Dual-eligible individuals are those who qualify for both Medicare and Medicaid coverage. In these situations Medicare generally covers the first 80% of an approved claim and Medicaid covers the remaining 20%. The Office of the New York State Comptroller recently dug into these payments and found some concerns. Notably, the group claims the state has not only made millions in overpayments but has also failed to go after entities for repayment.
What were the findings?
The auditors found almost $9 million in improper payments. Examples include a questionable $5 million payment to providers who allegedly made claims using excessive Part B coinsurance amounts and another $2 million from those who made claims for services not covered by Medicaid.
As a result, the Comptroller has called on the state to review payments and take action to recover funds.
What should providers take-away from this audit?
The state will likely come after payment if they believe your group received an improper payment. The Comptroller also called on the state to advise providers on proper reporting with a focus on accurate claim information. As such, providers should not be surprised if contacted by the Comptroller in the near future.
It is important to take any correspondence from the Comptroller or other agency that contains notice of additional action or an investigation into allegations of an improper claim seriously. You have rights in these situations. Rights which can include fighting back if the government’s claim is inaccurate. An attorney experienced in these matters can review the claim and discuss your options.
Attorney John Rivas is responsible for this communication
