Health Care Compliance Watch : New York Health Care Compliance Lawyer & Attorney : Ilana Sable : NY Physician Representation Law

After spending a few days absorbing the newly issued Office of the Medicaid Inspector General (“OMIG”) regulations regarding NY State provider compliance programs, I am wondering what the term “Medicaid Providers …” includes.

It is clear that providers who meet the $500,000 minimum simply by billing directly to Medicaid are subject to the regulations, but what about those providers who devote a significant portion of their practice to patients enrolled in Medicaid managed care programs. Most Medicaid eligible people residing in mandatory counties are required to join a managed care health plan, and are therefore utilizing Medicaid benefits through an alternative means. However, the problem is that often times providers cannot distinguish which of their managed care patients are Medicaid recipients.

For example, in Kings County, New York, Medicaid managed care plans are available through managed care providers such as:

• GHI HMO
• Metroplus Health Plan
• Neighborhood Health Providers
• United Healthcare of New York

These managed care plans offer coverage to the general public, as well as Medicaid recipients, thereby making it very difficult for providers to determine when they are providing services to Medicaid recipients.

Furthermore, managed care generally covers most of the benefits recipients will use, including all preventative and primary care, inpatient care, and eye care. Therefore, it is likely that many New York State providers will fall into a category where they meet the $500,000 minimum set by the OMIG simply by providing services to patients enrolled in Medicaid managed care programs. New York State providers are strongly encouraged to further investigate, and prepare for, this possibility.

Whether or not a provider falls into a category of “Medicaid Provider,” as defined by the OMIG, it is highly advisable for all providers to draft and implement a comprehensive compliance program for their practices. At minimum, these programs will ward off potential privacy breaches, detect and prevent improper billing, and educate and train employees in regulatory compliance. The reward will certainly outweigh any investment of time, money and personnel.
 

• Email This
• Print
• Comments
• Trackbacks

On January 14, 2009, the New York State Office of the Medicaid Inspector General (“OMIG”) adopted regulations stating that New York State providers of care, services and supplies for which the Medicaid program constitutes a substantial portion of their business operations are required to adopt and implement effective compliance plans.

The OMIG defines “substantial portion” of business operations to mean any of the following:

1. a person, provider or an affiliate of the provider claims or orders, or has claimed or has         ordered, or should be reasonably expected to claim or order at least $500,000 in a consecutive twelve-month period from the medical assistance program;
2. a person, provider or an affiliate of the provider receives or has received, or should be reasonably expected to receive at least $500,000 in any consecutive twelve-month period directly or indirectly from the medical assistance program; or
3. a person, provider or an affiliate of the provider who submits or has submitted claims for care, services, or supplies to the medical assistance program on behalf of another person or persons in the aggregate of at least $500,000 in a consecutive twelve-month period.

The OMIG regulations also state that the mandatory compliance programs shall be applicable to:

• billings;
• payments;
• medical necessity and quality of care;
• governance;
• mandatory reporting;
• credentialing; and
• other risk areas that are or should with due diligence be identified by the provider.

The OMIG regulations are in line with previous compliance guidance offered by agencies such as the Department of Health and Human Services. Specifically, the OMIG requires that required providers’ compliance programs shall include the following elements:

1. written policies and procedures;
2. designation of a compliance officer;
3. training and education of all affected employees and persons associated with the provider;
4. communication lines to the compliance officer;
5. disciplinary policies to encourage good faith participation in the compliance program;
6. a system of routine identification of compliance risk areas;
7. a system for responding to compliance issues as they are raised; and
8. a policy for non-intimidation and non-retaliation for good faith participation in the compliance program

In the future, the OMIG is expected to issue specific compliance program guidelines for certain types of required providers.

• Email This
• Print
• Comments
• Trackbacks (1)

The most common question posed by private medical practices concerning the incentive payments available under the American Recovery and Reinvestment Act ("ARRA") goes something along the lines of: "how do you actually get the money"? 

Well, as you can imagine, the government won't just mail you a check.  Non-hospital based providers will be eligible to receive up to $44,000.00 in bonus payments from Medicare, over an above the allowed Medicare charges.  The incentive payments will either be broken down into several partial payments throughout the calender year, or they will be paid in a lump sum; the technicalities are yet to be worked out.

However, in order to be eligible for the incentive payments, providers must make "meaningful use" of their EHR software.  “Meaningful use” is not specifically defined in the ARRA, but the ARRA does give the Secretary of Health and Human Services (HHS) advisory guidance regarding how to determine its meaning.

On April 29, 2009, the National Committee on Vital and Health Statistics, the key advisory panel to HHS on Health Information Technology, held a two-day hearing on "meaningful use" of EHR systems.  To date, no determination as to the definition of "meaningful use" has been made, but an HHS rulemaking determining its statutory definition is expected this year.

• Email This
• Print
• Comments
• Trackbacks