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Medical provider may have abused the New York State Health Insurance Program

Medical provider may have abused the New York State Health Insurance Program
Source: Office of the State Comptroller

An audit report released May 5, 2009 by State Comptroller Thomas P. DiNapoli alleges that a Nassau County ?non-participating? medical practice took in an extra $787,134 in payments by routinely waiving the required out-of-pocket costs for services provided to employees and retirees, and their dependents, having health insurance coverage under the "Empire Plan" of New York State's Health Insurance Program (NYSHIP).*

When members of the Empire Plan, NYSHIP?s primary health benefits plan, receive services from a non-participating provider, the member is responsible for paying a larger portion of their medical bill. Auditors found South Island Orthopedic Group of Cedarhurst waived out-of-pocket costs for patients and passed those costs on to the state by submitting inflated bills to the Empire Plan.

DiNapoli?s auditors found that from January 1, 2001 through October 31, 2008, South Island "apparently waived the fees to attract patients who would not otherwise pay higher costs to use non-participating providers." This practice, the auditors claimed, allowed South Island to remain a non-participating provider and collect significantly higher reimbursement rates.

The Comptroller?s office indicated that it conducts regular audits of NYSHIP.

Recently auditors initiated a series of audits examining the practices of individual medical providers and have uncovered widespread problems. In October 27, 2008 DiNapoli released a report that found 20 medical providers had routinely submitted inflated claims to NYSHIP after they inappropriately waived out-of-pocket costs for state and local government employees. The inflated claims cost the state almost $14 million. The Comptroller's audit report is posted on the Internet at: http://www.osc.state.ny.us/audits/allaudits/093008/08s130.pdf

Department of Civil Service Commissioner Nancy G. Groenwegen said: ?This practice of waiving patients? normal out-of-pocket costs undercuts a key cost control feature of the Empire Plan? and my department?s efforts to discover ?this abuse and halt any similar practices ? will be aggressive.?

* NYSHIP is the largest public employer health insurance program in the nation, aside from the Federal government, providing health insurance to more than 1.2 million current and former state and local government employees.

Click here to access a copy of the audit of South Island Orthopedic Group or go to:
http://www.osc.state.ny.us/audits/allaudits/093009/08s173.pdf

Full post as published by New York Public Personnel Law on May 06, 2009 (boomark / email).