Deadline Approaches to Certify Compliance Programs

November 20, 2018 | Ashley Algazi | Compliance, Investigations & White Collar | Health Services

The December 31 deadline for certain Medicaid providers and third-party billers to certify as to the effectiveness of their compliance program is fast approaching.

New York State Medicaid providers and third-party billing companies who claim, bill, order or receive at least $500,000 in any consecutive 12-month period from the Medicaid Program or Managed Medicaid payors are required to implement an effective compliance program aimed at detecting and preventing fraud, waste and abuse. In addition, facilities licensed under Article 28 or Article 36 of the New York Public Health Law (which include hospitals, ambulatory surgery centers, diagnostic and treatment centers and home care agencies) must have a compliance program regardless of the amount they bill, order or receive from Medicaid.

The Office of Medicaid Inspector General (OMIG) recommends that certifying providers/entities conduct a self-assessment of the operation of their compliance program and make any necessary adjustments prior to certification.

An effective compliance program must include eight fundamental elements:

  1. Written policies and procedures describing compliance expectations
  2. Designation of an employee to serve as the Compliance Officer
  3. Training and education of employees
  4. Communication lines to the Compliance Officer that are accessible to all employees
  5. Disciplinary policies to encourage good-faith participation in compliance efforts
  6. A system for routine identification of compliance risk areas
  7. A system for responding to compliance issues when they arise
  8. A policy of non-intimidation and non-retaliation for good faith participation in the compliance program.

Providers and third-party billing companies that are required, yet fail, to certify with OMIG may be subject to administrative sanctions, ranging from censure to termination of the provider’s enrollment with the Medicaid program. Further, OMIG’s Bureau of Compliance “uses certification history as a metric to identify providers that may be subject to compliance program reviews.”  Providers that are subject to an OMIG Compliance Program Review will be scrutinized and will have to provide evidence that each of the eight fundamental elements are adequately satisfied.

It is important that providers start reviewing their policies now to ensure compliance with the December 31 deadline.

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