Audit Part of OMIG’s Successful Efforts to Contain Costs, Fight Fraud in Medicaid Program
Over 100 Million in identified overpayments for the first half of 2013
ALBANY, NY -- Irregularities in billings for prescriptions for Medicaid recipients discovered during an audit of Rite Aid Pharmacy location #3507, 650 East Tremont Street in the Bronx, led to projected overpayments of more than $193,275, according to the New York State Office of the Medicaid Inspector General (OMIG).
The Rite Aid audit revealed a number of findings. Included among them were billing for a different drug than ordered by the prescriber, refilling a prescription more than 180 days after it was initiated by the prescriber, and refilling a prescription in excess of the prescriber’s authorization—all practices that violate Medicaid regulations. Other findings included instances in which the ordering prescriber differed from the prescriber named on the claim, and billings for which a prescription was missing.
“All providers who participate in the Medicaid program are expected to follow its rules and regulations,” said Medicaid Inspector General James C. Cox. “Taxpayers should not be footing the bill for these excesses and discrepancies.”
The audit covered five years of Medicaid-funded services. The final report (#09-5096)can be found on OMIG’s Web site at www.omig.ny.gov under the final audit report section.
This audit is part of OMIG’s overall effort to fight fraud, waste, and abuse in the Medicaid program. In the first six months of 2013, OMIG identified more than $100 million in Medicaid overpayments, according to preliminary audit, investigative and date match findings. From January 1, to June 30, 2013, findings totaled $103 million; the previous high for six months was $111 million. Actual cash recoveries also increased during the same period by 21.5 percent over the previous year to $61.7 million, according to the same six-month preliminary audit, investigation, and data match numbers.
Cox added that the Rite Aid audit, along with other successes counted in the six-month total, were achieved with fewer staff members and more efficient audit and investigation methods. “At the end of state fiscal year 2011-12, OMIG had 662 staff. As of the end of the last state fiscal year (2012-13), OMIG had 500 employees. We are doing more with less.” Audits such as the one completed at this Rite Aid pharmacy are an important component OMIG’s overall effort to fight fraud and recover improper payments in the Medicaid program, according to Cox. “One of the Medicaid program’s goals is to provide excellent health care at a cost that taxpayers can afford,” he notes. “Our work helps to contain costs while improving health care access and quality for Medicaid consumers.”
New Yorkers can assist the Office of the Medicaid Inspector General in fighting fraud, waste, and abuse by reporting potentially suspicious behavior or incidents. OMIG encourages anyone who observes instances of potential Medicaid fraud, waste, or abuse to contact OMIG’s fraud hotline at 1-877-87-FRAUD or visit the Web site at www.omig.ny.gov. Tips can be completely anonymous and OMIG investigates information from all calls.
Our mission is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices in the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.
A Manhasset pharmacy will not be allowed to serve the Medicaid population following an investigation by the Office of the Medicaid Inspector General (OMIG).
Click here for the full press release.
Kristina Zelinsky was indicted on August 6, 2013 in Brooklyn by Kings County District Attorney Charles J. Hynes for fraudulently collecting more than $25,000 in Medicaid benefits since 2003. The action was the result of a collaboration between the DA's Office, OMIG, and the New York City Human Resources Administration.
The full press release is available here.
You can help stop Medicaid fraud: Call OMIG’s Fraud Hotline at 1-877-87 FRAUD (1-877-873-7283), or click here to file a complaint electronically.
The OMIG may sanction some providers by excluding them from participating in the Medicaid program. These providers are excluded from offering services to Medicaid enrollees and also cannot be paid with Medicaid dollars. Prior to adding new staff members, employers should check to see if prospective employees have been excluded from Medicaid. To make it easier to perform such a check, OMIG set up a dedicated service to check the status of any exclusion.
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Anytime a health care organization discovers that it was paid more than it was due, this should be reported to OMIG. Our Self-Disclosure section provides information for health care organizations to complete the recently revamped self-disclosure process.
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