Core Elements of New York Medicaid Compliance Program

This is the third and final article in the series evaluating the NYS Medicaid Compliance Program requirements. The previous two articles looked at those providers required to have a compliance program as well as the annual certification requirement. In this article, we examine the core elements of a compliance program.

Core Elements of a Compliance Program

While no two compliance programs will be the same, an effective compliance program under New York law must include eight core elements that are discussed fully in NY SSL 363-d and 18 NYCRR §521.3(c).  In sum, providers are required to:

  1. have written policies and procedures detailing compliance expectations
  2. designate an employee with responsibility for the day-to-day operation of the compliance program
  3. train and educate, during orientation and periodically thereafter, all affected employees and persons associated with the provider, including executives
  4. maintain open lines of communications to the compliance officer (e.g.anonymous reporting of compliance issues)
  5. have clear methods of discipline of personnel for failing to comply with or participate in the compliance program
  6. self audits
  7. means of responding to compliance issues as they arise, including self-reporting to Medicaid for compliance lapses and overpayment refunds
  8. maintain a policy of non-intimidation and non-retaliation for good faith participation in the compliance program

To be effective the compliance program has to conform to the needs and resources of the organizations. OMIG recognizes this and has previously stated that while the core elements apply to all providers, regardless of size, the agency acknowledges that “there is no ‘one size fits all’ approach to compliance, and an effective compliance program must be tailored to a provider’s size, scope of items or services provided, complexity, resources, and culture.”

If you have questions about the NYS Medicaid compliance program requirements, provider Medicare or Medicaid enrollment or revalidation requirements, the New York State or New Jersey Medicaid Programs, or need other legal assistance, please contact us.