New York State Office of the Medicaid Inspector General 2025 Work Plan

Introduction

The New York State Office of the Medicaid Inspector General (OMIG) is responsible, pursuant to Section 32 of the Public Health Law, for coordinating and conducting activities to prevent, detect and investigate medical assistance program fraud, waste and abuse, and recover improperly expended Medicaid funds.

OMIG does not independently establish Medicaid program requirements but works closely with the Department of Health (DOH) and other state and local agencies responsible for administering Medicaid services to enforce their requirements. OMIG also works cooperatively and in a coordinated manner with other federal and state agencies, including the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), the New York State Attorney General’s Medicaid Fraud Control Unit (MFCU), and the New York State Comptroller, as well as the special investigative units maintained by each Medicaid managed care organization operating within the state. In conducting these program integrity activities, OMIG promotes the delivery of appropriate and high-quality patient care to Medicaid recipients. 

This work plan provides a comprehensive roadmap for citizens, policymakers, providers, managed care organizations, and other stakeholders to follow as a guide to OMIG’s program integrity initiatives planned for 2025. This product should not be viewed as an exclusive list of all activities that OMIG will conduct over the course of the year. OMIG reserves the right to conduct all activities necessary to meet its responsibilities.

OMIG will continue its commitment to engage and enhance transparency with the provider community through a comprehensive range of education, information, and outreach activities. These efforts are intended to promote open communication and enable the agency to incorporate stakeholder input and evaluate the operational impacts of its program integrity activities. OMIG encourages providers and stakeholders to share information and feedback, which can be submitted to the agency via email at [email protected]. 

Compliance

Providers and Medicaid Managed Care Organizations (MMCOs) play a vital role in advancing program integrity by operating within Medicaid requirements and detecting irregularities. 

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. Individuals, providers, and/or affiliates are required to have a compliance program under New York State Social Services Law (SSL) § 363-d and 18 New York Codes, Rules, and Regulations (NYCRR) Part 521 if they are a “required provider” as defined in 18 NYCRR § 521.2(a). MMCOs are required by contract to have a compliance program.

​OMIG will continue to assist providers in meeting their compliance requirements and conduct compliance program reviews to assess whether a provider’s compliance program is meeting requirements, identify program integrity risks, and provide feedback to providers on compliance program enhancements. OMIG anticipates completing approximately 100 compliance program reviews in 2025. Additionally, the Bureau will continue its outreach and education efforts by responding to inquiries from providers, updating and publishing guidance, and providing in-person presentations. OMIG will also be expanding the areas where compliance-related guidance and requirements are listed, such as the Final Audit Reports and eMedNY.

Self-Disclosure

Medicaid providers are obligated to report, return, and explain any overpayments that they receive within 60 days of identification. Medicaid providers are also required to prepare and maintain contemporaneous records supporting their claiming for Medicaid payment. The Self-Disclosure Program also provides a conduit for providers to make a required report on damaged, lost or destroyed records. This provider disclosure should be made as soon as practicable, but no later than thirty (30) calendar days following discovery.  Additional information can be found in the self-disclosure Guidance document and Frequently Asked Questions (FAQs), which are posted on OMIG’s website.

​OMIG developed the Self-Disclosure Program and Abbreviated Self-Disclosure process to assist fee-for-service providers in meeting these requirements. While the number of self-disclosures continue to increase, OMIG is still identifying challenges in meeting self-disclosure requirements, particularly as it relates to reporting within MMCOs. OMIG will continue to process submissions received under the Abbreviated Self-Disclosure Process and the Full Self-Disclosure Process, and plans to increase awareness of and compliance with both processes through targeted outreach to providers that have never previously self-disclosed, providing education to smaller provider programs that have a history of lower instances of self-disclosures, and including self-disclosure information on eMedNY and in Medicaid Updates.  

Medicaid Managed Care Audits

​OMIG will continue to review Medicaid Managed Care Operating Reports (MMCOR) submitted to the State to ensure that reported costs and data is accurate, complete, and allowable. These reviews will ensure that MMCO payments calculated using this data are appropriate. In 2025, OMIG expects to increase the number of MMCOR reviews conducted and to incorporate reviews of Managed Long-term Care Plans. 

