Whom Does the Term "Medicaid Providers" Include?
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.
