Program Integrity Reporting for MLTC

(Feb. 18, 2025) The February 2025 Medicaid Managed Care Policy and Planning meeting featured a presentation by the Office of the Medicaid Inspector General (OMIG) on new requirements for Managed Long Term Care (MLTC) plans to notify OMIG of planned provider audits and to report provider review activity on a quarterly basis. The requirements already apply to Mainstream Medicaid plans and will apply to Partially Capitated and Medicaid Advantage Plus (MAP) plans as well as to Programs of All-Inclusive Care for the Elderly (PACE) starting this year.

Starting March 1, 2025, MLTC plans will be required to submit Audit Notification Requests to OMIG each time a plan intends to initiate a provider audit. “Audit” is defined as an activity which will or may result in a post-payment recovery and/or referral to OMIG. The agency has 10 days to respond to the plan whether there may be a conflicting OMIG audit of the same provider covering the same time period. If a plan does not receive a response within 10 days, it may proceed with the audit. Similarly, OMIG will notify the plan of its intent to audit a network provider, which will require a response from the plan within 10 days. If the plan is not intending to audit the provider, it is required to share all records required by OMIG to complete its audit. Plans should expect to receive guidance on this process shortly.

In addition, MLTC plans will now be required to file quarterly Provider Investigative Reports (PIRs) in a format similar to quarterly cost reports for each of their business lines. As with cost reports, plans will be notified when the report template is posted, with the first report due June 30, 2025. Each MLTC will need to designate submitters of the report (accessed through the Healthcare Financial Data Gateway on the Health Commerce System) as well as an individual with the responsibility of certifying the contents of the report. MLTC plans should expect to receive a request for contact information for their designated submitters and certifiers. OMIG intends to provide virtual training and guidance on the process for MLTC staff.

The presentation slides are available here, and OMIG is fielding questions at mmcreporting@omig.ny.gov.

LeadingAge NY Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841