NYS Medicaid Compliance Program: Annual Certification Requirement

This is our second article in a series discussing the New York State Medicaid’s compliance program requirements. In our first article we focused on which providers are required by law to have a compliance program. In this article, we turn our attention to the annual certification requirement.

Annual Certification Requirement

New York’s regulation, 18 NYCRR §521.3(b), states that each provider required to have a compliance program, upon enrollment and then during the month of December each year thereafter, must certify on a form provided by Office of the Medicaid Inspector General (OMIG) that the provider has a compliance program meeting the statutory and regulatory requirements. Providers should be aware that there are no paper-based certifications and should become familiar with the on-line certification process.

Newly enrolling Medicaid providers required to have a compliance program and those providers performing an annual certification must first conduct a self assessment of their compliance program.  As part of the self assessment, providers should evaluate, along with other factors, whether the compliance program meets the requirements of Social Service Law §363-d and 18 NYCRR §521, whether the self assessment tool is sufficiently robust to capture areas in need of improvement, and, where applicable, whether the results of the self assessment were discussed with upper management. It is a good idea to conduct this analysis early on in the year to allow for time needed to make changes prior to the annual certification in December.

OMIG recommends that providers not certify that they are in compliance if they determine that their compliance program does not comply with the statutory and regulatory requirements. Instead, providers are encouraged to follow the directions on the certification form for alternatives. OMIG also recommends that the official certifying the annual certification should not be the organization’s compliance officer. Rather, OMIG “strongly encourages” that the certifying individual be a member of senior management or governing authority of the provider. Likewise, OMIG requires a separate annual certification for each Federal Employment Identification Number (FEIN)/SSN if more than one FEIN/SSN is used to receive payments for the organization. This is the case even if the compliance program, compliance officer, and certifying official are the same for all related entities.

Failure to develop, adopt and implement an effective compliance plan exposes providers to possible sanctions. As of October 1, 2009, OMIG has the authority to impose sanctions and penalties on providers that include, but are not limited to, revocation of a provider’s agreement to participate in the Medicaid Program.

Our next article will discuss the core elements of a compliance program.

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.