Author Archives: David Ross

Cardiology Group to Pay More than $1.33 Million to Settle Allegations of Stark Law and False Claims Act Violations

According to United States Attorney Richard Hartunian of the Northern District of New York, Cardiovascular Specialists, P.C., has agreed to pay the federal government $1,336,636.98 plus interest to settle allegations that it violated the federal Physician Self-Referral Law (also known as the Stark Law) and the federal False Claims Act by knowingly compensating its physicians in a manner that violated federal law. Cardiovascular Specialists is a group practice of cardiologists with offices throughout upstate New York does business as New York Heart Center (NYHC).

USDOJ alleges that NYHC used a compensation system that violated the Stark Law, and thereby the False Claims Act, by compensating each NYHC partner-physician using a formula that took into account the volume or value of that physician’s referrals for nuclear scans and CT scans.   Continue reading

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Filed under False Claims Act, Stark Law

CMS Audit of OPWDD ICFs Seeks Recovery of $1.26 Billion from New York State

New York State is appealing to the Secretary of the United States Department of Health and Human Services (“HHS”) for reconsideration of a July 25, 2014 Centers for Medicare and Medicaid Services (“CMS”) final audit report that found the State liable for $1,257,499,670 in federal Medicaid overpayments.  In its letter to the State, CMS indicated it would be initiating similar reviews of the State’s two subsequent fiscal years based upon the audit findings.  To make matters worse, this federal cost recovery  is in addition to an agreement between the State and CMS to lower Medicaid rates for developmental disability centers, effective April 1, 2013, resulting in an approximately $1.1 billion reduction in federal Medicaid funding annually. Continue reading

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Filed under Health Care Reform, HHS OIG, Medicaid, New York State Agencies

NYC HRA Sued under False Claims Act by Whistleblower; Settles with US DOJ for $1.05 Million

According to United States Attorney Richard S. Hartunian, the City of New York (NYC) has agreed to pay the United States Department of Justice (US DOJ) $1.05 million to settle allegations that the NYC Human Resources Administration (HRA) violated the federal False Claims Act by causing various managed care organizations (MCOs) to provide Medicaid coverage to individuals that HRA knew, or should have known, were ineligible to receive New York State Medicaid benefits because they had moved outside New York State. The case was brought by a whistleblower and investigated by the US DOJ and United States Department of Health and Human Services Office of the Inspector General (OIG). Continue reading

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Filed under False Claims Act, Fraud and Abuse, HHS OIG, Medicaid, Medicaid Fraud, New York State Agencies, NY Office of Medicaid Inspector General, NYC HRA

UPDATE: OMIG Releases Revised Compliance Guidance to OASAS Providers

The Office of the Medicaid Inspector General (“OMIG”) has issued Revised Compliance Guidance for use by providers regulated by the New York State Office of Alcoholism and Substance Abuse Services (“OASAS”). 

The revision clarifies that the Compliance Guidance examples are taken from OMIG Audit Protocols for OASAS Chemical Dependence Programs and Services for dates of service prior to the date that the Ambulatory Patient Group (“APG”) regulations (14 NYCRR Part 822) went into effect.  Once OMIG audit protocols are developed for the APG reimbursement system, OMIG may update this compliance alert.

Check out our original post for more information about this Compliance Guidance.

The Revised OMIG Compliance Guidance for OASAS providers is available here.

Kathleen Evers wrote this post.  For more information, please contact David R. Ross, who served as Acting New York State Medicaid Inspector General under governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General.  Prior to his service at the OMIG, David held several positions at the New York State Office of Alcoholism and Substance Abuse Services, including Acting General Counsel, Deputy Counsel, and Associate Counsel.  He can be reached at (518) 462-5601 or via e-mail at dross@oalaw.com.