​OMIG conducts Managed Care Program Integrity Reviews (MCPIR) to measure Medicaid Managed Care plan compliance with their program integrity obligations under its contract with the department. OMIG will continue to complete as well as initiate a new round of reviews with a Review Period covering the 2023 calendar year. MCPIR is also expanding its focus to include additional types of Managed Care Plans for review, including Managed Long-Term Care (MLTC) plans. 

​OMIG will also continue to audit MMCOs in the following areas:​ 

• Incarceration Match – To identify and recover capitation payments paid for individuals who were incarcerated for an entire payment month.
• ​Deceased Enrollees – To identify and recover capitation payments paid after an enrollee’s date of death.
• ​Retroactive Disenrollment - To identify Medicaid Managed Care plans that have not voided in response to notification from the local district.
• ​Out of State Medicaid Recipients – To identify and recover capitation payments for Medicaid Managed Care enrollees who resided in another state for the entire payment month.
• ​Supplemental Maternity and Newborn Capitation Payments – To identify maternity and newborn supplemental payments for which supporting encounter data was not submitted or the maternity case ended in termination or miscarriage.
• ​Supplemental Low Birth Weight Newborn Capitation Payments – To identify low birth weight newborn supplemental payments that may have been inappropriately paid.
• ​Multiple Client Identification Numbers (CIN) – To identify and recover capitation payments paid when one member has been issued two CINs and two monthly capitation payments have been made to the same plan for the same member.
• ​Family Planning Chargeback Fee-for-Service (FFS) Audit - After completing the family planning reconciliation for the managed care plans, OMIG conducts a follow-up audit for claims removed from the managed care plan’s liability. This audit recovers FFS payments submitted to Medicaid by network providers who have a contractual agreement with the managed care plan and should have billed the plan for these family planning services.
• ​Enhanced Nursing Home Capitation Payments – To identify instances where the MMCO did not qualify for enhanced reimbursement level.
• Partial Cap – Eligibility & Care Management – To make recoveries when OMIG identifies a capitation payment as inappropriately paid due to a lack of rendered services, loss of eligibility, or delayed disenrollment. 
• ​Medicaid Advantage Plus (MAP) – Eligibility & Care Management – OMIG plans to conduct reviews of MAP plans to evaluate the eligibility of members enrolled in the Plan and whether the care management provided by the Plan aligned with enrollee-specific care plans and assessments.
• ​Audit of Fee-For-Service Claims Billed by Network Providers for Medicaid Managed Care Enrollees (“Category H”) - OMIG will continue to identify and recover duplicate payments resulting from eligibility issues caused by conflicting eligibility information between NY State of Health (NYSoH) and Welfare Management System (WMS). OMIG plans to review the 2021-2022 audit period during 2025. 

Provider Audits

Long-Term Care Services 

​Medicaid is a principal policy driver and primary payor for long-term residential placements for the aged and disabled. Nursing homes and Assisted Living Programs (ALPs) remain an area of focus for OMIG to ensure that residents are appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations.  OMIG activities in this area will include:

• Nursing Home Rate Audits - OMIG will maintain collaboration with the DOH’s Bureau of Nursing Home a Long-Term Care Rate Setting to ensure that facilities comply with DOH reimbursement policies and regulations. Additionally, OMIG will audit the relevant costs and data submitted concerning capital rates and ancillary services.
• ​Minimum Data Set (MDS) Reviews - OMIG will continue to review the accuracy of MDS submissions for selected nursing homes, completing the 2018 audit period and working on the 2019 audit period in 2025. These submissions are used by the DOH to calculate the direct cost portion of each nursing home’s Medicaid rate.
• ​​Assisted Living Programs Audits (view Assisted Living Program Protocol)

Home & Community-Based Services 

​Home and community-based services continue to grow as the population ages and consumers seek alternatives to hospitalization or long-term care placements. OMIG’s continued oversight in this area is to ensure that recipients are appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations. OMIG activities in this area will include: 

