OMIG Issues New Guidance on Compliance Program Reviews

Last week, the New York State Office of the Medicaid Inspector General (OMIG) posted its Compliance Program Review Guidance, which provides details on how OMIG assesses provider compliance programs required under New York State Social Services Law § 363-d and 18 NYCRR Part 521. The OMIG guidance addresses the eight elements of a compliance program, as well as prime risk areas – billing, payment, medical necessity and quality of care, governance, mandatory reporting, credentialing – and other potential compliance risks.

Under 18 NYCRR Part 521, Article 28 providers (including nursing homes and clinics), Article 36 providers (including CHHAs and LHCSAs) and any person who has submitted at least $500,000 in Medicaid claims in any consecutive 12-month period are required to have an effective compliance program in place and certify annually that they have an effective program.

Assisted Living Program (ALP) providers with at least $500,000 in annual Medicaid claims are also subject to this requirement. Any ALP that operates a LHCSA to serve their ALP will need to have an effective compliance program in place for the LHCSA, even if the ALP did not submit $500,000 in annual Medicaid claims.

Providers subject to the mandatory compliance program requirement must certify annually each December that they have an effective compliance program that meets all the requirements of the law and regulations, using the OMIG website certification page (https://omig.ny.gov/compliance/certification). This certification must be completed within the month of December for it to be valid for the certifying year.

Contact: Dan Heim, dheim@leadingageny.org, 518-867-8866