By Deniza Gertsberg, Esq., on May 18th, 2021
Last year, as part of the 2020-2021 budget, the New York State Legislature made significant changes to the NYS Mandatory Compliance Program requirement. Providers required to adopt and implement an effective compliance program should be aware of the changes to avoid the imposition of penalties or other sanctions.
While dealing with the fall-out of the Pandemic in 2020, many providers may not have noticed that effective April 1, 2020, the Social Service Law 363-d underwent significant changes.
The first significant change was the specification that meeting the requirements of New York Social Services Law (“SSL”) § 363-d is now a “condition of payment from the medical assistance program,” for those providers mandated to adopt and implement an effective compliance program. This legislative change now provides the Medicaid Inspector General (“OMIG”) with the direct authority to recoup Medicaid payments made to a provider during a period when OMIG determines that a provider was non-compliant with the compliance program requirement.
In addition to recoupment, the amended law now gives OMIG the power to impose penalties on those providers that fail to adopt and implement an effective compliance program. OMIG may impose a penalty of $5,000.00 per month for up to twelve months. If OMIG imposed penalties on a provider for failing to adopt and implement an effective compliance program within the past five years, then OMIG is authorized to impose penalties of $10,000.00 per month for up to twelve months.
The third significant amendment entails OMIG’s authority to impose penalties on a provider for failing to report and return an overpayment within 60 days after the date on which the overpayment was identified (or the date a cost report is due, if applicable). The language of the amended statute gives OMIG broad powers to sanction a provider if the agency determines that a provider should have, but did not, exercise reasonable diligence to identify an overpayment. Specifically, it states that “[a] person has identified an overpayment when the person has or should have through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.” (emphasis added). Furthermore, “[a] person should have determined that the person received an overpayment and quantified the amount of the overpayment if the person fails to exercise reasonable diligence and the person in fact received an overpayment.”
In furtherance of the requirement to report and return an overpayment within 60 days, the law now has adopted a formal self-disclosure program which mainly tracks the self-disclosure protocol that OMIG has already implemented prior to the legislative amendment.
Other changes include a requirement that compliance programs not only prevent waste, fraud and abuse but also prevent, detect and correct non-compliance with NYS Medicaid requirements.
Separately from the legislative action, OMIG made changes to the annual December certification requirement for providers. Specifically, providers no longer need to complete the annual “SSL Certification,” on OMIG’s website. Instead, a provider adopting and maintaining an effective compliance program will now record (attest to) this as part of their annual “Certification Statement for Provider Billing Medicaid.” This annual certification occurs on the anniversary date of the provider’s enrollment in Medicaid.
If you have questions regarding the new compliance program requirement under New York Social Services Law (“SSL”) § 363-d and the implementing regulations at 18 NYCRR Part 521, the annual provider certification requirement, or have other health law related questions, please contact our office.
By Deniza Gertsberg, Esq., on November 16th, 2020
On October 7, 2020, New York State Public Health Law 230 was amended to require every physician’s “practice setting” to post a conspicuous sign regarding where to report professional misconduct.
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By Deniza Gertsberg, Esq., on January 6th, 2020
Beginning with dates of services of January 1, 2020, all non-exempt New York State Medicaid payments to providers will be uniformly reduced by 1%.
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By Deniza Gertsberg, Esq., on November 19th, 2019
Similar to other licensed healthcare professionals, New Jersey’s ophthalmic dispensers and ophthalmic technicians have to follow certain rules and regulations when it comes to adverting their practice. New Jersey’s State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians (“Board”), the state licensing and governing agency, has extensive regulations governing the do’s and don’ts of advertising for ophthalmic dispensers and technicians. Below we summarize a subset of those rules.
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By Deniza Gertsberg, Esq., on October 13th, 2019
It is the twenty-second year of the Health Care Fraud and Abuse Control Program (HCFAC) established by the Health Insurance Portability and Accountability Act of 1996. The HCFAC’s annual report for 2018 shows continued focus on preventing and eliminating fraud, waste and abuse from the Medicare and Medicaid programs and increased cooperation between government agencies to facilitate data sharing.
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By Deniza Gertsberg, Esq., on September 23rd, 2019
The Centers for Medicare & Medicaid Services (“CMS”) announced in April of this year that it is adding 12 new HCPCS codes to the Required Prior Authorization List of DMEPOS items that require prior authorization as a condition of payment. Prior authorization for Pressure Reducing Support Surfaces will be implemented nationwide in October.
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By Deniza Gertsberg, Esq., on September 9th, 2019
On July 2, 2019, New Jersey’s Governor, Phil Murphy, signed into law the Jake Honig Compassionate Use Medical Cannabis Act (“Act”) (previously known as the New Jersey Compassionate Use Medical Marijuana Act) which greatly expands and reforms New Jersey’s Medical Marijuana program. Several of the legislative updates are based on the recommendations made by the New Jersey Department of Health March 2018 Report (drafted pursuant to Executive Order No. 6). Below we highlight some of the significant changes.
