NY Watchdog Releases Its Annual Fraud Fighting Plan

The New York State Office of the Medicaid Inspector General (OMIG or agency) has recently issued its 2017-2018 Workplan. The Workplan identifies key areas of OMIG’s focus impacting health care providers and suppliers.

The 2017-2018 identifies three overarching OMIG goals: 1) enhancing provider and supplier compliance efforts; 2) addressing fraud, waste and abuse; and 3) improving the use of technology to detect and prevent fraudulent Medicaid activity. OMIG has stated that “each goal has equal significance and weight in helping [the agency] achieve its mission.”

Provider and supplier compliance continues to be an important agency consideration. Pursuant to this goal OMIG conducts education and compliance reviews to determine whether providers and suppliers are meeting the statutory and regulatory program requirements. OMIG has also expanded compliance reviews in 2016-2017 period to include Medicaid Managed Care Organizations (MCOs) and will continue such work in the current workplan year. Providers who fail to to meet the statutory and regulatory compliance program requirements may face penalties and fines.

OMIG’s also continues to focus on fighting fraud, waste and abuse in the State’s Medicaid Program. Eighty thousand providers and suppliers are enrolled with Medicaid to provide items and services to six million New Yorkers through the traditional fee-for-service Medicaid as well as through over 90 MCOs. The agency’s program integrity efforts include independent investigations and administrative actions (such as exclusions) as well as collaborative investigations with the FBI, the DOJ, the federal OIG, as well as other state and federal agencies. OMIG also cooperates and coordinates its investigation efforts with the Medicaid Recovery Audit Contractor, Health Management Systems Inc., to recoup Medicaid overpayments.

This year OMIG’s integrity efforts have been expanded to target prescription drug abuse (including opiods). Under this program, OMIG scrutinizes physicians’ prescribing practices as well as beneficiary prescription drug abuse/fraudulent behavior. For example, Medicaid or Medicaid MCOs can restrict recipient’s access to Medicaid services “if it is found that [recipients] have received duplicative, excessive, contraindicated or conflicting health care services, drugs, or supplies,” or if the recipient engages in fraudulent behavior.

Additional on-going integrity efforts focuses on home health services, nursing home care, managed long term care (e.g., adult day care centers), pharmacies, transportation, among other providers and suppliers. Similarly, OMIG reviews high risk provider enrollment applications (e.g., pharmacies, DMEs, transportation, etc.,) and also plays the primary gate-keeping role in reinstating excluded providers or suppliers.

OMIG’s also continuous to use undercover patients in its integrity efforts. These individuals receive services from a Medicaid provider or supplier, record conduct during an undercover operation which is then reconciled with provider or supplier claims. OMIG stated that it uses such undercover operations to identify quality-of-care issues, billing problems, systemic fraud, such as paying recipients to undergo unnecessary medical tests, as well as to gather important intelligence on how organizations operate and the types of drugs/services being abused.

As part of its goal to use technology to detect fraudulent activities, OMIG performs data mining to idenfy improper claims and overpayments. Data mining is also used to analyze MCO encounter data which is critical to OMIG’s for effective program integrity oversight activities. OMIG also uses data analytics to enhance third party recoveries.

If you have questions about the Medicaid program, OMIG, enrollment, revalidation, exclusion, reinstatement or have other health law questions, please contact our office.