The New York State Office of the Medicaid Inspector General (OMIG) is the New York State (NYS) Medicaid program’s “watchdog” agency. (Last year they recovered in excess of $851 million from providers and others.) It is one of the most prominent state OMIG’s in the country, so providers in other states keep an eye on what the NYS OMIG does even if they do not operate in New York. The NYS OMIG issues a Work Plan each year outlining the programs OMIG plans to review for that year regarding fraud and abuse enforcement. OMIG recently released its State Fiscal Year 2014-2015 Work Plan for work to be performed from April 1, 2014 through March 31, 2015.
The Work Plan organizes OMIG’s efforts into Business Line Teams (BLTs), or specialized multi-disciplinary teams that help coordinate program integrity activities with other federal, state and local partners. Each BLT consists of auditors, investigators, clinicians, attorneys and technicians, all of whom have different areas of expertise and experience.
This year’s Work Plan delineates the following categories of services assigned to the BLTs:
- Home and Community Care Services
- Review certified home health agencies, long-term home health care programs, personal care aides, traumatic brain injury, and private duty nursing services for appropriate provision of services, consistency with patient care plans, and proper application of spend down rules.
- Hospital and Outpatient Services
- Focus on the review of Medicaid payments for selected outpatient services, improper billing for emergency room, clinic and ancillary services during an inpatient stay, and payments for services provided by diagnostic and treatment centers.
- Managed Care
- Review whether managed long term care plans are properly enrolling and managing the care provided to members; also focus on ongoing audit and review of duplicate billing, coding and cost reporting.
- Medical Services in an Educational Setting
- Focus on school supportive health services provided to special education students between the ages of three and twenty-one.
- Mental Health, Chemical Dependence, and Developmental Disabilities Services
- Work in close collaboration with the Office of Alcoholism and Substance Abuse Services, the Office of Mental Health and the Office for People with Developmental Disabilities to promote program integrity among service providers under their regulatory limitations.
- Pharmacy and Durable Medical Equipment
- Includes drug and durable medical equipment services aiming to reduce Medicaid waste by reducing drug diversion and drug misuse.
- Physicians, Dentists, and Laboratories
- Includes all health care practitioners who submit Medicaid claims for physician, dentist and laboratory services to identify improper billing practices, and excluded providers who continue to bill for Medicaid services provided, as well as other areas of concern.
- Residential Health Care Facilities
- Reviews nursing facilities and assisted living programs focused on documentation of care, timeliness of evaluations/assessments/plans of care and the presence of relevant evidence of service provision.
- Transportation
- Collaborate with the following New York State Departments: Department of Motor Vehicles, Medicaid Fraud Control Unit, Department of Health and individual counties to assess whether services were provided in accordance with applicable Medicaid rules.
This year’s Work Plan includes multiple BLT and individual BLT strategies and focuses on expanding review of Medicaid managed care and compliance activities. The multiple BLT activities appear to be a continuation of those from 2013, including, for example, corporate integrity agreement enforcement, identification of providers who have engaged in kickbacks and inducements, prepayment review and self-disclosure portal functions. Notably, this Work Plan reintroduces (previously mentioned in the 2011 Work Plan) undercover investigator operations to assist in discovering quality-of-care issues, billing problems, and systematic fraud, as well as gather information on how organizations operate and the types of drugs subject to abuse.