State cites Albany health center Comptroller: Bone and Joint Center may have committed insurance fraud BY JAMES SCHLETT Gazette Reporter Reach Gazette reporter James Schlett at 395-3040 or jschlett@dailygazette.net
An Albany orthopedic-surgical facility allegedly jacked up bills for the state by waiving outof-pocket costs for services provided to state workers, leaving taxpayers to pick up the $2.4 million inflated tab. The state Office of the Comptroller on Monday released the results of audits at four facilities. The audits suggest systematic abuse in the way health care facilities bill the state’s insurance administrator for the Empire Plan, United HealthCare. Between January 2001 and December 2006, United overpaid those facilities an estimated $8 million, according to the Comptroller’s Offi ce. Capital Region Ambulatory Surgery Center was the only facility of the four in this area. “The abuse identified in these audits is particularly insidious and difficult to detect because each instance appears on the surface to show a physician merely agreeing to accept what the insurance company pays,” state Civil Service Commissioner Nancy Groenwegen said in a statement. At the Washington Avenue health center, also known as the Bone and Joint Center, CRASC allegedly routinely waived the out-of-pocket costs Empire Plan members are required to pay for out-of-network care. Although the physicians who operate at the center participate in the Empire Plan — the state’s primary health benefi ts program under the New York State Health Insurance Program — CRASC itself does not. State auditors said they believe CRASC waived its out-of-pocket obligations because Empire Plan members would likely have balked at obtaining referred services at the center if they knew they would have to pay substantially more for that out-of-network care. The Capital Region Orthopedic Group, which consists of 23 physicians, operates the center. Fourteen of those doctors own CRASC. Calls to CRASC seeking comment Monday were not immediately returned. Other health care facilities allegedly caught waiving out-of-pocket costs include the Endoscopy Center of Long Island in Garden City, which United overpaid by $2.7 million. The Digestive Health Center of Huntington was overpaid $1.5 million and the Day-Op Center of Long Island in Mineola was overpaid $1.4 million. The Comptroller’s Office said the providers might have committed insurance fraud by submitting insurance claims with false information. During the six-year audit period at CRASC, the Comptroller’s Office identified 2,689 billings totaling $12.2 million for which United was the primary payer. A randomly selected sample of 178 of those billings found that out-of-pocket costs were waived for 176 of them. Auditors estimated that random sample resulted in an $197,508 overpayment. CRASC reported to United the entire bill amount without subtracting the claim for the waived out-of-pocket costs. In one instance at CRASC, United paid $25,115. But if the Empire Plan member had received the same surgery at an in-network facility the cost would have been $1,272. The Comptroller’s Office said United should recover the $2.4 million in improper charges from CRASC. Also, it said, the Civil Service Department should bar the Albany facility from waiving patients’ out-of pocket costs.
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