N.Y. State Comptroller DiNapoli: Audit Finds Lax Oversight of Medicaid Payments May Have Cost Taxpayers Nearly $300M
Too often Medicaid pays medical bills that a third-party insurer should have covered, and not enough is being done to make sure Medicaid recovers that money, according to an audit by
"Medicaid is essential for millions of New Yorkers, but the program needs to ensure that funding is only used for appropriate costs for those who need it," said Comptroller DiNapoli. "This is my office's latest audit to uncover weaknesses in the Medicaid system's oversight. These potentially unnecessary payments likely contributed to significant waste and a missed opportunity to recover the nearly
The
Per federal law and state regulations, Medicaid is always the payer of last resort. This means that if a Medicaid recipient has third-party health insurance (TPHI) coverage, then those third-party benefits must be exhausted before the Medicaid program is billed.
To address instances where a TPHI should have paid instead of Medicaid, the DOH--in partnership with
Between
According to HMS officials, internal processes are not set up to track why individual claims are excluded from the recovery process. Auditors determined that without proper oversight and this level of tracking, there is no way to ensure that all appropriate recoveries are being made. Also concerning, HMS did not have comprehensive reports of its activities available upon auditors' request. DiNapoli's audit recommended:
* A review of the
* An assessment of pharmacy claims that were billed to TPHI carriers but did not result in recovery of payment to ensure that proper steps are taken to obtain recoveries where appropriate;
* An assessment of the third-party liability recovery process for managed care pharmacy services and implementation of corrective actions where necessary; and,
* Implementation of ongoing monitoring of the TPHI recovery process for managed care pharmacy services to ensure that all appropriate recoveries are made within the statute of limitations.
In response to our audit, officials stated that all claims are reviewed as part of existing processes. However, officials acknowledged that they are working on enhancements to the entire recovery process, which will include developing additional reporting to give OMIG greater insight into why claims were not billed to TPHI carriers for recovery.
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Report:
Medicaid Program: Recovering Managed Care Overpayments for Pharmacy Services on Behalf of Recipients With
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Track state and local government spending at Open Book New York. Under State Comptroller DiNapoli's open data initiative, search millions of state and local government financial records, track state contracts, and find commonly requested data.
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REPORT: https://www.osc.state.ny.us/files/state-agencies/audits/pdf/sga-2022-20s39.pdf
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Original text here: https://www.osc.state.ny.us/press/releases/2022/07/dinapoli-audit-finds-lax-oversight-medicaid-payments-may-have-cost-taxpayers-nearly-300-million
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