Department of Health – Medicaid Program: Claims Processing Activity April 1, 2025 Through September 30, 2025 (2025-S-11)

During the 6-month period ended September 30, 2025, the Department of Health’s (DOH) claims processing system, eMedNY, processed almost 331 million claims, resulting in payments to providers of nearly $55 billion.  Auditors identified over $12.1 million in improper Medicaid payments.  As a result of the audit, nearly $3.4 million of the improper payments was recovered.  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.  In response to the findings, DOH removed 12 providers from the Medicaid program; one of the remaining two providers was referred to the New York State Education Department’s Office of Professions, and the other provider was referred to DOH’s Office of Professional Medical Conduct.

Department of Health – Medicaid Program: Oversight of Clinical Trials (2024-S-22)

Clinical trials are research studies that evaluate the safety and effectiveness of medical care.  New York’s Medicaid program generally does not cover investigational items or services that are the subject of the clinical trial, nor does it cover services provided solely for data collection, but does cover the routine costs of items or services that are necessary for clinical trial participants and are typically covered outside of the trial under the state plan or waiver.  In addition to verifying a member’s Medicaid status, a coverage determination must be based on an attestation of the appropriateness of the clinical trial by both the principal investigator and the health care provider responsible for the trial.  The audit found that the Department of Health did not always receive an attestation form before members participated in a clinical trial, as required.  Additionally, it identified a limited number of improper Medicaid payments for services that were the responsibility of the clinical trial sponsor, investigational services not covered by the member’s managed care organization, or services that lacked supporting prior authorization.