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Filed under NY Office of Medicaid Inspector General

Congressional Panel Hears HHS OIG Testimony About Increasing Oversight of New York State’s Medicaid Program

The United States Congress House Committee on Oversight and Government Reform, Subcommittee on Energy Policy, Health Care and Entitlements, held a hearing on July 29, 2014 entitled “Examining the Federal Government’s Failure to Curb Wasteful State Medicaid Financing Schemes.” Mr. John Hagg, Director of Medicaid Audits for the United States Department of Health and Human Services Office of Inspector General (OIG), testified, and, at the Subcommittee’s request, focused on the State of New York’s alleged Medicaid compliance issues. Continue reading

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Filed under Fraud and Abuse, Medicaid, Medicaid Fraud, NY Office of Medicaid Inspector General

Attention OASAS Providers: OMIG Releases Compliance Guidance for Inpatient Chemical Dependency Rehabilitation and Outpatient Chemical Dependency Services

The New York State Office of the Medicaid Inspector General (“OMIG”) has released Compliance Guidance for use by providers regulated by the New York State Office of Alcoholism and Substance Abuse Services (“OASAS”).

New York State Social Services Law Section 363-d and the implementing regulations at 18 NYCRR Part 521 require OMIG to routinely identify compliance risk areas relating to the particular type of services being offered by Medicaid providers.  The purpose of the OMIG’s Compliance Guidance is to offer examples of compliance risk areas that may be of particular concern to those providing Inpatient Chemical Dependence Rehabilitation and Outpatient Chemical Dependence services.  Many of the examples are taken from OMIG Audit Protocols for OASAS Chemical Dependence Programs and Services, which can be found on OMIG’s Web site at www.omig.ny.gov.

Update: The OMIG Compliance Guidance for OASAS providers has been revised, and the guidance we wrote about in this post is no longer available online.  Please see our post about the recent revision to this Guidance.

Kathleen Evers wrote this post.  For more information, please contact David R. Ross, who served as Acting New York State Medicaid Inspector General under governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General.  Prior to his service at the OMIG, David held several positions at the New York State Office of Alcoholism and Substance Abuse Services, including Acting General Counsel, Deputy Counsel, and Associate Counsel.  He can be reached at (518) 462-5601 or via e-mail at dross@oalaw.com.

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Filed under NY Office of Medicaid Inspector General

The Trouble with RACs

It seems the United States House of Representatives has taken aim at Medicare Recovery Audit Contractors (“RACs”). The RACs are private, non-governmental entities that are authorized by the Medicare program to conduct audits of Medicare providers and suppliers.

In December, 2013, the Office of Medicaid Hearings and Appeals (“OMHA”) sent a letter to providers with “a significant number of Medicare appeals currently pending” informing them that OMHA had temporarily suspended all Medicare claim and entitlement appeals “due to the rapid and overwhelming increase in claim appeals.” At the end of 2013, the number of appeal requests had grown to approximately 15,000 per week. The goal of the suspension was to “allow OMHA to adjudicate appeals involving almost 357,000 claims for Medicare services and entitlements already assigned to its 65 Administrative Law Judges.” The current wait time for a hearing to review the results of a RAC audit with an Administrative Law Judge is over two years. Continue reading

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Filed under Medicare

Auditing the Auditors: OSC Audits the OMIG and Questions the Accuracy of OMIG’s Cost Saving Figures

The New York State Office of the State Controller (“OSC”) has released its audit of the New York State Office of the Medicaid Inspector General (“OMIG”) entitled “Accuracy of Reported Cost Savings.” The final report, issued July 11th, presented OSC’s findings regarding the accuracy of the OMIG’s reported cost savings for calendar years 2008 through 2012. Continue reading

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Filed under Medicaid, NY Office of Medicaid Inspector General

Attention OMH Continuing Day Treatment Providers: OIG Releases Audit of CDT Programs, Seeks Repayment of over $18 Million to Federal Medicaid Program

The United States Department of Health and Human Services Office of the Inspector General (“OIG”) conducted an audit of New York State’s nonhospital-based Continuing Day Treatment (“CDT”) program.  

CDT services are clinic services administered by the New York State Office of Mental Health (“OMH”). OMH’s CDT program provides Medicaid recipients with treatment designed to maintain and/or enhance current levels of functioning and skills, to maintain community living, and to develop self-awareness and self-esteem through the exploration and development of strengths and interests. CDT services include, but are not limited to, assessment and treatment planning, discharge planning, medication therapy, case management, psychiatric rehabilitation, and activity therapy.

