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Review of Clinic and Practitioner Claims Billed as Family Planning Services Under the New York State Medicaid Program

The State improperly received enhanced 90-percent Federal reimbursement for 102 family planning claims submitted by clinics and practitioners. Based on our sample results, we estimated that the State improperly received $17.1 million in Federal Medicaid reimbursement. This overpayment occurred because providers incorrectly claimed services as family planning, and the State's Medicaid Management Information System (MMIS) edit routines did not adequately identify claims unrelated to family planning.

We recommended that the State (1) refund $17.1 million to the Federal Government, (2) reemphasize to providers that only services directly related to family planning should be billed as family planning, (3) ensure that MMIS edit routines use all appropriate claim information to identify claims that are ineligible for enhanced 90-percent Federal reimbursement, and (4) determine the amount of Federal Medicaid funds improperly reimbursed for claims unrelated to family planning subsequent to our audit period and refund that amount to the Federal Government. In its comments on our draft report, the State generally concurred with our recommendations.

Filed under: Centers for Medicare and Medicaid Services