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A Deeper Dive on the OMIG Work Plan

As reported last month, the New York State Office of the Medicaid Inspector General (OMIG) has announced a number of new initatives to combat fraud, waste and abuse in the Medicaid program in 2016-17, while continuing many of the initiatives commenced last year. A detailed summary of the OMIG's annual Work Plan, prepared by attorneys at Hinman Straub, is avalable here

Among the new intitiatives of particular interest to long term care providers and plans are:

  • Compare managed care encounter data with other plan-submitted data to assess the consistency and completeness.
  • Continue to investigate social adult day care centers and coordinate with the New York State Department of Health (DOH) and the New York State Office for the Aging (NYSOFA) to implement the State’s social adult day certification process.
  • Review Managed Long Term Care (MLTC) enrollment records to determine whether MLTC plans have properly determined eligibility for enrollment and whether they have provided appropriate care management.
  • Work with the DOH Bureau of Narcotics Enforcement (BNE) to ensure provider compliance with the Internet System for Tracking Over-Prescribing (I-STOP) and monitor compliance with the e-prescribing mandate.
  • Review Assisted Living Program (ALP) nurse assessments and rate setting tools to ensure that documented needs of residents are met (e.g.,the interim assessment nurses section, functional assessment, patient review instrument (PRI), and the Uniform Assessment System for New York (UAS-NY)).

In addition to these new external audit initaitives, the OMIG and DOH are collaborating on a new Managed Care Organization (MCO) Incentive Program. The program incentivizes MCOs to fight fraud, waste and abuse by deducting amounts from MCO rates to reflect fraud recovery targets. This program was included in the enacted 2016-17 state budget, with a cumulative target of $30M. The OMIG will monitor plan activity and provide support.

The OMIG will also monitor the implementation of  the state's Value Based Payment (VBP) reforms and will adapt its oversight activities accordingly.  Finally, the OMIG is implementing a new project management approach to guide its efforts in combatting fraud, waste and abuse in Medicaid manage care.

Contact:  Karen Lipson, kipson@leadingageny.org, 518-868-8383 ext. 124