OMIG’s 2014-2015 Workplan

The New York State’s Office of the Medicaid Inspector General (OMIG) has released its program of activities for the current fiscal year. As in previous years, the agency’s audit and investigation functions remain strong.

Managed Care

A major focus for OMIG this fiscal year is managed care. According to OMIG, the agency “has identified a series of robust initiatives to significantly strengthen the detection of fraud, waste and abuse in the Medicaid managed care environment.” Some of those initiatives include review of fee-for-service payments to determine if the services were already included in a patient’s managed care benefits package; analyze data for managed care patients who had date of service after their date of death, during period of incarceration or institutionalization; as well as, identify consumer fraud or abuse.

Adult Care Centers

OMIG will also audit and investigate complaints concerning social adult day care centers regarding overcrowding, inappropriate solicitation of Medicaid patients, and enrollment of unqualified patients in the managed long-term care program. OMIG will also conduct credential verification and record reviews of the documentation provided in response to subpoenas.

Pharmacies and DMEs

While OMIG’s work in the managed care program is expanding, the traditional focus areas of OMIG investigations remain just as strong.  For example, pharmacies and durable medical equipment (DME) suppliers continue to be entities of considerable interest to the agency. For example, DME suppliers will be analyzed for compliance with Medicaid rules and regulations, including, dispensing of equipment pursuant to a script from an authorized licensed practitioner, whether DME was delivered on the dates billed, and whether accurate billing codes were used.

Pharmacies will be audited for drug diversion, subjected to inventory reviews, as well as analysis of whether claims submitted to Medicaid were also submitted to the Medicare Part D program. Similarly, the agency will continue analyzing pharmacies for compliance with federal and state laws including, adherence to rules relating to documentation and billing.

Dentists, Physical Therapists and X-Rays 

In addition to DME and pharmacy suppliers, OMIG will also conduct pre-enrollment reviews of physical therapists and portable x-ray supplier enrollment applications.

OMIG will also focus on dental providers’ preventative services and whether fee-for-service program payments for dental benefits included in the managed care benefits package were made.

EHR Audits & Other OMIG Work

The agencies other audit and investigative activities include: 1) review of new enrollment applications to determine whether providers should be permitted to enroll in the Medicaid program, 2) review of ownership changes with particular interest on providers who have been excluded and/or are undergoing an audit or investigation and are selling their business, 3) investigate providers for kickbacks and other inducements, and 4) audit providers and suppliers who were the recipients of the Medicaid Electronic Health Record (EHR) incentive payments. OMIG will also conduct pre-payment reviews for transportation, pharmacy, private duty nurses, health home agencies and DME providers.

Secret Shoppers and Secret Patients

Providers should be aware that OMIG conducts undercover operations in which undercover agents posing as patients/consumers receive services and/or products. Thereafter OMIG analyzes the billing of claims for providers rendering those services. According to OMIG, “[u]ndercover operations discover quality-of-care issues, billing problems, systemic fraud, as well as gather important intelligence on how organizations operate and the types of drugs being abused.”

Of note is OMIG’s close working relationship and data sharing with the FBI, Health and Human Services Office of the Inspector General, the Attorney General’s Medicaid Fraud Control Unit, as well as other federal, state and local law enforcement and program integrity entities and district attorneys.

OMIG is an independent entity, answerable directly to the governor, within the New York State Department of Health that is charged with improving and preserving the integrity of the State’s Medicaid program.

If you have questions regarding OMIG, the NY Medicaid Program, enrollment, exclusion or have other questions concerning your case, please contact our office.