State Comptroller's audit reveals $16.2 million in improper Medicaid claim payments

STATEWIDE — NEW YORK STATE DEPARTMENT OF HEALTH'S eMedNY COMPUTER system improperly paid $16.2 million in Medicaid claims during a six-month period that started in October 2023, reports an audit that State Comptroller Thomas P. DiNapoli released on Thursday, Feb. 6. The audit found 370 million claims totaling nearly $49.6 billion were processed between October 2023 and March 2024. The bulk of the improper payments, coming to $11.8 million, were disbursed to 27,480 Medicaid managed care premiums for recipients who were ineligible for managed care coverage because they had comprehensive third-party insurance and should have instead been enrolled in Medicaid fee-for-service. The audit results helped recover more than $2.8 million in improper payments.

Some of the audit's key findings: that $126,786 was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer; $2 million was paid for fee-for-service inpatient claims that should have been paid by managed care; $1.3 million was paid for newborn birth and maternity claims that reported inaccurately low newborn birth weights, which increased reimbursements; $964,333 was paid for inpatient, pharmacy, referred ambulatory, and clinic claims that did not comply with Medicaid policies; and that $35,441 was paid for managed care premiums on behalf of incarcerated recipients whose coverage should have been suspended.

The audit also identified 10 Medicaid providers (nine of whom the DOH has since removed) who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs.

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