OMIG 2017-2018 Work Plan

The New York State Office of the Medicaid Inspector General (OMIG) has posted its 2017-2018 Work Plan. The Plan details OMIG’s program integrity focus areas in the Medicaid program from April 1, 2017 to March 31, 2018.

For providers, managed care organizations (MCOs), and other stakeholders, it provides a roadmap of OMIG’s intended areas of review for this period. The Work Plan will focus on three goals: enhancing compliance; fighting fraud, waste, and abuse; and promoting innovative analytics.

As stated in the Executive Summary, “New York State’s Medicaid program is the state’s largest payer of health care and long-term care. Over six million New Yorkers receive Medicaid eligible services through a network of more than 80,000 health care providers and over 90 managed care plans. The total federal, state and local Medicaid spending for SFY 2018 is expected to be $65 billion.”

Under Goal #2 (coordinating with stakeholders to identify and address fraud, waste, and abuse in the Medicaid program), OMIG will be targeting areas in Home Health and Community-Based Care Services, Long Term Care Services and Medicaid managed care.

Specific areas under Home Health and Community-Based Care Services are:

Home Health Verification Project – All participating providers (CHHAs, LTHHCPs or personal care providers who are either located in New York City or receive Medicaid reimbursement exceeding $15 million per calendar year through Medicaid, including fee-for-service (FFS) and/or managed care) are required to utilize a verification organization (VO). OMIG will continue to work with the VOs to standardize the reports in the VO portals and to identify areas of potential improvement.

Long Term Home Health Care Program (LTHHCP) – OMIG continues to audit LTHHCP FFS Medicaid claims to verify per-visit and hourly rates calculated for the various ancillary services provided, with a focus on LTHHCPs with both high Medicaid utilization and rate capitations. They will also review rate add-ons, including funds dedicated to worker recruitment, training, and retention.

Duplicative Billing – OMIG will review and recover billings for claims identified as duplicative.

Certified Home Health Agencies (CHHAs) and Personal Care Services – OMIG will continue to conduct personal care and CHHA FFS audits and will initiate CHHA Episodic Payment System (EPS) audits.

Traumatic Brain Injury (TBI) and Nursing Home Transition and Diversion (NHTD) Medicaid waivers – OMIG will continue to examine TBI and NHTD FFS claims to determine compliance with program requirements. Pursuant to the audit protocols, the reviews will primarily focus on verification that services were provided, that services billed were included in the service plan, that service plans were updated in a timely manner, and that services were provided by qualified staff. The OMIG Work Plan mentions developing an audit plan to examine TBI in the managed care environment but does not mention developing an NHTD audit plan.

Wage parity/Minimum Wage – OMIG, DOH, and the Department of Labor will work collaboratively to ensure compliance pertaining to Minimum Wage and Wage Parity laws. OMIG will audit MCOs and contracted network providers’ records and reports to ensure that funds provided for employee wage increases are properly distributed to health care workers in accordance with statutory requirements and the procedures established by DOH.

Specific areas under Nursing Homes:

OMIG will audit nursing home capital calculations, specifically for those homes that have filed attestations to correct the capital component computed by DOH. Although the report indicates that OMIG will audit nursing home MDS assessment submissions used to calculate the case mix index, the most recent information from DOH suggests that the state is seeking an outside contractor to perform these audits.

Medicaid Managed Care focus areas:

OMIG intends to continue targeted reviews and audit other issue areas identified through data mining and analysis. OMIG has launched a project team approach to Medicaid managed care program integrity activities and has created teams with specific areas of focus. The Managed Care Contract and Policy Relationship Management Team will focus on developing amendments to model contracts for managed care plans, including Managed Long Term Care (MLTC), to address requirements contained in the federal Medicaid Managed Care rule. These amendments include changes to compliance program requirements for Managed Care Organizations (MCOs); referrals of fraud, waste, and abuse; MCO self-disclosure programs; MCO payment suspensions for credible allegations of fraud; MCO record retention and audit periods; and how MCO recoveries are treated and retained.

A team will focus on the accuracy of the certain aspects of the managed care operating reports, and another will perform audits of providers within MCO networks to ensure accuracy of encounter claim submissions and confirm that provider records are in regulatory and contractual compliance. OMIG will also evaluate Value Based Payment (VBP) reimbursements from a program integrity perspective.

Encounter data reporting will also remain a focus with Bureau of Business Intelligence (BBI) staff continuing to analyze and evaluate the integrity of encounter data. Staff will perform comparative analyses of encounters and other plan-submitted data to evaluate the consistency and completeness of MCO encounter reporting. Data sources examined include individual MCO paid claim files, MMCORs, comprehensive provider reports and PBM data.

Areas of focus that OMIG has identified related specifically to MLTC include social adult day care centers and audits to ensure that MLTC plans are meeting contractual obligations in serving their recipient population. OMIG will continue to review enrollment records, recipient Plans of Care and claims data to determine if the MLTC plans are providing the specific services deemed medically necessary and examine Case/Care Management system notations to confirm that appropriate care management is being rendered.

Assisted Living Program

Areas of focus that OMIG identified were resident care audits and coordination of oversight with the Department of Health (DOH). According to the workplan, OMIG will conducting field audits to validate payments for services and ensure the documented needs of patients are being met. OMIG reviews the patient records for up-coding and overbilling for services rendered to ALP residents, as well as to ensure patient records reflect the required authorizing documents. Additionally, OMIG will provide oversight of ALP resident care audits that are conducted as part of the County Demonstration program.

OMIG and DOH Division of Adult Care Facilities and Assisted Living Surveillance coordinate efforts to monitor ALP provider’s compliance with Medicaid regulations. In the event OMIG identifies a potential quality of care or patient endangerment issue, DOH is contacted immediately and remedial activities are coordinated. Quality of service and fiscal issues of entities are addressed to ensure that the population serviced by the program is safe and adequately served while maintaining claiming accuracy.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871; Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841; and Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828