In addition to ongoing program integrity endeavors, the activities in this section are centered on several priority areas: fighting prescription drug and opioid abuse; home health and community-based care; long-term care; transportation; and managed care.
In pursuing cases of Medicaid fraud, OMIG will continue to engage in collaborative efforts with federal, state, and local law enforcement agencies; and with local Departments of Social Services (LDSS). OMIG will continue to participate in the Federal Bureau of Investigation-directed Health Care Fraud Strike Forces throughout the state. OMIG will continue to participate in the U.S. Department of Justice (DOJ) Medicare Fraud Strike Force, based in the Eastern District of New York, and will assist in health care fraud investigations they conduct. OMIG will continue to work with the New York State Attorney General’s Medicaid Fraud Control Unit (MFCU) and will also work collaboratively with District Attorneys across the state to identify and prosecute those individuals attempting to defraud New York State taxpayers and the Medicaid program.
Combatting Prescription Drug and Opioid Abuse
To help fight opioid abuse, OMIG will continue to dedicate resources to a variety of activities to reduce drug misuse, prescription opioid abuse, and drug diversion.
OMIG will work in tandem with the DOH Bureau of Narcotics Enforcement (BNE) to ensure provider compliance with the Internet System for Tracking Over-Prescribing (I-STOP), NYS’s Prescription Monitoring Program (PMP) registry. OMIG monitors provider compliance with mandated electronic prescribing and identifies fraudulent prescriptions being billed to Medicaid.
OMIG is working to proactively educate providers where a substance utilization review indicates that a recipient may have an accumulation of a controlled substance although they did not meet the criteria for restriction under OMIG’s Recipient Restriction Program. A “Controlled Substance Accumulation” notice will be sent to alert providers of the potential overutilization and abuse.
Similarly, OMIG developed Medication Therapy Review Form to alert prescribers to instances of apparent therapeutic duplication. This will allow the prescriber to reconcile the recipient’s medication list and identify potential forgeries or overutilization.
Recipient and Provider Investigations
OMIG will review recipient data to identify and investigate physicians prescribing excessive amounts of controlled substances or providing unnecessary services, and refer them to MFCU, if appropriate, for prosecution.
Recipient Restriction Program
OMIG will use the Recipient Restriction Program (RRP) to limit a recipient's access to Medicaid care and services if it is found that they have received duplicative, excessive, contraindicated or conflicting health care services, drugs, or supplies. This addresses a Medicaid recipient’s ability to obtain duplicate prescription fills through doctor or pharmacy shopping. It also may be utilized where recipients have engaged in fraudulent or abusive practices such as forgery, selling drugs obtained through Medicaid, or providing their Medicaid card to another person.
OMIG will monitor MCO compliance in: administering their RRP programs, providing monthly data on current restriction information; sharing new OMIG-initiated restrictions on enrollees; monitoring enrollees who change plans and sending the appropriate restriction information to the new plan; and coordinating provider changes with the MCO by acting as a conduit of the plan to the local district or the Health Benefit Exchange (HBE), as appropriate, to make changes in eMedNY.
OMIG will continue to work closely with the Centers for Medicare and Medicaid Services (CMS), the Department of Justice, the FBI, and national health insurance companies, as well as state and local law enforcement agencies, and continue to participate on the Governor's Task Force to Combat Heroin and Opioid Addiction.
Home Health and Community-Based Care Services
Home and community-based care services continue to grow as the population ages and the Medicaid program moves away from hospitalization and long-term care placements under the value-based payment system. The need for oversight of the home care services workers providing services to vulnerable home-bound recipients is critical.
Long-Term Home Health Care Program (LTHHCP)
OMIG will continue to audit LTHHCP fee-for-service (FFS) Medicaid claims to verify per-visit and hourly rates calculated for the various ancillary services provided, with a focus on LTHHCPs with both high Medicaid utilization and rate capitations. OMIG will also review rate add-ons, including funds dedicated to worker recruitment, training, and retention.
Certified Home Health Agencies (CHHA)
OMIG will continue to conduct both CHHA FFS audits and CHHA Episodic Payment System (EPS) audits.
Personal Care Services (PCS)
OMIG will continue to audit and investigate PCS FFS Medicaid claims, as well as PCS services provided through MCOs. MCOs are responsible for assessing Medicaid recipients and making service determinations. OMIG convenes a monthly meeting with a cross section of team representatives to discuss initiatives relating to personal care services. When auditing or investigating matters related to personal care assistants, OMIG also assesses the responsibilities of any entity associated with the personal caregiver and takes appropriate actions when those responsibilities are not being met.
