States to share data from respective Prescription Monitoring Programs in joint effort to prevent stockpiling, resale, and abuse of dangerous controlled substances

Governor Andrew M. Cuomo today announced New York State has begun sharing Prescription Monitoring Program (PMP) data with New Jersey to prevent the stockpiling and resale of dangerous controlled substances and to help fight the abuse of prescription drugs.

New York and New Jersey are using the National Association of Boards of Pharmacy PMP InterConnect hub, which allows them to securely share their prescription data with authorized requestors from other states in the hub. The Prescription Monitoring Program provides practitioners and pharmacists with a patient's recent controlled substance prescription information. By providing more complete records of patients' multi-state prescription histories, states work together to prevent those who would evade state laws from obtaining and stockpiling or reselling dangerous controlled substances for nonmedical use.

New York began data sharing with New Jersey on April 14, 2016. Through just April 22, over 16,000 controlled substance records have been requested, with over 12,000 of those requests coming from New York to New Jersey.

"Sharing controlled substance data with neighboring states allows us to more effectively combat prescription drug abuse and fraud," said Governor Cuomo. "New York has seen an important decrease in the number of controlled substance prescriptions issued since we launched our aggressive I-STOP program in 2012, and I am confident that sharing data across state lines will further that success throughout the region. Prescription drug abuse impacts families nationwide, and I am proud of the crucial step we are taking to stem this epidemic."

Governor Cuomo initiated New York's PMP - known as the Internet System for Tracking Over-Prescribing Act (I-STOP) - in 2012, and the program has revolutionized the way controlled substances are prescribed, distributed and tracked in New York State.

State Health Commissioner Dr. Howard A. Zucker said, "Participating in InterConnect not only facilitates the transmission of PMP controlled substance data across state lines to authorized requestors, it also enhances New York's ability to track and prevent over-prescribing of potentially dangerous drugs and strengthens Governor Cuomo's comprehensive effort to combat prescription drug abuse."

State Office of Alcoholism and Substance Abuse Services Arlene González-Sánchez said, "I applaud the Governor's initiative to share prescription information across State lines. Prescription opioid misuse is leading to chronic addiction impacting our families and communities. By sharing prescription information across state lines we can better monitor dispensing and minimize fraudulent prescribing practices and misuse of these prescriptions."

Senator Kemp Hannon, Chair of the Senate Health Committee, said, "Fighting the opioid epidemic is going to require the kind of collaboration announced today by Governor Cuomo. By sharing prescription data, we will be better able to quickly spot those patients who are trying to illegally obtain controlled substances. This is a major step forward in our efforts to stem the dangerous epidemic of opioid abuse."

Senator Andrew Lanza said, "Knowing is half the battle. Through the Prescription Monitoring Program and I-STOP, New York state has compiled a valuable database of controlled substance use to better serve patients and combat abuse. By making this information available between states, New York adds another layer of deterrence to those who would overprescribe, or would-be drug seekers crossing state lines. Tracking prescriptions regionally not only makes sense, it saves lives."

Assemblyman Richard N. Gottfried, Chair of the Assembly Health Committee, said, "The prescription drug monitoring program we enacted in 2012 has been an important tool for reducing prescription drug abuse in New York. Connecting it to New Jersey's system - and eventually to other state systems - will make it even more effective."

Assemblyman Michael Cusick said, "The opioid epidemic is not simply a problem confined to the borders of any single state. Opioid misuse and abuse has become a regional issue, one that demands creative solutions with our partners in neighboring states. The sharing of data with New Jersey is a start and will enable doctors and pharmacists in New York to more closely monitor a patient's efforts to illegally obtain these dangerous controlled substances."

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The Continuing Legal Education Board has approved 4.5 CLE credits for OMIG's nine-part Compliance Elements Webinar Series (webinars # 26 - # 34). To earn the 4.5 CLE credits, individuals must view each webinar in the series and make note of the three codes provided in each webinar (27 codes total). No partial credits will be issued. Be sure to include all codes on the attorney application, which is posted on OMIG's website at: http://omig.ny.gov/images/stories/Webinar/attorney_cle_application_26-34.pdf

If you wish to apply for these credits, please email your completed attorney application, including your name and contact information, to: information@omig.ny.gov

The Compliance Elements Webinar Series is available at: http://www.omig.ny.gov/resources/webinars

Thank you for your interest in OMIG webinars.

