New York State Office of the Medicaid Inspector General 2026 Work Plan

2026 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.

In support of its program integrity mission, OMIG works closely with New York State Department of Health (DOH) as well as other state and local agencies responsible for administering Medicaid services. OMIG does not independently establish Medicaid program requirements but shares recommendations for process and program improvements in support of its work. OMIG also partners with other state and federal agencies, including the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), New York State Attorney General’s Medicaid Fraud Control Unit (MFCU), and the Office of the State Comptroller (OSC). The agency also works in close collaboration with the provider community, including multiple special investigative units maintained by each Medicaid managed care organization operating within the state.

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 2026. This plan should not be considered a list of all activities that OMIG will conduct over the course of the year. OMIG reserves the right to conduct any and all activities necessary to meet its program integrity responsibilities.

OMIG is equally committed to engage with Medicaid providers and other stakeholders to support their compliance with Medicaid requirements through a comprehensive range of education, information, and outreach activities.  These efforts serve to enhance the overall quality of care delivered to Medicaid beneficiaries by ensuring providers are well-informed about program policies, billing procedures, and clinical guidelines. Additionally, these activities provide a valuable platform for fostering collaboration and communication among OMIG, provider organizations, and other stakeholders. OMIG encourages providers and stakeholders to share information and feedback, which can be submitted to the agency via email at [email protected].

Due process protections are built into the laws and regulations that govern OMIG and is a fundamental element of all its Medicaid oversight activities. OMIG seeks to promote opportunities for all parties to be heard and for these discussions to be considered in determining the final outcome. Awareness of these process protections lends support to our vigorous defense of agency actions.

Taken together, OMIG’s program integrity activities and outreach efforts contribute to a more sustainable, responsive, and high-quality health care delivery system.

2026 OMIG Medicaid Program Integrity Key Focus Areas. Compliance, Self-disclosure, Home & COmmunity Based Services, Managed Care and Pharmacy.

Compliance

Medicaid Managed Care Organizations (MMCOs) and providers play an important 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. Persons, providers, and 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 by providing technical assistance and conducting compliance program reviews (CPRs) that assess whether a provider’s compliance program is meeting regulatory requirements as outlined in Part 521, identify program integrity risks, and provide feedback to providers on compliance program enhancements. OMIG anticipates completing approximately 200 CPRs in 2026.

Compliance Reviews:              

​Prior to July 1, 2025, all CPRs utilized a three-month review period. All reviews initiated after that date use a 12-month review period. In 2026, OMIG aims to complete and issue assessments for any remaining three-month reviews. OMIG will fully concentrate on providing guidance specific to the full year reviews of required providers’ compliance plans. OMIG is also implementing internal process changes to streamline the review process and enhance provider assessments. OMIG will also seek to obtain supplementary information prior to the start of a review that will better inform reviewers of a provider’s makeup and unique characteristics.

​Compliance Education: 

The Bureau will continue its outreach and education efforts by responding to inquiries from providers, updating and publishing guidance, and providing in-person presentations. Given the increased number of assessments completed in 2025, OMIG aims to give more focused presentations geared toward content areas and/or provider type, where applicable, and publish trends on OMIG’s compliance webpage following the completion of all 3-month CPRs. OMIG will also be expanding the areas where compliance-related guidance and requirements are listed, such as in Medicaid Updates and eMedNY.

Self-Disclosure  

Medicaid providers are required by Federal law to report, return, and explain any overpayments that they receive within 60 days of identification, including those they void or adjust, through OMIG’s Self-Disclosure Program. Voids and adjustments on their own do not satisfy these requirements.

OMIG’s Self-Disclosure Program and Abbreviated Self-Disclosure Process assists providers in meeting these requirements. OMIG’s Bureau of Self-Disclosure will continue to process self-disclosure submissions in an efficient manner, provide high-quality customer service to the submitting individual(s), and educate the Medicaid provider and plan community regarding self-disclosure requirements.

