NY State Audit Reveals $1.5M Anthem Overpayments in Empire Plan Claims

A recent follow-up audit by the New York State Comptroller has uncovered continued substantial overpayments by Anthem Blue Cross for physician-administered drugs under the Empire Plan, a state health insurance program.

Between January 2022 and December 2024, Anthem made more than $1.5 million in duplicate payments due to insufficient oversight and coordination with the New York State Department of Civil Service, which manages the New York State Health Insurance Program (NYSHIP). This finding builds on a 2023 audit identifying over $2.7 million in previous overpayments. The audits highlight systemic challenges in data reconciliation and claims management between hospital and prescription drug programs, both reimbursing for identical drugs without adequate cross-referencing. Although Anthem has recovered over $600,000 to date, the majority of flagged overpayments remain outstanding. The report emphasizes slow progress on implementing audit recommendations; only two of seven measures have been fully enacted, including improved controls for no-cost drugs and safeguards against Medicare overbilling.

Critical issues persist, such as incomplete review and recovery of earlier claims exceeding $1 million and lack of education for healthcare providers on proper billing documentation. The New York State Comptroller urges Anthem and Civil Service to finalize data-sharing protocols and enhance provider training to reduce future errors. This ongoing scrutiny underscores the importance of robust claims oversight, inter-agency collaboration, and compliance within large public health insurance programs to mitigate financial leakage and improve fiscal stewardship.