On the heels of publishing their final regulations, on January 31, the New York Office of the Medicaid Inspector General (OMIG) released a variety of guidance documents addressing compliance programs; self-disclosure; and Medicaid managed care fraud, waste and abuse prevention programs. The guidance documents can be found at:
Provider Compliance Programs
Self-Disclosure Program
Medicaid Managed Care Fraud, Waste, and Abuse Prevention Programs
The Compliance Guidance Document discusses the benefits of an effective compliance program and the consequences of not having one. It also walks through OMIG’s expectations on their updated 7 Elements (the reduction from the previous published 8 Elements brings NYS Medicaid’s compliance requirements in line with the Federal Sentencing Guidelines and DHHS OIG Compliance materials) and includes helpful references and authorities. Perhaps most importantly, it lays out the process, criteria and scoring for OMIG’s Compliance Program Reviews. Addendum A to the Guidance provides a crosswalk to the statutory changes to the implementing Legislation (NYS Social Services Law Section 363-d). Addendum B lays out the requirements of the Deficit Reduction Act related to fraud and abuse, which OMIG has now extended to all “Required Providers” – i.e., those that meet the statutory and/or monetary thresholds that necessitate implementation of an effective compliance program.
The Self-Disclosure Program Instructions and Guidelines clarify the requirements and process for timely disclosing an identified overpayment. The guidance includes criteria for eligibility, timelines for submission and responses to inquiries, and also specifies the information required to be submitted. It also includes warnings against, and consequences for, failing to timely disclose or follow the prescribed process. The document concludes with a reminder of documentation retention requirements and what to do if records are damaged, lost or destroyed. The Guidance is supplemented by FAQs, a Self-disclosure Submission Information and Instructions sheet, and a Submission Checklist.
The Medicaid Managed Care Fraud, Waste and Abuse Prevention Programs Guidance, which overlaps with both the Compliance and Self-Disclosure Guidance, provides additional details on both internal and network provider oversight activities including a robust SIU and MMCO audit and investigation requirements. The guidance also includes OMIG expectations on reporting cases of FWA and establishing a formal self-disclosure process for MMCO providers. The guidance is rounded out by discussing requirements for plans to develop FWA Prevention Plans and publishing an Annual Report (an Annual Report Form is provided) to document progress with implementing the Prevention Plan.
The guidance documents deserve significant attention, including a thorough review, as the contents will surely be included in future OMIG reviews. The timing of the release of the additional materials suggests that OMIG is poised to start their enforcement sooner rather than later, and providers and plans are encouraged to review and supplement existing compliance policies, procedures and initiatives to ensure that they address these new and modified requirements.
