Dinapoli Audit Discloses $14 Million "Fraud" Scheme vs NYSHIP: "Systemic Abuse" is Regulators' Preferred Term (Crackdown‪)‬

Twenty medical providers have submitted inflated claims to the New York State Health Insurance Program (NYSHIP) costing the State nearly $14 million. The fraudulent claims were discovered through an audit of 22 providers that were not participating providers in the Empire Plan by the State Comptrollers Office, the New York State Insurance Department and the New York State Department of Civil Service. The audits conducted between January 2001 and December 2007 found that 20 of the 22 providers "inappropriately waived out of pocket costs for patients and submitted inflated medical bills," New York State Comptroller Thomas P. DiNapoli said. "The most common way of overstating these charges is for the non-participating provider to waive the Empire Plan member's co-insurance (i.e. the member's 20 percent share of the bill)," DiNapoli said. "If a non-participating provider charged an Empire Plan member $1,000 for a service, the provider would submit a claim to the Empire Plan for $1,000. The Empire Plan would then reimburse the provider for $800 of this $1,000 (80 percent), and the member would owe the balance. However, if the provider routinely waived the member's share of the charges, the provider should actually be charging the Empire Plan only $800 for the service. In this case the resulting reimbursement would be only $640 (80 percent of $800), which is $160 lower than the reimbursement on the inflated charge."