OMIG Issues Updates to Self-Disclosure Guidance

The New York State Office of the Medicaid Inspector General (OMIG) released updates to its recent self-disclosure guidance and supporting documents. The updates principally reflect the creation of two pathways for self-disclosure of Medicaid overpayments – full self-disclosure and abbreviated self-disclosure. The guidance and disclosure pathways arise out of regulations adopted earlier this year (described here) governing compliance programs and Medicaid managed care, as well as self-disclosure.

The self-disclosure component of the regulations requires providers and other covered entities to report, return, and explain overpaid Medicaid funds within 60 days of identifying an overpayment. Voiding or adjusting claims does not satisfy the entity’s/provider’s obligation to report and explain the identified overpayment. An overpayment has been identified when "a Medicaid entity/Provider has, or should have, through the exercise of reasonable diligence, determined that a Medicaid fund overpayment was received, and they have quantified the amount of the overpayment."

The updated guidance provides for an abbreviated self-disclosure process for certain types of overpayments. For example, the abbreviated process may be used for the following:

Routine credit balance/coordination of benefits overpayments;
Typographical human errors;
Routine Net Available Monthly Income (NAMI) adjustments;
Instance of missing or faulty authorization for services due to human error;
Instance of missing or insufficient support documentation due to human error;
Inappropriate rate, procedure, or fee code used due to typographical or human error; and
Routine recipient enrollment issue.

Full disclosure statements must be submitted for the following:

Any error that requires a Medicaid entity/Provider to create and implement a formal corrective action plan;
Actual, potential, or credible allegations of fraudulent behavior by employees or others;
Discovery of an employee on the Excluded Provider list;
Documentation errors that resulted in overpayments;
Overpayments that resulted from software or billing systems updates;
Systemic billing or claiming issues;
Overpayments that involved more than one Medicaid entity/Provider (for example, Health Homes and Care Management Agencies);
Non-claim-based Medicaid overpayments;
Any error with substantial monetary or program impacts; and
Any instance upon direction by OMIG.

In addition to overpayment disclosures, the Self-Disclosure Program accepts provider reports of damaged, lost, or destroyed records. If a provider becomes aware that their records have been damaged, lost, or destroyed, they must report that information as soon as practicable, but no later than 30 days after discovery.

More information about the Self-Disclosure Program, including the Self-Disclosure Program Requirements Guidance, Frequently Asked Questions (FAQs), and forms and instructions, is available here.

Contact: Karen Lipson, klipson@leadingageny.org