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National Insurance Crime Bureau

Dinapoli: Medicaid Fraud Cost NY State Taxpayers More Than $1.5 Billion, August 19,2021

The state Department of Health (DOH) allowed more than $1.5 billion in improper Medicaid payments over the course of several years due to errors in its billing system and may have exposed patients to unqualified and uncredentialed health care providers, according to three reports released today by State Comptroller Thomas P. DiNapoli.

“Troubling errors like the ones routinely identified by my auditors are extremely costly. They can also put patients at risk,” DiNapoli said. “By not fixing problems with the Department of Health’s eMedNY system and other issues, hundreds of millions of dollars more in taxpayer dollars could be misspent and unqualified providers could continue to treat Medicaid patients. The department must act on our recommendations and address these shortfalls, so Medicaid recipients receive the level of care they deserve, and taxpayers’ dollars are spent effectively.”

For the state fiscal year that ended March 31, 2020, New York’s Medicaid program had approximately 7.3 million recipients and Medicaid claim costs totaled $69.8 billion.

The Affordable Care Act and federal regulations mandate that state Medicaid agencies require all ordering and referring physicians and other professionals providing services through the Medicaid fee-for-service program to be enrolled as participating providers and their National Provider Identifiers (NPIs) to be included on Medicaid claims. This screening and provider enrollment process improves the efficiency of the health care system and helps to reduce fraud and abuse. It also helps to ensure the quality of services and protects public health by validating that providers have the appropriate credentials to provide services and are not prohibited from participating in the Medicaid program by the federal government.

In the first report, DiNapoli’s auditors found that a significant number of claims were paid even though they did not have a proper NPI to ensure the ordering, prescribing, referring, or attending provider was properly qualified or credentialed, creating a risk for patients. Processing weaknesses in eMedNY, the Medicaid claims processing and payment system, allowed $1.5 billion in payments for Medicaid clinic and professional claims without an appropriate NPI.

For example, some claims contained NPIs of providers who were not enrolled in Medicaid, while other claims did not contain an NPI at all.

Auditors also found $57.3 million in payments for pharmacy claims that did not contain an appropriate prescriber NPI and $19.4 million in payments for claims that contained an NPI but, according to regulations, should not be included on Medicaid claims or that should be further reviewed by DOH due to past misconduct.

A second report found that from Jan. 1, 2015 through Dec. 31, 2019, claims totaling $28.5 million were paid for Medicaid recipients who were reported as discharged from a hospital, but then admitted to a different hospital less than 24 hours later. These claims raise the possibility that the first hospital wrongly recorded a patient’s transfer as a discharge, which is a red flag that the claims are at a high risk of overpayment.

Auditors recommended that the Department of Health develop a process to identify and recover Medicaid overpayments for fee-for-service inpatient claims that have a high risk of incorrect patient status codes such as those identified by the audit. Article