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State Departments and Agencies
The New York State Department of Health (DOH) made $965 million in payments to providers, including facilities, for services ordered, prescribed, referred, and attended by practitioners who were not enrolled in the health care program, including those who had been barred due to misconduct, according to an audit released by State Comptroller Thomas P. DiNapoli. Two other audits released found an additional $17 million in overpayments.
“Medicaid is a critically important program, but its payment system is rife with errors,” DiNapoli said. “My auditors found the system was allowing payments on claims involving providers who were not certified to treat Medicaid patients. This not only costs taxpayers, but also allows providers who should be excluded, and may be unqualified, to treat patients. DOH must improve its efforts to fix the shortcomings with its billing system.”
The New York State Medicaid program provides a wide range of medical services to low-income New Yorkers or to those who have special health care needs. For the state Fiscal Year ended March 31, 2021, New York’s Medicaid program had approximately 7.3 million recipients and Medicaid claim costs totaled $68.1 billion.
Auditors found eMedNY, DOH’s Medicaid claims processing system, allowed improper payments for services involving ordering, prescribing, referring, and attending providers who were no longer actively enrolled in the Medicaid program at the time of the service. The improper payments included $5.8 million for services involving providers who were excluded from participating in Medicaid due to past improper behavior or wrongdoing.
The audit covered the period of January 2015 to December 2019. DiNapoli noted DOH made changes to eMedNY in February 2018 which led to a significant drop in the amount of improper payments. However, for the period March 2018 through December 2019, auditors still identified about $45.6 million in claim payments for 135,476 services by ineligible providers.
DiNapoli’s auditors noted that when inactive providers are included on Medicaid claims, DOH lacks assurance those providers can furnish such services, and it increases the risk that excluded, or otherwise unqualified, providers are treating Medicaid enrollees.
DiNapoli recommended DOH:
- Review the $965 million in payments for Medicaid claims involving inactive providers and determine an appropriate course of action;
- Enhance controls to prevent improper Medicaid payments for claims that do not report an active provider; and
- Update guidelines to clarify billing requirements.
Department officials generally agreed with most of the audit recommendations and indicated that certain actions have been and will be taken to address them. DOH’s full response is included in the audit.
A second audit found that from January 2016 through December 2020, DOH potentially overpaid $9.6 million for durable medical equipment, prosthetics, orthotics, and supplies that likely should have been provided by nursing homes as part of the daily all-inclusive rate paid to those facilities.
A third audit covering Medicaid claims processing for the six months ended March 31, 2021 found nearly $7.4 million in improper Medicaid payments, including $3.3 million paid for fee-for-service inpatient claims that should have been paid by managed care or that were also reimbursed by managed care, and $1.5 million paid for inpatient claims that were billed at a higher level of care than what was actually provided. Auditors contacted providers and by the end of the audit fieldwork, about $5.6 million of the improper payments had been recovered.
Audits
Medicaid Program: Claims Processing Activity October 1, 2020 Through March 31, 2021.
School Districts
Delaware-Chenango-Madison-Otsego Board of Cooperative Educational Services (2021M-207) Board of Cooperative Educational Services (BOCES) officials did not properly monitor and account for fixed assets. Thirty-two of the assets tested and valued at $64,300 were not properly accounted for. Auditors found that 28 assets (computers, electrostatic sprayers, nursing beds and other assets) with combined purchase prices of approximately $47,500 did not have required asset tags, were not on the inventory or information technology (IT) inventory asset lists and/or had incorrect or no location noted on the inventory list. A color copier and refrigerator with a combined purchase price of more than $7,200 could not be located. Another two assets (a phone server and a computer) valued at $9,600 were listed in BOCES inventory as active and could not be found.
Lynbrook Union Free School District – Purchasing (Nassau County) The purchasing agent did not ensure purchases adhered to the district’s purchasing policy for goods and services not subject to competitive bidding. As a result, the purchasing agent approved 17 purchases totaling $150,961 without knowing whether the purchases were a prudent and economical use of taxpayer money, and in the district’s best interest.
Pelham Union Free School District – Information Technology (Westchester County) District officials did not establish adequate controls over user accounts to help prevent against unauthorized use, access, and loss, and did not adopt an adequate IT contingency plan. In addition to sensitive IT control weaknesses that were communicated confidentially to officials, officials did not periodically review unneeded user accounts and permissions to determine whether they were appropriate or needed to be disabled.
Municipal Audits
Herkimer County Industrial Development Agency – Claims Auditing (2022M-12) Auditors reviewed 100 claims totaling $846,279 and determined they were for appropriate purposes and generally supported by adequate invoices and/or other documentation. However, none of these claims were independently reviewed and approved prior to payment. The board did not appoint someone to audit claims and did not develop and adopt written policies, procedures or other guidance to communicate expectations for the claims audit process.
City of Hornell – Business Improvement District (BID) (Steuben County) The council did not provide sufficient oversight of the BID and the BID Plan lacked sufficient detail to allow city officials to adequately monitor the use of BID funds. The council did not enter into a written agreement with the district management association or monitor how the association used BID funds, resulting in revenues of at least $3,915 that were unaccounted for and 138 questionable disbursements by the association’s executive director totaling $24,955. Based upon audit findings and a subsequent investigation, the executive director of the association was arrested in January 2020 and charged with Grand Larceny in the Fourth Degree and Falsifying Business Records in the First Degree. On January 7, 2022, the executive director pled guilty to Grand Larceny in the Fourth Degree and was ordered to pay $1,711 in restitution.
City of Lackawanna – Garbage Collection Fees (Erie County) City officials did not always assess and bill garbage fees in accordance with the City Code. Officials also did not provide adequate oversight or develop policies and procedures for assessing and billing garbage fees. Of the 33 properties reviewed, 30 were not assessed and/or billed the correct garbage fees in accordance with the code. Twenty-five of these properties were underbilled a total of $6,350. While 16 organizations were billed for garbage services they received, the Code indicates the organizations were not eligible for such services. Of the 27 garbage fee exemptions reviewed, 14 lacked appropriate support and/or did not comply with city requirements.
City of Lackawanna – Network Management and Internal Controls (Erie County) City officials did not establish adequate controls to safeguard the network against unauthorized access or disruption. City officials did not regularly review, identify and disable unnecessary network user accounts. As a result, 14 unnecessary generic network user accounts and 26 usernames associated with inactive or former employee accounts were not disabled. City officials have not developed written IT policies and did not provide users with IT security awareness training.
Schonowe Volunteer Fire Company, Inc. – Board Oversight (Schenectady County) The board did not develop financial procedures for collections and disbursements, periodically monitor the budget or ensure the constitution was followed. As a result, the company was unable to confirm all money was recorded and deposited intact. Collections totaling $8,956 lacked proper supporting documentation to determine whether they were deposited intact and disbursements totaling $3,052 were not properly supported, audited or authorized before payment.
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