Lance's Corner

OMIG Restores Medicaid Restricted Recipient Program

Feb 25, 2025

Per the notice below, the New York State Office of the Medicaid Inspector General (OMIG) has restored the Medicaid Restricted Recipient Program system.

NYS OMIG Logo

OMIG Update

Recipient Restriction Program (RRP) Restriction Edits Restored

Effective February 24, 2025, restriction edits supporting the Recipient Restriction Program (RRP) have been restored.  As a result, a restricted recipient will be required to obtain all of their care, directly or by referral, from their assigned providers.

  • An assigned Primary Care Provider (PCP) is responsible for providing direct medical care or coordinating care through referral to another medical provider for specialty services.  The assigned PCP is also responsible for ordering all non-emergency transportation, laboratory, DME, and pharmacy services for the assigned restricted recipient.  A referral will be needed from the assigned PCP for any non-emergency medical services when a specialist is required.  Claims submitted for a restricted recipient will be denied if information for the assigned PCP is not included on the claim as the referring provider.
  • A pharmacy filling prescriptions for a restricted member is required to coordinate with the assigned PCP to safely manage the delivery of medications, including verifying referrals if prescriptions were not written by the assigned PCP.  The pharmacy is responsible for using professional judgement in filling prescriptions without regard to restriction requirements if the prescriptions were written as part of an emergency department visit and the assigned PCP is unavailable (i.e., after hours) to verify the prescriptions.  The pharmacy is responsible for contacting the assigned PCP the next business day regarding the prescriptions obtained by the recipient.
  • An assigned primary inpatient hospital is responsible for providing all non-emergency inpatient services to the restricted recipient except for services provided pursuant to an authorized referral.

EMERGENCY PHARMACY SITUATIONS:
In the event of an emergency, such as: drug shortages, unexpected pharmacy closures, and/or unexpected travel, see below:

During normal business hours, the recipient can obtain a temporary authorization to fill the prescription at an alternate pharmacy location by contacting:

OMIG (Monday – Friday) (8a – 4p)
518-474-6866 or omig.sm.rrp@omig.ny.gov

The local department of social services (LDSS) - for upstate recipients
https://www.health.ny.gov/health_care/medicaid/ldss.htm

NYC Human Resources Association (HRA) - for NYC recipients
888-692-6116

NY State of Health (NYSoH) - for coverage obtained through the NYSoH
518-457-0761 or hxrestrict@health.ny.gov

During nights and weekends the pharmacy can obtain a prior authorization by contacting: eMedNY call center (Monday – Friday 4p –10p); 
Saturday and Sunday (8:30a – 5:30p)
800-343-9000

Additional Information:

The goal of the RRP is to coordinate medical services and improve quality of care for Medicaid recipients.  Coordination of care reduces the potential over-utilization of health care services and prevents abusive or fraudulent behavior.  A restriction is implemented if it is found that a recipient has received duplicative, excessive, contraindicated, or conflicting health care services, drugs, or supplies, or if a recipient commits fraudulent acts with their benefit card (i.e., forged prescriptions, card loaning, doctor shopping).  The RRP may restrict the recipient to care provided by a PCP, Inpatient Hospital, and/or Primary Pharmacy.

Additional information regarding the Recipient Restriction Program can be found on the OMIG website at: https://omig.ny.gov/information-resources/about-recipient-restriction-program-rrp.

New York State Office of the Medicaid Inspector General
 
Our mission is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.
 
Contact us: OMIG, 800 North Pearl Street, Albany, NY 12204.  Phone: (518) 473-3782; Fax: (518) 474-6773; Fraud Hotline: 1-(877) 87-FRAUD/1-(877) 873-7283.
 
Visit us on the Web at: www.omig.ny.gov.

USDOL Issues Comprehensive Employer Guidance on Long COVID

The United States Department of Labor (USDOL) has issued a comprehensive set of resources that can be accessed below for employers on dealing with Long COVID.

Supporting Employees with Long COVID: A Guide for Employers

The “Supporting Employees with Long COVID” guide from the USDOL-funded Employer Assistance and Resource Network on Disability Inclusion (EARN) and Job Accommodation Network (JAN) addresses the basics of Long COVID, including its intersection with mental health, and common workplace supports for different symptoms.  It also explores employers’ responsibilities to provide reasonable accommodations and answers frequently asked questions about Long COVID and employment, including inquiries related to telework and leave.

Download the guide

Accommodation and Compliance: Long COVID

The Long COVID Accommodation and Compliance webpage from the USDOL-funded Job Accommodation Network (JAN) helps employers and employees understand strategies for supporting workers with Long COVID.  Topics include Long COVID in the context of disability under the Americans with Disabilities Act (ADA), specific accommodation ideas based on limitations or work-related functions, common situations and solutions, and questions to consider when identifying effective accommodations for employees with Long COVID.  Find this and other Long COVID resources from JAN, below:

Long COVID, Disability and Underserved Communities: Recommendations for Employers

The research-to-practice brief “Long COVID, Disability and Underserved Communities” synthesizes an extensive review of documents, literature and data sources, conducted by the USDOL-funded Employer Assistance and Resource Network on Disability Inclusion (EARN) on the impact of Long COVID on employment, with a focus on demographic differences.  It also outlines recommended actions organizations can take to create a supportive and inclusive workplace culture for people with Long COVID, especially those with disabilities who belong to other historically underserved groups.

