Health and Safety

NYS Medicaid Overpayments Millions

July 16, 2013
By Stephanie West

New York State's Medicaid program overpaid providers $11.4 million, largely because providers overstated the amounts of Medicare coinsurance charges and incorrect rate changes, according to two audits of the Department of Health (DOH) released by State Comptroller Thomas P. DiNapoli. The state has recovered $3.8 million of these overpayments.

"New York's Medicaid system continues to be rife with waste," DiNapoli said. "Year after year my auditors identify the same types of Medicaid errors due to weak controls. As a result, New York taxpayers pay millions more than they should. DOH needs to greatly improve its supervision of the program to protect taxpayer dollars."

Many of the state's Medicaid recipients are also eligible for Medicare. Generally, Medicare is the primary payer of claims for services provided to dual eligible recipients. After Medicare processes a claim, Medicaid pays the balance that is not covered by Medicare. Auditors obtained Medicare Part B payment data and compared that data to the

Medicare amounts providers reported to DOH's eMedNY computer system for Medicaid claims processed in 2009, which was the most current Medicare data available at the time. DiNapoli's auditors determined that Medicaid overpaid more than 210,000 claims by more than $7 million, primarily because providers incorrectly reported the amounts of Medicare coinsurance charges. Providers reported their own charges for Part B services to Medicaid instead of the Medicare-approved amounts, therefore inflating the amount they were reimbursed by Medicaid.

Medicaid made the overpayments to 8,727 providers, of which 24 received overpayments of more than $41,000. Three providers each received overpayments of more than $114,000, with one receiving overpayments of more than $192,000. In one case, a provider reported a charge of $250 to Medicaid for a session of psychotherapy instead of the

Medicare-approved amount of $102. As a result, Medicaid overpaid the provider $148, or 145 percent more than it should have. On balance, the 210,000 claims were overpaid by about 50 percent. In addition, auditors found almost $239,000 in additional overcharges because Medicaid incorrectly designated certain providers as eligible for enhanced payments under federal law. In one instance, a provider submitted a claim for $216 to cover a Part B coinsurance charge. However, because DOH incorrectly designated the provider for enhanced payments, Medicaid paid $745 on the claim.

July 16, 2013

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