To be eligible for the CDT program, a recipient must have a diagnosis of a designated mental illness as well as a dysfunction due to a mental illness. The recipient’s treatment plan must be completed in a timely manner; be signed and approved by both the recipient and the physician involved in the treatment; include a diagnosis of a designated mental illness, treatment goals, objectives, and related services, a plan for the provision of additional services, and criteria for discharge planning; and be reviewed every 3 months. Additionally, progress notes must be recorded at least every 2 weeks by the clinical staff members who provided CDT services to the recipient. The progress notes must identify the particular services provided and the changes in goals, objectives, and services, as appropriate. In addition, CDT services must be adequately documented, including type, duration, and need for continuing services.

The OIG audit report alleges that New York State claimed federal Medicaid reimbursement for nonhospital CDT services that did not comply with federal and State requirements. Of the 100 claims in the OIG’s random sample, 66 claims complied with federal and State requirements, while 34 claims allegedly did not.  The audit period was from April 1, 2009 to August 17, 2011.

According to the OIG audit report, the alleged deficiencies occurred because (1) certain nonhospital CDT providers did not comply with federal and State regulations and (2) the State did not ensure that OMH adequately monitored the CDT program for compliance with certain federal and State requirements. On the basis of the sample results, the OIG estimated that the State improperly claimed at least $18,093,953 in federal Medicaid reimbursement for nonhospital CDT services that did not meet federal and State requirements.

The OIG recommended that the State refund $18,093,953 to the Federal Government;  work with OMH to issue guidance to the provider community regarding federal and State requirements for claiming Medicaid reimbursement for nonhospital CDT services; and work with OMH to improve OMH’s monitoring of the CDT program to ensure compliance with federal and State requirements.

According to the OIG audit report, New York State responded as follows:. “In written comments on our draft report, the State agency disagreed with our first recommendation (financial disallowance) and did not indicate concurrence or nonconcurrence with our remaining recommendations. Specifically, State agency officials stated that we based our findings entirely on State regulations and, if OMH found claims to have violated the State regulations we cited, those violations “would not have rendered the services non-reimbursable.” The State agency also disagreed with our determination that, for one sampled claim, progress notes were not prepared by a staff member who provided a service. Specifically, State agency officials stated that, for the sampled claim (#73), a progress note clearly demonstrated that “the treatment provider was actively engaged” with the beneficiary during the 2-week period that included the sampled service date. In addition, the State agency disagreed with our determination that certain sampled claims did not meet reimbursement standards. State agency officials indicated that their preliminary analysis of our workpapers revealed that providers supplied us with schedules of group services that beneficiaries were scheduled to attend each day they visited the CDT provider. State agency officials stated that these schedules document the frequency and types of services planned for each beneficiary.”

As a result of the OIG audit, it is likely that the New York State Office of the Medicaid Inspector General (“OMIG”) will be conducting additional audits of CDT providers. 

The OIG audit report is available at http://oig.hhs.gov/oas/reports/region2/21201011.pdf.  

For more information, please contact the author, David R. Ross, who served as Acting New York State Medicaid Inspector General under governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General (OMIG). He can be reached at (518) 462-5601 or via e-mail at dross@oalaw.com

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Filed under Health Care Reform, Medicaid, Medicaid Fraud

Attention Medicaid and Medicare Providers: US DOJ Sues Providers for Failing to Return Overpayments Within 60 Days

On June 27, 2014, in the case of United States ex rel. Kane v. Healthfirst, Inc., et al., No. 11-2325 (S.D.N.Y.), the United States Department of Justice (USDOJ), via the United States Attorney’s Office for the Southern District of New York, sued several Medicaid providers under the federal False Claims Act for failing to return Medicaid overpayments within 60 days of identifying them. Continue reading

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Filed under False Claims Act, Federal Case Updates, Fraud and Abuse, Medicaid, Medicaid Fraud, Medicare, Medicare Fraud