NYS OMIG Releases 2014-15 Work Plan

The New York State Office of the Medicaid Inspector General (OMIG) has released its 2014-15 Work Plan, setting forth its audit, investigation and education activities for the upcoming year.  The Work Plan contemplates an expansion of the OMIG’s involvement in managed care program integrity and additional activities in home care.  Highlights of the plan relevant to long term care providers and managed long term care plans include:

Certified Home Health Agencies (CHHAs), Long Term Home Health Care Programs (LTHHCPs), Personal Care, Traumatic Brain Injury and Private Duty Nursing

• Provision of Services and Care Plans: Claims analysis to ensure that supervision is provided where required, that services are delivered by qualified staff, that care plans are appropriate and approved, and that services delivered are consistent with care plans.
• Spend Down Reviews: Ensure proper administration of the spend down requirement by home care agencies, where applicable.
• Home Health and Personal Care for Inpatients and Nursing Facility Residents: Identify home health and personal care claims for services delivered while the consumer is hospitalized or in an institution and where the services are covered by the facility rate.
• Home Health Aide Overlapping Payments: Ensure that Medicaid is the payer of last resort for home health services delivered to dual eligibles.
• LTHHCP and CHHA Rates: Verify per-visit and hourly rates for ancillary services and review rate add-ons, including funds for worker recruitment, training and retention.

Managed Care Organizations (MCOs)

• Managed Long Term Care (MLTC): Review enrollment records to determine whether MLTC plans properly determined eligibility for enrollment and provided proper care management to members.
• Duplicate Billing: Review Fee-For-Service (FFS) payments made for managed care enrollees to determine if the services were already included in the managed care benefit package.
• Enrollee Eligibility Status: Examine claims related to enrollees with services delivered after death or while incarcerated or institutionalized.
• Managed Care Coding: Examine managed care coding policies for patient encounter forms that are used in determining risk scores for managed care rates.
• Managed Care Cost Reporting: Examine the underlying data in cost reports to identify any unallowable costs.
• Retroactive Disenrollment: Determine whether MCOs are returning capitation payments based on local districts’ retroactive disenrollment of consumers.
• Collaborative Managed Care Surveys: Work with DOH on MCO operational surveys to determine whether MCO special investigation units are effective.

Social Adult Day Care Centers

OMIG, the Attorney General’s Medicaid Fraud Control Unit, and the New York City Buildings Department will continue to investigate several social adult day care centers in connection with overcrowding, improper solicitation of Medicaid clients, and enrollment of unqualified clients in MLTC plans.  OMIG will conduct credential verification reviews and record reviews in connection with subpoenaed documents.

Assisted Living Programs (ALPs)

• Assisted Living Program Resident Care: Review documentation of care in relation to timely medical evaluations, interim assessments, plans of care, functional assessments and evidence of service provision.
• Goods or Services Included in the Assisted Living Program Rate: Identify goods and services delivered to ALP residents and included in the ALP rates that were billed to the Medicaid program by other providers.

Nursing Homes

• Base Year Audits: Review new base year rates, focusing on inappropriate and unallowable costs, including add-ons.
• Bed Holds: Review nursing facilities' reserved bed payments to determine whether they were billed appropriately.
• Capital: Audit capital costs included within the capital component of the rate and make appropriate adjustments.
• Medicaid Rate Part B Offset: Deploy new data matching technique to capture systematically the Part B reimbursement information associated with dual eligible residents of facilities that are rated as high risk and review any appeals processed by DOH.
• Minimum Data Set: Review MDS submissions.
• Notice of Rate Changes (Rollovers): Carry forward base year operating cost audit findings and adjust rates accordingly.
• Rate Appeals: Review rate appeals approved by DOH and audit underlying costs associated with selected appeals to determine appropriateness.
• RAC Projects: Will continue in the coming year in the form of credit balance reviews and payment integrity reviews to identify overpayments, including analysis of Net Available Monthly Income, Coordination of Benefits, bed-reserve days and rate code billing.

Contact:  Karen Lipson, klipson@leadingageny.org, 518-867-8383, ext. 124