Department of Health – Medicaid Program: Managed Care Payments to Unenrolled Providers (Follow-Up) (2025-F-21)

The 21st Century Cures Act mandated that managed care in-network providers, with certain exceptions, enroll as participating providers in the state Medicaid program by January 1, 2018.  Through the screening and provider enrollment process, the Department of Health (DOH) gains some assurance of providers’ validity to provide Medicaid services.  A prior audit, issued in June 2024, found that DOH did not monitor encounter claims to identify inappropriate managed care payments to providers who were not enrolled in Medicaid and found weaknesses in controls that led to over $1.5 billion in improper and questionable payments.  DOH officials made some progress in addressing the problems identified in the initial audit report.  Of the initial report’s 10 audit recommendations, two were implemented, five were partially implemented, and three were not implemented.

Department of Health – Medicaid Program: Recovering Managed Care Payments for Inpatient Services on Behalf of Recipients With Third-Party Health Insurance (Follow-Up) (2025-F-10)

The Department of Health (DOH) uses post-payment reviews to identify when a third-party health insurance (TPHI) carrier may be responsible for payments for services originally paid by Medicaid.  The Office of the Medicaid Inspector General (OMIG) contracted with Health Management Systems, Inc. (a Gainwell Technologies company [Gainwell]), to perform these reviews and to pursue recoveries from TPHI carriers or providers.  A prior audit, issued in September 2023, determined that DOH and OMIG lacked adequate oversight of the third-party liability recovery process.  Gainwell had not billed TPHI carriers for the recovery of about $52.2 million in inpatient encounter claims that Medicaid managed care organizations paid as the primary insurance for recipients who, according to eMedNY (DOH’s Medicaid claims processing and payment system), had TPHI inpatient coverage.  DOH and OMIG officials made minimal progress in addressing the problems identified in the initial audit report.  Of the initial report’s eight audit recommendations, two were implemented, two were partially implemented, and four were not implemented.

Department of Health – Medicaid Program: Medicaid Payments for Early Refills of Prescription Drugs and Supplies (2024-S-16)

Through NYRx, New York State Medicaid’s Pharmacy program, the Department of Health (DOH) pays pharmacies directly for medically necessary prescription drugs and supplies provided to Medicaid members.  Early refills are refills on prescriptions before the previous supply has been fully used.  For the period from April 2023 through October 2024, auditors identified over 3.6 million claims totaling approximately $585.2 million for drugs and supplies refilled too early.  While many claims were filled just a few days earlier than allowed by policy, nearly 43% of the findings had 20 or more excess supply days.  Auditors identified multiple weaknesses in DOH’s edit logic that allowed these claims to be paid despite meeting DOH’s criteria for denial.

Department of Health – Medicaid Program: Claims Processing Activity October 1, 2024 Through March 31, 2025 (2024-S-26)

During the 6-month period ended March 31, 2025, the Department of Health’s (DOH) claims processing system, eMedNY, processed over 328 million Medicaid claims, resulting in payments to providers of over $46 billion.  Auditors identified over $13.8 million in improper Medicaid payments.  As a result of the audit, more than $3.4 million of the improper payments was recovered.  The audit also identified 14 Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs.  In response to these findings, DOH removed 13 providers from the Medicaid program and was reviewing the ownership status of the remaining provider.