According to an audit released by New York state Comptroller Tom DiNapoli, Medicaid-managed care organizations (MCOs) have made millions of dollars in improper and questionable payments to providers who were not enrolled in Medicaid. Providers are required to be enrolled under federal and state law to receive payments for services provided to Medicaid recipients. The state Department of Health pays for Medicaid through fee-for-service and managed care arrangements. Under fee-for-service, providers are paid directly by DOH for services rendered, while under managed care, MCOs receive monthly premiums from DOH for each Medicaid recipient enrolled.
Auditors examined claims from January 2018 through June 2022 and discovered $1.5 billion in improper and questionable payments. This included cases where organizations paid out $916 million for services by in-network providers who were not enrolled in Medicaid at the time of service, $833 million for services by providers whose Medicaid applications were denied or withdrawn, and $9.6 million in payments to providers who were excluded or ineligible for the Medicaid program.
DiNapoli expressed concern over the findings, noting that the enrollment requirements for providers were established over five years ago and yet payments were still being made to unenrolled or denied providers. He stressed the importance of maintaining the integrity of the Medicaid program, which is essential for providing quality healthcare to millions of New Yorkers in need. The audit recommended that the Health Department improve oversight of MCO payments, ensure compliance with enrollment requirements, and take appropriate action to recover funds where necessary.