"System flaws and incorrect or incomplete information have caused duplicate Medicaid premium payments for a long time," DiNapoli said. "
The Medicaid program is a federal, state and local government-funded program that provides a wide range of medical services to people who are economically disadvantaged or have special health care needs.
Many of the state's Medicaid recipients receive their services through managed care organizations (MCOs).
Patients Incorrectly Getting Two ID Numbers
Each individual who applies for benefits under Medicaid is assigned a Client Identification Number (CIN). Individuals have several options for enrolling in Medicaid, and as a result may have more than one CIN assigned to them, but only one CIN should have active eligibility at a time.
DiNapoli's auditors found this has not been the case. From
Auditors found many breakdowns that led to the improper payments, including flaws at the local level for updating incorrect and incomplete applicant information. They also found limitations in usage of the downstate and upstate Welfare Management Systems (WMS), and NY State of Health (NYSOH) system flaws that failed to notify DOH's payment system when some residents lost their Medicaid eligibility.
Source of Problems
The state's Local Departments of Social Services (Local Districts) determine eligibility and enrollment for certain segments of the Medicaid program. Local Districts use the WMS to process applicant data for the various public assistance programs, including Medicaid. WMS is composed of two components: a downstate system for
Under the federal Patient Protection and Affordable Care Act of 2010, the state developed NYSOH, an online marketplace where individuals may obtain health insurance coverage, including Medicaid. Of the approximately 7.3 million recipients enrolled in Medicaid during state fiscal year 2017-18, about 3.7 million enrolled through NYSOH.
DOH, Local Districts and the
For example, auditors found:
* Many of the suspected cases of people with multiple CINs identified by DOH's eMedNY system went unresolved. As a result, there was a backlog of cases needing review;
* Medicaid made duplicate managed care premium payments for many months for some cases because individuals with multiple CINs had overlapping managed care enrollment that had not been terminated in a timely manner; and
* MCOs did not always identify multiple CIN cases as they should have.
DiNapoli recommended DOH:
* Review the
* Ensure Local Districts make timely and accurate updates to information on all Medicaid cases to allow proper CIN assignment for new applications and efficient reconciliation of existing duplicates;
* Evaluate the feasibility of building a central tracking database of potential multiple CIN cases that shows the status of each case and can be shared among all the stakeholders in the duplicate CIN research and resolution process;
* Ensure that the unit dedicated to multiple CIN research and resolution takes steps to improve the efficiency and timeliness of resolving duplicate CINs; and
* Evaluate the feasibility of creating a control to prevent confirmed multiple CINs from being reused in the future.
DOH agreed with many of the audit recommendations and indicated that certain actions have been and will be taken to address them. The department's full response and auditors' responses to certain comments are included in the audit.
Read the report, or go to: http://osc.state.ny.us/audits/allaudits/093019/sga-2019-18s24.pdf
Earlier audits by DiNapoli's office found similar problems with duplicate payments.
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