Compliance

Overview

The Bureau of Compliance (BOC) works to educate, assist, and assess Medicaid program providers in meeting their obligation to establish and operate effective compliance programs by evaluating whether they are meeting the mandatory compliance program requirements.

BOC assesses the compliance programs of Medicaid providers to ensure they create a control structure to reduce the potential for fraud, waste, and abuse, and have systems in place to identify and self-correct errors before the Medicaid program is billed.

Who Must Have a Compliance Program?

NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules and Regulations (18 NYCRR) Part 521 defines those factors that require providers to have a compliance program.

If you answer YES to any of the following questions, you are required to have a compliance program in New York State.

  1. Is your organization subject to Article 28 or Article 36 of the NYS Public Health Law (PBH)?
  2. Is your organization subject to Article 16 or Article 31 of the NYS Mental Hygiene Law?
  3. Notwithstanding the provisions of § 4414 of the NYS PBH, is your organization a managed care provider, as defined in SOS § 364-j, which includes managed long-term care plans?
  4. Does your organization claim or order—and/or can be reasonably expected to claim or order—Medicaid services or supplies of at least $500,000 in any consecutive 12-month period?
  5. Does your organization receive Medicaid payments—and/or can be reasonably expected to receive payments—either directly or indirectly, of at least $500,000 in any consecutive 12-month period?  Indirect Medicaid reimbursement is any payment that you receive for the delivery of Medicaid care, services, or supplies that comes from a source other than the State of New York.  For example, if you provide covered services to a Medicaid beneficiary who is enrolled in a Medicaid Managed Care Plan, the payment you receive from the Managed Care Organization is considered an indirect payment.
  6. Does your organization submit Medicaid claims of at least $500,000 in any consecutive 12-month period on behalf of another person or persons?

Please see the resources in the Compliance Library for additional information about compliance programs.

Contact the Bureau of Compliance

If you have any compliance-related questions, please contact the Bureau of Compliance at (518) 408-0401 or [email protected].