The Office of the New York State Comptroller (OSC) has issued two audit reports on Medicaid payment activities of the New York State Department of Health (NYSDOH).  OSC found that NYSDOH was still making millions of dollars in improper Medicaid payments for Medicare Part C plans and for durable medical equipment claims.  You can access and read the OSC audit reports below.

Department of Health: Medicaid Program – Overpayments for Medicare Part C Claims (2023-S-13)

Under Medicare Part C, private insurance companies administer Medicare benefits through Medicare Advantage Plans.  From a judgmental sample of 89 claims identified as high-risk, totaling $1,325,452, from five hospitals, auditors determined Medicaid made improper payments for 49 Part C claims (55%) totaling $881,233.  The improper payments occurred in part because hospitals misinterpreted state regulations and billing guidelines, did not properly submit Claim Adjustment Reason Codes on claims, or indicated Medicare Advantage Plans did not cover services when they actually did.  Auditors also found improvements are needed to the Department of Health’s automated claims processing and payment system to prevent incorrect payments.

Department of Health: Medicaid Program – Excessive Payments for Durable Medical Equipment Rentals (Follow-Up) (2024-F-18)

Medicaid recipients receive necessary durable medical equipment (DME, i.e., devices and equipment available on a monthly rental basis) as a benefit of the Medicaid program.  There are typically limits (or caps) on the number of monthly rental payments.  A prior audit, issued in April 2023, found about $1.5 million in overpayments and $503,619 in questionable payments for DME rentals.  DOH made little progress in addressing the issues identified in the initial audit report.  For example, DOH had not formally determined whether it is efficient and appropriate to require a cap on the number of rental payments for oxygen equipment.  Of the initial report’s seven audit recommendations, one was partially implemented and six were not implemented.