• ​Diagnostic and Treatment Centers (View audit protocol)
• ​Home Health (Episodic payment) (View audit protocol)
• ​Personal Care Services (View audit protocol)
• ​Private Duty Nurses Agency (View audit protocol)
• ​Private Duty Nurses Independent (View audit protocol)
• ​Nursing Home Transition and Diversion (View audit protocol)
• ​Consumer Directed Personal Assistance Program (View audit protocol)
• ​Physician Services (protocols in development)
• Traumatic Brain Injury Services (View audit protocol)

Behavioral Health/Addiction Services and Supports

New York State continues to advance and invest in services and social supports to serve the needs of people living with addiction, mental illness and other complex health care needs. Consistent with program requirements established by the Office of Mental Health (OMH) and the Office of Addiction Services and Supports (OASAS), OMIG will continue to conduct audits in this area to ensure that these populations are appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations. OMIG is also actively developing and updating audit protocols for several of these areas, and which will be posted to OMIG’s website when finalized. OMIG activities in this area will include: 

• ​New in 2025 -- OMH Personalized Recovery Oriented Services (PROS) 
• ​New in 2025 -- OMH Telehealth Services
• ​OMH Mental Health Outpatient Treatment and Rehabilitative Services
• ​OMH Continuing Day Treatment
• ​OMH Day Treatment for Children
• ​OMH Partial Hospitalization
• ​OMH Community Rehabilitation Services
• ​OASAS Opioid Treatment Program (View audit protocol)
• ​OASAS Inpatient Rehabilitation Services (View audit protocol)
• OASAS Substance Use Disorder Outpatient Programs (View audit protocol)

Person-Centered Services and Supports

New York State maintains an extensive network of services and supports for individuals with developmental disabilities. In close collaboration with the Office for People With Developmental Disabilities (OPWDD), these services remain an area of focus to ensure that this population is appropriately served, that services are rendered properly and documented in accordance with Medicaid rules and regulations. OMIG is also developing and updating audit protocols for several of these areas, and which will be posted to OMIG’s website and linked when finalized. OMIG activities in this area will include: 

• ​New in 2025 - OPWDD Community Habilitation
• ​​OPWDD Care Coordination/Health Home Services
• ​OPWDD Supported Employment
• ​OPWDD Day Habilitation
• ​OPWDD IRA Residential Habilitation
• ​OPWDD Prevocational 

Early Intervention (EI) 

​The NYS Early Intervention Program offers a variety of therapeutic and support services to eligible infants and toddlers with disabilities and their families. This remains a focus of OMIG to ensure that recipients are receiving services in compliance with Medicaid regulations and programmatic guidance. Fee-for-Service Early Intervention audits will continue to be conducted (View audit protocol).

Health Home Services  

​The NYS Health Home program provides comprehensive care management to chronically ill individuals. This remains a focus of OMIG to ensure that recipients are receiving services in compliance with Medicaid Regulations. Fee-for-Service Health Home audits will continue to be conducted (View audit protocol).

Pharmacy

​Pharmacy remains an OMIG focus area to ensure compliance with existing Medicaid regulations and appropriate authorization of payment for controlled substance claims. Fee-for-Service Pharmacy Audits will continue to be conducted (View audit protocol).

Transportation 

​Non-emergency transportation services remain a focus area for OMIG due to significant billings, federal oversight, and provider turnover. Fee-for-Service Audits will continue to be conducted in the following areas: 

• ​Transportation Ambulette (View audit protocol)
• Transportation Taxi/Livery (View audit protocol) 

Durable Medical Equipment (DME)

​Fee-for-Service Durable Medical Equipment Audits will continue to be conducted (View audit protocol).

System Match

​OMIG uses 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. These audits also provide OMIG the opportunity to educate providers so they can improve their compliance with Medicaid billing rules and are performed in several project areas. Anticipated project areas for 2025 include MMCO and FFS home health payments during an inpatient or skilled nursing facility stay (SNF), MMCO payments for services not coordinated through recipient restriction program providers, and MMCO payments to unenrolled or excluded providers.  