Read the brief

Long COVID and Disability Accommodations in the Workplace

The policy brief “Long COVID and Disability Accommodations in the Workplace” explores Long COVID’s impact on the workforce and provides examples of policy actions different states are taking to help affected people remain at work or return when ready.  It was developed by the National Conference of State Legislatures (NCSL) as part of its involvement in USDOL’s State Exchange on Employment and Disability (SEED) initiative.

Download the policy brief

Understanding and Addressing the Workplace Challenges Related to Long COVID

The report “Understanding and Addressing the Workplace Challenges Related to Long COVID” summarizes key themes and takeaways from an ePolicyWorks national online dialogue through which members of the public were invited to share their experiences and insights regarding workplace challenges posed by Long COVID.  The dialogue took place during summer 2022 and was hosted by USDOL and its agencies in collaboration with the Centers for Disease Control and Prevention and the U.S. Surgeon General.

Download the report

Working with Long COVID

The USDOL-published “Working with Long COVID” fact sheet shares strategies for supporting workers with Long COVID, including accommodations for common symptoms and resources for further guidance and assistance with specific situations.

Download the fact sheet

COVID-19: Long-Term Symptoms

This USDOL motion graphic informs workers with Long COVID that they may be entitled to temporary or long-term supports to help them stay on the job or return to work when ready, and shares where they can find related assistance.

Watch the motion graphic

A Personal Story of Long COVID and Disability Disclosure

In the podcast “A Personal Story of Long COVID and Disability Disclosure,” Pam Bingham, senior program manager for Intuit’s Diversity, Equity and Inclusion in Tech team, shares her personal experience of navigating Long COVID symptoms at work.  The segment was produced by the USDOL-funded Partnership on Employment and Accessible Technology (PEAT) as part of its ongoing “Future of Work” podcast series.

Listen to the podcast

HHS OIG Issues Annual Report on State MFCUs

Per the notice below, the Office of the Inspector General (OIG) of the United States Department of Health and Human Services (HHS) has issued its annual report on the performance of state Medicaid Fraud Control Units (MFCUs).

Medicaid Fraud Control Units Fiscal Year 2023 Annual Report (OEI-09-24-00200) 

Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud and patient abuse or neglect. OIG is the Federal agency that oversees and annually approves federal funding for MFCUs through a recertification process. This new report analyzed the statistical data on annual case outcomes—such as convictions, civil settlements and judgments, and recoveries—that the 53 MFCUs submitted for Fiscal Year 2023.  New York data is as follows:

Outcomes

  • Investigations1 - 556
  • Indicted/Charged - 9
  • Convictions - 8
  • Civil Settlements/Judgments - 28
  • Recoveries2 - $73,204,518

Resources

  • MFCU Expenditures3 - $55,964,293
  • Staff on Board4 - 257

1Investigations are defined as the total number of open investigations at the end of the fiscal year.

2Recoveries are defined as the amount of money that defendants are required to pay as a result of a settlement, judgment, or prefiling settlement in criminal and civil cases and may not reflect actual collections.  Recoveries may involve cases that include participation by other Federal and State agencies.

3MFCU and Medicaid Expenditures include both State and Federal expenditures.

4Staff on Board is defined as the total number of staff employed by the Unit at the end of the fiscal year.

Read the Full Report

View the Statistical Chart

Engage with the Interactive Map

GAO Issues Report on Medicaid Managed Care Service Denials and Appeal Outcomes

The United States Government Accountability Office (GAO) has issued a report on federal use of state data on Medicaid managed care service denials and appeal outcomes.  GAO found that federal oversight is limited because it doesn't require states to report on Medicaid managed care service denials or appeal outcomes and there has not been much progress on plans to analyze and make the data publicly available.  To read the GAO report on federal use of state data on Medicaid managed care service denials and appeal outcomes, use the first link below.  To read GAO highlights of the report on federal use of state data on Medicaid managed care service denials and appeal outcomes, use the second link below.
https://www.gao.gov/assets/d24106627.pdf  (GAO report on federal use of state data on Medicaid managed care service denials and appeal outcomes)
https://www.gao.gov/assets/d24106627_high.pdf  (GAO highlights on federal use of state data on Medicaid managed care service denials and appeal outcomes)

CMS Issues Latest Medicare Regulatory Activities Update

The Centers for Medicare and Medicaid Services (CMS) has issued its latest update on its regulatory activities in the Medicare program.  While dentistry is only minimally connected to the Medicare program, Medicare drives the majority of health care policies and insurance reimbursement policies throughout the country.  Therefore, it always pays to keep a close eye on what CMS is doing in Medicare.  To read the latest CMS update on its regulatory activities in Medicare, use the link below.
https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-03-14-mlnc