“Troubling errors like the ones routinely identified by my auditors are extremely costly. They can also put patients at risk,” DiNapoli said in announcing the reports. “By not fixing problems with the Department of Health’s eMedNY system and other issues, hundreds of millions of dollars more in taxpayer dollars could be misspent and unqualified providers could continue to treat Medicaid patients. The department must act on our recommendations and address these shortfalls, so Medicaid recipients receive the level of care they deserve, and taxpayers’ dollars are spent effectively.” 

For the state fiscal year that ended March 31, 2020, New York’s Medicaid program had about 7.3 million recipients and Medicaid claim costs totaled $69.8 billion.

The Affordable Care Act and federal regulations mandate that state Medicaid agencies require all ordering and referring physicians and other professionals providing services through the Medicaid fee-for-service program to be enrolled as participating providers and their National Provider Identifiers (NPIs) to be included on Medicaid claims. This screening and provider-enrollment process seeks to improve the efficiency of the health-care system and help to reduce fraud and abuse. It’s supposed to also help ensure the quality of services and protects public health by validating that providers have the appropriate credentials to provide services and are not prohibited from participating in the Medicaid program by the federal government.

In his first report, DiNapoli’s auditors found that a significant number of claims were paid even though they did not have a proper NPI to ensure the ordering, prescribing, referring, or attending provider was properly qualified or credentialed, creating a risk for patients. Processing weaknesses in eMedNY, the Medicaid- claims processing and payment system, allowed $1.5 billion in payments for Medicaid clinic and professional claims without an appropriate NPI.

For example, some claims contained NPIs of providers who were not enrolled in Medicaid, while other claims did not contain an NPI at all.

Auditors also found $57.3 million in payments for pharmacy claims that did not contain an appropriate prescriber NPI and $19.4 million in payments for claims that contained an NPI but, according to regulations, should not be included on Medicaid claims or that should be further reviewed by DOH due to past misconduct.

DiNapoli’s office made a series of recommendations for the DOH to implement to avoid these kinds of errors in the future. DOH “officials agreed with the audit recommendations and said actions will and have been taken,” the comptroller’s office said.