Introduction

The New York State Office of the Medicaid Inspector General (OMIG) is responsible, pursuant to Section 32 of the Public Health Law, for coordinating and conducting activities to prevent, detect and investigate medical assistance program fraud, waste and abuse, and recover improperly expended Medicaid funds.  OMIG does not independently establish Medicaid program requirements but works closely with the Department of Health (DOH) and other state and local agencies responsible for administering Medicaid services to enforce their requirements.  OMIG also works cooperatively and in a coordinated manner with other federal and state agencies, including the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), the New York State Attorney General’s Medicaid Fraud Control Unit (MFCU), and the New York State Comptroller, as well as the special investigative units maintained by each Medicaid managed care organization operating within the state.  In conducting these program integrity activities, OMIG promotes the delivery of appropriate and high-quality patient care to Medicaid recipients. 

This work plan provides a comprehensive roadmap for citizens, policymakers, providers, and managed care organizations to follow as a guide to OMIG’s program integrity initiatives planned for 2024.  This product should not be viewed as an exclusive list of all activities that OMIG will conduct over the course of the year.  OMIG reserves the right to conduct all activities necessary to meet its responsibilities and will update this work plan as new priorities and issues arise.

Education, engagement and collaboration with Medicaid stakeholders are essential elements in how OMIG approaches its program integrity responsibilities.  In addition to the key activities highlighted below, OMIG will continue to incorporate stakeholder input and evaluate the operational impacts of its program integrity activities in conducting its work.  Information or input can be provided to OMIG via e-mail at: information@omig.ny.gov.

Compliance Program Reviews

Medicaid Managed Care Organizations (MMCOs) and providers play an important role in advancing program integrity by operating within Medicaid requirements and detecting irregularities.  Effective compliance programs create a control structure to reduce the potential for fraud, waste, and abuse through self-correction and/or self-reporting of errors by providers.  Persons, providers, or affiliates are required to have a compliance program under New York State Social Services Law (SSL) § 363-d and 18 New York Codes, Rules, and Regulations (NYCRR) Part 521 if they are a “required provider” as defined in 18 NYCRR § 521.2(a). MMCOs are required by contract to have a compliance program.

To better leverage these benefits, OMIG will continue to assist providers in meeting their compliance requirements and conduct compliance program reviews of providers to assess whether a Medicaid provider’s compliance program is implemented and operating as required.  Analysis of MMCO compliance programs will also be included as part of the Managed Care Program Integrity Reviews (MCPIR).

Self-Disclosure

Medicaid providers are obligated to report, return and explain any overpayments that they receive within 60 days of identification.  OMIG developed the Self-Disclosure Program to assist providers in meeting these requirements.

In 2023, OMIG developed and implemented the Abbreviated Self-Disclosure Process to give Medicaid-enrolled providers a streamlined and less administratively burdensome avenue to satisfy their obligations under Federal and State law to report and explain self-identified Medicaid overpayments that stem from routine or transactional errors and have been voided or adjusted as repayment.

The Self-Disclosure Unit will continue to process submissions received under the Abbreviated Self-Disclosure Process and the Full Self-Disclosure Process.

Medicaid providers are also required to prepare and maintain contemporaneous records supporting their claiming for Medicaid payment.  The Self-Disclosure Program also provides a conduit for providers to report damaged, lost or destroyed records.  This provider disclosure should be made as soon as practicable, but no later than thirty (30) calendar days following discovery.

Medicaid Managed Care Audits

OMIG will continue to review Medicaid Managed Care Operating Reports (MMCORs) submitted to the State to ensure that reported costs and data is accurate, complete, and allowable.  These reviews will ensure that MMCO payments calculated using this data are appropriate.

MMCOs are required to have Special Investigations Units (SIUs) and other appropriate staffing to conduct proper oversight and program integrity reviews across their organization and provider networks.  OMIG will continue to use MCPIR to assess Medicaid Managed Care plan performance as it relates to their program integrity obligations under the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Contract.

