OMIG posted the finalized Assisted Living (ALP) protocol Click here to see the complete list of OMIG protocols. The ALP protocol is listed there.
New York State identified $496 million in Medicaid erroneous payments and recovered $211 million from the federal government for errors relating to home care recipients who are dually-eligible for both Medicare and Medicaid funds. Through the action of the Office of the Medicaid Inspector General (OMIG), the New York State Department of Health’s Fiscal Group received the $211 million payment, representing the state’s share of the funds, on October 1, 2013, representing the largest single monetary recovery in OMIG’s history. These recoveries are part of the Third-Party Liability Home Health Care Demonstration Project, a federal project looking at home health care involving dual-eligible recipients, conducted in conjunction with the University of Massachusetts Medical School. New York State’s portion of the money reflects project efforts during the years 2007-10 and totals more than $496 million, with $211 million in state share funds. These dollars are a planned part of the Medicaid global cap and will help to ensure that New York contains costs within the Medicaid program.
In the case of dual-eligible recipients, here’s how the billing should work: Home health care providers should first bill Medicare, and then bill Medicaid for whatever portion of the bill Medicare does not pay. Once that process is complete, the dual-eligible recipient’s bill is paid in full. Having dual eligibility in both Medicare and Medicaid is not an unusual circumstance.
“As in most cases, Medicaid is the payer of last resort for dual-eligible recipients,” Medicaid Inspector General James C. Cox explained. “In the cases reflected in these overpayments, bills for these home health care patients were inadvertently sent to Medicaid before first sending them to Medicare and following the correct process. Through the demonstration project, we were able to prove that Medicaid was overcharged and recover the money.”
Jason Helgerson, director of the Medicaid program said, “This finding is further validation of the path set forward by the Medicaid Redesign Team of moving all services and populations into high-quality managed care, which will help to ensure that New York will contain costs within the Medicaid program. We are thankful for the work of the Office of Medicaid Inspector General and the University of Massachusetts to accomplish these savings.”
“We are grateful to have had the opportunity to help the State of New York in its pursuit of payment for these services from the federal government,” said Marc Thibodeau, executive director of the University of Massachusetts Medical School’s Center for Health Care Financing.
This process is an example of government efficiency and process improvement in action. In the project’s initial phases, beginning in 2000, the traditional approach had been to examine each questionable dual-eligible claim on a claim-by-claim basis. This became overwhelmingly cumbersome. The Centers for Medicare and Medicaid Services (CMS) agreed to allow OMIG and UMass to employ a sampling methodology, enabling project staff to use a 200-case sample universe of claims for dual-eligible beneficiaries who received home care services paid by Medicaid for each year audited.
Following the establishment of the sampling methodology, OMIG and University of Massachusetts Medical School staff applied an extrapolation technique to calculate payments that New York State Medicaid had made that should instead have been made by Medicare first. “The administrative burden posed by the claim-by-claim approach had been enormous,” Cox added. “The extrapolation and sampling technique are standard processes used in professional auditing, and it makes sense that we were able to employ this technique to achieve the success of this project.”
“This is tremendous news for New York,” Cox said. “It reflects the tenacity and hard work of the staff within OMIG’s Third-Party Liability Unit to enforce regulations that dictate that Medicaid is the payer of last resort in dual-eligibility cases.” New York was one of three states, along with Massachusetts and Connecticut, to join with the University of Massachusetts Medical School in this project; the total reported here reflects only New York State’s portion of the recoveries.
New Yorkers can assist the Office of the Medicaid Inspector General in fighting fraud, waste, and abuse by reporting potentially suspicious behavior or incidents. OMIG encourages anyone who observes instances of potential Medicaid fraud, waste, or abuse to contact OMIG’s fraud hotline at 1-877-87-FRAUD or visit the Web site at www.omig.ny.gov. Tips can be completely anonymous, and OMIG investigates information from all calls.
United Cerebral Palsy (UCP) of Ulster County was overpaid $2.27 million by New York State’s Medicaid program, discovered after two audits completed by the Office of the Medicaid Inspector General (OMIG) found issues resulting mainly from excessive levels of missing documentation.
The audits reviewed UCP’s day treatment program services. Under day treatment, persons with developmental disabilities receive a comprehensive array of coordinated services designed to promote and attain independence, inclusion, and productivity in the community.
Out of 200 records that were reviewed as part of the audit, 107 contained deficiencies. The largest single category of error involved missing documentation that would have provided evidence that a physician had reviewed an individual’s treatment plan. Other findings included missing records that would prove that a service has been provided or missing progress notes, despite the fact that services had been billed and paid by Medicaid.
“Physicians must authorize services, and their medical knowledge is the cornerstone of establishing medical necessity,” said Medicaid Inspector General James C. Cox. “Without proof that a doctor has ordered a service, no one can verify that a service should have—or was—provided.”
These audits are part of OMIG’s overall effort to fight fraud, waste, and abuse in the Medicaid program. In the first six months of 2013, OMIG identified more than $100 million in Medicaid overpayments, according to preliminary audit, investigative and data match findings. From January 1 to June 30, 2013, findings totaled $103 million; the previous high for six months was $111 million. Actual cash recoveries also increased during the same period by 21.5 percent over the previous year to $61.7 million, according to the same six-month preliminary audit, investigation, and data match numbers.
Audits such as those completed at these day treatment programs are an important component OMIG’s overall effort to fight fraud and recover improper payments in the Medicaid program, according to Cox. “One of the Medicaid program’s goals is to provide excellent health care at a cost that taxpayers can afford,” he notes. “Our work helps to contain costs while improving health care access and quality for Medicaid consumers.”
New Yorkers can assist the Office of the Medicaid Inspector General in fighting fraud, waste, and abuse by reporting potentially suspicious behavior or incidents. OMIG encourages anyone who observes instances of potential Medicaid fraud, waste, or abuse to contact OMIG’s fraud hotline at 1-877-87-FRAUD or visit the Web site at www.omig.ny.gov Tips can be completely anonymous and OMIG investigates information from all calls.
Three nursing homes will reimburse New York State a combined total of $1,069,348 because of overpayments disclosed in a series of OMIG audits.
Click here for the full press release.
You can help stop Medicaid fraud: Call OMIG’s Fraud Hotline at 1-877-87 FRAUD (1-877-873-7283), or click here to file a complaint electronically.
The OMIG may sanction some providers by excluding them from participating in the Medicaid program. These providers are excluded from offering services to Medicaid enrollees and also cannot be paid with Medicaid dollars. Prior to adding new staff members, employers should check to see if prospective employees have been excluded from Medicaid. To make it easier to perform such a check, OMIG set up a dedicated service to check the status of any exclusion.
Anytime a health care organization discovers that it was paid more than it was due, this should be reported to OMIG. Our Self-Disclosure section provides information for health care organizations to complete the recently revamped self-disclosure process.
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