OMIG Posts 2025 Work Plan
(Feb. 3, 2025) The NYS Office of the Medicaid Inspector General (OMIG) has posted its 2025 Work Plan, which is meant to be a roadmap for citizens, policymakers, providers, managed care organizations (MCOs), and other stakeholders to OMIG’s planned program integrity initiatives for the coming year. OMIG indicates that oversight of compliance programs and self-disclosure requirements will be accompanied by educational activities and outlines target areas of managed care and provider audits planned for 2025. We encourage members to review the Work Plan and become familiar with the information and resources available on the OMIG website.
On the compliance front, OMIG anticipates completing 100 compliance program reviews to assess whether they meet set requirements while identifying integrity risks and providing feedback to providers on program enhancements. Compliance program requirements and resources are provided on the OMIG site here.
In the self-disclosure realm, OMIG reports some challenges in organizations meeting self-disclosure requirements, specifically related to Medicaid managed care reporting. OMIG plans to do targeted outreach to providers that have never self-disclosed while providing education to smaller provider programs that have lower instances of self-disclosures. The requirements and processes for providers and plans to disclose any Medicaid overpayments are outlined here.
In 2025, OMIG intends to increase the number of Medicaid managed care cost report reviews, which are expected to encompass Managed Long Term Care (MLTC) reports as well. The Bureau will initiate a new round of Managed Care Program Integrity Reviews (MCPIR) covering the 2023 calendar year and expand the focus of MCPIR to include MLTC.
Other Medicaid MCO (MMCO) audit areas will include retroactive disenrollments, deceased or incarcerated enrollees, out-of-state recipients, multiple client IDs, and duplicate fee-for-service payments made for plan members. MLTC plan reviews will focus on eligibility and care management: for partially capitated plans, OMIG will seek to identify inappropriate payments due to a lack of rendered services, loss of eligibility, or delayed disenrollment; for Medicaid Advantage Plus (MAP) plans, it intends to evaluate eligibility and whether the care management provided by the plan aligned with enrollee-specific care plans and assessments.
On the provider audit side, nursing homes and Assisted Living Programs (ALPs) will remain an area of focus for OMIG to ensure that individuals are appropriately served and that services are rendered properly and documented in accordance with Medicaid rules and regulations. The same holds true for community-based services, which are listed in the Work Plan with links to their specific audit protocols. The Plan anticipates an enhanced focus on the Consumer Directed Personal Assistance Program (CDPAP) sector to help ensure that services are delivered effectively, funds are used appropriately, and recipients’ health and safety are protected. Health Care Worker Bonus (HWB) claim audits, begun in 2024, are expected to continue. For nursing homes, OMIG plans to audit data related to capital and ancillary services reimbursement while completing audits of 2018 Minimum Data Set (MDS) data and moving forward with 2019 MDS audits.
The Work Plan notes that OMIG uses analytical tools such as machine learning and predictive modeling to data-mine Medicaid claims to proactively detect suspicious patterns and irregularities in claims data for potential recoveries. Anticipated project areas for 2025 include MMCO and fee-for-service home health payments during a nursing facility stay, MMCO recipient restriction program practices, and MMCO payments to providers not enrolled in, or excluded from, Medicaid.
In the Plan, OMIG states its intent to continue to engage with the provider community through a range of education, information, and outreach activities. Slides used during the most recent round of outreach sessions can be downloaded here. The goal is to promote open communication and enable the agency to incorporate stakeholder input and evaluate the operational impacts of its program integrity activities. Stakeholders are urged to share information and feedback via email to information@omig.ny.gov.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841