The Affordable Care Act requires Medicaid providers to "self-disclose" - to report and return any dollars that the provider should not have received. In order to aid providers in this process, on August 6th, 2014 the Office of the Medicaid Inspector General (OMIG) hosted a webinar that shows Medicaid providers in New York how to self disclose. Self disclosure efforts by OMIG and providers yielded over $20 million in returned payments during OMIG's last reporting year. OMIG suggests that every Medicaid provider view Webinar #21 - Self Disclosure to understand how the process works, and what they can do as a provider to comply with this important requirement.
OMIG published Compliance Guidance 2014 - 04 Revision # 1. This compliance guidance gives information relevant to inpatient chemical dependency rehabilitation and outpatient chemical dependency services providers. This document is part of a series of guidance documents that can be seen here.
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.
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.
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.
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.
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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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