NYS OMIG Focuses on Compliance, Fraud, Waste & Abuse and Detection

New York State Office of the Medicaid Inspector General (OMIG) annual 2018-2019 Work Plan highlights three areas of concern for the agency: (1) provider compliance; (2) identifying and addressing fraud, waste and abuse in the program; and (3) improving methods of detecting fraudulent activities.

Provider compliance remains an important area of consideration for the agency. OMIG will conduct compliance program reviews of providers and Managed Care Organizations to analyze whether a Medicaid provider’s compliance program is implemented and operating as required by statute and regulations. OMIG has indicated it will censure noncompliant providers.

In addition to on-going fraud, waste and abuse activities, OMIG will dedicate resources to a variety of activities to reduce drug misuse, prescription opioid abuse, and drug diversion. Prescribers beware: OMIG will analyze data to “identify and investigate physicians prescribing excessive amounts of controlled substances or providing unnecessary services, and refer them to MFCU, if appropriate, for prosecution.” OMIG will also issue drug utilization notices to providers alerting them to controlled substance accumulation for certain patients even if such patients have not met the criteria for the restrictions under OMIG’s Recipient Restriction Program.

Additionally, OMIG will conduct field and claims audit of several Medicaid programs, including, the long term home health care program as well as the personal care services program. Similarly, OMIG will audit and investigate Consumer Directed Personal Assistance Program for compliance with rules and regulations.

Other providers that OMIG continues to focus its investigatory and audit resources include transportation service providers, pharmacies, DMEPOS, home health, and diagnostic treatment centers. The agency is also involved in providing secondary review during the enrollment process to high-risk providers such as pharmacies, DMEPOS, and transportation providers. OMIG’s additional responsibilities include reviewing all reinstatement applications and requests for removal from the OMIG Exclusion list. The agency similarly audits recipients of the EHR Incentive Payment Program for compliance with eligibility requirements.

OMIG plans to focus on improving methods of detecting fraudulent activity, its third area of concern, by using data analytics and working together with its Recovery Audit Contractor (RAC) and other contractors to investigate, audit and recoup overpayments. For example, during fiscal year 2019, OMIG and RAC will focus reviews on the following areas: ordered ambulatory services, intensive rehab add on, and home health.*

Similarly, the Medicaid RAC will continue conducting pre-payment insurance verification to identify and utilize third-party coverage for Medicaid recipients, to conduct third-party retroactive recoveries, and engage in estate and casualty recoveries.

* The entire list of areas of audit focus for the Medicaid RAC is as follows:

  • Credit Balance Audit FFS and Encounter
  • Graduated Medical Education and Indirect Medical Education
  • MCO/FFS/Same Plan Overlap
  • Long-Term Care – Bed Hold Days/Net Available Monthly Income/Correct Co-insurance/Coordination of Benefit Errors/Rate Code Errors
  • Duplicate Payment of Professional Services Included in Ambulatory Patient Group Rate Code
  • Alternate Level of Care Days
  • Medicare – Inpatient Part B/Crossover Overpayment/Incorrect Reimbursement for Medicare Part C Claims (NY RAC 033)
  • Medicare Medicaid Duplicate Payment/Crossover Overpayments
  • Medicaid Payment Exceeds Billed Charge
  • Intensity Modulated Radiation Therapy Plan Unbundling
  • Duplicate Comprehensive Psychiatric Emergency Program Case Rates/Inpatient Overlap/Brief vs. Full
  • Intensive Rehab Add On
  • Ordered Ambulatory Services
  • JCode Incorrect Reimbursement
  • Home Health

If you have questions about Medicaid audits, enrollment, revalidation, exclusion, reinstatement, or have other health law related questions please contact our office.