Office of Medicaid Inspector General Releases New Work Plan

May 31, 2013

The New York State Office of the Medicaid Inspector General (“OMIG”) recently released its Work Plan for fiscal year 2013-2014 (the “Work Plan”). The Work Plan describes activities that OMIG plans to initiate or continue during 2013 and 2014, including its outline of areas of fraud that the agency will target in the new fiscal year.  The Work Plan has important implications for health plans and providers participating in New York’s Medicaid program. 

In its executive summary of the Work Plan, OMIG stated that it plans on topping last year’s “savings”, which included saving more than $2.5 billion due to “cost avoidance techniques” and more than $410 million in audit recoveries.  OMIG also noted that its audit targets are incorporated within the global Medicaid spending cap and, therefore, if OMIG does not achieve its audit targets, providers, as a group, will be subject to Medicaid rate adjustments or other cost control measures. 

Some of the highlights from the Work Plan are set forth below: 

Hospital and Outpatient Services

Outpatient Department Services – OMIG will review Medicaid payments for selected hospital outpatient services and review emergency room, clinic and ordered ambulatory services and review the underlying documentation, such as physician orders and test results. A limited number of these reviews will involve time periods preceding the implementation of ambulatory patient groups (“APGs”). 

Diagnostic and Treatment Centers – OMIG will review payments for services provided by D&TCs to determine whether services were provided and medically necessary and that appropriate coding was used. A key component of the review will be to determine the appropriateness of payments for physical, speech, and occupational therapy services, as well as HIV primary care services. These reviews will involve time periods preceding the implementation of APGs.  Additionally, OMIG will identify whether Federally Qualified Healthcare Centers (“FQHCs”) received the enhanced rate for services provided at an approved FQHC location when the services were provided at a non-FQHC-approved location.  OMIG will also identify whether the FQHCs received inappropriate payments when an FQHC provided service to a Medicaid managed care consumer. 

Mental Health, Chemical Dependence and Developmental Disabilities Services

Chemical Dependence Inpatient Rehabilitation, Outpatient Chemical Dependence Services – OMIG will continue to review Medicaid payments for these services to determine whether services were provided in accordance with Medicaid requirements. 

Comprehensive Outpatient Program Supplemental Reimbursement – The amount of comprehensive outpatient program supplemental (“COPS”) reimbursement that a provider can receive is limited to a yearly threshold amount.  The Office of Mental Health has identified COPS reimbursements that exceeded the threshold amounts for prior years, and OMIG will continue to issue COPS reports and facilitate the collection of overpayments for remaining open COPS audits. 

Physicians, Dentists, and Laboratories

Primary Care Services under the Affordable Care Act – The Affordable Care Act requires state Medicaid programs to reimburse qualified physicians for designated primary care services up to the Medicare fee schedule price in 2013-14. The Centers for Medicare and Medicaid Services (“CMS”) will require that OMIG complete an audit of a random sample of physician attestations from fee-for-service and managed care programs to ensure that requirements for payment enhancements have been met.

Dental Review – OMIG will review providers of dental services to verify that services billed were performed, documentation supports the services billed and that the claims are submitted in accordance with Medicaid program rules, regulations and policy.  Orthodontic dental services will be reviewed for exceeding age limits and maximum number of treatment quarters outlined in Medicaid regulation. Excessive preventive services provided by private dentists that exceed the frequency limits to the same consumer within a certain time period will also be reviewed for possible recovery of overpayments. 

Providers with Excessive Ordering of Controlled Substances – OMIG has produced a list of providers whose controlled substance ordering habits exceed those of their peers.  OMIG will review the ordering of these providers to determine if the ordering was medically necessary. 

Compliance-Related Activities

Compliance Program Reviews – OMIG desk and onsite compliance program reviews will initially focus on providers who do not meet the annual certification requirements under the New York State Social Services Law and the federal Deficit Reduction Act of 2005.  In addition, reviews will include providers identified to have repeated issues associated with claims submissions. 

Investigative Activities

Kickbacks and Inducements – Providers are prohibited from offering, soliciting, giving, or receiving any referral fee, rebate, discount, bribe or kickback, whether in-kind or financial, in return for referring, accepting a referral from or providing services to a consumer.  Providers doing so will be identified and appropriate actions taken to recoup overpayments, to refer them for prosecution and/or to exclude them from the Medicaid program. 

Service Bureaus Run by Disqualified Providers – Service bureaus provide enrolled Medicaid providers with billing and other assistance.  Disqualified providers are not allowed to participate in the Medicaid program and OMIG will identify disqualified providers who have an ownership interest in service bureaus. 

For the complete plan, please visit: 

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