Review of Abortion-Related Laboratory Claims Billed as Family Planning Under the New York State Medicaid Program

EXECUTIVE SUMMARY:

Our objective was to determine whether claims for abortion-related laboratory services for which New York State received Federal reimbursement at the enhanced 90-percent rate of Federal financial participation (FFP) qualified as family planning services.

The State improperly received the enhanced 90-percent FFP rate for abortion-related laboratory services that did not qualify as family planning services. In our opinion, 98 of the 100 claims in our sample did not qualify as family planning services. As a result, we estimate that the State improperly received $3,235,640 in Federal Medicaid funds. However, we have set aside this amount for consideration by the Centers for Medicare & Medicaid Services (CMS) and the State because no medical review was performed of the 100 sample claims.

We recommended that the State (1) work with CMS to resolve $ 3,235,640 in set-aside claims , (2) reemphasize to all providers that abortion-related services are not considered family planning and the Medicaid claim form must be properly coded when an abortion-related service is provided, (3) strengthen systems to make use of all appropriate claim information to properly identify abortion-related laboratory claims that are ineligible for Federal funding, and (4) determine the amount of Federal Medicaid funds improperly reimbursed at the 90-percent rate for ineligible abortion-related laboratory services and work with CMS to determine the amount to be refunded to the Federal Government. New York State concurred with our findings and recommendations.