OMIG imposes Corporate Integrity Agreements (CIA) on certain providers that OMIG determines have committed unacceptable practices, but whose removal from the Medicaid program would negatively impact access to necessary services. The CIA allows for strict oversight of a provider. Providers under a CIA are subjected to monitoring that includes, but is not limited to, annual claims reviews, cost reporting reviews, and compliance program reviews.

Corporate Integrity Agreement executed:

Elant, Inc., Elant at Brandywine, Inc., Elant at Fishkill, Inc., Glen Arden, Inc., Elant at Goshen, Inc., and Elant at Newburgh, Inc. d/b/a Elant at Meadow Hill (collectively "Elant")

View the CIA at: http://on.ny.gov/24V9CgQ

Corporate Integrity Agreement expires:

OMIG's Corporate Integrity Agreement with Young Adult Institute, Inc. expired on January 19, 2016. View the expiration notice here: http://on.ny.gov/1TSQ0qj

All CIAs can be viewed at: https://omig.ny.gov/compliance/corporate-integrity-agreements

OMIG has released its 2016-17 Work Plan, detailing the areas of focus in the Medicaid program for State Fiscal Year April 1, 2016 to March 31, 2017.

This year's Work Plan continues a focus on organizing work according to categories of service. Building on the 2015-16 Work Plan, OMIG continues to utilize its Business Line Teams across a number of areas, including but not limited to the Delivery System Reform Incentive Payment Program (DSRIP), Managed Long Term Care, Transportation, Home and Community Care Services, and Managed Care. Further, OMIG will continue to emphasize provider outreach and education, particularly focusing on providers having proactive compliance programs that will prevent or, when necessary, detect and address abusive practices. Through its array of compliance webinars, guidance materials, self-assessment tools, presentations, and a dedicated compliance email address and phone number, OMIG's oversight activities and educational efforts increase provider accountability and contribute to improved quality of care.

The work plan, and plans from previous years, can be viewed at: https://www.omig.ny.gov/index.php/information/work-plan

Joint Legislative Budget Testimony
Testimony of Dennis Rosen
Medicaid Inspector General
Office of the Medicaid Inspector General


Hearing Room B
Legislative Office Building
Albany, New York

January 25, 2016

Good morning Chairwoman Young, Chairman Farrell, distinguished members of the Senate Finance and Assembly Ways and Means Committees, and Health Committee Chairs Senator Hannon and Assemblyman Gottfried. I am Dennis Rosen, Medicaid Inspector General, and I appreciate this opportunity to discuss the activities and initiatives of the Office of the Medicaid Inspector General (OMIG) as they relate to the 2016-17 Executive Budget.

OMIG is nationally recognized for its commitment to protecting the integrity of New York State's Medicaid program. It has done so through its investigative work and partnerships with other law enforcement agencies, innovative auditing techniques, and proactive outreach and compliance initiatives - all of which have resulted in billions of dollars in cash recoveries and cost savings. As such, OMIG plays a vital role in ensuring that Medicaid recipients throughout the State have access to New York's high-quality, cost-effective healthcare delivery system.

OMIG pursues recoveries where overpayments have been made. Even more important, in my view, are OMIG's efforts to, up front, prevent improper costs and billings in the Medicaid program. As we all know, it is far more cost effective to prevent improper payments in the first place, as opposed to chasing dollars after they have been paid out.

OMIG's cost-avoidance initiatives for 2015 delivered savings of more than $1.4 billion through September. These results are on track to exceed 2014's cost-avoidance results of $1.8 billion. Each of OMIG's cost-avoidance initiatives has its own comprehensive methodology for accurately calculating Medicaid program dollars that are saved. For example, OMIG uses pre-payment program edits that we build into the Medicaid billing system that deny improper provider claims. Another area of cost savings is, where OMIG has had an intervention with a provider, OMIG will subsequently compare billing patterns prior to the intervention with those after to determine the cost savings attributable to the modifications in the provider's operations that were a result of our involvement.

In addition to cost-avoidance, identifying and recovering dollars that have actually been paid because of fraud, waste or abuse in the Medicaid program is a core OMIG function. OMIG's 2015 preliminary audit results through September show more than 1,700 audits initiated and over 725 audits finalized. Cash recoveries for this nine-month period, including audits, third-party liability, and investigations total approximately $250 million.

Moreover, holding accountable those who intentionally defraud the system is priority number one. To this end, OMIG works independently and in collaboration with partners at all levels, including local, state and federal law enforcement, provider organizations, and health plan special investigation units (SIUs). These collaborative efforts have become more effective as the healthcare delivery system continues its shift from a predominantly fee-for-service model to a managed care approach.

