The report alleges the ASC waived New York State Health Insurance Program Empire Plan members’ required out-of-pocket costs for services provided and, as a result, United Healthcare subsequently overpaid claims submitted during the audit period of January 1, 2001 through November 30, 2007.
New York State provides health insurance coverage to active and retired state, local government and school district employees and their dependents. This coverage is provided under several benefit plans, including the Empire Plan.
The New York State Department of Civil Service contracts with United to process and pay medical claims for services provided to Empire Plan members. The state reimburses United for the payments it makes under the Empire Plan.
According to the report, the billing practices conducted by the ASC “further drives up costs for the Empire Plan, since it increases the likelihood that members will use non-participating providers … which generally receive higher reimbursement rates than participating providers. Furthermore, routinely waiving such costs is a billing practice that may violate the State Insurance Law.”
This audit is part of the comptroller’s continued examination of potential abuse in the state health insurance program that started last year. So far, nine DiNapoli audits have identified nearly $33 million in alleged overpayments and fraud, according to a press release from the comptroller’s office.
