Weaknesses in the state's post-payment review process allowed for $292 million in overpaid Medicaid claims to go unrecovered, New York State Comptroller Thomas DiNapoli said.
The state comptroller's office conducted an audit of drug claims paid by Medicaid managed care plans between October 2015 and May 2020, according to a July 13 news release from Mr. DiNapoli's office. Auditors found $292 million worth of claims from beneficiaries who also had third-party health insurance plans.
If a Medicaid recipient has third-party health insurance, then those benefits must be exhausted before Medicaid is billed, according to the news release.
The New York Department of Health partners with the state's Medicaid inspector general and Health Management Systems to conduct post-payment reviews. Auditors presented a sample of 50 claims to the Medicaid inspector general and Health Management Systems and asked why the third-party health insurer was not billed. Health Management Systems was unable to determine why 38 of the 50 claims were not recovered. Auditors found the explanations for another nine were not justified.
Health Management Systems officials told auditors that internal processes are not set up to track why individual claims are excluded from the recovery process, according to the news release. Auditors determined that without proper oversight and this level of tracking, there is no way to ensure that all appropriate recoveries are being made.