STATEWIDE — MEDICAID MANAGED CARE ORGANIZATIONS made as much as $1.5 billion in improper and questionable payments to providers who did not appear to be enrolled in the federal low-income health care program, according to the latest audit released on Tuesday, June 4, from State Comptroller Thomas P. DiNapoli. Federal and state law requires that providers be enrolled, a process that gives DOH assurance that they are equipped and eligible to deliver services. DOH pays for Medicaid in two ways — fee-for-service (in which Medicaid-enrolled providers are paid directly for their services) and managed care, in which the Department of Health pays monthly premiums to Managed Care Organizations for each enrolled Medicaid recipient, and in exchange, MCOs arrange for services with providers. Managed Care Organizations are supposed to terminate providers from their networks who do not enroll in the state’s Medicaid program. However, the audit found that five MCOs paid $916 million in claims for services by in-network providers whose IDs did not match with a Medicaid enrolled provider on the date of service. $832.5 million in claims were for services by providers whose Medicaid application was denied or had been withdrawn by DOH either because they failed to meet Medicaid program standards or were automatically withdrawn because the application was missing information.
DiNapoli’s audit recommended that DOH improve its oversight of Managed Care Organization claim payments, ensure MCOs are following the requirements under the Act, review the payments and providers the audit identified, and take appropriate action, including recovering money where appropriate.
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