The Medicaid program is made up of a network of health care providers, coordinators and services that help millions of New Yorkers every year. This includes direct care providers and managed care plans that coordinate services. The "Provider" section of the Office of the Medicaid Inspector General (OMIG) Web site is a resource for these health care professionals. The vast majority of health care professionals and organizations in the Medicaid program want to follow the rules. Other providers have engaged in unacceptable practices, which means that they can not participate in the Medicaid program. As an aid to health care professionals and organizations, OMIG provides access to the list of these Medicaid Terminations and Exclusions.
Providers may also see fraud in their day to day activities. Some examples of fraud may include:
- Billing for unnecessary services – Ordering and then subsequently charging the Medicaid program for services a patient does not need;
- "Phantom" billing – Billing Medicaid for services or for dispensing products that the patient never received, such as patient visits that never took place, dental fillings for teeth that had previously been extracted, medical equipment that was never delivered;
- Multiple billing – Intentionally sending bills to Medicaid for the same procedure or office visit more than once;
- Improper Upcoding – Intentionally billing Medicaid for a more expensive treatment or medication than the one the patient actually received;
- Kickbacks – When Medicaid providers such as physicians, hospitals, dentists, clinics, etc., give money, items of value, or other considerations to other healthcare providers in exchange for referrals or for business; and
- Selling drugs/forging or altering prescriptions – When a Medicaid patient fills a legitimately authorized prescription, written by an authorized physician, and then sells the contents for profit, that is fraud. Altering the amount of the prescription, or stealing a prescription pad from a doctor and then using is also fraud.
Providers can contact the Medicaid Fraud Hotline by calling 1-877-87 FRAUD (1-877-873-7283) or by by clicking under the Fraud tab above and selecting "File an Allegation."
When 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.
OMIG puts a real value on making sure that providers have ways to improve operations and comply with the requirements of the Medicaid program. Some of the resources to help providers are listed below:
- Best Practices for Medicaid Compliance
- Joint OMIG/DOH Letter on Antipsychotics, March 2013
- Compliance Alerts
- Compliance Guidance Library.
- Webinars that help providers learn what the rules are
New York State leads the nation in its commitment to program integrity. Integrity requires a system with rules and sunlight. OMIG is committed to transparency as a way to lead integrity efforts. As a result, OMIG wants the people we review to know more about our efforts. That's why we publish:
- Audit protocols – the standard instructions followed by our auditors.
- Annual Workplan – a catalog of what we intend to review in the next year.
- Regulations – the rules and regulations we follow.
- Decisions by Administrative Law Judges.
Health care professionals are on the frontlines in fighting fraud. We want to make sure we keep in touch. Here's some ways you can: