The New York State Office of the Medicaid Inspector General (OMIG) released its 2024 work plan in furtherance of its mission to coordinate and conduct activities to prevent, detect and investigate medical assistance program fraud, waste and abuse, and to recover improperly expended Medicaid funds. The work plan gives providers and other entities participating in the Medicaid program a comprehensive (but non-exhaustive) roadmap to better understand OMIG’s program integrity initiatives in 14 key areas:
- Compliance
- Self-Disclosures
- Transportation
- Durable Medical Equipment (DME)
- Clinics
- Behavioral Health
- Early Intervention
- Personal Care Services
- Hospice
- Home and Community Based Services
- Nursing Homes/Assisted Living Programs
- Pharmacy/Drug Diversion
- Telehealth
- Managed Care
The work plan addresses each of these key areas and identifies various tools and strategies OMIG will use to promote program integrity within them.
Some highlights for this year include:
- Compliance Program Reviews
Persons, providers, or affiliates are required to have a compliance program under New York State Social Services Law (SSL) § 363-d and 18 New York Codes, Rules, and Regulations (NYCRR) Part 521 if they are a “required provider” as defined in 18 NYCRR § 521.2(a). Medicaid Managed Care Organizations (MMCOs) are required by contract to have a compliance program. OMIG will continue conducting compliance program reviews to ensure that these compliance programs are implemented and operating as required.
- Self-Disclosures
OMIG’s Self-Disclosure Unit will continue processing submissions received under the Abbreviated Self-Disclosure Process and the Full Self-Disclosure Process. Medicaid providers are obligated to report, return, and explain any overpayments that they receive within 60 days of identification. Providers are also required to prepare and maintain contemporaneous records supporting their claims. OMIG advises providers to make disclosures as soon as practicable, but no later than 30 calendar days following discovery.
- Medicaid Managed Care Audits
OMIG will continue reviewing Medicaid Managed Care Operating Reports (MMCORs) to ensure costs and data are accurate, complete, and allowable. Additionally, OMIG will keep using program integrity reviews to assess MMCO plan performance related to program integrity obligations under the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Contract. OMIG also plans to continue its auditing work across a diverse range of program areas such as:
- Supplemental Maternity and Newborn Capitation Payments;
- Family Planning Fee-for-Service Chargebacks;
- Enhanced Nursing Home Capitation Payments; and
- Medicaid Advantage Plus (MAP) – Eligibility & Care Management, among others.
- Provider Audits
OMIG will continue performing provider audits with special emphasis on:
- Long-term care services;
- Home health and community-based services;
- Behavioral health/addiction services and supports, including Office of Mental Health (OMH) Personalized Recovery Oriented Services (PROS) and Telehealth Services;
- Person-centered services and supports, including Office of Persons with Developmental Disabilities Community Habitation;
- Early intervention/pre-school and school-supported health services;
- Pharmacy, including authorization of payments for controlled substance claims, and DME; and
- Transportation, including non-emergency use of ambulettes and taxi/livery services.
- Investigations
OMIG will continue using various investigative tools and reviews with particular attention to:
- Credential verification reviews, including of transportation providers;
- Pre-payment reviews, including in dental and private duty nursing, among others; and
- Managed care billing and practice patterns related to family planning, dental, DME, and physician and transportation specialties.
OMIG will continue providing secondary reviews of provider enrollment applications in certain high-risk categories such as: pharmacies, DME suppliers, physical therapists, and transportation providers to determine if applicants should be enrolled in the Medicaid program. OMIG will also continue reviewing all reinstatement applications and requests for removal from its Exclusion List.
- System Match
OMIG will continue expanding its use of data analytics to identify improper claims and potential recoveries with special focus on:
- Physician services in OMH Clinics to ensure that only licensed OMH programs seek and receive reimbursement, and to prevent duplicative fee-for-service billing outside of the OMH rate;
- Partial hospitalizations to ensure that treatment does not exceed 6 calendar weeks; and
- Transportation to verify that the vehicle license numbers and driver’s license numbers listed were authorized on the date(s) of service.
- Pharmacy/Drug Diversion
Pharmacy owners and supervising pharmacists are responsible for ensuring compliance with regulations. Pharmacy ownership and supervision will be a key focus area in 2024, and OMIG will be conducting more frequent Credential Certification Reviews throughout the state.
The 2024 Work Plan represents a much-anticipated and much-needed glimpse into OMIG’s program integrity initiatives for the year ahead. It also serves as an important signal to providers that OMIG continues to expand the depth and breadth of its investigation and oversight of Medicaid programs. Providers would be well-served, therefore, to add one more resolution to their lists for 2024 – to perform an evaluation that identifies their specific risk areas, assesses the effectiveness of their compliance programs, and make necessary adjustments, particularly if they operate in one of the above-mentioned key areas.
A complete copy of the 2024 Work Plan is available at: https://omig.ny.gov/2024-new-york-state-office-medicaid-inspector-general-work-plan
Should you have any questions regarding the above, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or contact us at [email protected].