OMIG’s Self-Disclosure Program is in accordance with OMIG’s enabling legislation:
- New York State Public Health Law (NYS PHL) §32(18) states OMIG shall, in conjunction with the commissioner, develop protocols to facilitate the efficient self-disclosure and collection of overpayments and monitor such collections, including those that are self-disclosed by providers. The provider's good faith self-disclosure of overpayments may be considered as a mitigating factor in the determination of an administrative enforcement action.
- Affordable Care Act (ACA) of 2010 §6402 states that Medicaid and Medicare overpayments must be returned within 60 days of identification, or by the date any correspondence cost report was due, whichever is later.
- Title 42 of the United States Code (USC) §1320a-7k(d)(1) & (2) requires a person who has received an overpayment to report the overpayment, the reason for the overpayment, and to return the overpayment within 60 days of identification or by the date the corresponding cost report is due, if applicable.
- Social Services Law (SOS) §363-d(6) & (7) requires a person to report and return overpayments under the medical assistance program to OMIG within 60 days of identification, or by the date any corresponding cost report is due, if applicable. It also outlines eligibility criteria for participation in the self-disclosure program and overpayment report processing timeframes.
- Social Services Law (SOS) §145-b(4)(D)(iii) states that payment of monetary penalties may be required in restitution to the medical assistance program for any person who knew or should have known that an overpayment was identified and was not reported, returned and explained in accordance with SOS §363-d.
- Title 18 of the New York Code of Rules and Regulations (NYCRR) §521-3 establishes the requirements that persons shall report, return and explain overpayments to the OMIG, and explains the requirements of the self-disclosure program administered by OMIG.
- Model Contract 3/1/2019 section 18.5(a)(viii)(G) states that the Medicaid Managed Care Organization (MMCO) shall report to the Department of Health (SDOH) and OMIG within sixty (60) days of identification of any capitation payments in excess of amounts specified in the Model Contract Agreement.
Federal and State Regulation regarding Self-Disclosure of Medicaid Managed Care:
- Title 42 of the code of Federal Regulations (C.F.R.) § 438.608(d)(2) states that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment.
- Title 18 of the New York Code of Rules and Regulations (NYCRR) §521-2.4(f) requires that Medicaid Managed Care Organizations (MMCO) shall establish policies and procedures in accordance with the requirements of section 363-d of the Social Services Law for its participating providers and other subcontractors to report, return and explain overpayments to the MMCO within sixty (60) days of identification. Additionally, it requires the MMCO to promptly report all recoveries, including recoveries which result from a provider or subcontractor reporting, returning and explaining an overpayment.
- Title 18 of the New York Code of Rules and Regulations (NYCRR) §521-2.4(h) requires the MMCO to make available on its website information on how and where to report, return and explain overpayments to the MMCO.
- Title 18 of the New York Code of Rules and Regulations (NYCRR) §521- 3.3(b)(5) states that, for an overpayment made by an MMCO to a Network Provider, a Network Provider satisfies its obligation for self-disclosure by reporting, returning and explaining the overpayment to the MMCO, provided that it is reported and returned within sixty (60) days of identification.
- Model Contract 3/1/2019 section 22.7(e) codifies that the MMCO shall have procedures in place for applicable parties to report when they have received an overpayment, to return the overpayment to the MMCO within sixty (60) days from the identification date, and to notify the MMCO in writing of the reason for the overpayment. The MMCO shall report any amount recovered in its quarterly Medicaid Managed Care Operating Report and its Provider Investigative Report.