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.
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.
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 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
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.
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.
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.
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.
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
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.