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OMIG Reveals Areas of Focus in the Coming Year

The New York State Office of the Medicaid Inspector General (OMIG) has released its 2016-17 Work Plan, detailing its plans during this state fiscal year to focus on various types of providers, services and managed care plans. According to the work plan, OMIG will continue to organize its work according to categories of service and will continue to use its Business Line Teams across several areas including Managed Long Term Care (MLTC), transportation, home and community-based services, residential health care facilities and mainstream Medicaid managed care.

Among the areas of focus in the work plan are the following of particular interest to LeadingAge New York members:

Home Health Verification Project: Review verifications for home health providers with total Medicaid reimbursement exceeding $15M per calendar year.

Hospice services: Verify whether patients and/or family members voluntarily elected services; a certification of terminal illness was obtained; qualifying services were authorized; and all required documentation supporting continued care was in the patient file.

Home health services: Review provision of services; consistency with patient care plans/service plans; processing of spend-down requirements; duplicative and overlapping payments; Medicare maximization requirements; and CHHA/LTHHCP rates and workforce funds.

Consumer-Directed Personal Assistance Program (CDPAP): Verify that services billed to Medicaid were actually delivered, and that CDPAP assistants comply with personnel requirements.

Nursing Home Transition and Diversion waiver: Verify that services were provided, that services billed were included in the service plan; that service plans were timely updated; and that services were provided by qualified staff.

MLTC: Continue to jointly investigate Social Adult Day Care (SADC) centers with State and NYC agencies; verify documentation that SADC centers must maintain for certification; and review enrollment records to determine if MLTC plans properly determined eligibility for enrollment and provided care management to selected members.

Assisted Living Program (ALP): Review to ensure that documented needs of residents are being met and there is no overcharging for services rendered; and identify goods and services delivered to ALP residents by other providers and billed to Medicaid that were also included in ALP payment rates.

Nursing homes: Audit costs reported for new base years; capital costs and rate appeals; continue  previous years’ audit results; review eligibility for bed hold payments; and review Minimum Data Set submissions impacting the July 1, 2014 through June 30, 2015 Medicaid rates. 

The Work Plan indicates that OMIG will continue to emphasize provider outreach and education, with a focus on providers having proactive compliance programs that will prevent or, when necessary, detect and address abusive practices. Proactive measures may include compliance webinars, guidance materials, self-assessment tools, and presentations.

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