OMIG will also continue to audit MMCOs in the following areas:

• Incarceration Match – To identify and recover capitation payments paid for individuals who were incarcerated for an entire payment month.
• Deceased Enrollees – To identify and recover capitation payments paid after an enrollee’s date of death.
• Retroactive Disenrollment - To identify Medicaid Managed Care plans that have not voided in response to notification from the local district.
• Out of State Medicaid Recipients – To identify and recover capitation payments for Medicaid Managed Care enrollees who resided in another state for the entire payment month.
• Supplemental Maternity and Newborn Capitation Payments – To identify maternity and newborn supplemental payments for which supporting encounter data was not submitted.
• Multiple Client Identification Numbers (CIN) – To identify and recover capitation payments paid when one member has been issued two CINs and two monthly capitation payments have been made to the same plan for the same member.
• Family Planning Chargeback Fee-for-Service (FFS) Audit - After completing the family planning reconciliation for the managed care plans, OMIG conducts a follow-up audit for claims removed from the managed care plan’s liability.  This audit recovers FFS payments submitted to Medicaid by network providers who have a contractual agreement with the managed care plan and should have billed the plan for these family planning services.
• Enhanced Nursing Home Capitation Payments – To identify instances where the MMCO did not qualify for enhanced reimbursement level.
• Partial Cap – Eligibility & Care Management – To make recoveries when OMIG identifies a capitation payment as inappropriately paid due to a lack of rendered services, loss of eligibility, or delayed disenrollment.
• Medicaid Advantage Plus (MAP) – Eligibility & Care Management – OMIG plans to conduct reviews of MAP plans to evaluate the eligibility of members enrolled in the Plan and whether the care management provided by the Plan aligned with enrollee-specific care plans and assessments in mid to late 2024.
• Audit of Fee-For-Service Claims Billed by Network Providers for Medicaid Managed Care Enrollees (“Category H”) - OMIG will continue to identify and recover duplicate payments resulting from eligibility issues caused by conflicting eligibility information between NY State of Health (NYSoH) and Welfare Management System (WMS).  OMIG plans to review the 2021-2022 audit period during 2024.

Provider Audits

Long-Term Care Services

Medicaid is a principal policy driver and primary payor for long-term residential placements for the aged and disabled.  Nursing homes and Assisted Living Programs (ALPs) remain an area of focus for OMIG to ensure that residents are appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations.  OMIG activities in this area will include:

• Nursing Home Rate Audits - OMIG will continue to work with DOH’s Bureau of Nursing Home and Long-Term Care Rate Setting to ensure facilities conform to DOH’s policy and reimbursement regulations and will audit submitted pertinent costs and data related to the capital calculations and ancillary services.
• Minimum Data Set (MDS) Reviews - OMIG will continue to review the accuracy of MDS submissions for selected nursing homes, completing the 2018 audit period and starting the 2019 audit period in 2024.  These submissions are used by the DOH to calculate the direct cost portion of each nursing home’s Medicaid rate.
• Adult Day Health Care Audits
• Assisted Living Programs Audits (View audit protocol)

Home Health & Community-Based Services

Home and community-based services continue to grow as the population ages and consumers seek alternatives to hospitalization or long-term care placements.  OMIG’s continued oversight in this area is to ensure that recipients are appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations.  OMIG activities in this area will include:

• Diagnostic and Treatment Centers (View audit protocol)
• Home Health (Episodic payment) (View audit protocol)
• Personal Care Services (View audit protocol)
• Private Duty Nurses Agency (View audit protocol)
• Private Duty Nurses Independent (View audit protocol)
• Nursing Home Transition and Diversion (View audit protocol)
• Consumer Directed Personal Assistance Program (View audit protocol)

Behavioral Health/Addiction Services and Supports

New York State continues to advance and invest in services and social supports to serve the needs of people living with addiction, mental illness and other complex health care needs.  Consistent with program requirements established by the Office of Mental Health (OMH) and the Office of Addiction Services and Supports (OASAS), OMIG will continue to conduct audits in this area to ensure that these populations are appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations.  OMIG activities in this area will include:

• New in 2024 -- OMH Personalized Recovery Oriented Services (PROS) 
• New in 2024 -- OMH Telehealth Services
• OMH Mental Health Outpatient Treatment and Rehabilitative Services (View audit protocol)
• OMH Continuing Day Treatment (View audit protocol)
• OMH Day Treatment for Children (View audit protocol)
• OMH Partial Hospitalization (View audit protocol)
• OMH Community Rehabilitation Services (View audit protocol)
• OASAS Opioid Treatment Program (View audit protocol)
• OASAS Inpatient Rehabilitation Services (View audit protocol)