The Consumer Directed Personal Assistance Program (CDPAP) continues to expand. OMIG will audit and investigate CDPAP providers to ensure compliance with rules and regulations. Audit activities will include services reimbursed through fee-for-service and MCOs.
Traumatic Brain Injury (TBI) Waiver Services
OMIG will continue to examine TBI FFS claims to determine compliance with program requirements.
Nursing Home Transition and Diversion Waiver
OMIG will continue to examine NHTD FFS claims to determine compliance with program requirements.
OMIG will continue to conduct reviews and work collaboratively with DOH and the Department of Labor to ensure that home care providers are providing wage and fringe benefit compensation to employees in compliance with wage parity laws.
Minimum Wage/Fair Labor Standards Act
OMIG will continue to conduct reviews and work collaboratively with DOH to ensure that MCOs are appropriately passing on supplemental Medicaid payments to home care providers, in compliance with DOH directives.
Long-Term Care Services
Assisted Living Program (ALP)
Resident Care Audits
OMIG will conduct field audits to validate payments for services and ensure the documented needs of patients are being met. OMIG will also provide oversight of ALP resident care audits that are conducted as part of the County Demonstration program.
OMIG and DOH Division of Adult Care Facilities and Assisted Living Surveillance will continue to coordinate efforts to monitor ALP provider’s compliance with Medicaid regulations. In the event OMIG identifies a potential quality of care or patient endangerment issue, DOH will be contacted immediately and remedial activities will be coordinated. Quality of service and fiscal issues of entities will be addressed to ensure that the population serviced by the program is safe and adequately served while maintaining claiming accuracy.
Nursing Home Audits
OMIG will continue to work with DOH’s Bureau of Long-Term Care Reimbursement (BLTCR) to ensure facilities conform to BLTCR’s policy and reimbursement regulations and will audit submitted pertinent costs and data related to the capital calculations.
Minimum Data Set
OMIG will continue to coordinate with BLTCR to review the accuracy of nursing home Minimum Data Set (MDS) submissions.
Managed Long-Term Care
Social Adult Day Care (SADC) Centers
OMIG will continue to independently investigate SADCs, and work jointly with MFCU, DOH, the New York City Buildings Department, the New York City Department for the Aging (DFTA) and the State Office for the Aging (SOFA). OMIG will also continue to have bimonthly discussions regarding complaints and new initiatives with MLTC plans, DOH, DFTA, and SOFA to review complaints, and discuss investigations and new initiatives.
OMIG will audit MLTCs to ensure enrollees are eligible to qualify for the program and that appropriate care management is being provided by the MLTC plans.
Enrollment and Eligibility Reviews
OMIG will review the enrollment records, recipient Plans of Care and claims data to determine if the MLTC plans are providing the specific services deemed medically necessary by those MLTC plans for their recipients. Additionally, OMIG will examine Case/Care Management system notations to confirm that appropriate care management is also being rendered to its members. OMIG will continue to assess MLTC plans to ensure that their contractual obligations in serving their recipient population are being met.
Medicaid Managed Care
OMIG’s ongoing efforts include performance of various match-based targeted reviews and other audits identified through data mining, analysis, and other sources. These audits lead to the recovery of overpayments and implementation of corrective actions that address system and programmatic concerns. As more service areas are transitioned into managed care, OMIG will continue to pursue initiatives that significantly enhance the detection of fraud, waste, and abuse in the MMC environment.
Managed Care Contract and Policy Relationship Management Project Team
OMIG’s Managed Care Contract and Policy Relationship Management Project Team will work to develop and advance new MCO contract amendments to address current and future Medicaid program integrity challenges and support the work of the other project teams, as well as work with DOH to continue implementation of provisions included in prior contract amendments.
Managed Care Plan Review Project Team
OMIG’s Managed Care Plan Review Project Team will conduct audits of Medicaid managed care operating reports (MMCOR). Audits will focus on the review of reported pertinent medical and administrative costs for accuracy and allowability to ensure only proper costs were utilized in the development of respective rate components.
Network Provider Review Project Team
OMIG’s Network Provider Review Project Team will perform audits of providers within MCOs’ networks to ensure the accuracy of encounter claim submissions and confirm that provider records are in regulatory and contractual compliance. OMIG will identify improper encounter claims that contribute to inflated capitation payments. OMIG will coordinate with MCOs and their Special Investigation Units (SIU) in its audit efforts.
Pharmacy Review Project Team
OMIG’s Pharmacy Review Project Team will conduct managed care network pharmacy audits to ensure pharmacy compliance with federal and state regulations, contract requirements, and the pharmacy benefit component of MMC.
