Review of the Island Peer Review Organization's Full and Partial Denials of Medical Assistance Claims That Have Not Been Recovered by New York State

EXECUTIVE SUMMARY:

The purpose of this audit was to determine if New York State (NYS) recovered the Island Peer Review Organization's (IPRO) full and partial denials of Medicaid claims and to determine if the Federal Government received its proper share of these denied claims. Although the IPRO had reported it Medicaid denial determinations to the NYS Department of Health, the State had not taken action to recoup the affected Medicaid funds or credit the Federal Government with its share of the denials. As a result, the State did not recoup $13,784,849 in overpayments. In addition, the State did not credit the Federal Government with its share of the overpayments totaling $5,256,013. We are recommending that the State immediately return $5,256,013 to the Federal Government. Additionally, we are recommending that the State ensure that all denial determinations identified by peer review organizations are recovered timely and that the Federal share is returned in accordance with the provisions of the Act.