​OMIG will continue to process self-disclosure submissions received and will be exploring options to streamline and/or enhance the submission process. Additionally, OMIG plans to continue efforts to increase awareness of and compliance with self-disclosure requirements through targeted outreach to providers that have never previously self-disclosed, providing education to provider programs that have lower rates of self-disclosure, and incorporating additional self-disclosure information on the OMIG website, eMedNY, and in Medicaid Updates. With OMIG’s focus on enhanced provider outreach and education, it is anticipated that the number of self-disclosure submissions will increase. OMIG will continue to update self-disclosure guidance and FAQs as further insights are realized and as circumstances necessitate.

Damaged, Lost or Destroyed Medicaid Records

Medicaid providers are required to maintain contemporaneous records supporting their claiming for Medicaid payments. OMIG has identified through its activities that a growing number of providers are unable to fully meet these requirements and will continue to conduct provider outreach and education to address this growing trend.

As a part of their compliance efforts, providers are encouraged to regularly assess that they maintain sufficient access and control of their Medicaid records.  Providers that identify that records have been damaged, lost or destroyed are required to report that information to OMIG as soon as practicable, but no later than 30 days after discovery. Further detail on these requirements and how to report can be found in June 2025 Medicaid Update.

Medicaid Managed Care Audits

​OMIG conducts reviews of Medicaid Managed Care Operating Reports (MMCOR) and Managed Long Term Care Cost Reports (MLTCCR) submitted to the Department. These reviews ensure that reported medical, administrative and care management costs are accurate and allowable per department rules and regulations. OMIG will continue reviews in progress and initiate new reviews for both managed care organizations and managed long term care plans (collectively MCOs).

OMIG conducts Managed Care Program Integrity Reviews (MCPIR) to assess 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 new reviews of MCOs. Continued effort will be made to engage different MCO plan types in MCPIR, including Medicaid Managed Care, Managed Long Term Care Partial Capitation, Health and Recovery Plans (HARP), and Special Needs Plans (SNP).

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.  
  • 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 in mid to late 2024.  
  • 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. 
  • Retroactive Enrollment – To identify and recover capitation payments for instances where enrollees were improperly retroactively enrolled in a managed care plan and there are no services rendered. 

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 continue to collaborate with the DOH’s Bureau of Nursing Home and Long-Term Care Rate Setting to ensure facilities comply with reimbursement policies and regulations as set by DOH. OMIG will audit the capital and ancillary rates by confirming and analyzing the relevant costs and data submitted. 
  • ​Minimum Data Set (MDS) Reviews - OMIG will continue to review the accuracy of MDS submissions for selected nursing homes, completing the 2019 audit period and working on the 2022 audit period in 2026. These submissions are used by the DOH to calculate the direct cost portion of each nursing home’s Medicaid rate. 
  • ​OMIG will continue its audits of Assisted Living Program providers and will initiate new reviews in 2026 following the publication of updated protocols. An updated protocol was published on November 20, 2025, following OMIG’s receipt and review of provider comment. (View audit protocol). ​ 
Home Health & 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: 

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: 

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 of Persons 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 actively 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: 

  • ​OPWDD Community Habilitation
  • ​OPWDD Care Coordination/Health Home Services 
  • ​OPWDD Supported Employment
  • ​OPWDD Day Habilitation 
  • OPWDD IRA Residential Habilitation 
  • OPWDD Prevocational 
Direct Medical Care 

​​OMIG has initiated a direct medical care review area.  Audits will validate services and confirm physician’s visits and orders for services in the fee for service and managed care environments.  The traditional Diagnostic and Treatment Centers, and Hospital Outpatient Departments will be supplemented with Physicians services and Independent Laboratory review.  This allows for the review of the full spectrum of outpatient care. 

​​OMIG initiated protocols in the Direct Medical Care services being rendered through: 

