Office of Medicaid Inspector General Releases Work Plan for 2016-2017

May 26, 2016 | Health Services

The New York State Office of the Medicaid Inspector General (“OMIG”) released its Work Plan for fiscal year 2016-2017 (the “Plan”) summarizing new and ongoing activities that OMIG will prioritize in the upcoming year. The Plan includes auditing, outreach and compliance initiatives to enhance Medicaid beneficiaries’ access to high-quality and cost-effective health care and prevent fraud, waste and abuse within the Medicaid system. Thus, the Plan has important implications for health plans and providers that participate in Medicaid. Highlights from the Plan are set forth below.

Delivery System Reform Incentive Payment Program

The Delivery System Reform Incentive Payment Program (“DSRIP”) was designed to restructure the Medicaid system. It offers financial incentives to networks of providers who achieve pre-determined targets in system transformation, clinical management and population health. Over six (6) billion dollars have been allocated for DSRIP by a Waiver Amendment from the Centers for Medicare and Medicaid Services (“CMS”).

To ensure long-term sustainability of DSRIP investments, the Waiver Amendment required the New York Department of Health (“DOH”) to prepare a roadmap for establishing a comprehensive value-based payment system for Medicaid. DOH created subcommittees to help develop and implement such roadmap. OMIG is already a member of the Value-Based Payment Regulatory Impact subcommittee and will additionally join the Program Integrity and HIPAA and Privacy subcommittees for 2016-2017. OMIG will continue to adapt its outreach and compliance activities as DSRIP continues to evolve.

Home and Community Care Services

OMIG will also continue to review the following components of home and community care services: provision of services; consistency with patient care plans; spend down requirements for Medicaid eligibility; payment for home health services provided in hospitals and other in-patient facilities; and billing and overpayments for Medicaid and Medicare dual eligible beneficiaries.

In addition, OMIG will continue to monitor data reported by verification vendors that home providers of home and community care services are required to utilize if their annual Medicaid reimbursements exceed fifteen (15) million dollars. Verification vendors ensure that home health aides and personal care assistants are properly registered, credentialed and not excluded from Medicaid and that the services they provide occur as scheduled and consistent with patient care plans. OMIG will implement corrective action plans for providers and caregivers that are identified as non-compliant.

Hospital and Outpatient Services

With respect to hospital and outpatient services, OMIG will focus on reviewing payments for diagnostic and treatment center services, outpatient department services and non-emergency services provided to non-U.S. residents. The goal of such reviews is to ensure that providers are using appropriate billing codes, in accordance with federal and state regulations, and not causing waste in Medicaid payments.

Managed Care

Managed Care Organizations (“MCOs”), including health maintenance organizations, prepaid health services plans and HIV special needs plans, coordinate provision, quality and cost of care for their enrolled populations. OMIG is tasked with reviewing performance data of MCOs and in the upcoming year OMIG will focus its efforts on the following categories:

  • Joint Venture with DOH

To prevent fraud, waste and abuse in managed care programs, the DOH Office of Health Insurance Programs is partnering with OMIG to propose a joint initiative that will establish certain targets to incentivize MCOs to better prevent and recover Medicaid overpayments. Once the targets are established and a plan is developed, OMIG will provide support to the MCOs as needed to ensure compliance.

  • MCO-Specific Clinical Risk Group Rate Adjustment

The MCO-specific clinical risk group rate adjustment calculates each MCO’s rate based on differences in health status of its enrollees. OMIG will implement audits of data used for such rate calculations to determine premium rates for managed care populations, including those enrolled in Medicaid.

  • Encounter-Based Payment Model

Recognizing that fee-for-service and encounter claims are based on two very different payment models, OMIG will perform an in-depth comparative analysis of the two models to better understand how claims are reported and to ensure consistency and completeness of data being reported.

  • Eligibility and Payments by Medicaid

OMIG will also review enrollment and eligibility requirements for MCOs to prevent inappropriate or double billing for Medicaid services. If audits lead to the discovery of overpayments, OMIG will implement corrective actions as necessary.

Excessive Ordering of Controlled Substances

With respect to prescriptions for controlled substances, OMIG will continue to analyze performance data and identify providers with exceptional prescribing patterns. OMIG will review orders to determine whether the prescription was medically necessary and whether the prescribing provider complied with I-STOP and the e-prescription mandate.

Medicaid Electronic Health Records Incentive Payments Program

Medicaid providers who become meaningful users of electronic health records (“EHR”) qualify for financial incentives under the Medicaid EHR Incentive Payments Program. As the program continues to receive guidance from CMS, OMIG will continue to provide oversight and will update program requirements and expectations as necessary.

For additional guidance on any of the aforementioned compliance and outreach initiatives, the entire OMIG Work Plan can be viewed at:

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