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«New York State Office of the State Comptroller Thomas P. DiNapoli Division of State Government Accountability Eye Care Provider and Family ...»

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New York State Office of the State Comptroller

Thomas P. DiNapoli

Division of State Government Accountability

Eye Care Provider and Family

Inappropriately Enroll as Recipients

and Overcharge for Vision Services

Medicaid Program

Department of Health

Report 2013-S-1 March 2016

2013-S-1

Executive Summary

Purpose

To determine if the owner of a Medicaid eye care provider and the owner’s associates

inappropriately enrolled as Medicaid recipients and to determine if the provider inappropriately billed Medicaid for vision services. This audit covered the period January 1, 2008 through September 30, 2013.

Background The Department of Health (Department) administers the Medicaid program in New York State.

Medicaid provides a wide range of medical services, including vision care, to individuals who are economically disadvantaged and/or have special health care needs. For the fiscal year ended March 31, 2014, New York’s Medicaid program had approximately 6.5 million enrollees and Medicaid claim costs for eye care services totaled about $10 million.

During the course of this audit, our fieldwork was temporarily suspended to avoid interfering with reviews conducted by other public oversight authorities of the matters addressed in this report.

Key Findings We found numerous violations and questionable practices connected to the owner of a Medicaid

eye care provider (Provider) and extending to the owner’s family, including:

• The owner and family members submitted false income information to secure Medicaid coverage and other medical assistance benefits. During the period of enrollment for the owner and the owner’s family, the State paid $68,483 in medical benefits on their behalf.

• The Provider received over $22,000 in improper Medicaid payments for claims with inappropriate coinsurance charges and/or for services not supported by medical records.

• The Provider allowed non-Medicaid-enrolled providers to render services, and on its claims to Medicaid identified a different, authorized, provider as the service renderer.

• The Provider used a non-Medicaid-enrolled billing service company to submit its claims. The owner of the Provider and the owner of the billing service company are married.

• The owner of the billing service company used other providers’ Medicaid identification numbers to gain unauthorized access to the eMedNY claims system and bill over $700,000 in Medicaid claims on behalf of 55 providers.

Further, we identified five additional Medicaid recipients who had a business or personal connection to a member of the Provider’s family and, we believe, submitted misleading information on their Medicaid applications to gain eligibility.

Also, recipients identified in this audit engaged in transactions that were not indicative of a person living at or below the income levels that qualify a person for Medicaid eligibility. For example, we identified over $400,000 in deposits made to the Provider’s family’s personal bank accounts (much of which appeared to be income). Additionally, in November 2012, the Provider’s owner and the owner’s spouse paid $105,000 toward the purchase of a condominium for one of their family members.

Division of State Government Accountability 1 2013-S-1 Key Recommendations

• We made eight recommendations to the Department to: assess the eligibility of the identified Medicaid recipients, deactivate ineligible Medicaid recipients and providers, conduct an expanded review of improper Medicaid claims, recover improper State payments, and improve claims processing controls.

Other Related Audits/Reports of Interest Department of Health: Medicaid Claims Processing Activity April 1, 2012 through September 30, 2012 (2012-S-24) Department of Health: Overpayments of Certain Medicare Crossover Claims (2011-S-28) Department of Health: Medicaid Claims Processing Activity April 1, 2009 through September 30, 2009 (2009-S-21)

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State of New York Office of the State Comptroller Division of State Government Accountability March 21, 2016 Howard Zucker, M.D., J.D.

Commissioner Department of Health Corning Tower Empire State Plaza Albany, NY 12237

Dear Dr. Zucker:

The Office of the State Comptroller is committed to helping State agencies, public authorities, and local government agencies manage government resources efficiently and effectively and, by so doing, providing accountability for tax dollars spent to support government operations.

The Comptroller oversees the fiscal affairs of State agencies, public authorities, and local government agencies, as well as their compliance with relevant statutes and their observance of good business practices. This fiscal oversight is accomplished, in part, through our audits, which identify opportunities for improving operations. Audits can also identify strategies for reducing costs and strengthening controls that are intended to safeguard assets.

Following is a report of our audit of the Medicaid program entitled Eye Care Provider and Family Inappropriately Enroll as Recipients and Overcharge for Vision Services. This audit was performed pursuant to the State Comptroller’s authority under Article V, Section 1 of the State Constitution and Article II, Section 8 of the State Finance Law.





This audit’s results and recommendations are resources for you to use in effectively managing your operations and in meeting the expectations of taxpayers. If you have any questions about this report, please feel free to contact us.

