Corporate Compliance

GOV'T AUDIT INSIDER Medicaid overpayments to MOMS in New York

Healthcare Auditing Weekly, September 6, 2005

The state of New York has received nearly $1.6 million in Medicaid payments for unapproved obstetrical maternal services (MOMS) between January 1, 2000 and December 31, 2003, a recent OIG audit found.

The audit was to determine whether the Medicaid obstetrical maternal services for which New York received federal reimbursement at a special 90% reimbursement rate qualified as family planning services. The audit determined that the services did not qualify.

The OIG has recommended that the state

  • refund the overpayment
  • instruct providers not to preset the family planning indicator field to "yes" in their Medicaid claims software
  • issue clear guidance to providers that not all procedures provided to pregnant women may not be claimed as family planning services

    To accomplish their objective, the OIG took the following steps:

  • Reviewed applicable laws and documents
  • Surveyed three MOMS providers to understand their coding procedures
  • Identified a universe of 11,915 MOMS claims totaling $3,983,545 believed to be ineligible for 90% federal funding
  • Used simple random sampling techniques to select a discovery sample of 30 claims to validate that all 11,915 MOMS claims were ineligible
  • Reviewed the medical records for the 30 sampled claims to determine whether services provided were eligible
  • Calculated the unallowable amount paid.

      Click here to read the audit report, "Review of Medicaid Obstetrical Maternal Services Claims Billed as Family Planning Under the New York State Medicaid Program," (A-02-05-01001) issued July 20, 2005.

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