A New York state audit released Tuesday found that more than $1.5 billion in “improper and questionable” payments were made under New York’s Medicaid system over a nearly four-year period to health care providers who were not enrolled in the government-funded system that provides care to disadvantaged residents and people with specific health needs.
Medicaid managed care organizations contract with clinicians and other health care providers to help their members receive health care services. According to an audit by the New York State Comptroller’s Office, the payments were made between January 2018 and June 2022. But the federal 21st Century Cures Act It was signed into law in 2016. The audit noted that generally, providers in the organization’s network were required to enroll in Medicaid by 2018, meaning at least some of the providers who received payments were not enrolled in the program.
The audit said payments to unenrolled providers were made for a number of reasons, including a lack of oversight by the Department of Health, which administers the state’s Medicaid system and pays monthly premiums to MCOs.
“Although the deadline for managed care organizations and their providers to meet enrollment requirements was more than five years ago, our audit shows payments to providers who are still not enrolled in Medicaid or have been denied,” New York State Comptroller Thomas DiNapoli said in a statement.
“Medicaid is essential to millions of New Yorkers who need quality health care, and the Department of Health must do more to ensure the integrity of the program,” DiNapoli said.
As outlined in the audit, ensuring that providers providing care are enrolled in the Medicaid program provides a level of confidence that they are eligible and can provide appropriate services. Without that, Medicaid patients may receive care from providers who are not Medicaid-approved, some of whom may have been denied Medicaid eligibility due to safety concerns, the audit noted.
For example, the report noted that pharmacy providers were still receiving MCO payments even though they were denied Medicaid coverage because of expired medications on the shelves, unclean conditions and other issues.
But the agency said in a statement that the full extent of the issue is not yet known and “could have a larger impact.” The agency only reviewed claims from five MCOs.
The five paid roughly $915 million in claims to providers whose identification numbers did not match those who were enrolled in Medicaid on the date of service, according to the report.
State officials said the audit found that MCOs paid about $830 million in claims to providers whose Medicaid applications were rejected or withdrawn by the Department of Health for lack of information or for not meeting the program’s standards.
The audit noted that the coronavirus pandemic caused the health department to redirect its registration efforts elsewhere. Managed Care Organizations If a provider is denied or withdrawn from enrollment. Managed care organizations are responsible for removing providers from their network who do not participate in the New York State Medicaid program.
In a statement included in the audit, the Ministry of Health said: The system used to process Medicaid claims was designed before the 2018 enrollment requirements were implemented and is compatible with systematic reviews.
Before the act The ministry said it instructed MCOs to search for and register in-network providers after the law came into effect, and that it has posted a list of providers pending registration and those who have been registered on its website.
The audit made several recommendations, including reviewing payments and developing procedures for informing managed care organizations of providers that have been denied Medicaid enrollment or have withdrawn from the program.
The New York Health Plans Association, a group of 26 managed-care health plans, agrees the health department and the comptroller’s office have systemic problems in determining providers’ enrollment status and wants to see them resolved, said Eric Linzer, the association’s president and CEO.
“Plans welcomes the opportunity to work with the Department of Health to develop a better process for communicating the status of providers who have been denied or terminated from Medicaid coverage,” he said in a statement.
But Bill Hammond, a senior fellow for health policy at the Empire Public Policy Center, an Albany-based think tank, said the figures at issue are not that high compared with the total spending in the state’s Medicaid program over a roughly four-year period.
The audit said New York’s Medicaid system will cost about $80 billion in the 2023 state fiscal year, with $50 billion of that going to managed care premium payments.
The type of record-keeping required to manage large amounts of money and enrollment numbers would likely involve typos and other errors, he said. Hammond said the mandate went into effect in 2018.
“Growth is expected “It’s painful,” Hammond said.
Still, he thinks the number of problems will decrease as people learn the process and it becomes more routine.
“They will gradually get their act together and this problem will become smaller,” he said.
