Reminder to New York Medicaid Providers: Certification of Compliance Program Must be Completed by December 31, 2016

November 11, 2016 | Health Services

New York State Medicaid providers who claim, order or receive at least $500,000 in any consecutive 12-month period from the Medicaid Program are required to implement a compliance program aimed at detecting and preventing Medicaid fraud, waste and abuse. This requirement also applies to third party billing companies that bill or receive the threshold amount on behalf of New York providers. In addition, facilities licensed under Article 28 or Article 36 of the New York Public Health Law (which includes hospitals, ambulatory surgery centers and home care agencies) must have a compliance program regardless of the amount they bill, order or receive from the Medicaid Program. Providers must certify as to the effectiveness of their compliance program by the end of each calendar year.

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; and (8) a policy of non-intimidation and non-retaliation for good faith participation in the compliance program. The Office of the Medicaid Inspector General (“OMIG”) recommends that providers conduct a self-assessment of the operation of their compliance program and make any necessary adjustments prior to certification.

In addition, before a provider can certify with OMIG, all of its employees and associated persons, including its executives and governing body members, must receive annual training and education on compliance issues, expectations and the compliance program. Attendance records and training materials indicating the completion of the required annual training must be maintained by the Compliance Officer and be readily available for production if requested by OMIG.

In mid-December, the 2016 Certification Form will be posted on OMIG’s website at The form must be completed and submitted online by December 31, 2016. The “Certifying Official” who submits the Certification Form for each provider should be a member of senior management or the governing board, but should be someone other than the Compliance Officer. The questions that will need to be answered on the Certification Form are as follows:

  1. Have you implemented written policies and procedures that describe compliance expectations that support a compliance program?
  1. Have you designated an employee vested with responsibility for the day-to-day operation of the compliance program?
  1. Is there routine training and education of all affected employees and persons associated with the provider, including executives and governing body members, on compliance issues, expectations and the compliance program?
  1. Do all employees and persons associated with the provider have access to the compliance officer to allow for compliance issues to be reported, including a method for anonymous reporting?
  1. Have disciplinary policies been implemented and enforced to encourage good faith participation in the compliance program by all affected individuals?
  1. Do you have a system for routine identification of compliance risk areas specific to your provider type and do you conduct audits of those risk areas?
  1. Do you have a system in place for investigating and responding to compliance issues as they are raised, including reporting compliance issues to New York State Department of Health or OMIG and refunding overpayments?
  1. Have you implemented a policy of non-intimidation and non-retaliation for good faith participation in the compliance program?

OMIG is authorized to impose sanctions or penalties, including, but not limited to, termination of a provider’s agreement to participate in the Medicaid Program, against providers who fail to develop, adopt and implement an effective compliance program. In addition, the Certifying Official may be subject to criminal prosecution for a misdemeanor or felony under the New York State Penal Law if a false statement is made on the Certification Form. If you would like assistance in completing the annual training prior to certification or have questions about the effectiveness of your compliance program, please contact us prior to the December 31, 2016 deadline.

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