• Home Health Services During an Inpatient or Skilled Nursing Facility Stay (SNF) - OMIG will perform system match audits in this area to ensure MMCO and FFS payments were not made for home health services during a recipient’s inpatient of SNF stay.  Medicaid SNF patients and hospital inpatients are provided a full range of patient services during their stay.  Home health and personal care services, with certain exceptions, are not necessary during these stays as they are duplicative.  Medicaid reimbursement may not be made for services which duplicate/substitute for services that are required to be provided by another entity.
• MMCO Payments For Services Not Coordinated Through Recipient Restriction Program Providers - ​Under federal authorization, the Recipient Restriction Program (Restriction Program) was created to reduce the cost of inappropriate utilization by identifying Medicaid recipients who demonstrate a pattern of misusing and abusing the Medicaid program. With certain exceptions, Medicaid recipients in the Restriction Program must receive certain care through only their designated health care providers or via referral from those providers. OMIG will perform system match audits in this area to identify and recover, where appropriate, MMCO payments for services that were not coordinated through a recipient’s designated provider as required.
• MMCO Payments to Unenrolled or Excluded Providers - ​OMIG will perform system match audits to identify and recover, as appropriate, MMCO payments to in-network providers that were not enrolled in the NYS Medicaid program when the services were rendered when required.  Additionally, OMIG will identify instances of MMCO payments made to providers who were excluded from the NYS Medicaid program when the services were rendered.   
• Home Health Care Medicare Maximization - ​To ensure that NYS Medicaid remains the payor of last resort, OMIG contracts with the University of Massachusetts Chan Medical School (UMass) to perform a Medicare Home Health Appeals Initiative. Under this initiative, and where determined appropriate, providers will continue to be directed to demand bill Medicare for home health care services rendered to dual eligible Medicare/Medicaid beneficiaries that have previously been paid by Medicaid. UMass will pursue coverage for Medicare payment denials via the federal Medicare appeals process. Provider audits will continue in instances where providers fail to comply with demand billing requirements or fail to reimburse NYS Medicaid as directed, after Medicare has remitted payment. 

Third Party Liability Match

Medicaid is intended to be the health care payor of last resort. Under the Third-Party Liability Contract (TPL), OMIG utilizes its contractor to ensure that Medicaid is only billed after all other forms of insurance coverage have been exhausted.

OMIG staff continue to work with its contractor on Pre-Payment Insurance Verification (PPIV) match and delivery of Commercial Insurance segments to ensure accurate identification of third-party coverage. Inappropriate Medicaid payments are averted by edits to the payment system.

OMIG staff also work with its contractor on third-party retroactive recoveries. Recovery attempts are made by sending Medicaid reclamation claims to insurance carriers or by engaging directly with Medicaid providers.

Advanced Analytics 

In 2024, as part of its Bureau of Business Intelligence, OMIG developed the Advanced Analytics Team. In 2025, the team will apply sophisticated data analysis techniques - machine learning and predictive modeling, for example - to identify and prevent fraud, waste, and abuse within the Medicaid program. This approach enables OMIG to proactively detect suspicious patterns and irregularities in claims data, which enhances the agency’s abilities to safeguard both the Medicaid program and recipients.

Detection methods include:

• Pattern recognition: Identifying unusual patterns in claims data, such as abnormally high billing frequencies from a single provider or unusual service combinations.  
• Outlier analysis: Identifying data points that are impossible or significantly deviate from expected trends.
• Predictive modeling: Based on historical data, using algorithms to predict potentially fraudulent activity.  

OMIG’s ongoing efforts in this area will enhance the ability to apply analytics across multiple Medicaid data sources (Medicaid Data Warehouse, EVV Data, MAS Transportation Data, PACDR Encounter Data, etc.) to expand fraud, waste, and abuse detection and enforcement efforts. 

Recovery Audit Contract (RAC) Reviews

Per federal requirement, OMIG’s Recovery Audit Contractor (RAC) coordinates with OMIG to identify and collect overpayments that would likely go undetected by reviewing Medicaid claims data alone. OMIG will continue to work with its RAC, providers, and the Centers for Medicare & Medicaid Services’ Unified Program Integrity Contractor to promote and inform future program integrity projects.