Person-Centered Services and Supports

New York State maintains an extensive network of services and supports for individuals with developmental disabilities.  In close collaboration with the Office of Persons With Developmental Disabilities (OPWDD), these services remain an area of focus to ensure that this population is appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations.  OMIG activities in this area will include:

• New in 2024 - OPWDD Community Habilitation
• OPWDD Article 16 Clinic treatment (View audit protocol)
• OPWDD Care Coordination/Health Home Services
• OPWDD Supported Employment (View audit protocol)
• OPWDD Day Habilitation (View audit protocol)
• OPWDD IRA Residential Habilitation (View audit protocol)
• OPWDD Prevocational (View audit protocol)

Early Intervention (EI) / Pre-School and School-Supported Health Services (SSHS)

Fee-for-Service Early Intervention (EI) (View audit protocol) and School-Supported Health Services (SSHS) audits (View audit protocol) will continue to be conducted. 

Pharmacy

Pharmacy remains an area of focus for OMIG as to ensure compliance with existing Medicaid regulations and appropriate authorization of payment for controlled substance claims.  Fee-for-Service Pharmacy Audits will continue to be conducted (View audit protocol).

Transportation 

Non-emergency transportation services remain a focus area for OMIG due to significant billings, federal oversight, and provider turnover.  Fee-for-Service Audits will continue to be conducted in the following areas:

• Transportation Ambulette (View audit protocol)
• Transportation Taxi/Livery (View audit protocol)

Durable Medical Equipment (DME)

Fee-for-Service Durable Medical Equipment Audits will continue to be conducted (View audit protocol)

Third Party Liability Match

Medicaid is intended to be the health care payor of last resort.  Under the Third-Party Liability Contract (TPL), OMIG utilizes its contractor to ensure that Medicaid is only billed after all other forms of insurance coverage have been exhausted.

OMIG staff continue to work with its contractor on Pre-Payment Insurance Verification (PPIV) match and delivery of Commercial Insurance segments to ensure accurate identification of third-party coverage.  Inappropriate Medicaid payments are averted by edits to the payment system.

OMIG staff also work with its contractor on third-party retroactive recoveries.  Recovery attempts are made by sending Medicaid reclamation claims to insurance carriers or by engaging directly with Medicaid providers.

Recovery Audit Contract (RAC) Reviews

Per federal requirement, OMIG’s Recovery Audit Contractor (RAC) coordinates with OMIG to identify and collect overpayments that would likely go undetected by reviewing Medicaid claims data alone.  OMIG will continue to work with its RAC, providers, and the Centers for Medicare & Medicaid Services’ Unified Program Integrity Contractor to promote and inform future program integrity projects.

Casualty & Estate/Medicaid Liens Reconciliations

OMIG will continue to carry out the Casualty & Estate program in coordination with its contractor, DOH, and Local Department of Social Services (LDSS) to represent the State’s Medicaid interest.  OMIG’s internal process has been revised and continues to improve the intake and assignment of Medicaid lien cases, as well as increase the contractor’s efficiency in gathering necessary case information.

Investigations

Credential Verification Reviews

OMIG will continue to conduct on-site and remote Credential Verification Reviews (CVRs) throughout New York State to determine providers’ compliance with Medicaid requirements and educate providers on Medicaid guidelines. 

For example, to ensure Medicaid transportation providers adhere to all requirements outlined within DOH’s Transportation Manual policy guidelines, OMIG will continue to conduct CVRs and collaborate with state partners in the New York State Department of Motor Vehicles, the Medicaid Fraud Control Unit (MFCU), and New York State Department of Transportation, as well as individual counties, to support these reviews.

Pre-Payment Review

OMIG will continue to conduct pre-payment claims reviews of pended FFS claims in a variety of areas like dental, private duty nursing, and others.  Through analysis of post payment reports, data mining and referrals, OMIG identifies providers whose billing practices appear aberrant and pends payment of claims to identify their compliance with Medicaid guidelines prior to payment.  These reviews are utilized in several ways; as a compliance tool, to monitor limited enrollments, and to prevent inappropriate costs to the Medicaid program.

With the shift of provider billing activity through Managed Care, staff will be expanding their focus on managed care billings and patterns of practice in 2024.  OMIG is currently anticipating increasing medical reviews into specialties like family planning, dental, DME, physician and transportation based on billing data trends in these areas and is committed to working with providers to educate them on billing requirements.

