According to United States Attorney Richard S. Hartunian, the City of New York (NYC) has agreed to pay the United States Department of Justice (US DOJ) $1.05 million to settle allegations that the NYC Human Resources Administration (HRA) violated the federal False Claims Act by causing various managed care organizations (MCOs) to provide Medicaid coverage to individuals that HRA knew, or should have known, were ineligible to receive New York State Medicaid benefits because they had moved outside New York State. The case was brought by a whistleblower and investigated by the US DOJ and United States Department of Health and Human Services Office of the Inspector General (OIG).
In New York, Supplement Security Income (SSI) recipients receive Medicaid benefits automatically. When a Medicaid recipient living in New York City moves to another state and enrolls for SSI benefits, the federal government provides a notification to the New York State Department of Health (DOH) which, in turn, is required to promptly forward the individual’s information to HRA. HRA must quickly review the notification and, if appropriate, terminate a recipient’s Medicaid benefits if it determines the recipient no longer resides in New York City. Absent this termination, the managed care organization (MCO) insuring that person will continue receiving monthly payments from the Medicaid program, even though the recipient is no longer eligible to receive New York State benefits.
The US DOJ/OIG investigation allegedly revealed that, although MCOs on several occasions notified HRA that certain recipients may have moved out of New York State, HRA failed to appropriately follow up on that information and work with DOH to stop the monthly Medicaid payments.
According to the US DOJ press release, available here, as part of the settlement HRA accepted responsibility for failing to timely review and terminate certain Medicaid benefits after being provided information that those recipients may have moved outside of New York City. HRA also admitted that its inaction caused one or more MCOs to receive payments to insure individuals who were ineligible for New York State Medicaid benefits.
HRA also agreed, as part of the settlement, to establish a process to investigate and terminate Medicaid benefits whenever it receives information suggesting that a Medicaid recipient no longer resides within its coverage area.
The whistleblower in this case will receive $175,000 from the $1.05 million settlement between the US DOJ and HRA.
For more information, please contact the author, David R. Ross, who served as Acting New York State Medicaid Inspector General under Governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General (OMIG). He can be reached at (518) 462-5601 or via e-mail at email@example.com.