“Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.”
This phrase appears on each page of the newly released New York State Office of the Medicaid Inspector General (OMIG) State Fiscal Year 2012-2013 Work Plan.
On the Executive Summary page, the OMIG’s stated mission is to “enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.”
Fraud is generally defined in the Medicaid context as intentional acts of improper billing. Matters involving actual fraud—which are criminal in nature—are typically referred by the OMIG to the New York State Attorney’s General’s Medicaid Fraud Control Unit pursuant to a memorandum of understanding between the two agencies, or referred to other criminal law enforcement authorities. Matters involving “abuse” or “waste” are different matters entirely, and involve unintentional, inadvertent acts, or even negligent acts, of erroneous or improper Medicaid billing.
Of course, if the OMIG limited itself to fighting actual fraud, most Medicaid providers would breathe a sigh of relief, as those pesky OMIG audits, which seek extrapolated recoveries of overpayments based largely upon technical deficiencies in record keeping, would disappear. Will the new Medicaid Inspector General, James Cox, steer the agency away from the OMIG’s historical tendency to impose, sometimes retroactively, hypertechnical interpretations of regulations or policies upon providers? Only time will tell.
According to the Work Plan, the OMIG has established nine “business line teams” that each consist of multiple OMIG personnel from various functional areas within the OMIG that work as a team. The goals of these specialized, multidisciplinary teams include improved efficiency, more thorough reviews and investigations, and reduced time to completion.
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.
Broad areas of Medicaid service provision that the OMIG has established business line teams for include, but are not limited to, the following: managed care; home and community care services; hospital and outpatient services; mental health, chemical dependence and developmental disabilities services; pharmacy and durable medical equipment; physicians, dentists and laboratories; residential health care facilities; and transportation. Each business line will face varying degrees of scrutiny by the OMIG this state fiscal year. There is a discussion of each area in the Work Plan.
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, perhaps the most significant part to the government, is the ability of the provider to identify and return Medicaid overpayments 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 County Demonstration project will likely see additional counties participating this year. This is when a participating county, either directly or through a contractor, conducts audits of Medicaid providers under the supervision of the OMIG.
The OMIG is also intending to pursue the enforcement of violations of anti-kickback laws.
There are other areas of focus in the OMIG’s Work Plan. If you would like to discuss any of them, please feel free to contact the author, David R. Ross, Esq., former New York State Acting Medicaid Inspector general under Governors Pataki and Spitzer.