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New York State Office of the

Medicaid Inspector General

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.

A Nassau County physician, Mark Shaffer, was denied reinstatement into the New York State Medicaid program following an evaluation of his application by the New York State Office of the Medicaid Inspector General. This denial was based on concerns about his past behavior which had included failure to maintain patient records, allowing unqualified staff to administer inoculations, and filing false reports with the aim of inflating insurance reimbursements.

Shaffer has been excluded from participation in the Medicaid program since 2007 and recently applied for reinstatement. The exclusion was based on a consent order he signed with the New York State Board of Professional Medical Conduct in which he “agreed not to contest” charges of negligence on more than one occasion.

As the result of the signed consent order, his medical license was suspended for one year, with active suspension for the first three months and the final nine months stayed. He was then placed on probation for 36 months and required to practice under the supervision of another physician throughout the 36-month period.

After a full review of the facts supplied to the agency with his re-application materials, OMIG issued the denial for reinstatement into Medicaid. OMIG made this determination via authority under the regulations guiding the agency. Following OMIG’s determination, Shaffer will remain on the Exclusion/Termination list. Providers must make a formal application to be considered for removal from this list. Shaffer must wait at least two years from the date of the denial letter before submitting another application for reinstatement to the Medicaid program.

Details of the process are available on the OMIG Web site, including the ability to check the Exclusion/Termination list for additional names.

Reliance Ambulette, a Flushing, New York -based provider of medical transportation services, overbilled the Medicaid program by $2,487,129 during a two-year period, according to a recent audit (#08-1781) completed by the New York State Office of the Medicaid Inspector General (OMIG) in conjunction with the New York City Human Resources Administration. The audit cites the company for lack of compliance with standards required by the Medicaid program. The audit was conducted under the auspices of the County Demonstration Program, a joint state and local partnership, overseen by OMIG.

Reliance was cited for several issues. These included:

  • failure to ensure that all drivers were duly licensed by the New York City Taxi and Limousine Commission (T&LC) and 19-A certified by the New York State Department of Motor Vehicles
  • failure to prepare and maintain contemporaneous records demonstrating its right to receive payment, and
  • missing or inaccurate information on the Medicaid claims submitted for payment.
  • The audit can be seen here.

Stuart Blankman, a Manhattan optometrist, requested reinstatement into the Medicaid program. New York City Criminal Court had convicted Blankman in September 2012 for harassment after he admitted to inappropriate conduct that placed a female patient in reasonable fear of physical injury and led to her having an order of protection instituted against him. OMIG denied reinstatement under 18 NYCRR §515.10(g) since Blankman’s conviction has a direct bearing on his ability to potentially provide safe, high-quality care to Medicaid patients.

For more information on the reinstatement process and how it works, see the OMIG webinar on the Exclusion and Reinstatement Process

Manor Pharmacy Inc. in Sullivan County applied for enrollment as a provider with Medicaid. After discrepancies were found in the application, OMIG conducted an undercover investigation at the pharmacy. Investigators discovered that Manor filled a prescription later billed to Medicaid through another provider, Sullivan Pharmacy. Based on this unacceptable practice, OMIG denied enrollment to Manor Pharmacy under 18 NYCRR §504.5(a) (13). OMIG sent an educational letter to the billing pharmacy to instruct them that they may not bill for prescriptions that are not filled at their store.

Governor Andrew M. Cuomo today announced that New York’s Medicaid program saved taxpayers more than $58 million in 2013 through the use of corporate integrity agreements (CIAs) to monitor and improve provider operations. This announcement by the Governor and the Office of the Medicaid Inspector General (OMIG) comes during National Corporate Compliance and Ethics Week 2014.

“Three-and-a-half years ago, we said we would change Medicaid in New York by cutting the waste and bureaucracy to better serve those who benefit from these services the most—taxpayers. That is exactly what we have accomplished,” said Governor Cuomo. “This state leads the nation in Medicaid recoveries and compliance efforts, proving that the use of ‘Corporate Integrity Agreements’ are worth the investment. I applaud the Office of the Medicaid Inspector General for continuing to find savings for taxpayers while maintaining the high quality of service New York is known for.”

CIA agreements are offered by OMIG to providers with a history of program integrity issues as an alternative to exclusion from the Medicaid program, when exclusion might lead to extenuating circumstances such as service shortages within a given geographical area. Providers who enter into a CIA are required to learn about compliance and create compliance-testing structures. Each provider subject to a CIA must also pay for an independent review organization (IRO) which reports to OMIG and monitors provider adherence to the CIA. These activities result in cost avoidance to the Medicaid program which totaled $58,090,814 in 2013.

Medicaid Inspector General James C. Cox said, “Measuring the effect of CIAs gives us a handle on some of the impact of our expanded compliance efforts. Improving provider regulatory adherence has the added benefit of saving taxpayer dollars.”

Each CIA is unique, as is each provider. If the IRO detects a material breach of the terms of the CIA and reports this to OMIG via the monitoring process, the provider may ultimately be excluded from the Medicaid program. However, the goals of the CIA process are to improve the provider’s program integrity efforts, to educate providers about ways in which they can improve their compliance programs which directly relate to detection of internal risk areas, and lead to preventing and reducing fraud, waste and abuse in the Medicaid program

Two major features characterize CIAs. The first is heightened monitoring of the “eight elements” of the compliance program required under Part 521 of New York’s Code of Rules and Regulations (NYCRR) for Medicaid providers. The second is overseeing providers’ progress in correcting issues, including improvements in provider billing and record-keeping systems, among others, that contributed to the unacceptable practice(s) that gave rise to the need for a CIA. OMIG has maintained CIAs since 2009, and all providers who are being monitored under CIAs are listed on OMIG’s Web site under the Compliance section.

During National Compliance Week 2014, OMIG will post new compliance information and updates every day. Additionally, OMIG will host a live tweet session from 1-2 PM via OMIG’s Twitter feed (@NYSOMIG), using #ComplianceNY, when members of the provider community will have the opportunity to tweet questions to OMIG’s compliance team and receive responses. Providers can send questions in advance to information@omig.ny.gov for consideration for answers during the live session.

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 received.

Click here to read the Governor's announcement.