  • ​Diagnostic and Treatment Centers (View audit protocol) 
  • ​Hospital Outpatient Department (OPD) Emergency Room/Clinic Protocol (View audit protocol) 
  • ​Hospital Outpatient Department (OPD) – Laboratory Protocol (View audit protocol) 
  • ​Hospital Outpatient Department (OPD) Ordered Ambulatory Services –   Other Than Laboratory Protocol (View audit protocol) 
  • ​Physician Services (Targeted Publication in 2026) 
  • ​Independent Laboratories (Targeted Publication in 2026)​
Children and Youth Services
  • Applied Behavior Analysis (ABA) – These services are defined by Article 167, Section 8801 of New York State Education Law as the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. These services are available to individuals under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and/or Rett Syndrome. OMIG is developing audit protocols of this program and anticipates beginning audits in late 2026. 
  • Children and Family Treatment and Support Services (CFTSS) – authorized under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefits, services offer opportunities to better meet the behavioral health needs at earlier junctures in a child/youth’s life to prevent the onset or progression of behavioral health conditions.  OMIG is developing audit protocols of this program and anticipates beginning audits in late 2026. 
  • Children’s Home and Community Based Services (HCBS) – services are designed for children/youth who, if not receiving these services, would require the level of care provided in a more restrictive environment such as a long-term care facility or psychiatric inpatient care, as well as children/youth stepping down from a long-term care facility or psychiatric inpatient care.  OMIG is developing audit protocols of this program and is anticipates beginning audits in late 2026.
  • 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 EI 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 audit protocols will be updated to include a focus on improperly claimed tolls. 

Durable Medical Equipment (DME)

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

​​​Healthcare Worker Bonus

OMIG will continue its audits of the Healthcare Worker Bonus program.

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 2026 include:   

  • 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 continue its 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. 

  • Payments Made for Clinic/Emergency Room/Ancillary Services Billed During an Inpatient Hospital Stay

    OMIG will perform system match audits to identify and recover, as appropriate, fee-for-service claims and MMCO reported encounters for clinic, emergency room, laboratory, and/or ordered ambulatory services (other than labs) billed during an inpatient stay, where those services were covered by the all-inclusive hospital rate. 

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. 

Additional Initiative

OMIG has commenced and will expand its audits of providers reviewing both fee-for-service claims and managed care encounters in one audit engagement. These audits will provide a comprehensive review of compliance with program requirements, which enhances efficiency by eliminating the need to engage providers in separate audits for the fee-for-service and managed care components.

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, HMS, 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.

Advanced Analytics 

In 2024, OMIG developed the Advanced Analytics Team. In 2026, the team will apply sophisticated data analysis techniques and updated software resources, 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, including modeling research to identify providers that have similar billing patterns to providers with high error rates in recent audit samples.
  • Outlier analysis: Identifying data points that are impossible or significantly deviate from expected trends. 
  • Integration of new data sources into the claim data catalogue, with the goal of independently verifying claim data elements that can be manipulated by providers to increase claim reimbursement or detecting undisclosed provider relationships which would lead to more intelligent identification of providers to audit.
  • Developing and deploying customized dashboards and reports that deliver current intelligence and analytics directly to decision makers – reducing the time it takes to stop emerging schemes and enhancing the depth of information available in support of audits and investigations.

​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.

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.

Recovery Audit Contract (RAC) Reviews

Per federal requirement, OMIG’s Recovery Audit Contractor (RAC), Performant, 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. These projects have largely focused on the identification of other forms of third-party health insurance coverage to ensure that Medicaid was the payor of last resort. While these reviews have historically been limited to a review of Medicaid data, in 2026 projects will be initiated that also incorporate available Medicare data. With approved data use agreements, this information will be supplied via secure feeds to the RAC Contactor and allow the RAC to have faster, more-accurate access to data to enhance RAC Audits.  Projects that will be utilizing this data include:

  • Medicare-Medicaid Duplicate Payments - An audit of the Provider’s Medicaid Fee-for-service claims and/or Medicaid Managed Care encounters to identify potential overpayments as a result of the Provider failing to report the Medicare payment on the claim.  These claims and/or encounters were adjudicated, and a duplicate primary payor payment was made to the Provider. The objective of this audit project is to assess the Provider’s adherence to applicable laws, regulations, rules, contractual obligations, and policies governing the New York State Medicaid program and to identify and recover in instances where the Provider: failed to report to Medicaid Fee-for-Service a primary insurance payment from Medicare for a dual eligible recipient, and, where the Provider failed to report to DOH’s Medicaid Managed Care Division a primary insurance payment from Medicare for a dual eligible recipient. 
      