The team will also audit pharmacy encounter data to verify accuracy in billing and payment of encounter claims.
Value-Based Payments Project Team
OMIG’s Value-Based Payments (VBP) Project Team will continue to work with DOH to: gain an understanding of how value-based payments will be reflected in the Medicaid data; to discuss ways of ensuring integrity within the data; and to ensure access to information is readily available to OMIG to be able to audit and investigate in a VBP environment.
Managed Care/Family Planning Chargeback
OMIG will audit claims for family planning and health reproductive services paid by MCOs for enrollees who go to non-network providers when family planning services are included in the managed care organization's benefit package.
MC Capitation Payment Audits
OMIG will audit instances where MC plans receive a capitation payment from Medicaid subsequent to an enrollee's month of death.
OMIG will audit instances where MC plans receive a capitation payment from Medicaid when the enrollee was incarcerated for the entire payment month.
OMIG will continue to strengthen the MCO referral process and work with MCO SIUs to coordinate activities related to fraud investigations. Each MCO has been assigned a designated OMIG liaison to work with their SIU representative. OMIG liaisons meet regularly with the MCOs’ SIU representative to discuss fraud, waste, and abuse-related referrals and general fraud trends. The liaison process was implemented to improve communications and increase referrals so that appropriate action can be taken to address overall program integrity.
Retroactive Disenrollment Monitoring/Recovery
OMIG will continue to maintain and update the database file used to monitor the retroactive disenrollment of enrollees by MCOs and to perform a secondary review of retroactive disenrollment activities by other agencies.
OMIG will continue to work with the New York State Department of Motor Vehicles, MFCU, DOH, and New York State Department of Transportation, as well as individual counties, to conduct reviews of Medicaid ambulette and taxi services providers. Reviews will determine if services were properly ordered, if paid services were provided, if Medicaid claims were accurately submitted to eMedNY, and if drivers were qualified to drive the vehicles used to provide the service.
OMIG is conducting Credential Verification Reviews (CVR) throughout New York State to ensure Medicaid transportation providers are adhering to all of the requirements outlined within the Department of Health Transportation Manual policy guidelines.
Ongoing Program Integrity Activities
County Demonstration Program
OMIG will continue to work with LDSSs and the New York City Human Resources Administration (NYC-HRA) to conduct reviews of pharmacy, durable medical equipment, transportation (ambulette, taxi and livery), long-term home healthcare and ALPs.
Enrollment, Reinstatement, and Removal from the Excluded Provider List
OMIG will continue to provide a secondary review of provider enrollment applications in certain high-risk categories such as pharmacies, durable medical equipment suppliers, physical therapists, and transportation providers to determine if applicants should be enrolled in the Medicaid program. OMIG will also review all reinstatement applications and requests for removal from the OMIG Exclusion List.
OMIG will respond to external audits from other government entities such as the Office of the New York State Comptroller, the federal Health and Human Services Office of Inspector General, and CMS. OMIG will analyze the external audit data, searching for and providing documentation not found during the course of the audit, researching applicable regulations, contract language and policy, and working with OMIG staff to recover inappropriately paid claims.
OMIG will conduct audits of various FFS providers in areas of concern or to meet federal waiver requirements. Programs that will be audited include, but will not be limited to:
- Diagnostic and Treatment Centers
- Durable Medical Equipment
- Health Homes
- Office of Alcoholism and Substance Abuse Services
- Outpatient Services
- Inpatient Rehabilitation Services
- Opioid Treatment Program
- Office of Mental Health
- Clinic Treatment
- Continuing Day Treatment
- Children’s Day Treatment
- Partial Hospitalization
- Intensive Psychiatric Rehabilitation Program
- Children with Serious Emotional Disturbances
- Office for Persons With Developmental Disabilities
- Clinical and Medical Services
- Day and Residential Habilitation
- Pre-School and School Supportive Health Services
- Private Duty Nursing Agencies
OMIG will continue to investigate both providers and recipients to identify those who abuse the Medicaid program.
Medicaid Electronic Health Records (EHR) Incentive Payment Program
OMIG will continue to provide oversight and conduct reviews to ensure that the CMS eligibility requirements of the Medicaid EHR Incentive program are met. In addition, the post-payment audit team will continue to conduct knowledge-sharing and collaboration sessions with stakeholders throughout the state in an effort to keep providers informed of changes in audit requirements and provide updates to the post-payment audit section of the program website as necessary.
OMIG staff will continue to work closely with providers through the self-disclosure process and will be available to address any questions or concerns that they may have.