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, including for items that should have been paid by the Essential Plan.  You can access and read the OSC audit reports below.

Department of Health – Medicaid Claims Processing Activity April 1, 2024 Through September 30, 2024 (2024-S-5)

During the 6-month period ended September 30, 2024, the Department of Health’s eMedNY computer system processed almost 249 million claims, resulting in payments to providers of nearly $50.6 billion.  OSC’s audit of claims processing activity identified over $11.5 million in improper Medicaid payments for claims that were not processed in accordance with Medicaid requirements.  The audit also identified 14 Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs.

Department of Health – Improper Medicaid Payments During Permissible Overlapping Medicaid and Essential Plan Coverage (Follow-Up) (2024-F-40)

The Department of Health (DOH) administers the State’s Medicaid program and the Essential Plan, both of which provide health care services to individuals who are economically disadvantaged.  As eligibility factors change, individuals may transition between Medicaid and the Essential Plan, resulting in DOH-authorized periods of overlapping coverage and the Essential Plan should be the primary payer and Medicaid, as secondary payer, should pay any remaining liabilities, such as deductibles and coinsurance.  A prior audit, issued in September 2023, found Medicaid improperly paid $93.7 million in claims during periods of overlapping Medicaid and Essential Plan coverage because DOH did not account for the Essential Plan as a liable primary payer.  DOH officials made some progress in addressing the problems identified in the initial audit report, but minimal progress in recovering the improper payments identified by the initial audit.  Of the initial report’s two audit recommendations, one was partially implemented and one was not implemented.