Should a compliance officer or president (certifying party) retire, resign, etc. during the certified year and be replaced by another person, should the OMIG be notified of the changes and if so, by what mechanism?
Answer: There is currently no mechanism to update the information on the certification form until the next annual certification period. The updated information should be used during the next annual certification cycle. OMIG recommends that the Medicaid provider's compliance officer maintain a file that notes the information that should be updated and that the updates be consulted prior to completing form for the coming year.
If a NYS Medicaid provider does not receive payments in the amount of $5 million, do the DRA and the DRA certification obligation apply to the Medicaid provider? If the DRA obligation does not apply to a NYS Medicaid provider, is the Medicaid provider's only obligation to certify under the NYS Social Services Law Section 363-d?
Answer: The DRA Certification is required for those New York State Medicaid providers who receive or pay at least $5 million during a federal fiscal year. The federal fiscal year is from October 1st through September 30th each year. The amount billed the Medicaid program is not a factor in computing if the $5 million threshold is being met; it only considers amounts received, or amounts paid out. CMS FAQs provide additional guidance and can be accessed at http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD032207Att1.pdf
If a NYS Medicaid provider does not reach the $5 million threshold for the DRA, the provider may have an obligation to have a compliance program under NYS Social Services Law Section 363-d, and, as a result, may have the obligation to certify that the Social Services Law compliance program meets the requirements of Section 363-d.
Could you please confirm that Early Intervention programs are subject to the NY compliance requirements? They have in the past but were not mentioned when discussing the "article" categories.
Answer: The Early Intervention Programs are subject to the New York State Social Services Law Section 363-d mandatory compliance program if Medicaid is a "substantial portion of business operations" as that is defined in 18 NYCRR 521.2(b).
How should you enter a person's name into the form if that person goes by his or her middle name, e.g. J Andrew Doe?
Answer: Since the certification form allows only a single letter for the middle initial data field, OMIG recommends using the full first name and the middle initial, as that will help to ensure that the correct person is identified in the Compliance Officer or Person Certifying data fields.
What happens if you make a mistake completing the certification form and want to correct the mistake after already submitting the form?
Answer: If a Medicaid provider makes a mistake in any data field on the SSL or the DRA certification forms, Person Certifying can submit a new form during the month of December only. Since there is no current method to update the information that has been entered (see question 1 above) outside of December, OMIG recommends that the provider's compliance officer make a record of the correction or update and have it available for inspection if requested by any state or federal agency.
I am a new physical therapist and I have accepted cases from a placement agency to work with developmentally disabled children in a school district. Is there any Medicaid training or certification course I must take, since my clients are Medicaid eligible? I am not an employee of the placement agency. I am an independent contractor.
Answer: The independent contractor should contact the New York State Department of Education and the New York State Department of Health to inquire about any training or certification requirements. Additionally, the independent contractor may also need to consider applying with the New York State Department of Health's Office of Health Insurance Programs to become a participating Medicaid provider.
Can providers get a history of their past submissions?
Answer: Currently there is no secure data base that can be consulted to obtain a copy of a Medicaid provider's past certifications. OMIG recommends that Medicaid providers maintain copies of the confirmation e-mails that are issued by OMIG at the time of certification.
There were three different Medicaid trainings that were required and they were available on the Web up until the end of September 2012 but they are no longer available. What is required now?
Answer: Medicaid training for Medicaid providers is established by the New York State Department of Health. The person asking this question should contact the Department of Health to inquire about required trainings.
Will the compliance officer of the organization also receive an e-mail showing receipt of certification? It seems to say on the certification confirmation page that "an e-mail will also be sent to the compliance officer." Will an e-mail also be sent to the certifying party?
Answer: Yes. Starting in 2013, the Compliance Officer and the Person Certifying will receive an e-mail from OMIG. Previously, only the Person Certifying would receive the OMIG e-mail. OMIG uses the information on the certification form to address the e-mails.
Does the DRA requirement to disseminate information to employees and contractors also apply to the provider's governing board members?
Answer: OMIG recommends that the person asking this question seek a legal opinion from their attorney on the scope of the DRA to governing board members.
Are physician's charges counted toward the $500,000 threshold?
