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Review of Family Planning Claims Submitted by Selected Providers Under the New York State Medicaid Program

New York State improperly claimed enhanced 90-percent Federal reimbursement for Medicaid family planning claims submitted by selected providers. Of the 105 claims in our sample, 50 qualified as family planning services and could be claimed at the enhanced 90-percent Federal reimbursement rate. However, the remaining 55 could not be claimed as family planning services. Of those 55 claims, 51 were for services unrelated to family planning and 4 lacked documentation. Based on our sample results, we estimate that the State received $3.8 million in unallowable Federal Medicaid reimbursement. This overpayment occurred because selected 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 $3.8 million to the Federal Government and (2) consider the results of this review in its evaluation of our prior recommendations to ensure that providers only bill as family planning those services directly related to family planning and ensure that MMIS edits appropriately identify claims that are ineligible for enhanced 90-percent Federal reimbursement. In its comments on our draft report, the State agreed with our recommendations and described corrective actions that it planned to take.

Filed under: Centers for Medicare and Medicaid Services