1. What is OMIG’s Self-Disclosure Program?
The Self-Disclosure Program is the mechanism providers and other entities can use to return self-identified Medicaid fund overpayments. The Self-Disclosure Program is the mechanism providers must use to self-report Medicaid Program matters 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 sixty (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.
2. What is OMIG’s self-disclosure process?
Please refer to the Self-Disclosure Program Requirements Guidance document.
3. Once I identify an overpayment, how do I meet the 60-day requirement for report, return, and explain?
When you have identified an overpayment, you should submit a Self-Disclosure Statement, Certification, and Claims Data File (if applicable) to the secure uplink that contains all required information. 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. You should cooperate with the self-disclosure process and provide any additional requested information to keep that sixty (60) days tolled during the review.
4. What circumstances require a self-disclosure?
Inappropriate Medicaid payments received should be self-disclosed. Examples could include, but are not limited to:
- Billing errors;
- 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 changing billing systems.
5. What information should NOT be self-disclosed?
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, and so forth. 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, and so forth.
- Underpayments – Any underpayments must be re-billed to eMedNY; claims are subject to their own rules and regulations.
6. Is there a dollar threshold for reporting?
No, there is no dollar threshold for reporting.
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 (for example, an 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 entities?
If your self-disclosure involves more than one entity, that should be explained in the Self-Disclosure Statement. All impacted entities and their involvement in the disclosure should be identified and fully explained, and contact information should be provided for them. All impacted entities 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 Statement is available here: Self-Disclosure Statement
11. What is the Claims Data File used for?
The Claims Data File is used to disclose overpaid Medicaid claims. A link to the Claims Data File is embedded in the Self-Disclosure Statement. For a list of data elements required, please refer to the Self-Disclosure Program Requirements Guidance document.
12. What is the Mixed Payer Calculation form used for?
The Mixed Payer Calculation (MPC) form 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 cannot be isolated and identified. The MPC form is linked to in the Self-Disclosure Statement. See FAQ #10 for a link to the Self-Disclosure Statement.
The Mixed Payer Calculation form should include the following:
- Dates the excluded individual worked and compensation earned while the individual was excluded. Compensation should include gross earnings, benefits and welfare earnings, and pension earnings.
- 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 Statement. 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 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. However, OMIG 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.
- 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 (that is, tax returns) by the due date specified in order to be considered for this payment option.
15. What is an SDCA and when is it used?
A Self-Disclosure and Compliance Agreement (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 the 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 an 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)(a)(iii) for failure to report, return, and explain the overpayment.
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)(b) and the process outlined in 18 NYCRR Part 516.
- The provider may be subject to other penalties under State and Federal law for failing to report and return overpayments to the Medicaid program.
18. 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.
Statement of Damaged, Lost or Destroyed Records
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 the loss, damage, or destruction of records 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.
19. For more Information
If you have additional questions, please reach out to OMIG’s Self-Disclosure Unit by email at: [email protected]