Answer: To the extent that a physician's charges are included on claims submitted for Medicaid reimbursement, the physician's charges will be counted toward the $500,000 claimed threshold referenced in 18 NYCRR Part 521.2(b)(1). The claim threshold of 18 NYCRR Part 521.2(b)(1) is different from the $500,000 paid threshold under 18 NYCRR Part 521.2(b)(2).
What does "MCO" stand for?
Answer: Managed Care Organization.
I work with a facility that changed ownership in May 2013. They have submitted an application to New York State to transfer their provider numbers to the new operator and the new operator's FEIN. This application has not been approved to date. Does the new owner only certify under their FEIN or must the old operator certify under its FEIN since Medicaid payments are still being made under their FEIN/NPI combination?
Answer: Depending upon the circumstances, the new owner may need to certify under their FEIN as well as the old operator's FEIN. This will be very fact-driven. Each FEIN that is active or has been active since the last certification period should be considered for certification in December.
Does Compliance certification only apply to providers and not managed care?
Answer: No. If Medicaid is a substantial portion of a managed care organization's (MCO's) business operations, the MCO must have a compliance program and must certify that its compliance program meets the requirements of New York State Social Services Law Section 363-d and 18 NYCRR Part 521. Substantial portion of business operations is defined in 18 NYCRR 521.2(b).
Do the Compliance Program Assessment Form and/or our Compliance Plan documents need to be submitted with our certification?
Answer: No. Providers should not submit a Compliance Program Assessment form and/or compliance plan documents with their certification. The certification submission is limited to the information on the online certification form.
If OMIG wishes to review compliance program documents or the Compliance Program Assessment Form, providers will receive invitation letter or email requesting submission of same. That request will be outside of the provider's certification process.
For the NYS Social Services Law's certification obligation, must there be a separate certification for each Federal Employer Identification Number (FEIN)?
Answer: Yes. OMIG tracks certification by FEIN.
In computing the point when the $500,000 threshold is met based on dollars received, do the payments include direct payments by New York State (e.g., fee-for-service-type payments) and indirect payments?
Answer: Yes. Direct payments (from NYS) and indirect payments are aggregated to determine when the $500,000 threshold is met. The most common form of indirect payment is a payment provided by an MCO to its network providers for Medicaid care, services, or supplies provided to MCO members. Other indirect payments can occur beyond just those made through MCOs. An example of that is when a certified home health agency (CHHA) uses a licensed home care agency to provide home care services to a Medicaid beneficiary under the CHHA's care. The CHHA in that case receives a direct payment from NYS and the licensed agency does not receive a direct payment from NYS, but rather receives its payment from the CHHA.
In computing the point when the $500,000 threshold is met, is it based on claimed amounts or received amounts?
Answer: It is based upon either when $500,000 is claimed or when $500,000 has been received, whichever occurs first. In many cases, a provider's charges are the basis for determining what is claimed. Charges are often greater than the amount that is ultimately paid under the Medicaid program.
If we do not meet the $500K, whether submitted or received, do we still need to file the compliance online?
Answer: If you have an obligation to have a compliance program, you must annually certify that the compliance program meets the requirements of Social Services Law Section 363-d and 18 NYCRR Part 521. The only way that the certification can be accomplished is through OMIG's online form.
Those that must have a compliance program (and therefore must certify) are those where Medicaid is a "substantial portion of business operations," as defined in 18 NYCRR 521.2(b). This is where the $500,000 threshold is set out. However, Social Services Law Section 363-d subd. 4 and 18 NYCRR 521.1 (a) and (b) require those that are subject to New York State Public Health Law Article 28 or Article 36; or subject to New York State Mental Hygiene Law Article 16 or Article 31 to also be subject to the mandatory compliance program obligation and therefore the certification requirement.
Just to clarify, if we do not bill or receive anywhere near $5M, than we do not need to certify through DRA. Correct?
Answer: The federal Deficit Reduction Act of 2005 requires action if a provider receives $5 million in payments from the state's Medicaid program. Please refer to the DRA's FAQs 13 through 22 which can be accessed at http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD032207Att1.pdf
The above FAQs are intended to provide responses to questions of general interest related to the certification requirement set out in Social Services Law Section 363-d and 18 NYCRR 521.3(b). If you have a specific question or if you have a question that is not addressed in the above FAQs, please contact OMIG's Bureau of Compliance by e-mail at email@example.com and raise your question. The Bureau of Compliance will attempt to address your specific question.