2019-2020 OMIG Work Plan

OMIG outlined three overarching goals in its 2019-2020 Strategic Plan (see graphic). It is important to note that the goals are not presented in order of priority - each goal has equal significance and weight in helping OMIG achieve its mission. In fulfilling its mission, OMIG prioritizes work and allocates resources accordingly. In addition to the mandatory requirements set forth in laws and regulations, OMIG evaluates projects for the potential for positive impact on the Medicaid program and Medicaid recipients.

The first goal focuses on provider and managed care organization (MCO) compliance with the rules, regulations, and contracts of the New York State Medicaid program.

The second goal focuses on safeguarding Medicaid resources to ensure that the State can meet the needs of eligible recipients by actively employing best practices and state-of-the-art tools to address fraud, waste, and abuse.

The third goal focuses on recipient safety and promoting high-quality patient care through program integrity initiatives.

Finally, OMIG’s Work Plan is a dynamic document that is updated throughout the year as new priorities and issues arise.

See Previous OMIG Work Plans

 The following are new action items in OMIG's Work Plan:

• Managed Long-Term Care Plan Site Visits

Compliance Programs

Effective compliance programs create a control structure to reduce the potential for fraud, waste, and abuse through self-correction and/or self-reporting of errors by providers. Persons, providers, or affiliates are required to have a compliance program under New York State Social Services Law (SSL) § 363-d and 18 NYCRR Part 521 if they are a “required provider” as defined in 18 NYCRR § 521.2(a). Managed Care Organizations are required by contract to have a compliance program. A recent change to SSL § 363-d establishes that an MCO’s compliance program, which meets the federal requirements as specified in the contract, shall also meet the state requirements.

Compliance Program Reviews

OMIG will conduct compliance program reviews of providers to analyze whether a Medicaid provider’s compliance program is implemented and operating as required by SSL § 363-d and NYCRR Part 521 and issue censures as needed. Analysis of MCO compliance programs will be part of the Managed Care Program Integrity Reviews.

Corporate Integrity Agreement Monitoring and Enforcement

OMIG will continue to implement, monitor, and enforce corporate integrity agreements (CIA) when terminating or excluding a provider found to have committed fraud, waste, or abuse would have significant impact on recipient access to care.

Medicaid Managed Care

Managed Care Program Integrity Reviews

MCOs, including Managed Long-Term Care (MLTC) plans, are contractually bound to adhere to and perform the requisite program integrity functions delineated in their contracts with New York State. OMIG will be conducting program integrity reviews of MCOs to determine adherence to the contract. OMIG, in consultation with the Department of Health (DOH), will publish a list of those contractual obligations that may be subject to review on its website, including benchmarks, prior to the reviews. OMIG will conduct its reviews in the same manner that it conducts audits of Medicaid providers.

Managed Long-Term Care Plan Site Visits

OMIG is conducting on-site visits with Managed Long-Term Care (MLTC) plans across the state to discuss program integrity-related processes and procedures. The visits serve to review with MLTCs the rules, regulations and contract requirements relating to program integrity, and inform OMIG's program integrity efforts in this area going forward.

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 on ensuring the integrity of value-based payments as they are reflected in the Medicaid 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.

MC Investigations

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. OMIG has instituted a multi-disciplinary statewide review process for all referrals received from the MCO plans in order to provide timely responses to the plans.

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.

Data Review Project Team

The Data Review Project Team will continue to ensure OMIG has reliable and usable data from a wide variety of sources, including the Medicaid Data Warehouse (MDW), Salient Data Mining Solution, All Payer Database, Data Mart, and Encounter Intake System. The Team represents OMIG on the Encounters Steering Committee, a committee that is accountable for governance of Encounter Intake System changes with the goal of promoting transparency, stakeholder communication and shared decision-making.

Encounter Analysis

OMIG will continue to analyze and evaluate the integrity of encounter data, performing comparative analyses of encounters and other plan-submitted data to evaluate the consistency and completeness of MCO encounter reporting. OMIG will also collaborate with DOH to improve data reporting by plans and facilitate data availability in the MDW.

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.

External Audits

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.

Fee-for-Service Audits

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 Addiction Services and Supports
  • 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

Investigations

OMIG will continue to investigate both providers and recipients to identify those who abuse the Medicaid program. Through the newly implemented multi-disciplinary referral review process, OMIG has identified ways to better assess the impact to program integrity and to focus the response and planned agency actions. OMIG applies a clinical and data analysis to all referrals, as well as an investigative look to assure concerns are promptly addressed. Taking cases from intake through case completion and action, OMIG invests valuable resources to protect the Medicaid Program and its participants.

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.

Self-Disclosure

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.

Innovative Analytics

OMIG and DOH will be partnering with a data analytics firm to recover erroneous payments made on behalf of incarcerated and/or deceased recipients.

System Match Recovery

OMIG will continue to use analytical tools and techniques, as well as knowledge of Medicaid program rules, to data mine Medicaid claims and identify improper claim conditions for potential recoveries of inappropriate Medicaid expenditures.

