New York State Provider Compliance Programs: Office of the Medicaid Inspector General Regulations
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:
- 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;
- 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
- 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:
- written policies and procedures;
- designation of a compliance officer;
- training and education of all affected employees and persons associated with the provider;
- communication lines to the compliance officer;
- disciplinary policies to encourage good faith participation in the compliance program;
- a system of routine identification of compliance risk areas;
- a system for responding to compliance issues as they are raised; and
- 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.
