Latest OMIG Plan Outlines New Areas for Medicaid Audits

In the workplan released earlier in the week, the New York State Office of the Medicaid Inspector General (OMIG), which is an independent agency within the Department of Health, renewed its commitment to fighting fraud, waste and abuse in the New York Medicaid Program. One of the nine business lines that the agency will focus on during the 2012-2013 fiscal year includes the following three providers: physicians, dentists and laboratories. 

OMIG reminded providers that:

Physicians must be licensed and currently registered by the New York State Education Department or meet the certification requirements of the appropriate state in which they practice.  Dental care in the Medicaid program includes only essential care rendered by dentists, oral surgeons, and orthodontists.  Laboratory services may only be provided to enrollees by clinical laboratories, physicians, or podiatrists within their scope of practice.

The agency’s focus will be specifically on: 1) obstetrics/gynecological physicians; 2) physician place of service; 3) ordered services; 4) dental consultations; 5) dental procedure combinations.

With respect to obstetrics/gynecological physicians the agency will review provider billings for duplicate delivery billings or billing for global delivery fees when delivery-only codes were appropriate for the services rendered.

OMIG focus is also on the place of service and the agency will  identify inappropriate  physician billings for office visits when the services were instead delivered in another setting, such as a clinic or outpatient hospital setting.

Providers know that the services they render to patients must be medically necessary. To that end, OMIG will review services to determine  whether they were medically necessary. The first service claims to be reviewed are enteral feeding claims and providers who ordered a high volume of home health services.

OMIG continues its focus on dental consultation claims (D9310), which must arise from referrals from providers other than the ones performing the consultation and must be followed by written reports to the referring providers. The dental consultation code  is typically used by specialists such as oral surgeons and orthodontists when evaluating a patient referred by a requesting dentist. OMIG has specific documentation requirements to demonstrate that this service has been rendered. During its reviews of dental providers, OMIG will determine whether a consultation was authorized, was deemed medically necessary, and whether appropriate follow-up occurred.

Lastly, OMIG will review  inappropriate  combinations of procedure codes billed by dentists for procedures, such as, for example, billing for a pulled or crowned tooth for an enrollee who has full dentures or dental services included in a residential capitated rate.

If you have questions about New York State OMIG audits, documentation requirements or need legal assistance, please contact us.