The New York State Office of the Medicaid Inspector General (OMIG) recently updated its Self-Disclosure Guidance and Frequently Asked Questions (collectively, “Updates”). These Updates give participating providers and entities additional insight into how to report overpayments involving unresponsive Medicaid Managed Care Organizations (MMCOs) or multiple entities, as well as those that are untimely, have adjusted or voided claims, or lost or damaged records.
Medicaid Managed Care Organizations
Network Providers must self-disclose identified overpayments according to the MMCO’s policies and procedures. There are times when an MMCO may be unresponsive to such disclosures. According to the Updates, Network Providers facing this dilemma should document their attempts to contact the MMCO, and submit that documentation along with a completed Full Self-Disclosure Statement to OMIG. OMIG will review the submission and work with the Network Provider to determine the appropriate course of action.
Abbreviated Self-Disclosure Notification Process
The Updates clarify what providers can expect after the submission of an Abbreviated Self-Disclosure Statement. Specifically, the disclosing party will receive electronic confirmation that OMIG received the submission. The disclosing party should retain this email for record keeping purposes because it: (1) includes a unique identifier code to use in future correspondence; and (2) satisfies OMIG’s requirement to “report and explain” overpayments. OMIG will not contact the disclosing party unless it needs more information.
Disclosures with Multiple Entities
Entities may submit self-disclosures jointly when necessary. The Updates provide the following guidance for self-disclosures with multiple entities:
- The entity filing a claim is responsible for maintaining the documentation for 6 years in support of the claim;
- The entity billing and receiving payment for the overpaid claim is required to be part of the Self-Disclosure submission;
- When the error causing the overpayment is not routine or transactional, and it involves multiple entities or providers, use the Full Self-Disclosure Statement;
- The disclosing party should identify all impacted entities and providers, the relationship between the impacted entities and providers, and explain their involvement in the conduct being disclosed; and
- The disclosing party should include the contact information for each of the impacted entities and providers in its submission.
Voiding or Adjusting Claims and Transaction Control Numbers
Voiding or adjusting claims alone does not satisfy the obligation to “report and explain” identified overpayments. A disclosing party that uses the Abbreviated Self-Disclosure Statement must void or adjust claims before submitting their disclosure. According to the Updates, the Full Self-Disclosure Statement gives a disclosing party greater flexibility to void or adjust claims either (1) prior to submitting their disclosure; or (2) by indicating in the submission that the voids or adjustments are “in process.” The Updates also clarify that voiding or adjusting claims is the recommended form of repayment when using the Full Self-Disclosure Statement because it allows the claim record to remain accurate. All self-disclosures should include the original Transaction Control Number(s).
Untimely Self-Disclosures
OMIG may accept and process disclosures made more than 60 days after the identification of an overpayment, but such submissions may not be eligible for the waiver of interest or consideration of extended repayment.
Disclosing Damaged, Lost or Destroyed Records
Finally, a provider who becomes aware that their records have been damaged, lost or destroyed must report that information to the Self-Disclosure Program as soon as practicable, but no later than 30 calendar days after discovery.
OMIG’s updated Self-Disclosure Guidance and its Frequently Asked Questions are available at: https://omig.ny.gov/self-disclosure-guidance and https://omig.ny.gov/self-disclosure-frequently-asked-questions
Should you have any questions regarding the above, please contact the authors, the Garfunkel Wild attorney with whom you work regularly work, or contact us at [email protected].