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By Deniza Gertsberg, Esq., on August 8th, 2019
New Jersey pharmacy owners know that every New Jersey pharmacy must appoint a Pharmacist-In-Charge (“PIC”) and a pharmacy cannot operate without a PIC for longer than 30 days. Below we review some of the many responsibilities that go with the title.
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By Deniza Gertsberg, Esq., on July 16th, 2019
The Department of Health and Human Services (“HHS”) and the Office of the Civil Rights (“OCR”) recently proposed changes to Section 1557 of the Affordable Care Act (“Act”). This Section of the Act prohibits civil rights discrimination in certain health programs or activities. Some of the major changes, include, among others, revising the regulatory definition of what constitutes discrimination on the “basis of sex”. The proposal also includes healthcare conscience protections. Additionally, the proposed rule would eliminate taglines and notices requirement and it would revise the language access and grievance procedures of the rule.
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By Deniza Gertsberg, Esq., on June 23rd, 2019
An electronic medical records company recently settled with the Office of the Civil Rights (“OCR”) for violating the Health Insurance Portability and Accountability Act (“HIPAA”) following a discovery of a cyberattack on its servers which contained the protected health information (PHI) of approximately 3.5 million individuals.
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By Deniza Gertsberg, Esq., on May 19th, 2019
The New Jersey Department of Health’s recent biannual report recommended ways to improve the New Jersey’s Medical Marijuana Program in three key areas.
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By Deniza Gertsberg, Esq., on April 5th, 2019
The Office of the Inspector General (“OIG”) recently published the False Claims Act settlements risk spectrum for the first quarter of 2019. The risk spectrum identifies the number of settled cases and their assigned risk category.
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By Deniza Gertsberg, Esq., on February 25th, 2019
Many website design and development contracts as well as marketing and electronic medical records agreements (“technology contracts”) contain onerous terms and layers of user fees. If a physician or a dentist (“provider”) decides to part ways with the vendor under a technology contract the transition may be costly or cost prohibitive. One of the best ways providers can protect themselves against a slue of additional costs and concerns about possible loss of data is to have the contract reviewed by a healthcare attorney before signing on the dotted line.
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By Deniza Gertsberg, Esq., on February 7th, 2019
In a newly proposed rule the Office of the Inspector General (“OIG”) is proposing to exclude from the discount safe harbor certain types of remuneration offered by drug manufacturers to Part D plan sponsors and Medicaid MCOs that may pose a risk to the Federal health care programs and beneficiaries. The OIG is also proposing to add two new safe harbors. The first would protect certain manufacturer point-of-sale reductions, and the second would protect certain fixed service fees that manufactures pay to pharmacy benefits managers for services rendered to the manufacturer that meet specific criteria.
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By Deniza Gertsberg, Esq., on September 25th, 2018 The New Jersey Board of Dentistry (Board) recently expanded the scope of practice of licensed dental hygienists, limited registered dental assistants in orthodontics and registered dental assistants. Effected providers should become familiar with these expanded parameters.
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By Deniza Gertsberg, Esq., on September 11th, 2018 The New Jersey Board of Pharmacy and the New Jersey Board of Medical Examiners recently adopted new regulations and amended existing ones that effect the way providers practice. The changes concern pediatric immunizations performed by pharmacists and the administration of subcutaneous and intramuscular injections and venipunctures by certified medical assistants. We briefly summarize these recent changes below.
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By Deniza Gertsberg, Esq., on August 27th, 2018 The Centers for Medicare & Medicaid Services (CMS) recently published a proposed rule that, if codified, would bring about sweepings revisions to many Medicare payment policies under the physician fee schedule. Among many other changes CMS is proposing to simplify the documentation requirement for evaluation and management (E/M) code levels 2 through 5 but also proposes a flat fee for those levels of services. These and certain other proposed policy changes are briefly summarized below.
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By Deniza Gertsberg, Esq., on July 31st, 2018 New sweeping regulations went into effect on July 1, 2017 for dental anesthesia services in New York. The regulations, among other things, would require dentists to meet specific practice requirements, maintain more exacting records than previously required and complete additional and specific continued education courses. The regulations will also impose more stringent requirements on dentists providing dental sedation to patients 12 years old and younger. Below is a brief summary of the new requirements.
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By Deniza Gertsberg, Esq., on July 6th, 2018 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.
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By Deniza Gertsberg, Esq., on May 31st, 2018 Recent analysis by the Comprehensive Error Rate Testing (CERT) initiative of physical therapy claims revealed that insufficient documentation contributed to improper payments issued to providers.
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