state of new york office of the state comptroller medicaid audit
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State of New YorkOffice of the State Comptroller
Medicaid Audit
New York StateMedicaid Program
$45 Billion 4 Million Clients 100,000+ Providers 1 Million claims daily
Responsibilities
Audit transactions before payment
Conduct reviews of program operations
eMedNYData Warehouse
ProviderEncounter Recipient Reference Other
Extract, Transform, Cleanse, Load, Maintain
EISDSSBI/QueryBI/AnalyzeBI/Cube CreatorArcGIS
MS ACCESS
ACL
PAID CLAIMS
NETTED CLAIMS
CLAIMS
ENCOUNTERS
DENIED CLAIMS
DIAGNOSIS
SPARCS
PROCEDURE
ECOMMERCE
RECIPIENT MMIS
PROVIDER
FORMULARY
PAYMENT
REFERENCE
RECIPIENT WMS
RECIPIENT MOAS
WMS
CHPlus
SPARCS
Offline Payments
Census
State Budget
1st Data Bank
Facts/Comp
Formulary
eCommerce
eMedNY
eMedNY
Claims
NYS Office of the State ComptrollerClementine Data Mining Server
Workbench for advanced data analysis
Five years of Medicaid claims data
State of New YorkOffice of the State Comptroller
IT Audit Examples
Viagra for Sex Offenders
Matched NY sex offender registry to Medicaid claims for Viagra.
Found 198 Level 3 sex offenders receiving Medicaid-funded Viagra.
Resulted in federal ban on Medicaid reimbursement for ED drugs for all sex offenders.
Cross-Invoice Matches
Clinics billing for hospitalized recipients.
Matched clinic claims to inpatient claims.
Identified $25 million in overpayments.
Top 2 clinics accounted for $5 million; stopped all future payments.
Medicaid Overpayments for Dual-Eligible Clients
Clinic only entitled to Medicare copay amount from Medicaid.
Clinic didn’t report Medicare payments they received (zero-filled).
Over $1.3 million in Medicaid overpayments.
Clinic kicked out of Medicaid program and under investigation by AG.
HIV Pre-Test Counseling
Limitation on number of times clients can be counseled in a year.
Numerous providers exceeded limitations.
$4.2 million in overpayments.
Overpayments for Mental Health Services
Provider Champion Project
Numerous analyses conducted to identify providers to audit: Unbundling Clinic/Practitioner double billing Services not provided (GIS, Time/Day)
Prescribing Outside Specialty
Podiatrists only allowed to prescribe medication for treating the foot.
Found podiatrists prescribing medication for acid reflux, high cholesterol, depression, sleep disorders, schizophrenia, and erectile dysfunction.
State of New YorkOffice of the State Comptroller
2005 Cost savings $144 million
http://www.osc.state.ny.us/audits/audits/agency_indexh.htm#H
State of New YorkOffice of the State Comptroller
CLEMENTINECLEMENTINE
State of New YorkOffice of the State Comptroller
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