Office of the Medicaid Inspector General Releases 2014-2015 Work Plan

The New York State Office of the Medicaid Inspector General (“OMIG) has released its State Fiscal Year 2014-2015 Work Plan

The Work Plan is a road map of where the OMIG intends to go in terms of its anti fraud, waste and abuse efforts within the Medicaid program. The OMIG’s mission is one of “preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid [program and recovering improperly expended Medicaid funds while promoting high quality patient care. The Work Plan intends to “fight fraud, improve integrity and quality, and save taxpayer dollars.

According to the Work Plan, the OMIG has established nine “business line teams that each consist of multiple OMIG personnel from various functional areas within the OMIG that work as a team. The goals of these specialized, multidisciplinary teams include improved efficiency, more thorough reviews and investigations, and reduced time to completion.

Broad areas of Medicaid service provision that the OMIG has established business line teams for include, but are not limited to, the following: home and community care services; hospital and outpatient services; managed care; medical services in an educational setting; mental health, chemical dependence and developmental disabilities services; pharmacy and durable medical equipment; physicians, dentists and laboratories; residential health care facilities; and transportation.  Each business line will face varying degrees of scrutiny by the OMIG during this state fiscal year. 

In addition to the Business Line Teams discussed above, the OMIG also conducts various activities that relate to Medicaid program integrity across multiple business lines. The OMIG is again emphasizing the requirement for Medicaid providers to have an effective compliance plan, and the OMIG will be reviewing compliance plans for effectiveness. Part of an effective compliance plan, and the most significant part as far as the government is concerned, is the ability of the provider to identify and return Medicaid overpayments that the provider has received. The 60 day “report, repay and explain self-disclosure requirement imposed by the federal Affordable Care Act is also a game changer. The OMIG will continue to review providers who do not make periodic self disclosures or who have never made such disclosures.

The areas listed in the OMIG’s Work Plan that cross multiple business lines are as follows:

AIDS-Related Issues

Ambulatory Patient Groups

Collaborative Efforts with Law Enforcement/Medicare Fraud Strike Force

Collaborative Managed Care Surveys

Compliance Program General Guidance and Assistance

Compliance Program Reviews

Corporate Integrity Agreement Enforcement

County Demonstration Program

Enrollment and Reinstatement

Estate and Casualty Recovery

Fee-for-Service Third-Party Retroactive Recovery Projects

Kickbacks and Inducements

Location of Services Unknown to New York State Department of Health

Managed Care Third-Party Retroactive Recovery Projects

Medicaid Consumer Investigations

Medicaid Electronic Health Records Incentive Payment Program

Medicaid Integrity Contract Audits

Medicaid Recovery Audit Contractor

Medicare Coordination of Benefits with Provider-Submitted Claims

Patient Protection from Disqualified Providers

Payment Error Rate Measurement Project

Pre-Enrollment Review

Prepayment Insurance Verification

Prepayment Review

Prior Findings

Self-Disclosure Efforts

Third-Party Liability and Commercial Direct Billing

Undercover Operations

There will be a continued emphasis on excluding those providers who commit fraud and abuse. Those who commit “inappropriate and fraudulent acts will face exclusion from the Medicaid program, then, by operation of law, exclusion from the Medicare program, and in essence become virtually unemployable by most health care providers who accept federal funds.

If you would like to discuss any of the areas identified in the OMIG’s Work Plan, or anything else related to the Medicaid program, please feel free to contact the author of this article, David R. Ross, Esq., who was formerly New York State’s Acting Medicaid Inspector General under Governors Pataki and Spitzer. Mr. Ross was also the Director of OMIG audits and investigations as well as the OMIG’s General Counsel. He can be contacted via e-mail at dross@oalaw.com or reached by telephone at (518) 462-5601.