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The NY Office of Medicaid Inspector General (OMIG) issued its work plan for 2008-09. NY Office of Medicaid Inspector General (OMIG) James Sheehan filed the new plan with CMS on April 18, 2008, and it outlines areas of audit and review within the state's Medicaid program. The OMIG will conduct these audits in FY 2008 and FY 2009. Sheehan said that the work plan was an indication to New York Medicaid providers of risk areas they should review in their own organizations. The Plan is available at the OMIG website (www.omig.state.ny.u s), and as a link to the 43-page PDF HERE.. Read excerpted text below:
OMRDD PLAN
OMRDD has been highly successful in implementing a comprehensive Medicaid accountability system which includes the establishment of clear billing standards, regular communication and training for providers on these standards, field reviews that audit against the standards, routine desk reviews of Medicaid-paid claims to identify inappropriate claims, and special targeted Medicaid field reviews based on eMedNY data analyses. OMRDD is also working on a series of governance recommendations to advance as part of our own agenda and as part of a workgroup formed with OMH, OASAS, CQCAPD and OMRDD. These recommendations are designed to create greater corporate accountability, improve program integrity and reduce the likelihood of fraud, overpayments and imprudent use of public funds. OMRDD has extensive Medicaid auditing processes in place. The OMIG will work collaboratively with OMRDD on expanded reviews of Medicaid payments for selected OMRDD-licensed HCBS waiver providers, day treatment providers (14 NYCRR §§ 690), clinic providers (14 NYCRR §§ 679), and case management providers who fail the initial OMRDD review. These reviews are designed to determine if providers claimed reimbursement in accordance with applicable billing standards established by OMRDD. OMRDD regularly makes referrals to the OMIG of voluntary provider agencies when there is suspected Medicaid waste, fraud, or other abuse involving Medicaid, or there is a lack of documentation to support Medicaid claims. OMRDD also refers to the OMIG providers who have self-disclosed Medicaid-related issues to OMRDD. OMRDD conducts a due diligence review to verify the information in the provider's written self disclosure. The OMIG conducts an audit or investigation of providers referred by OMRDD pursuant to the circumstances described above. In addition to the above, the OMIG will conduct audits in the following areas.
Health Care Benefits Initiative
The Commission on Quality of Care (CQC) has received complaints about OMRDD's health care initiative. This initiative, in effect, helps to subsidize health care premiums for direct care staff in order to attract individuals into the system. Complaints have been received that the subsidy provided to provider agencies has not been used for its intended purpose. The OMIG will review the use of these payments.
Outpatient Services
The OMIG will review Medicaid payments for selected OMRDD providers to determine if providers claimed reimbursement in accordance with 14 NYCRR §§ 679 and 690. In addition, OMIG will conduct an audit or investigation of OMRDD providers who were referred to the OMIG by OMRDD. The OMIG will conduct audits of OMRDD providers who did not pass the phase I audit conducted by OMRDD involving a small sample of claims.
Case Management Services
Case management is a process which assists persons eligible for Medicaid to access necessary services in accordance with goals contained in a written case management plan. 18 NYCRR § 505.16 provides details of the regulatory requirements for case management services. The OMIG will review providers of case management services to ensure that the procedural requirements for the provision of services are met and that those services have been billed correctly and have supporting documentation for the units of service billed.
WAIVER PROGRAMS
Home and Community-Based Services (HCBS) - Long Term Home Health Care Program Waiver
The OMIG will review Medicaid payments made for services provided under the Long Term Health Care waiver to determine compliance with the Long Term Care Program Reference Manual and 18 NYCRR §§ 505.21(b)(4), 540.6(e) and Social Services Law §367-c. HCBS waiver programs allow states to provide alternative services for individuals who would otherwise require care in a nursing home. Home and Community-Based Services (HCBS) - Medicaid Waiver for Individuals with Traumatic Brain Injury (TBI) The OMIG will review Medicaid payments for services provided to participants in the TBI program. Medicaid HCBS waiver programs allow states to provide alternative services for individuals who would otherwise require care in nursing homes. The OMIG will examine documentation in support of TBI claims to determine compliance with the HCBS/TBI Waiver Provider Manual. Prior audits have found significant problems with the lack of documentation for services billed, billing for services not included in the service plan, and billing for more hours than documented.
Services Provided Under § 1915(c) of the Social Security Act: Home and Community-Based Services Waiver
The purpose of the waiver is to decrease the risk of institutionalization by providing such services as day habilitation, residential habilitation, respite, and family education and training. Any waiver service provided to a participant must be included in the participant's service plan and also the amount, frequency and duration of each service. The OMIG will review Medicaid payments to providers to determine if services provided to individuals with developmental disabilities were in accordance with § 1915(c) approved waiver agreements and 18 NYCRR Parts 624, 633, 635, 636, 686 and 671.
VOLUNTARY DISCLOSURES
The OMIG has offered and continues to offer all Medicaid providers a voluntary disclosure program. Extensive outreach is made to communicate this to the various provider, medical and legal associations. Providers who identify internal billing or operational issues that might affect their right to Medicaid reimbursement are strongly encouraged to come forward and disclose the parameters of the problem and its potential Medicaid financial impact. The OMIG determines that the issue is a true disclosure (not the result of audit or investigation), validates the parameters described and works with the provider for repayment, which may include extended repayment terms and/or forgiveness of some accrued interest.
Finally, the OMIG recognizes that the rules governing a $48-billion program to provide effective care to four million New Yorkers can be complex. The OMIG appreciate the efforts of New York's health care providers, as well as their compliance officers, and billing and coding staff, to comply with the rules of the program. Through this multi-pronged approach to compliance, and with the support of policymakers and legislators, OMIG will enhance protection for vulnerable Medicaid enrollees in all parts of New York State.
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