MM Curator summary
[ MM Curator Summary]: 3 recent audits of the NY Medicaid program show significant preventable losses.
The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.
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ALBANY, N.Y. (NEWS10) – New York State Comptroller Thomas P. DiNapoli has released three reports that found more than $100 million in improper payments made by the Department of Health (DOH) for the Medicare buy-in program, maternity care, and drug and therapy claims. Nearly $400,000 in premiums may have been paid for deceased individuals.
“The Medicaid program provides critical health care services to millions of New Yorkers but the program is dogged by oversight problems and payment errors,” said DiNapoli. “Over the years, we’ve uncovered billions of dollars of waste and abuse in the system. DOH should act on our recommendations to ensure significant unnecessary expenses and preventable mistakes don’t end up costing taxpayers.”
The New York State Medicaid program is administered by DOH and is a federal, state, and local government funded program that provides medical services to economically disadvantaged populations. As of March 2021, the program had about 7.3 million recipients and claim costs totaled more than $68 billion.
One audit found that Medicaid made $31.7 million in improper Medicare premium payments from January 1, 2015 through December 31, 2019. Medicaid also paid $372,716 in Medicare premiums for 282 individuals who were deceased. Auditors found Medicaid paid $23.6 million in premiums for individuals who were automatically added to the buy-in program with coverage beginning more than two years retroactively, despite limitations on this.
The second audit examined Medicaid recipients who receive their services through managed care. DOH pays managed care organizations (MCOs) a monthly premium for each enrolled recipient and the MCOs pay for services their members require. MCOs can also receive a Supplemental Maternity Capitation Payment (SMCP) for prenatal and postpartum physician care and delivery costs. However, MCOs are not eligible to receive SMCPs for maternity cases that end in termination or a miscarriage.
Auditors found about $55 million in improper and questionable SMCPs to MCOs from August 1, 2015 to July 31, 2020. They found $29.1 million was paid without the required supporting data, $23.4 million was paid where the data or other evidence indicated the maternity case ended in termination or miscarriage, and $2.4 million was paid when the SMCP date of service preceded the birth by one to six months.
A report released in October 2019 examined payments made for prescription drugs and therapy services. It found Medicaid paid $20.1 million for services that should have been paid by Medicare. A follow-up report found DOH made some progress in addressing these problems, however, auditors identified another $17.7 million in payments that should have been paid by Medicare.