Respectfully submitted, Office of the State Comptroller Division of State Government Accountability

–  –  –

State Government Accountability Contact Information:

Audit Director: Andrea Inman Phone: (518) 474-3271 Email: StateGovernmentAccountability@osc.state.ny.us

Address:

Office of the State Comptroller Division of State Government Accountability 110 State Street, 11th Floor Albany, NY 12236 This report is also available on our website at: www.osc.state.ny.us

–  –  –

Background The New York State Medicaid program is a federal, state, and local government-funded program that provides a wide range of medical services to those who are economically disadvantaged and/or have special health care needs. For the fiscal year ended March 31, 2014, New York’s Medicaid program had approximately 6.5 million enrollees and Medicaid claim costs totaled about $50.5 billion, of which eye care claim costs totaled about $10 million. The federal government funded about 49.25 percent of New York’s Medicaid claim costs; the State funded about 33.25 percent; and the localities (the City of New York and counties) funded the remaining 17.5 percent.

The State Department of Health (Department) administers Medicaid and various other medical assistance programs offered to New Yorkers. During the scope of our audit, individuals coordinated with their respective local district social services office (local district) to receive Medicaid and other medical assistance benefits. Local districts determined Medicaid eligibility based on several factors including household size and income. New York State has 58 local districts, each representing a county in all areas of the State except New York City. The five boroughs of New York City comprise one local district, which is overseen by the New York City Human Resources Administration (HRA).

Many of the State’s Medicaid recipients are also enrolled in Medicare, the federal health care program for people 65 years of age and older and people under 65 years old with certain disabilities. Individuals enrolled in Medicaid and Medicare are commonly referred to as “dualeligible.” Generally, Medicare is the primary payer for medical services provided to dual-eligible individuals and Medicaid pays remaining balances, such as deductibles and coinsurance.

The Department’s eMedNY computer system processes Medicaid claims submitted by providers for services rendered to Medicaid-eligible recipients and generates payments to reimburse the providers for their claims. When Medicaid claims are processed by eMedNY, they are subject to various automated edits. The purpose of the edits is to determine whether the claims are eligible for reimbursement and the amounts claimed for reimbursement are appropriate. For example, some edits verify the eligibility of the Medicaid recipient, others verify the eligibility of the medical service, and some verify the appropriateness of the amount billed for the service.

The Department requires health care providers seeking reimbursement for services to dualeligibles to use the Department’s automated Medicare/Medicaid crossover system. Under this system, which the Department implemented in December 2009, providers need only to submit claims to Medicare. After Medicare makes its payment, claims are then automatically forwarded to eMedNY, and Medicaid pays the remaining patient liability (typically a deductible or coinsurance).

Prior to the crossover system, health care providers submitted claims to both Medicare and Medicaid. The Department relied on providers to direct-bill Medicaid and accurately self-report the amount Medicare paid and the corresponding amount Medicaid then owed. However, misreported claim information often led to Medicaid overpayments of Medicare coinsurance claims.

–  –  –

Audit Findings and Recommendations We found numerous violations and questionable practices connected to the owner of a Medicaid

eye care provider (Provider), and extending to the owner’s family, including:

• The owner and family members submitted false income information to secure Medicaid coverage and other medical assistance benefits. During the period of enrollment for the owner and the owner’s spouse and three other family members, the State paid $68,483 in medical benefits on their behalf.

• The Provider received over $22,000 in improper Medicaid payments for claims with inappropriate coinsurance charges and/or for services not supported by medical records.

• The Provider allowed non-Medicaid-enrolled providers to render services, and on its claims to Medicaid identified a different, authorized, provider as the service renderer.

• The Provider used a non-Medicaid-enrolled billing service company to submit its claims.

The owner of the Provider and the owner of the billing service company are married.

• The owner of the billing company used other providers’ Medicaid identification numbers (IDs) to gain unauthorized access to the eMedNY claims system and bill over $700,000 in Medicaid claims on behalf of 55 providers.

We also identified five additional Medicaid recipients who had a business or personal connection to a member of the Provider’s family and, we believe, submitted misleading information on their Medicaid applications to gain eligibility.

We provided the Medicaid identification information of the ten recipients identified by this audit to the New York City Human Resources Administration (HRA). HRA officials investigated five of the ten recipients and determined they were ineligible for the Medicaid benefits they received.

Subsequently, these recipients were disenrolled from the Medicaid program and ordered to repay $40,100 in restitution. Of the five recipients HRA had not investigated, two remained enrolled in the Medicaid program as of December 2015.

During the course of this audit, our fieldwork was temporarily suspended to avoid interfering with reviews conducted by other public oversight authorities of the matters addressed in this report.

Improper Medicaid and Family Health Plus Recipient Enrollments Owner and Family Members of the Provider Our audit determined the owner of the Provider and the owner’s family were not eligible for Medicaid and other medical assistance benefits they received. From January 1, 2008 to August 15, 2013, Medicaid and Family Health Plus (FHP)1 paid 323 claims totaling $68,483 for services provided to the family; a majority of the claims were managed care capitation payments. (During this time, the managed care plan that the family was enrolled in also paid its member providers During our audit scope, FHP was a public health insurance program for adults aged 19 to 64 who had income too high to qualify for Medicaid. (As a result of the Affordable Care Act, changes to the FHP program were made.)

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