New York OMIG’s Activities By The Numbers

New York Office of the Medicaid Inspector General’s (OMIG) 2013 annual report provides an important insight into the agency’s activities, recoveries and where it plans to focus its resources in the upcoming year.

According to the agency, in 2013, OMIG recovered $879 million, which brings a three year total of recoveries of “improperly expended funds” to $1.73 billion. OMIG has also suspended more than $46 million in provider payments using new powers granted by the Affordable Care Act (ACA) which permits state Medicaid agencies to suspend payments upon “credible allegations of fraud.” Additionally, 700 providers were excluded or terminated by OMIG in 2013. The agency also has referred 164 cases to the Attorney General’s Medicaid Fraud Control Unit (MFCU) for further investigation and possible criminal prosecution.

Sources of Investigations

OMIG’s report provided a breakdown of sources of investigations handled by OMIG’s Division of Medicaid Investigations. In addition to the Division pursuing its own investigations, it also investigated cases based on information received from anonymous sources, beneficiaries, OMIG’s audits, the general public and the Department of Health.

In 2013, 3,069 Medicaid fraud allegations were received by the agency of which 2,562 were transferred to investigations and only 507 were closed after preliminary review. In other words, more than 83% of the fraud allegations received were transferred for further investigation by the agency.


Not all providers know that OMIG screens applicants prior to enrollment with NYS Medicaid. Some providers, such as pharmacies and DMEs, have traditionally been the subject to mandatory unannounced visits and undercover operations prior to enrollment. The agency has also added “reviews [of] several other provider categories where pre-enrollment reviews would be beneficial to avoid enrolling unqualified applicants, including … transportation, opticians, laboratories, dental, physical therapy, portable X-ray, home health, personal care agencies, … and nurse registries.”

In 2013, OMIG received 940 enrollment applications and denied enrollment, reinstatement or removal from the Exclusion List to 165 providers.

Providers – Dental

OMIG continues to aggressively pursue dental providers by evaluating billing data for aberrant or suspicious patterns. OMIG also conducts unannounced visits to verify credentials of dental providers. During such inspections, OMIG thoroughly reviews the provider, including observing practice conditions, conditions of equipment, medication and instruments.

Providers – Pharmacies

OMIG conducted 22 pharmacy inventory reviews in 2013 and as a result excluded 3 pharmacies. The excluded providers were ordered to reimburse Medicaid more than $2.4 million.

Providers – Transportation

OMIG conducts periodic operations with NYS Taxi and Limousine Commission of routine stops in specific areas known to have Medicaid Providers with a high number of ordered transportation services. Transportation providers are stopped and while DMV checks the provider’s license, van registration, inspection and insurance documentation OMIG checks documentation relating to beneficiaries. OMIG also conducts beneficiary interviews.

In one operation during 2013, for example, OMIG and TLC observed 52 stops of certain transportation providers, seized 4 vans and issued 18 summonses for unlicensed drivers, unlicensed vans, and cell phone conversations without hand-held device.


The ACA as well as New York law requires providers to report and return overpayment by the later of the date which is 60 days after the date on which the overpayment was identified; or the date any corresponding cost report is due, if applicable. According to OMIG, its self-disclosure activities “identified overpayments of $16.3 million in 2013.”

Medicaid RACs

The ACA required State Medicaid agencies to contract with Recovery Audit Contractors (RACs) to audit Medicaid claims for overpayments and underpayments. HMS is NYS Medicaid’s recovery audit contractor. Through its activities, HMS “identified and recovered approximately $41.8 million in inappropriate Medicaid expenditures.”

If you have questions regarding OMIG, OMIG audits, OMIG’, enrollment, revalidation, exclusion, the annual compliance requirement, or have other health law questions, please contact our office.