Audit finds hospitals improperly billing Medicaid for pricier, inpatient care

Good morning and welcome to the Weekly New York Health Care newsletter, where we keep you posted on what’s coming up this week in health care news, and offer a look back at the important news from last week.

Beat Memo

Hospitals may be improperly billing Medicaid for inpatient services that should have been billed as outpatient care, a new audit by the office of New York state Comptroller Thomas P. DiNapoli suggests.

The audit, which was shared exclusively with POLITICO, identified nearly $361 million worth of fee-for-service inpatient claims for Medicaid enrollees discharged within 24 hours of hospital admission — suggesting a portion of those 34,000-plus claims were improperly billed as pricier inpatient claims instead of outpatient services, which are generally less expensive.

Inpatient care generally involves patients who, on the recommendation of a physician or licensed practitioner, stay at least overnight in a hospital and receive room, board and continuous nursing service.

Among a judgmental sample of 190 of those claims, representing six hospitals, auditors found 48 percent had been billed improperly.

“The state Department of Health needs to give clearer guidance so hospitals know whether to bill for services as outpatient, rather than more expensive inpatient care,” DiNapoli said in a statement. “Nearly half the bills we looked at got it wrong and that kind of error rate results in millions of dollars in Medicaid overpayments.”

In response to the audit, the Health Department said it will review its inpatient manual to see whether it clearly explains the criteria to submit an inpatient claim and make updates where appropriate.

The department said it would also explore processes to identify and review inpatient hospital claims for short stays, as recommended by the comptroller’s office.

IN OTHER NEWS:

— Catholic Health and New York-Presbyterian have signed a clinical collaboration agreement to expand access to cardiac care on Long Island, the health care systems announced.

The collaboration will expand St. Francis Hospital & Heart Center’s advanced heart failure, adult congenital heart disease and pediatric cardiology programs and also extend New York-Presbyterian’s heart transplant program to Long Island.

ON THE AGENDA:

— Today at 1 p.m. The Emergency Medical Services for Children Advisory Council meets.

— Thursday at 10:15 a.m. The Public Health and Health Planning Council’s Codes, Regulation and Legislation Committee will convene, followed by a meeting of the full council.

GOT TIPS? Send story ideas and feedback to Maya Kaufman at [email protected].

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What you may have missed

— The families of several New York nursing home residents who died of Covid-19 during the early days of the pandemic filed a proposed class-action lawsuit last week against former Gov. Andrew Cuomo, former Health Commissioner Dr. Howard Zucker and other members of Cuomo’s administration over a policy barring nursing homes from refusing new residents due to a confirmed or suspected Covid diagnosis.

“The actions of the defendants were a recipe for disaster and contributed to the suffering of thousands of our most vulnerable,” Joseph Ciaccio, the plaintiffs’ lawyer, said in a statement to POLITICO. “We look forward to seeking answers and accountability for our clients and thousands of families across New York.”

A Cuomo spokesperson slammed the lawsuit as meritless.

— Health insurance premiums will increase by an average of 12.4 percent for individual plans and 7.4 percent for small group plans in 2024, the state Department of Financial Services announced last week.

Insurers had originally requested average rate increases of 22.1 percent for individual plans and 15.3 percent for small group plans, which cover businesses with up to 100 employees, but state regulators slashed those asks. The department said it also reversed a plan by Fidelis Care to withdraw from Brooklyn.

Odds and Ends

NOW WE KNOW — The new Covid variant BA.2.86 has been detected in New York City wastewater.

TODAY’S TIP — To become more of a morning person, set a consistent wake time.

STUDY THIS — Blood clots could be to blame for the brain fog suffered by some long Covid patients, according to a recent study in Nature Medicine.

What We're Reading

— Long Island hospitals are not reinstating mask mandates amid a rise in Covid cases, bucking a trend upstate, Newsday reports.

— DocGo is in the running for a $4 billion federal contract for migrant services, the Albany Times Union reports.

— To pay for weight loss drugs, some take second jobs and ring up credit-card debts, The Wall Street Journal reports.

— Artificial intelligence may influence whether you can get pain medication, KFF Health News reports.

Around POLITICO

— Via Sam Sutton: “`Life and death situations': Lawmakers battle Wall Street over health care.”

— Nearly 3 in 4 nursing homes would have to add staff under CMS proposal, Daniel Payne reports.

MISSED A ROUNDUP? Get caught up on the New York Health Care Newsletter.