ALBANY — New York State’s Medicaid program paid more than $60,000 for erectile dysfunction drugs and treatments for dozens of sex offenders over a six-year period, State Comptroller Thomas DiNapoli said Wednesday.
An audit released by DiNapoli’s office found that Medicaid made nearly $934,000 in improper payments for drugs, procedures and supplies to treat erectile dysfunction between April 2012 and July 2018. Those payments included $63,301 for 47 sex offenders, 30 of whom were classified as Level 2 or Level 3 offenders.
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The comptroller also found that Medicaid made payments for erectile dysfunction drugs that are approved to treat other medical conditions, like benign prostatic hyperplasia (BPH) and pulmonary arterial hypertension (PAH).
The audit noted that significant percentages of those prescribed erectile dysfunction drugs approved to also treat BPH or PAH may not have had diagnoses of either condition.
Medicaid, meanwhile, paid more than $285,600 for erectile dysfunction drugs approved to also treat BPH or PAH for 14 sex offenders — four of whom appeared to have diagnoses of erectile dysfunction and eight whom supported diagnoses of BPH or PAH, according to the audit. One case was deemed indeterminate.
The audit further found that managed care organizations made most of the payments and that Medicaid laws and policies are inconsistent, with state policy prohibiting payment of erectile dysfunction drugs for treatment of BPH under fee-for-service, but allowing it under managed care.
Noting that rules clearly dictate what conditions Medicaid will cover regarding erectile dysfunction drugs, DiNapoli argued that “paying for sex offenders who’ve committed terrible crimes to get these drugs should never be lost in the bureaucratic administration of this program.”
“Nearly two decades ago this office identified this problem, which led to national and state changes. While the state Department of Health immediately followed up to make corrections during the course of our audit, our auditors found that the problem persisted and needed to be fixed,” he said in a statement.
The audit recommended that the Department of Health: review payments identified in the audit and ensure recoveries are made appropriately; regularly provide managed care organizations with lists of all erectile dysfunction drugs, procedures and supplies that are excluded or have limited Medicaid coverage; periodically monitor coverage, utilization and payment of such drugs, procedures and supplies; and take corrective actions.
DiNapoli also urged the health department to improve its eMedNY computer system controls to apply sex offender status in the processing of certain claims and prevent the processing of incomplete Division of Criminal Justice Services sex offender registry files.
DOH, in response to the audit, said it “summarily rejects OSC’s contention that $933,594 in claims over the six-year audit period were improper,” noting that drugs used to treat erectile dysfunction can also be used for other purposes, like treating PAH or BPH.
The agency also dismissed “the assumptions used by OSC to identify questionable payments for drugs indicated to treat sexual or erectile dysfunction, which can also be used to treat other indications.”
“There was absolutely no consideration for diagnoses contained in the medical or prior authorization record, and the look-back period for diagnosis in claims records should have been for one year from the prescription fill date, rather than six months or less,” officials wrote in their response. “OSC’s incorrect use of a one-year look-back period accounts for the limitations in claims data related to timeliness and completeness.”
A 2005 Office of the State Comptroller review found that Medicaid paid for the erectile dysfunction drug Viagra on behalf of nearly 200 registered Level 3 sex offenders — leading to overhaul to federal and state overhauls.
Current federal and state laws bar Medicaid from covering drugs to treat sexual or erectile dysfunction for Medicaid recipients, including registered sex offenders. State law further bars payment for procedures and supplies to treat erectile dysfunction for registered sex offenders, DiNapoli’s office noted.