On April 1, 2015, the New York State Office of Medicaid Inspector General (“OMIG”) released its Work Plan for fiscal year (“FY”) 2015-2016 (April 1, 2015 – March 31, 2016). The OMIG’s mission is to prevent and detect fraudulent, abusive, and wasteful practices and recover improperly expended Medicaid funds. For providers, suppliers, and managed care organizations (“MCOs”), the OMIG Work Plan provides a roadmap of the OMIG’s intended areas of review for the upcoming year.
As in prior years, the OMIG has organized its Work Plan according to categories of service called “Business Line Teams.”[1] This year, the OMIG added two new Business Line Teams: (1) the Delivery System Reform Incentive Payment (“DSRIP”) Program team, and (2) the Managed Long-Term Care team, both of which address emerging areas of interest in the New York State Medicaid program.
DSRIP is the primary mechanism by which New York State will implement the Medicaid Redesign Team Waiver Amendment. DSRIP’s purpose is to restructure New York State’s health care delivery system, with the primary goal of reducing avoidable hospital use by 25 percent over the next five years. Up to $6.42 billion are allocated to this program, with payouts to providers based upon achieving predefined results in system transformation, clinical management, and population health. As new corporations are formed and enrolled as leads of the Performing Provider Systems (“PPSs”) responsible for performing DSRIP projects, they will be subject to the State’s mandatory compliance requirements. The OMIG intends to provide guidance on the mandatory compliance obligations and on compliance risk areas associated with the organizational structure and functions of PPSs, and will conduct compliance program reviews of PPS leads to assess their success in meeting these mandatory compliance obligations.
Managed Long-Term Care (“MLTC”) organizations coordinate and streamline the delivery of long-term services to people who are chronically ill or disabled and who wish to stay in their homes and communities. These services, such as home care or adult day care, are provided through MLTC plans that are approved by the New York State Department of Health. The entire array of services to which an enrolled member is entitled can be received through the MLTC plan that the member has chosen. The OMIG’s Managed Long-Term Care Business Line team will review enrollment records to ascertain whether the MLTC plans properly determined eligibility for enrollment and provided proper care management to selected members. The OMIG will also continue to investigate social adult day care centers and, where possible, will seek to involve the New York State Attorney General’s Medicaid Fraud Control Unit and the New York City Department of Buildings in these investigations.
Other notable areas of focus for the OMIG for FY 2015-2016 include:
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Diagnostic and Treatment Centers. The OMIG will review payments for services provided by diagnostic and treatment centers to determine whether services were provided, that appropriate coding was used, and that services were medically necessary. A key component of this review will be to determine the appropriateness of payments for physical, speech, and occupational therapy services, as well as HIV primary care services. Importantly, these reviews will involve time periods preceding the implementation of the Ambulatory Patient Groups payment methodology.
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Federally Qualified Healthcare Centers (“FQHCs”). The OMIG will identify whether FQHCs received the enhanced rate for services provided at an approved FQHC location for services actually provided at a non-approved location.
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Managed Care. The OMIG will:
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identify initiatives to strengthen the detection of fraud, waste, and abuse in the Medicaid managed care environment as more service areas are rolled into managed care; and
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work with MCOs’ special investigative units (“SIUs”) to facilitate the exchange of fraud and abuse allegation information among MCOs’ SIUs.
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Mental Health and Developmental Disabilities Services. The OMIG will review day habilitation and day treatment providers to determine whether services were provided in accordance with Medicaid requirements.
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Durable Medical Equipment (“DME”) and Supplies. The OMIG will determine whether DME and supplies were authorized by a licensed practitioner, items were rendered for the dates billed, and appropriate procedure codes were used in the billing process.
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Dental Services. The OMIG will review dental services providers to verify that billed services were performed, documentation supports the billed services, and claims were submitted in accordance with Medicaid program rules, regulations, manuals, and policy.
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Prescription Practices. The OMIG will perform analytics on the prescribing of controlled substances to identify prescribers with exceptional prescribing patterns.
The OMIG also intends to focus on certain activities that relate to multiple business lines, including the following:
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Collaborative Efforts with Other Agencies. The OMIG will pursue cases of Medicaid fraud in collaboration with local, state, and federal law enforcement and prosecutorial agencies, and with local and county department of social service agencies.
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Compliance Program Education. The OMIG will continue its efforts to educate and assist providers in meeting requirements to implement and operate compliance programs that conform to statutory and regulatory requirements.
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Compliance Program Reviews. The OMIG will conduct compliance program reviews of identified subjects, with a focus on providers that do not meet annual certification requirements and those that have repeated issues with the OMIG or other regulating agency requirements.
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Self-Disclosures. The OMIG will maintain a Self-Disclosure Unit and provide web-based guidance on how to return Medicaid overpayments.
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Undercover Operations. The OMIG will use undercover investigators to identify fraud and assist other investigators in confirming the existence of fraud.
The FY 2015-2016 Work Plan demonstrates that the OMIG remains committed to scrutinizing the services being rendered to Medicaid and Medicaid managed care beneficiaries. At the same time, the OMIG recognizes the new challenges that stem from the Medicaid reform initiatives in New York State and has allocated additional resources to address these areas of concern. Providers, suppliers, and payors are strongly encouraged to review the entire FY 2015-2016 Work Plan, available here, for guidance specific to their programs and services.
ENDNOTE
[1] The Business Line Team service areas are the Delivery System Reform Incentive Payment (“DSRIP”) Program; Home and Community Care Services; Hospital and Outpatient Services; Managed Care; Managed Long-Term Care; Medical Services in an Educational Setting; Mental Health, Chemical Dependence, and Developmental Disabilities Services; Pharmacy and Durable Medical Equipment; Physicians, Dentists, and Laboratories; Residential Health Care Facilities; and Transportation.
