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OMIG Reveals Areas of Focus in Current Fiscal Year

The New York State Office of the Medicaid Inspector General (OMIG) has released its 2019-20 Work Plan detailing its plans during this state fiscal year to focus on various types of providers, services, and managed care plans. The agency has outlined three primary goals in order to achieve its mission, reflecting efforts to:

  1. ensure provider and managed care organization (MCO) compliance with the rules, regulations, and contracts of the State Medicaid program;
  2. safeguard Medicaid resources by employing best practices and tools to address fraud, waste, and abuse; and
  3. promote high-quality patient care and recipient safety through program integrity initiatives.

Managed care program integrity reviews are a new area of focus. MCOs, including Managed Long Term Care (MLTC) plans, are required to perform certain program integrity functions. OMIG will be conducting program integrity reviews of MCOs to determine adherence to their contractual responsibilities. OMIG, in consultation with the Department of Health (DOH), will publish a list of those contractual obligations that may be subject to review on its website, including benchmarks, prior to the reviews. OMIG plans to conduct MCO reviews in the same manner as it audits Medicaid providers.

Among other areas of focus in the work plan are the following of interest to LeadingAge NY members:

  • RAC Audits: Coordinate recovery initiatives with Health Management Systems, Inc., OMIG’s Recovery Audit Contractor (RAC), on issues such as bed hold days, Net Available Monthly Income, Medicare Medicaid duplicate payment/crossover overpayments, and home health services.
  • Medicare Maximization: Collaborate with OMIG's contractor, the University of Massachusetts Medical School, to review opportunities to maximize Medicare payments for dual eligibles receiving home health services.
  • Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) Waivers: Verify that NHTD and TBI fee-for-service (FFS) claims comply with program requirements.
  • Wage Parity: Ensure that home care providers are providing wage and fringe benefit compensation to employees in compliance with wage parity laws.
  • Minimum Wage: Ensure that MCOs are appropriately passing on supplemental Medicaid payments to home care providers, in compliance with DOH directives.
  • SADC: Continue to jointly investigate Social Adult Day Care (SADC) centers with State and New York City agencies.
  • Assisted Living Program (ALP): Conduct field audits to validate payments for services and ensure the documented needs of ALP patients are being met.
  • Nursing Homes: Audit costs reported for new base years, capital costs, and rate appeals; continue previous years’ audit results; and review Minimum Data Set (MDS) submissions.

Contact: Dan Heim, dheim@leadingageny.org, 518-867-8866