1. What is OMIG’s Self-Disclosure Program?
The Self-Disclosure Program is the mechanism providers must use to self-report Medicaid fund overpayments that involve possible fraud, waste, abuse, or inappropriate payment of funds which they have identiﬁed through self-review, compliance programs, or internal controls. Providers are required to report, return, and explain any overpayments received by them to OMIG within 60 days of identiﬁcation, or by the date any corresponding cost report was due, whichever is later. See Social Services Law (SOS) section 363-d.
Please Note: Voiding or Adjusting Medicaid Claims does not satisfy a Medicaid provider’s obligation to report and explain the identified overpayment.
2. What is OMIG’s self-disclosure process?
OMIG’s Self-Disclosure Program includes two pathways for Medicaid providers to report, return and explain self-identified overpayments. Both the Full Self-Disclosure Process and the Abbreviated Self-Disclosure Process begin with the same steps. A Medicaid entity/Provider discovers that they are in receipt of a Medicaid overpayment, and they investigate to identify and explain it. This identification includes:
- Determining why the overpayment occurred
- How it occurred
- Who/What was involved in causing it to occur
- Who was involved in discovering it
- What will be done to correct it and ensure it doesn’t reoccur
- And quantification of the overpayment amount (to the best of the Medicaid entity’s/Provier’s ability)
The Medicaid entity/Provider reviews the reason for the overpayment and determines which of OMIG’s self-disclosure processes is appropriate for them to utilize in satisfying their obligation to report, return and explain.
Within 60 days of the identification of the overpayment the Medicaid entity/Provider will submit a completed Full Self-Disclosure Statement, Certification form and Claim Data form or Mixed Payor Calculation (MPC) form, if applicable. They will receive confirmation of receipt via email which confirms the 60-day timeframe has been tolled. The Self-Disclosure Unit will review the submission documentation and will verify the overpayment amount as applicable. Additional information will be requested, if needed. The Medicaid entity/Provider will have 15 calendar days to supply any additional information requested. Once the review is complete a Determination Notice will be issued to the Medicaid entity/Provider confirming the total overpayment amount for the overpayment reason(s) disclosed, confirming any amounts already repaid through void or adjustment, and any balance still due. It will also contain repayment instructions as applicable. If the Medicaid entity/Provider has requested extended repayment terms they will be contacted by OMIG’s Office of Counsel.
Medicaid providers may utilize the Abbreviated Self-Disclosure Process to report and explain identified overpayments resulting from routine and transactional errors or meet other defined characteristics and have already been voided or adjusted. The Medicaid provider voids or adjusts the overpaid claim(s) within 60 days of identification as appropriate and adds it/them to the Self-Disclosure Abbreviated Statement form. As a convenience and best practice, providers may aggregate their submissions in a monthly report which will be submitted by the 5th of the month following the month in which the claims were voided or adjusted. They will receive confirmation of receipt via email. Additional information will be requested, if needed. The Medicaid provider will have 15 calendar days to supply any additional information requested. Overpaid claims reported and explained through the Abbreviated process are already repaid by void or adjustment, therefore no Determination Notice will be issued for Abbreviated process submissions. OMIG may, in its discretion, request that a Medicaid provider submit a Full Self-Disclosure Statement.
For more information, please refer to the Self-Disclosure Guidance document.
3. What circumstances require a self-disclosure?
All self-identified inappropriate Medicaid payments received should be self-disclosed.
Examples to be self-disclosed using the Self-Disclosure Full Statement include but are not limited to:
- Any error that requires a Medicaid entity/Provider to create and implement a formal corrective action plan;
- Actual, potential or credible allegations of fraudulent behavior by employees or others;
- Discovery of an employee on the Excluded Provider list;
- Documentation errors that resulted in overpayments;
- Overpayments that resulted from software or billing systems updates;
- Systemic billing or claiming issues;
- Overpayments that involved more than one Medicaid entity/Provider (example – Health Homes & Care Management Agencies);
- Non-claim-based Medicaid overpayments;
- Any error with substantial monetary or program impacts; and
- Any instance upon direction by OMIG.
Examples to be self-disclosed using the Self-Disclosure Abbreviated Statement:
- Routine credit balance/coordination of beneﬁts overpayments;
- Typographical human errors;
- Routine Net Available Monthly Income (NAMI) adjustments;
- Instance of missing or faulty authorization for services due to human error;
- Instance of missing or insufficient support documentation due to human error;
- Inappropriate rate, procedure or fee code used due to typographical or human error;
- Routine recipient enrollment issue
Questions regarding selecting the appropriate statement for submitting your Self-Disclosure can be submitted to the Self-Disclosure Unit at [email protected].
4. Once I identify an overpayment how do I meet the 60-day requirement for report, return and explain?
There are two options for meeting the 60-day requirement. The determination for which option is required is dependent on the circumstances that led to the identiﬁed overpayment.
