OMIG conducts audits of Medicaid expenditures across an extensive range of provider and payer types, including Medicaid Managed Care Organizations (MMCO), Managed Long Term Care Plans (MLTCP), hospitals, clinics, nursing homes, home health, assisted living, and medical practitioners. The purpose of these audits is to assess compliance with Medicaid program integrity statutes, as well as regulations and official directives issued by the Department of Health (DOH) or other relevant State agencies, to identify and resolve deficiencies and to recover associated overpayments. Audits are performed to ensure that Medicaid recipients have appropriate access to quality medical services, that services are documented and billed appropriately, and that those receiving program funds adhere to the program requirements which ensures that Medicaid recipients receive services at least equal to those who have private health insurance.
Where appropriate, OMIG publishes protocols created in consultation with the relevant State agencies and the provider community to ensure a common understanding and application of Medicaid requirements as part of the agency’s audit procedures. You can view the published protocols here: Audit Protocols.
Audits are conducted in a manner which fosters communication with providers (including MMCOs and MLTCPs) throughout the engagement to keep the auditee apprised of potential findings. OMIG reviews all submitted documentation and determines the accuracy and allowability of payments based on the information provided. Active provider participation and sharing of documentation, facilitates the audit process and may help to resolve audit findings and issues early in the process. OMIG’s audit process is collaborative, and providers are encouraged to remain engaged throughout the process. Where documentation is found to be out of compliance with Medicaid requirements, OMIG identifies and subsequently recovers the associated Medicaid overpayments. Providers are given the opportunity and are encouraged to respond to any notices of preliminary findings. Where a provider disagrees with OMIG’s final determination, a provider may request an administrative hearing to appeal the findings.
Audits are conducted by OMIG’s Division of Medicaid Audit, OMIG’s Third Party Liability Contractor, Medicaid Recovery Audit Contractor, and the County Demonstration Program. Authorized by Chapter 58 of the Laws of 2005, the County Demonstration Program was implemented in 2006 and is a partnership among OMIG, New York State local districts, and New York City to detect Medicaid provider fraud, waste and abuse and recoup any identified overpayments. Under the County Demonstration Program, participating counties and New York City conduct audits and investigations under the supervision and direction of OMIG.
OMIG’s planned audit activities for the 2024 calendar year can be found in the 2024 Work Plan.