Annual Medicaid Certification Requirement

It’s that time of the year again when qualifying providers enrolled with the NYS Medicaid Program must certify that they have a adopted, implemented and maintained an effective mandatory compliance program. The NYS Office of the Medicaid Inspector General (OMIG) is tasked with responsibility of overseeing that providers meet this requirement.

When it comes to the certification requirement, the following points are worth emphasizing. First, it is the responsibility of providers to determine if they are subject to the mandatory compliance program requirement. Second, if providers are subject to the mandatory compliance program requirement, they are then also responsible for determining whether the program in place meets the requirements of the law and that it’s effective. OMIG has been actively enforcing the compliance program requirement and the agency has repeatedly indicated that it is not enough to have a compliance program sitting in a binder on a shelf.

Even if providers are not mandated to have a compliance program, OMIG nonetheless encourages all providers enrolled in Medicaid to have a compliance program.

Providers certify annually between December 1 and 31 based on the Federal Employer Identification Number (FEIN) or Social Security Number (SSN) used to receive Medicaid payments. OMIG advises that if several EINs/SSNs are used to receive payments for an organization, then each FEIN/SSN will need to submit a separate certification form even if the compliance program, compliance officer, and certifying official are the same for all related entities. To determine which FEINs/SSNs need to certify, provider’s compliance officer and/or the certifying official can check with the provider’s billing and/or payment processing units to identify the specific FEIN/SSN to which Medicaid payments are made.

Providers’ compliance official and certifying official should be different individuals, recommends OMIG. While OMIG recognizes that in smaller organizations that may not be possible, nevertheless, having only one person act in both capacities is bound to raise flags with the agency leading to follow up requests to review a providers’ compliance program. Similarly, providers should avoid end of the month certifications as system overload could prevent timely certification raising further flags with the agency.

Failure to comply with the annual certification requirements could lead to serious sanctions, including exclusion from the Medicaid 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.