When you have identiﬁed an overpayment, within 60 days from identifying and quantifying it (when applicable), you should submit a completed Self-Disclosure Full Statement and Claim Data Form (if applicable) to the secure uplink. You will receive an auto generated response conﬁrming that your submission was received. This submission will toll, or pause, your 60 days while OMIG processes your disclosure, and it satisﬁes your report and explain requirement. You should cooperate with the self-disclosure process and provide any additional requested information to keep your time frame tolled during the review. Once the review is complete you will receive a Determination Notice with instructions on repayment and your 60 days will un-toll. Repayment within the time frame speciﬁed in the Determination Notice will satisfy your return requirement.
Overpaid claims should be voided or adjusted as appropriate once identiﬁed, and within 60 days of that identiﬁcation must be reported and explained to OMIG in aggregate using the Self-Disclosure Abbreviated Statement spreadsheet. As a best practice, Medicaid entities/Providers can submit Self-Disclosure Abbreviated Statements on a monthly basis reporting for the previous month.
Self-Disclosure Abbreviated Statements must be submitted by the 5th of each month as applicable. Completed Self-Disclosure Abbreviated Statements should be submitted as directed on the form. You will receive an auto generated response conﬁrming that your submission was received, this submission satisﬁes your report and explain requirement.
5. Is there a dollar threshold for reporting?
No, there is no dollar threshold for reporting. All self-identified inappropriate Medicaid payments received should be self-disclosed. However, the Medicaid entity/Provider should utilize the appropriate process for reporting inappropriate Medicaid payments – Full Self-Disclosure Process or the Abbreviated Self-Disclosure Process.
6. What information should NOT be self-disclosed?
All self-identified inappropriate Medicaid payments received should be self-disclosed. However, there are instances where Medicaid overpayments received may have been identified by OMIG or another enforcement entity. Providers should not self-disclose the following:
- When a provider’s overpayment is included in another separate review or audit being conducted by OMIG, the Oﬃce of the Inspector General, Attorney General, etc. Please note that providers are required to seek permission from the investigating entity before voiding or adjusting claims.
- When a provider’s overpayment is included in a broader state-initiated rate adjustment cost settlement or other payment adjustment mechanisms. For example: retroactive rate adjustments, charity care, cost reporting, etc.
Additionally, the Self-Disclosure Program can’t reconcile underpayments. All underpayments must be re-billed to eMedNY; claims are subject to their own rules and regulations.
7. Should I self-disclose if someone notified me of the overpayment, if I didn’t discover it through self-review?
Yes. If your oversight agency or another entity notiﬁes you of a possible overpayment, you are obligated to investigate and identify if an overpayment exists as well as the scope and amount of the overpayment. You are obligated to self-disclose Medicaid fund overpayments to OMIG’s self-disclosure program. The only exception to this obligation is if the overpayment is already encompassed by an existing review and will be recovered through that existing review (example – existing OMIG audit). If you are involved in an existing review, you should check with your review contact to ensure there is no overlap between the existing review and the overpayment you will be self- disclosing. If you have additional questions about potential overlap, please contact the Self-Disclosure Unit at [email protected].
8. What if my self-disclosure involves several Medicaid entities/Providers?
If your self-disclosure involves more than one Medicaid entity/Provider, it should be explained in the Self-Disclosure Full Statement. All impacted Medicaid entities/Providers and their involvement in the disclosure should be identiﬁed and fully explained, and contact information should be provided for them. All impacted Medicaid entities/Providers should be made aware of the disclosure as additional information may be requested during the self-disclosure review process.
9. What is the lookback period for self-disclosure?
The lookback period is six (6) years.
10. How do I submit a self-disclosure?
The Self-Disclosure Full Statement and Self-Disclosure Abbreviated Statement are available here. The website has a secure uplink, which is the preferred submission method.
11. What is the Claims Data File used for?
The Claims Data File is used to disclose overpaid Medicaid claims. It is embedded in the Self-Disclosure Full Statement. For a list of data elements required please refer to the Self-Disclosure Guidance document.
12. What is the Mixed Payer Calculation File used for?
The Mixed Payer Calculation File is used to determine the repayment amount for excluded or non-enrolled individuals whose salaries were paid through multiple sources. It should only be used in instances where the impacted Medicaid Claims can’t be isolated and identified. The MPC form is embedded in the Self-Disclosure Full Statement.
The Mixed Payer Calculation File should include the following:
Dates the excluded individual worked and compensation they earned while the individual was excluded. Compensation should include gross earnings, benefits and welfare earned, and pension earned.
Revenue amounts as found in the Provider’s fiscal or calendar year records, both the revenue from all sources including Medicaid, and the Medicaid only revenue.
13. Does the Self-Disclosure Program accept requests for Extrapolation as a methodology to calculate overpayments?
Providers who wish to request a Universe, Sample and Extrapolation methodology to calculate their overpayment amount must provide a justification explaining why that methodology is being requested in their Self-Disclosure Full Statement form. Approval is made in the sole discretion of OMIG.
