Audit of Medicaid ETIN Oversight and Claim Submission Controls
- The Department of Health failed to maintain adequate oversight of electronic transmitter identification numbers used for Medicaid billings, according to an audit examining fee-for-service claims submitted between January...
- Auditors determined that the Department of Health did not implement sufficient controls to ensure electronic transmitter identification numbers met all affiliation requirements.
- The review also examined the Medicaid enrollment statuses of 242 service bureaus whose ETINs appeared on claims during the audit window.
The Department of Health failed to maintain adequate oversight of electronic transmitter identification numbers used for Medicaid billings, according to an audit examining fee-for-service claims submitted between January 2020 and December 2024. The audit evaluated how the agency monitors unique identifiers known as ETINs, which providers and service bureaus rely on to submit medical claims through the eMedNY system.
Millions of Claims Processed with Unaffiliated Identifiers
Auditors determined that the Department of Health did not implement sufficient controls to ensure electronic transmitter identification numbers met all affiliation requirements. This oversight gap allowed the eMedNY payment system to process nearly 10.8 million claims submitted using 783 distinct ETINs that lacked active affiliation with the billing providers on the actual date of service. While the eMedNY system maintains automated controls to detect and block payments for certain claims submitted via expired ETIN affiliations, pharmacy claims are excluded from this edit logic. Out of the problematic numbers identified, 720 expired ETIN affiliations were used specifically to submit pharmacy service claims. The remaining 63 ETINs handled non-pharmacy claims where affiliations were either expired on the service date or never existed at all. Medicaid policy requires all entities submitting claims to hold an active, certified ETIN affiliation on file before transmitting paperwork.
Inactive and Excluded Service Bureaus Handling Claims
The review also examined the Medicaid enrollment statuses of 242 service bureaus whose ETINs appeared on claims during the audit window. Investigators found that 84 of those service bureaus—representing 35 percent of the total—held Medicaid identification numbers that remained inactive throughout the entire audit period. An additional three service bureaus had no Medicaid ID assigned at all. State and federal rules mandate that service bureaus enroll in the Medicaid program and that providers revalidate their enrollment at least every five years. Providers are also required to recertify their service bureau ETIN affiliations annually. However, auditors found that the Department of Health lacked controls to flag ETINs belonging to entities excluded from the Medicaid program by the Office of the Medicaid Inspector General. As a result, one excluded service bureau managed to submit 30,415 claims totaling $1.4 million after the agency barred it from participating in the program.
Audit Recommendations and Next Steps
To address the oversight vulnerabilities, the audit issued specific recommendations for state regulators. The Department of Health must determine and update the administrative status of the 783 ETINs that submitted claims while expired or completely unaffiliated. Investigators also called on the agency to tighten monitoring protocols over claim submissions and review all transactions tied to the service bureau that continued operating after its termination from the Medicaid program. Implementing these corrections is intended to restore visibility to the claim submission process and ensure unauthorized entities cannot process medical billings.