NATIONALLY RECOGNIZED FEDERAL LAWYERS
Millions of Americans obtain free or low-cost health insurance coverage through the Medicaid program. Federal and state governments run the program jointly. As a federal and state entitlement program Medicaid is highly regulated. All benefits claims or payments made to or on behalf of Medicaid recipients must be made in conformance with Medicaid regulations. Failure to comply with these regulations by any agency, provider, managed care entity, or individual when asserting a benefit, submitting a claim, or accepting monies not owed is considered fraud and/or abuse of the Medicaid program.
The Office of the Medicaid Inspector General (OMIG) is an autonomous entity within the New York City Department of Health that was created to ensure compliance with Medicaid laws and regulations. The mission of the OMIG is as follows:
“To enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.”
The OMIG educates, coordinates, and investigates New York State agencies, providers, and managed care entities about state law concerning Medicaid claims and payments. In the event that fraud or abuse is expected, the OMIG prosecutes and obtains repayment of wrongfully paid Medicaid funds.
OMIG Educates About Appropriate Use of Medicaid Funds
The phrase “fraud, waste, and abuse” encompasses any misuse of Medicaid expenses. Common types of Medicaid fraud, waste, or abuse include the following:
• Billing for unnecessary services and items
• Billing for services or items not rendered
• Upcoding (or performing more services than needed)
• Unbundling (or billing for services that are included in another service)
• Billing for non-covered services or items
• Beneficiary fraud
• Medical identity theft
In furtherance of its mission to prevent fraud, waste, and abuse, the OMIG educates state agencies, providers, and managed care entities about proper Medicaid practices by developing educational training materials and programs. OMIG trains all medical service providers on self-investigation techniques so that they may learn to self-identify areas of potential noncompliance or abuse. Toward that end, the OMIG has developed a compliance program that all agencies or individuals providing services funded by Medicaid must employ if they wish to continue to provide Medicaid services.
OMIG Coordinates with State Agencies to Prevent Fraud and Abuse
Medicaid helps fund several state services. The following agencies provide services funded by Medicaid:
• Department of Health;
• Offices of Mental Health, Alcoholism and Substance Abuse Services
• Temporary and Disability Assistance
• Children and Family Services
• Commission on Quality of Care and Advocacy for Persons with Disabilities
• Office for People with Developmental Disabilities
• Department of Education
The OMIG oversees and coordinates programs in these agencies to identify, prevent, audit, and control fraud, waste, or abuse of the Medicaid program. It meets quarterly with representatives from all social services districts in order to discuss the status of fraud and abuse prevention efforts as well as find potential areas for further collaboration or innovation.
The OMIG compels these agencies to abide by Medicaid regulations by partnering with state departments such as, the Attorney General’s Medicaid Fraud and Control Unit, the Welfare Inspector General, and the State Comptroller, as well as the federal prosecutor and other federal enforcement agencies. OMIG must keep all executive state governmental officials aware of its programs, plans, and investigations with respect to fraud and abuse of the Medicaid program.
OMIG Implements Regulations
New York state law empowers OMIG to execute rules and regulations, recommend and apply policies, and develop protocols and programs targeted at both the prevention of fraud and abuse and the recovery of wrongfully obtained Medicaid funds. It also develops protocols for both collecting overpayments and facilitating self-disclosure of such overpayments. The OMIG monitors the implementation of its recommendations.
OMIG Investigates Allegations of Medicaid Fraud, Waste, and Abuse
The OMIG responds to and examines allegations that an agency did not attempt to prevent, to detect, or to prosecute suspected Medicaid fraud or abuse. OMIG investigates allegations of actual fraud or abuse made by any individual or agency against a medical assistance program, a provider, a managed care program or an individual.
The OMIG Prosecutes Medicaid Abuse
The OMIG conducts on-site facility and office inspections for evidence of fraud, waste and abuse. In the course of its investigations, it has the right to remove documents, subpoena or demand records, and compel testimony.
If the OMIG has evidence of fraud or abuse, it may pursue civil and administrative enforcement actions against accused individuals or entities. Under New York state law, the OMIG has the authority to pursue a variety of actions. It many do any or all of the following: refer an action to regulator agencies and licensing boards; withhold the payment of funds; impose administrative sanctions and penalties; exclude providers from program participation; recover improperly paid funds including seizing property or assets connected to improper payments; and refer suspected criminal activities to the Attorney General’s Fraud and Medicaid Control Unit.