The Provider must also provide the data element parameters necessary for OMIG to extract a universe of potentially overpaid claims.
If the request is not approved, a claim-by-claim review of the potentially overpaid claims will be required.
If the request is approved, OMIG will extract a universe of potentially overpaid claims based on the parameters disclosed in the Self-Disclosure Full Statement and a statistically valid random sample of claims will be provided for review. The Provider must review and respond by the due date specified with the entire Sample and an explanation for each claim identifying if it was allowed or disallowed and why. The overpayment will be calculated using the lower limit of the 90% confidence interval based on the Sample response.
NOTE: The extrapolated overpayment amount repaid through a self-disclosure would reduce any amount owed due to overpayments found in any future review of the same claims. OMIG, however, reserves its right and the rights of any other entity authorized by law to conduct further audits, investigations, or reviews of the Provider’s participation in the Medicaid program for the same or a different time period and the same basis.
14. What types of payment options are available for the Self-Disclosure Program?
Payment options include:
Lump sum check, money order or electronic check payment. DO NOT send payment in with your submission.
Voids or Adjustments of the overpaid claims. These transactions should be completed prior to submission. Claims disclosed using both the Self-Disclosure Full Statement and the Self-Disclosure Abbreviated Statement can be voided or adjusted to repay Medicaid.
Installment Payments via a Self-Disclosure and Compliance Agreement (SDCA). A provider may request installment payments prior to the issuance of a Determination Notice. This payment option is granted or denied at the discretion of OMIG. A provider must supply all supporting financial documentation requested by OMIG (i.e., tax returns) by the due date specified to be considered for this payment option.
15. What is a Self-Disclosure and Compliance Agreement (SDCA) and when is it used?
An SDCA takes the place of the Stipulation Agreement document historically used for self-disclosures that have been approved for extended repayment terms. The SDCA can be used for extended repayment, or to document the provider’s commitment to a corrective action plan. The approval or requirement for an SDCA is at the sole discretion of OMIG.
16. What happens if a Provider fails to comply with the self-disclosure process?
Violations of Self-Disclosure process include but are not limited to:
Providing false material information in any disclosure documents.
Failure to cooperate in validating the overpayment amount disclosed.
Intentional omission of material information from any disclosure documents.
Failure to pay the overpayment amount and any interest as agreed.
Failure to timely execute a SDCA or any violation of the provisions detailed in the SDCA.
Providers who received a Medicaid overpayment and do not self-disclose it, or providers who fail to exercise reasonable diligence in discovering and identifying that overpayment, will be subject to penalties pursuant to SOS §145-b(4) for failure to report, return and explain the overpayment. Penalties can be imposed up to $10,000 per item or service, unless this penalty has already been imposed on the provider within the previous five years. In those cases the penalty can be up to $30,000 per item or service.
Once a provider has self-disclosed, violations of the self-disclosure process shall result in the provider becoming ineligible for the benefits of the Self-Disclosure Program.
OMIG may use the information disclosed. A provider’s failure to complete the self-disclosure process will result in OMIG’s pursual of any civil or criminal penalty that might apply to the misconduct disclosed as part of the program process, and OMIG shall impose penalties pursuant to SOS §145-b(4)(a)(iii) for failure to report, return and explain the overpayment.
Failure to report, return and explain
- The penalties imposed for failure to report, return, and explain shall be based on the guidelines speciﬁed in SOS § 145-b(4) and the process outlined in 18 NYCRR Part 516. Penalties can be imposed up to $10,000 per item or service, unless this penalty has already been imposed on the provider within the previous five years. In those cases the penalty can be up to $30,000 per item or service.
The provider may be subject to other penalties under State and Federal law for failing to report and return overpayments to the Medicaid program.
17. Am I required to report damaged, lost, or destroyed records?
Yes; pursuant to Title 18 of the New York Codes Rules and Regulations, Section 504.3, providers are required to prepare and maintain contemporaneous records demonstrating their right to receive payment under the medical assistance program and furnish the records, upon request. If a provider becomes aware that their records have been damaged, lost or destroyed that information should be reported as soon as practicable, but no later than thirty (30) calendar days after discovery.
For reports of lost, destroyed, or damaged records submissions, a Notice of Acceptance detailing the acceptance of the report is issued to the provider/authorized provider contact person.
Please note that providers must also notify any other State or local regulatory agency of their loss, damage or destruction as required by those regulatory agencies. OMIG’s receipt of a Statement of Damaged, Lost or Destroyed Records does not absolve a provider of its recordkeeping responsibilities. The paid claims and/or program associated with the lost/destroyed records remain available for audit, review, or investigation. In the event of a Medicaid audit or investigation in which sought records were not maintained as required by 18 NYCRR 504.3, OMIG will evaluate Statements of Damaged, Lost or Destroyed Records and determine on a case-by-case basis whether there are mitigating circumstances for the failure to maintain these documents.
For more Information
If you have additional questions, please reach out to OMIG’s Self-Disclosure Unit by email at: [email protected].