Casualty & Estate/Medicaid Liens Reconciliations

​OMIG will continue to carry out the Casualty & Estate program in coordination with its contractor, DOH, and Local Department of Social Services (LDSS) to represent the State’s Medicaid interest. OMIG’s internal reporting will be enhanced to improve the intake and assignment of Medicaid lien cases, allow for enhanced data reporting, and increase the contractor’s efficiency in gathering necessary case information. Additionally, OMIG has updated the Casualty & Estate webpage to provide additional information to impacted stakeholders.

Investigations

Credential Verification Reviews

OMIG will continue to conduct on-site and remote Credential Verification Reviews (CVRs) throughout New York State to determine providers’ compliance with Medicaid requirements and educate providers on Medicaid guidelines. 

To enhance Medicaid transportation providers’ adherence to requirements outlined in DOH’s Transportation Manual policy guidelines, OMIG will, in collaboration with its state partners in the New York State Department of Motor Vehicles, the Medicaid Fraud Control Unit (MFCU), New York State Department of Transportation, and individual counties, conduct CVRs. In addition to transportation CVRs, OMIG will continue to conduct reviews in other categories of service, including pharmacy and dental programs.

Pre-Payment Review

OMIG will continue to conduct pre-payment claims reviews of pended FFS claims in a variety of areas like dental, private duty nursing, and others. Through analysis of post payment reports, data mining and referrals, OMIG identifies providers whose billing practices appear aberrant and pends payment of claims to identify their compliance with Medicaid guidelines prior to payment. These reviews are utilized in several ways; as a compliance tool, to monitor limited enrollments, and to prevent inappropriate costs to the Medicaid program.

With the shift of provider billing activity through Managed Care, staff will be expanding their focus on managed care billings and patterns of practice in 2025. OMIG is currently anticipating increasing medical reviews into specialties like family planning, dental, DME, physician and transportation based on billing data trends in these areas and is committed to working with providers to educate them on billing requirements.  

Explanation of Benefits (EOMB)

EOMBs are an increasingly valuable tool and used by OMIG to educate Medicaid recipients on the care they receive and investigate if services were delivered appropriately. OMIG will continue to generate EOMBs as needed as an investigative tool to bring cases to a conclusion. 

Education Letters

When supported by investigative findings, OMIG will continue to issue provider education letters to enhance their understanding of and compliance with Medicaid program requirements and obligations. These letters also help forge connections between OMIG and providers, which foster improved communications. 

Provider Enrollment and Reinstatement

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. Enrollment will also review all reinstatement applications and requests for removal from the OMIG Exclusion List.

​​Consumer Directed Personal Assistance Program (CDPAP)

​OMIG will have an enhanced focus in the CDPAP sector and will utilize all tools available and appropriate to help ensure that services are delivered effectively, funds are used appropriately, and recipients’ health and safety are protected. 

Restricted Recipient Program (RRP)

OMIG will enhance its oversight in the RRP service area, including MMCO requirements, which focuses on implementing, monitoring, and managing the use of healthcare services by recipients identified as having a pattern of inappropriate or excessive utilization of services. Such enforcement helps ensure the program achieves its objectives, including improved care coordination, cost containment, and fraud, waste, and abuse prevention. Key areas of oversight include the identification and enrollment of restricted recipients, the coordination of care, and utilization review. 

​Agency Referrals 

​In accordance with its program integrity responsibilities, OMIG will continue to refer allegations of Medicaid fraud, as appropriate, to MFCU or its other law enforcement partners in local, state and federal agencies. Additionally, OMIG will continue to collaborate with its partners to address emerging fraud schemes and trends and take derivative Medicaid enforcement actions in support of other state agency findings. 

Healthcare Worker Bonus

OMIG developed and initiated an audit process in 2024 to validate Health Care Worker Bonus (HWB) claims that were filed for eligible employees, and these audits will continue to be conducted.  

OMIG also developed processes for the Employer Self-Disclosure of overpaid Healthcare Worker Bonus (HWB) funds and will continue to process submissions received.

Collections

OMIG will continue to engage in projects to develop and support provider-friendly processes such as the Financial Hardship and Electronic Payment Portals. The Hardship Process application provides an opportunity for extended repayment when a provider cannot afford to repay their OMIG liability within the standard repayment timeframe, which is two years at a rate of no less than 15 percent of their prior year’s billings.

Page last updated: January 2025