  • Medicare-Medicaid Outpatient Crossovers – The objective of this audit is to identify overpayments to Medicare Part A for dual eligible recipients where the patient responsibility amount paid by Medicaid was greater than the responsibility remaining after Medicare Part B payments. The provider’s Medicaid Fee-for-Service claims and/or Medicaid Managed Care encounters will be reviewed to identify potential overpayments as a result of incorrectly reported Medicare patient liability amount(s) for dual eligible recipients. These claims and/or encounters were adjudicated, and Medicaid and/or Medicaid Managed Care paid a greater Medicare Part B coinsurance and/or deductible amount than what was remaining after the Medicare Part B payment. The overall objective of this audit is to assess the Provider’s adherence to applicable laws, regulations, rules, contractual obligations, and policies governing the New York State Medicaid program and to identify and recover instances where the Provider: misreported a Medicare patient liability for a dual eligible recipient on a Medicaid Fee-for-Service claim, and, where the Provider misreported a Medicare patient liability for a dual eligible recipient on a Medicaid Managed Care encounter. 

OMIG will also continue to work Long Term Care audits conducted by RAC’s Contractor Performant in 2026. The primary audit objectives being to identify if Medicaid was the payor of last resort; that Medicaid reimbursable services were rendered for the dates billed; that appropriate rate codes were used to bill for services rendered and that Claims for payment were submitted in accordance with applicable rules and requirements.

Casualty & Estate/Medicaid Liens Reconciliations

​OMIG will continue to carry out the Casualty & Estate Recovery program in coordination with its contractor, the Department of Health (DOH), and Local Department of Social Services (LDSS) to represent the State’s Medicaid interest and seek appropriate repayment of identified Medicaid liens. OMIG’s 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. OMIG will also seek to improve awareness of Medicaid liens and facilitate the processing of these cases.

Investigations

Credential Verification Reviews

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

​For example, to ensure Medicaid transportation providers adhere to all requirements outlined within DOH’s Transportation Manual policy guidelines, OMIG will continue to conduct CVRs and collaborate with state partners in the New York State Department of Motor Vehicles, the Medicaid Fraud Control Unit (MFCU), and New York State Department of Transportation, as well as individual counties, to support these reviews.    

​Additionally, OMIG has conducted and will continue to perform CVR’s in other categories of service, including Pharmacy and Dental programs.

Pre-Payment Review

​OMIG will continue to conduct pre-payment claims reviews in a variety of areas encompassing Dental, Medical and Transportation. OMIG identifies providers whose billing practices appear aberrant through analysis of post payment reports, data mining, and referrals. The identified aberrant claim types are pended (paused) for review against Medicaid guidelines prior to payment. Claims that do not meet Medicaid guidelines are denied. 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, OMIG will be expanding its focus on managed care billings and patterns of practice in 2026. OMIG is currently anticipating a decline in FFS Dental claims. OMIG is increasing medical reviews into specialties like limited enrollment pharmacies, DME, physician and transportation based on billing data trends in these areas. OMIG is committed to working with providers to educate them on billing requirements.  

​Explanation of Medical Benefits (EOMB) 

​EOMBs are used by OMIG to communicate with Medicaid recipients on the care they receive and to ensure that they are receiving the services Medicaid is paying for based on claims submitted by their providers. OMIG will continue to generate EOMBs as an investigative tool.

​Education Letters

​OMIG will continue to issue education letters when supported by investigative findings to ensure that providers understand Medicaid program requirements and their obligations. Education letters also establish connections between OMIG staff and providers so they can request assistance or ask questions.

​Agency Referrals

​In accordance with its program integrity mission, OMIG will continue to refer allegations of Medicaid fraud, as appropriate, to MFCU or its partners in local, state and federal law enforcement 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.

​Consumer Directed Personal Assistance Program (CDPAP)

​OMIG will continue to focus in the CDPAP sector, utilizing 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 continue to 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, MMCO program education and adherence, and utilization review.

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.

Additional Initiative

​​​OMIG will commence pharmacy inventory reviews (PIR). These reviews are a reconciliation of a pharmacy’s inventory for a specific period to determine if a pharmacy invoiced adequate amounts of a specific drug to cover the units claimed for payment to the NYS Medicaid Program.

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 plan or 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. Through 2025, OMIG has recognized and approved appropriate reimbursement terms for one health plan and 23 providers.