Medicaid and Medicare Compliance and Self-Disclosure

Medicaid and Medicare providers often have a need for regulatory interpretation to better understand the myriad of requirements confronting them in their day-to-day operations, including whether or not to make a self-disclosure and return money paid by the Medicaid program, Medicare program, or private insurers. Self-disclosures are imposed upon health care providers by law, and the failure to make a self-disclosure when circumstances require can lead to health care program sanctions such as fines and penalties, exclusion from health care programs, being removed from an insurer’s network, and even potential criminal liability.

At O’Connell & Aronowitz, P.C., we provide legal counsel, advice, and representation to these providers to help them navigate the complex regulatory and compliance legal road map. This often includes interpreting and explaining regulations and guidance materials issued by New York State and federal regulatory agencies, as well as private insurance companies. We also counsel health care providers on ensuring compliance with appropriate program and regulatory requirements; and representing you if you are facing a potential need to self-disclose to Medicaid, Medicare, Medicaid Managed Care, Medicare Managed Care, and/or private insurance companies.

Meet Shareholder David R. Ross, Esq.

  • David R. Ross, Esq. is a Shareholder with our firm, and has over 27 years of experience interpreting Medicaid regulations and various guidance materials issued by New York State regulatory agencies including the Department of Health, the Office for Persons with Developmental Disabilities (OPWDD), and the Office of Addiction Services and Supports (OASAS), as well as the requirements of the Medicare program and private insurance companies.
  • Mr. Ross has served as the Director of Audits and Investigations and the General Counsel of the New York State Office of the Medicaid Inspector General (OMIG).
  • Prior to joining the Firm, Mr. Ross was the Acting Medicaid Inspector General for the State of New York.
  • Mr. Ross has personally handled many self-disclosures for Medicaid and Medicare providers of virtually all types over the last 17 years.

Navigating Medicaid Compliance

  • The Medicaid program requires providers to return overpayments. Medicaid fee-for-service overpayments must be returned within 60 days of discovering them using the OMIG’s Self Disclosure protocol. Medicaid Managed Care Organization (“MCO”) overpayments are handled directly by the provider with the MCO in accordance with the provider’s contract with the MCO, with recommended reporting to the OMIG.

Navigating OMIG’s Self Disclosure Process

  • Navigating the OMIG’s Self Disclosure protocol for fee-for-service overpayments can be tricky.
  • Knowing which OMIG process to use, the Full Self-Disclosure or the Abbreviated Self-Disclosure, and what information to provide in the forms is important as well.

Navigating Medicare Compliance

  • Medicare overpayments must be returned to the Medicare contractor.
  • Returning overpayments to Medicare can be tricky as well. It is important to know which form to use when making a self-disclosure to Medicare. Which form is used will be based upon the provider’s particular Medicare contractor, whether the provider is a Part A or Part B provider, and the jurisdiction they are in.

Have you received Medicaid or Medicare overpayments?

  • You may or may not have, depending on the circumstances, the appropriate rules and guidance materials, and the particular issue(s) you have.

If you have questions or concerns regarding your program and potential Medicaid, Medicare, Managed Care, or private insurance company self-disclosure reporting and repayment, contact Shareholder David R. Ross, Esq. at or via telephone at (518) 312-0167.