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Medicaid

Medicaid, the State and City program providing medical care for those without the means to properly obtain it, is supported in large part by IREA’s work at verifying eligibility and investigating fraud and abuse.  Due to the analytical nature of IREA’s investigative efforts, most Medicaid cases assigned to IREA are recommended for closure.  IREA investigates client fraud and abuse along with investigating and auditing providers to ensure Medicaid providers do not abuse the system. In 2012, IREA’s Medicaid efforts recovered $79 million and saved another $105.5 million.

Medical Assistance 2012 & 2013:

Sept
2013
Quarter 1
2013

Quarter 2
2013

Quarter 3
2013
CYTD
2013
CYTD
2012
Eligibility Verifications Completed (MllP) 836 2,795 2,588 2,812 8,195 n/a
Ineligible 770 2,436 2,287 2,518 7,241 n/a
Cost Avoidance $4,136,933 $13,087,751 $12,287,228 $13,528,308 $38,903,287 n/a
Field Visits 106 340 265 324 929 n/a
Investigations Completed (BFI) 289 4,322 3,619 3,974 11,915 17,503
Positive Dispositions 206 3,781 2,752 3,057 9,590 15,980
Neutral Dispositions 26 52 521 462 1,035 n/a
Negative Dispositions 57 489 346 455 1,290 1,523
Cost Savings $2,700,377 $17,363,208 $16,497,694 $16,903,152 $50,764,054 $124,445,778
Medicaid Provider Audits Completed 0 0 0 0 0 14
Dollars Recovered $8,899,332 $29,042,269 $24,769,831 $23,842,883 $77,654,983 $63,188,393
  • Data Matches:
    IREA’s investigators extensively utilize data matches to identify fraud and abuse

    • Clients with unreported income and residency outside of New York City, making them ineligible for the benefits they receive;
    • Clients and Medicaid providers involved in Medicaid prescription drug fraud activities; and
    • Clients who receive dual Medicaid benefits in both New York City and another state or county.
  • Investigations by Borough:
    • 2012, we had 28,078 with specific borough data
    • 6,300 investigations were in the Bronx,
    • 8,526 in Brooklyn,
    • 4,035 in Manhattan,
    • 7,895 in Queens, and
    • 1,322 on Staten Island

Medicaid Program Integrity Resources: