicaid program. An electronic transmitter identification number (ETIN) is a unique identifier used to submit fee-for-service (FFS) claims to Medicaid for medical services rendered to members. Claims are submitted by providers or by service bureaus that provide claim processing or claim submission services for or on behalf of providers. State regulations require service bureaus to be enrolled in the Medicaid program, and federal regulations require providers (regardless of provider type) to revalidate their Medicaid enrollment at least every 5 years.

Medicaid policy requires all entities that submit claims to Medicaid to have an active, certified ETIN affiliation on file before submitting claims. In addition to their own ETINs, providers must recertify annually any ETIN affiliations they have with service bureaus that submit claims on their behalf. ETIN information and certification documents are stored in eMedNY, DOH’s Medicaid claim processing and payment system.

The Office of the Medicaid Inspector General (OMIG)—which conducts and coordinates investigations, detections, audits, and reviews of Medicaid providers and members to ensure compliance with laws and regulations—maintains a list of restricted providers or entities that are excluded from the Medicaid program to prevent Medicaid payments for care, services, or supplies furnished, ordered, or prescribed by providers on the list.

Key Findings

We found that DOH has not implemented adequate controls to ensure that ETIN affiliations meet requirements. As a result, eMedNY processed nearly 10.8 million claims submitted with 783 ETINs that were not affiliated with the billing providers on the date of service. While eMedNY has controls in place to detect and prevent payment for certain claims submitted using expired ETIN affiliations, pharmacy claims are not included in the edit logic. Consequently, 720 ETINs with expired affiliations were used to submit claims for pharmacy services. The remaining 63 ETINs were used to submit non-pharmacy claims where some affiliations were expired as of the date of service and other affiliations did not exist. These deficiencies reduce visibility in the claim submission process, creating uncertainty about whether claim submitters that may have been previously authorized are still authorized to submit claims.

Additionally, we reviewed the Medicaid enrollment statuses of 242 service bureaus whose ETINs appeared on claims during the audit period. We found that 84 of these service bureaus (35%) had Medicaid IDs that remained inactive throughout the audit period. An additional three service bureaus had no Medicaid ID at all. DOH did not develop controls to detect the use of ETINs belonging to claim submitters that are excluded from the Medicaid program. For example, one service bureau submitted 30,415 claims totaling $1.4 million after OMIG excluded it from the Medicaid program. Without appropriate controls to ensure that only service bureaus with active Medicaid IDs in good standing are involved in claim submissions, there is a risk that service bureaus that should be prevented from submitting claims may still be able to do so.

Key Recommendations

• Determine and update the status of the 783 ETINs related to claim submissions identified in this report that were either expired or had never been affiliated with the billing providers.
• Improve DOH oversight and monitoring to ensure the appropriate use of ETINs for claim submissions.
• Review the claim submissions containing the ETIN affiliated with the claim submitter that was terminated from participating in the Medicaid program and take appropriate action.