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

ArcGISArcGIS