One example of this is OMIG's Managed Care Investigation Unit. The Unit investigates complaints received from managed care organizations (MCOs) relating to network provider fraud, and works with their SIUs to develop comprehensive investigative plans. OMIG conducts quarterly statewide meetings with all of the SIUs, at which it shares recent case referrals from SIUs to identify suspicious trends across plans, coordinate next steps, and provide additional information to enhance program integrity and drive results. OMIG has created a database, that is accessible to OMIG investigators, consisting of contact information for SIU staff in all managed care plans. Preliminary data for 2015 show that, as a result of OMIG's work with the SIUs, referrals from MCOs to OMIG totaled 344, up from 273 referrals in 2014.

Also, as part of its managed care focus, OMIG continues to generate results through its reviews of managed long-term care plans (MLTCs). These MLTC audits focus on enrollee eligibility for long-term care, and whether the plans are meeting the service needs of enrollees based on their plans of care. OMIG has engaged 26 MLTC plans for audit, and has reviewed enrollment eligibility criteria and related care plans for more than 4,900 enrollees.

In addition, OMIG, in concert with the Department of Health and the Office for the Aging, developed and implemented last year New York State's first-ever certification process for social adult day care providers (SADCs). This will play an important role in the State's oversight of managed long-term care organizations and their relationships with SADCs.

Additionally, OMIG has played a critical role in many collaborative law enforcement actions that have resulted in the takedown of major fraud schemes, enrollment fraud arrests, and drug diversion cases. One example of these joint-enforcement actions resulted in the indictment of 23 defendants who were involved in a $7 million Medicaid fraud scheme in Brooklyn. Last March, OMIG, along with the Brooklyn District Attorney, the United States Health and Human Services Office of the Inspector General, and the New York City Human Resources Administration, announced charges against nine physicians and 14 other individuals pursuant to a 199-count indictment. The defendants lured homeless people, and individuals from low-income areas, to medical clinics where they received unnecessary tests in exchange for free shoes. OMIG provided Russian-speaking staff, data collection and analysis, and intelligence gathering in the course of the investigation.

OMIG has also been very involved in drug diversion cases. For example, OMIG assisted the Suffolk County District Attorney's Office investigation of Ingrid Gordon-Patterson, a nurse practitioner based in Suffolk County. In a one-year period, she wrote more than 1,200 prescriptions of Oxycodone for patients who had no medical need for this highly addictive drug. OMIG's assistance included surveillance, data-mining services, and reviewing documentation from MCOs. On June 29, Gordon-Patterson was convicted on five counts, which included Criminal Sale of a Controlled Substance. On August 25, she was sentenced to nine to 19 years in prison.

Thus far our 2015 statistics regarding enforcement activity are robust. Preliminary numbers through September indicate that OMIG opened more than 2,700 investigations, completed more than 2,900, and referred 926 cases to law enforcement and other agencies. In addition, during the same nine-month period, OMIG excluded 844 providers from the Medicaid program, which exceeds the 822 provider exclusions for all of 2014.

OMIG also places great emphasis on provider outreach and education, particularly focusing on providers having proactive compliance programs that will prevent or, when necessary, detect and address abusive practices. We offer compliance webinars, guidance materials, self-assessment tools, presentations, and a dedicated compliance email address and phone number. OMIG's oversight activities and educational efforts increase provider accountability and contribute to improved quality of care.

In 2015, OMIG issued more than 30 compliance-related guidance materials and conducted over 20 educational presentations and webinars. The compliance section of the OMIG website had 36,000 visits to compliance webinars, 25,000 visits to compliance publications and 40,000 visits to compliance resources and FAQs. Many of our webinars are accredited for legal, accounting or compliance continuing-education credits. In 2016, 206 participants have already received credits, largely because last November OMIG created and posted on its website a nine-part series on New York's mandatory compliance program obligation, as well as a webinar detailing the 2015 Compliance Program Certification Process.

We at OMIG appreciate this opportunity to speak with you about our Medicaid program integrity activities. We believe that our provider education and outreach programs, our investigative efforts, and our success in identifying cost savings and recovering inappropriate Medicaid payments, play a vital role in preventing and detecting Medicaid fraud and abuse while promoting the delivery of high-quality care to millions of New Yorkers.

Thank you. I am happy to address any questions you may have.