18 NYCRR 504.3(a)
"By enrolling the provider agrees: ... to prepare and to maintain contemporaneous records demonstrating its right to receive payment under the medical assistance program and to keep for a period of six years from the date the care, services or supplies were furnished, all records necessary to disclose the nature and extent of services furnished and all information regarding claims for payment submitted by, or on behalf of, the provider and to furnish such records and information, upon request, to the department, the Secretary of the United States Department of Health and Human Services, the Deputy Attorney General for Medicaid Fraud Control and the New York State Department of Health:"
18 NYCRR 504.3(e)
"By enrolling the provider agrees: ... to submit claims for payment only for services actually furnished and which were medically necessary or otherwise authorized under the Social Services Law when furnished and which were provided to eligible persons:"
18 NYCRR 504.3(h)
"By enrolling the provider agrees: ... that the information provided in relation to any claim for payment shall be true, accurate, and complete;"
18 NYCRR 504.3
"By enrolling the provider agrees: ...to comply with the rules, regulations and official directives of the department."
18 NYCRR 518.1(c)
An "overpayment" is "any amount not authorized to be paid under the medical assistance program, whether paid as the result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse or mistake."
18 NYCRR 518.3(a)
"The department may require repayment from the person submitting an incorrect or improper claim, or the person causing such claim to be submitted, or the person receiving payment for the claim."
18 NYCRR Section 518.4(a)
“Interest may be collected upon any overpayments determined to have been made and will accrue at the rate and in the manner set forth in this section.”
Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract, March 1, 2019, Appendix H
"Failure by the NYSoH, Enrollment Broker, or LDSS to notify the Contractor of a disenrollment does not affect the right of the SDOH to withhold or recover capitation payment(s) as authorized by Section 3.6 of this Agreement or for the State Attorney General to bring legal action to recover any overpayment."
Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract, March 1, 2019, Section 19.7
OMIG has the right to "review, audit, and investigate contracts, encounter data, cost reports, plan benefit design or any other information used, directly or indirectly, to determine expenditures, claims, bills and all other expenditures of medical assistance program funds to determine compliance with federal and state laws and regulations and take such corrective actions as are authorized by federal or state laws and regulations."
Related Medicaid Recovery Audit Contractor Resources