Recovery Audit Contractor (RAC)

OMIG will continue to collaborate and coordinate recovery initiatives with its Recovery Audit Contractor (RAC), Health Management Systems Inc. (HMS). During FY19, HMS will focus reviews on the following:

• Credit Balance Audit FFS and Encounter
• Graduated Medical Education and Indirection Medical Education
• MCO/FFS/Same Plan Overlap
• Long-Term Care - Bed Hold Days/Net Available Monthly Income/Correct Co-insurance/Coordination of Benefit Errors/Rate Code Errors
• Duplicate Payment of Professional Services Included in Ambulatory Patient Group Rate Code
• Alternate Level of Care Days
• Medicare - Inpatient Part B/Crossover Overpayment/Incorrect Reimbursement for Medicare Part C Claims (NY RAC 033)
• Medicare Medicaid Duplicate Payment/Crossover Overpayments
• Medicaid Payment Exceeds Billed Charge
• Intensity Modulated Radiation Therapy Plan Unbundling
• Duplicate Comprehensive Psychiatric Emergency Program Case Rates/Inpatient Overlap/Brief vs. Full
• Intensive Rehab Add On
• Ordered Ambulatory Services
• JCode Incorrect Reimbursement
• Home Health

Unified Program Integrity Contract

OMIG will continue its collaboration with Safeguard Services (SGS) under CMS's Unified Program Integrity Contract (UPIC). OMIG and SGS have multiple projects in process involving data analysis, audits, investigations, and pre-payment reviews covering the following program areas: dental providers; home health; consumer-directed assistance program; and opioids. OMIG is looking to expand UPIC review areas to hospice and transportation providers.

Third Party Liability (TPL) Match and Recovery Services

OMIG’s contractor, HMS, will continue to conduct pre-payment insurance verification to identify and utilize third-party coverage for Medicaid recipients, to conduct third-party retroactive recoveries, and engage in estate and casualty recoveries.

Medicare Home Health Maximization

OMIG will continue to work collaboratively with its contractor, the University of Massachusetts Medical School (UMass), to maximize Medicare coverage for dual-eligible Medicare/Medicaid recipients who have received home health care services paid by Medicaid. OMIG will continue to work with CMS and the Office of Medicare Hearings and Appeals to achieve favorable outcomes of hearings and appeals for Medicaid cases. 

Medi-Medi Crossover

OMIG is collaborating with both UPIC and RAC contractors to identify duplicative payments occurring between Medicare and Medicaid. By utilizing Medicare data supplied by SGS and having our RAC contractor, HMS, match this data to the Medicaid paid claims, providers who are not properly using the Medicare crossover process and, therefore, obtaining duplicative payments will be identified and repayment of Medicaid claims will be sought.

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.

Wage Parity

OMIG continues to conduct reviews and work collaboratively with 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.

Nursing Home Audits

Rate Audits

OMIG will continue to work with DOH’s Bureau of Residential Health Care Reimbursement (BRHCR) to ensure facilities conform to BRHCR’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 BRHCR to review the accuracy of nursing home Minimum Data Set (MDS) submissions.

Partial Capitation/Enrollment and Eligibility Reviews

OMIG will review 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.

Fraud, Waste, and Abuse Investigation Collaborations

In pursuing cases of Medicaid fraud, OMIG will continue to engage in collaborative efforts with federal, state, and local law enforcement agencies, as well as 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 by providing ongoing case support and expertise. 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 individuals attempting to defraud New York State taxpayers and the Medicaid program.

In addition to the ongoing program integrity endeavors outlined in Goal #2, the activities in this section are centered on several priority areas that particularly impact recipient safety: fighting prescription drug and opioid abuse; home health and community-based care; long-term care; and transportation.

Combating 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.

Prescription Monitoring

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.

Utilization Alerts

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.

Collaborative Partnerships

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.

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.

Long-Term Care Services and Services for Older Adults

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.

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.

Transportation

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.

Transportation Reviews

OMIG will continue to conduct 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.

Abbreviations	Work Plan Acronyms
ALP	Assisted Living Program
BLTCR	Bureau of Long-Term Care Reimbursement
BNE	New York State Bureau of Narcotic Enforcement
CHHA	Certified Home Health Agency
CIA	Corporate Integrity Agreement
CMS	Centers for Medicare and Medicaid Services
DFTA	New York City Dept. for the Aging
DOH	New York State Department of Health
DOJ	U.S. Department of Justice
EHR	Electronic Health Record
eMedNY	Electronic Medicaid of New York
EPS	Episodic Payment System
FFS	Fee-For-Service
HBE	Health Benefit Exchange
HMS	Health Management Systems, Inc.
LDSS	Local Department of Social Services
LTHHCP	Long-Term Home Health Care Program
MCO	Managed Care Organization
MDS	Minimum Data Set
MDW	Medicaid Data Warehouse
MFCU	New York State Attorney General Medicaid Fraud Control Unit
MLTC	Managed Long-Term Care
MMC	Medicaid Managed Care
MMCOR	Medicaid Managed Care Operating Report
MRT	Medicaid Redesign Team
NHTD	Nursing Home Transition and Diversion Waiver
NYC-HRA	New York City Human Resources Administration
NYCRR	New York Codes, Rules and Regulations
NYSoH	New York State of Health
OIG	Health and Human Services Office of the Inspector General
OMIG	New York State Office of the Medicaid Inspector General
PCS	Personal Care Services
RAC	Recovery Audit Contractor
RRP	Recipient Restriction Program
SADC	Social Adult Day Care
SGS	Safeguard Services
SIU	Special Investigation Unit
SOFA	New York State Office for the Aging
SSL	Social Services Law
TBI	Traumatic Brain Injury
TPL	Third-Party Liability
UMass	University of Massachusetts
UPIC	Unified Program Integrity Contact
VBP	Value-Based Payment