Office of The Medicaid Inspector General Releases 2015-2016 Work Plan

The New York State Office of the Medicaid Inspector General (“OMIG”) has released its State Fiscal Year 2015-2016 Work Plan.  The Work Plan is a road map of where the OMIG intends to go in terms of its anti fraud, waste and abuse efforts with respect to the Medicaid program. The OMIG’s stated mission is “preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high quality patient care.”  The Work Plan intends to “fight fraud, improve integrity and quality, and save taxpayer dollars.”

According to the Work Plan, the OMIG will continue to focus on organizing its work according to the nine Business Line Teams (“BLTs”) it established in its 2014-2015 Work Plan.  You can find more information about these BLTs in our earlier post, found here.  Over the course of 2015-2016, the OMIG will be adding two additional BLTs to its review activities.  The first will focus on reviews of the Delivery System Reform Incentive Payment (“DSRIP”) program and the second focuses on reviews of services transitioned into Managed Long Term Care.  A more detailed discussion about each BLT can be found in the Work Plan.

In addition to the BLTs discussed above, the OMIG also conducts various activities that relate to Medicaid program integrity across multiple business lines. The OMIG is again emphasizing the requirement for Medicaid providers to have an effective compliance plan, and the OMIG will be reviewing compliance plans for effectiveness. Part of an effective compliance plan, and the most significant part as far as the government is concerned, is the ability of the provider to identify and return Medicaid overpayments that the provider has received. The 60 day “report, repay and explain” self-disclosure requirement imposed by the federal Affordable Care Act is also a game changer. The OMIG will continue to review providers who do not make periodic self disclosures or who have never made such disclosures.

The areas listed in the OMIG’s Work Plan that cross multiple business lines are as follows:

  • Collaborative Efforts with Federal and Local Authorities
  • Compliance Program General Guidance and Assistance
  • Compliance Program Reviews
  • Corporate Integrity Agreement Monitoring and Enforcement
  • County Demonstration Program
  • Enrollment and Reinstatement
  • Estate and Casualty Recovery
  • Fee-For-Service Third-Party Retroactive Recovery Projects
  • Kickbacks and Inducements
  • Medicaid Consumer Investigations
  • Medicaid Electronic Health Records Incentive Payment Program
  • Medicaid Integrity Contractor Audits
  • Medicaid Recovery Audit Contractor
  • Medicare Coordination of Benefits with Provider-Submitted Claims
  • Medi-Medi Project
  • Payment Error Rate Measurement Project
  • Prepayment Insurance Verification
  • Prepayment Review
  • Prior Findings
  • Self-Disclosure Efforts
  • Third-Party Liability and Commercial Direct Billing
  • Undercover Operations

There will be a continued emphasis on excluding those providers who commit fraud and abuse. Those who commit “inappropriate and fraudulent acts” will face exclusion from the Medicaid program, then, by operation of law, exclusion from the Medicare program, and in essence become virtually unemployable by most health care providers who accept federal funds.

The OMIG’s 2015-2016 Work Plan can be found here.

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.


David Ross

About David Ross

David is Partner and concentrates his practice on Medicaid, Medicare and private insurance audits & investigations, Health Law including fraud and abuse, governmental investigations of all kinds, Medicaid compliance plans and Article 78 cases. He is head of our Government Investigations practice and also works in Healthcare Fraud & Abuse.