Explanation of Benefits (EOMB)

EOMBs are used by OMIG to educate Medicaid recipients on the care they receive and investigate if services were delivered appropriately.  OMIG will continue to generate EOMBs as needed as an investigative tool to bring cases to a conclusion.

Education Letters

OMIG will continue to issue education letters when supported by investigative findings to ensure that providers understand Medicaid program requirements and their obligations.  Education letters also establish connections between OMIG staff and providers so they can request assistance or ask questions.

Provider Enrollment and Reinstatement

OMIG will continue to provide a secondary review of provider enrollment applications in certain high-risk categories such as pharmacies, durable medical equipment suppliers, physical therapists, and transportation providers to determine if applicants should be enrolled in the Medicaid program.  Enrollment will also review all reinstatement applications and requests for removal from the OMIG Exclusion List.

System Match

OMIG uses analytical tools and techniques, as well as knowledge of Medicaid program rules, to data mine Medicaid claims and identify improper claim conditions for potential recoveries of inappropriate Medicaid expenditures.  These audits also provide OMIG the opportunity to educate providers so they can improve their compliance with Medicaid billing rules and are performed in several project areas.  Anticipated project areas for 2024 include Physician Services in OMH Clinics, Partial Hospitalization, and Transportation.

Physician Services in OMH Licensed Clinics

OMIG will perform audits in this area to ensure that only the licensed OMH Program seeks and receives Medicaid reimbursement for the services provided under the auspice of the licensed program.  In ambulatory care for recipients with mental illness, the costs of routine physicians’ services are included in the facilities’ rate or fee and FFS physician claims billed separately from the OMH rate are duplicative and will be disallowed.

Partial Hospitalization

Partial hospitalization is an intensive outpatient treatment program, licensed by OMH, designed to serve as an alternative to admission to or a continued stay at an inpatient hospital.  OMIG plans to conduct audits in this area to ensure compliance with the OMH regulation that partial hospitalization treatment is not to exceed six calendar weeks.  Any service that exceeds the regulatory limit will be disallowed.

Transportation

In this audit, OMIG will perform reviews Medicaid FFS transportation claims for Medicaid recipients who were hospital inpatients on the date of service, and transportation claims for ambulette services to verify that the vehicle license number and driver’s license number listed were authorized on the date of service.  Inappropriate FFS Transportation claim payments will be disallowed.

Healthcare Worker Bonus

As part of the Fiscal Year 2022-23 Budget, Governor Kathy Hochul announced the launch of the Health Care and Mental Hygiene Worker Bonus (HWB) Program, which allocated $1.3 billion for the payment of recruitment and retention bonuses to certain health care and mental hygiene workers.  OMIG staff, in consultation with DOH through a dedicated work group, developed processes to ensure that these bonuses are appropriately distributed.

Beginning in 2023, OMIG began managing the New York State hotline and dedicated email box for inquiries and complaints related to the HWB program.  OMIG communicates with employees and employers to ensure all information is available so a complete review of HWB claims and payments can be conducted.  The final vesting period for the HWB ends on March 31, 2024.

OMIG also developed processes for the Employer Self-Disclosure of overpaid Healthcare Worker Bonus (HWB) funds and will continue to process submissions received.

Pharmacy/Drug Diversion

OMIG conducts comprehensive Pharmacy CVRs to evaluate an enrolled pharmacy provider’s compliance with NYS Medicaid pharmacy program requirements and pharmacy laws, rules, and regulations pertaining to the practice of pharmacy and operation of pharmacy establishments.  In 2024, OMIG will continue to conduct more frequent CVRs of pharmacies throughout NYS.

Pharmacy ownership and supervision will also be a key focus area in 2024.  Pharmacy owners and supervising pharmacists are responsible for ensuring operations within the pharmacy adhere to Medicaid rules and regulations, as well as NYS laws governing the practice of pharmacy.  Lack of appropriate supervision increases the risk of fraud, waste, and abuse in the delivery of pharmacy services and puts the health and safety of Medicaid recipients at risk.

Collections

OMIG will continue to engage in projects to develop and support provider-friendly processes like Financial Hardship and Electronic Payment Portals.  The Hardship Process application provides an opportunity for extended repayment when a provider cannot afford to repay their OMIG liability within the standard repayment timeframe, which is two years at a rate of no less than 15 percent of their prior year’s billings.