Which New York Providers Need a Compliance Program?

New York State Social Service Law §363-d and implementing regulations at 18 NYCRR §521 require that certain healthcare providers adopt and implement an effective compliance program and certify their compliance with the law every December. 

Who Needs a Compliance Program in New York?

The law mandates that providers subject to Article 28 (e.g., hospitals, diagnostic and treatment centers) or Article 36 (home health agencies), as well as those subject to Articles 16 (certain providers of services for people with developmental disabilities) or Article 31 (operators of mental health programs), must comply with this law irrespective of the amount these providers bill, expect to bill or receive from Medicaid.

Additionally, other providers or affiliates who provide care, services or supplies under the Medicaid program, or who submit claims for care, services or supplies for or on behalf of another person for which Medicaid is, or should be reasonably expected by the provider to be a substantial portion of their business operations are also required to adopt and implement an effective compliance program and certify annually. In essence, providers in this category claim or receive $500,000 or more (or are reasonably expected to claim or receive) in Medicaid funds, directly or indirectly, are required to comply with the compliance program requirement. Some providers assume the requirement does not apply to them if they only claim or bill below the threshold level of fee-for-service Medicaid.  The law, however, is broad and includes funds claimed or received for Managed Care Organizations (the “indirectly” portion of the regulation).

Compliance Plan Notice From OMIG

The New York State Office of the Medicaid Inspector General (OMIG) has recently issued a compliance alert and sent out notices directly to those providers that were likely required to, but did not, certify their compliance with the law last December. For now the education notice serves as a reminder to providers to adopt and implement an effective compliance plan and certify as much in December or otherwise let OMIG know why requirement does not apply. Continued failure to certify, however, could result in an OMIG investigation and possible sanctions against non-compliant providers.

If you have questions regarding New York’s Compliance program certification law, adopting and implementing an effective compliance plan, or have other healthcare law questions, please contact our office.