After years of operations without a published work plan, the New York State Office of the Medicaid Inspector General (OMIG) recently issued its 2024 Work Plan. The plan “provides a comprehensive roadmap for citizens, policymakers, providers, and managed care organizations to follow as a guide to OMIG’s program integrity initiatives planned for 2024.” It supplies valuable insight into the agency’s priorities that can help providers anticipate and prepare from a compliance perspective.
OMIG’s Medicaid program integrity key focus areas for 2024 include:
- Compliance
- Self-Disclosure
- Transportation
- Durable Medical Equipment (DME)
- Clinics
- Behavioral Health
- Early Intervention
- Personal Care Services
- Hospice
- Home and Community Based Services
- Nursing Homes and Assisted Living Programs
- Pharmacy and Drug Diversion
- Telehealth
- Managed Care
Unlike the previous work plan, the 2024 Work Plan does not set forth any objective “goals” but instead describes priorities and focus areas. For example, as an overarching priority, OMIG signals in the plan its ongoing efforts to enhance compliance via the conduct of compliance program reviews of Medicaid Managed Care Organizations (MMCOs) and Medicaid providers.
Safeguarding Medicaid resources remains a priority for OMIG in 2024, as OMIG devotes a significant portion of the 2024 Work Plan to audits and investigations. With respect to audits, OMIG will continue to audit MMCOs in a variety of areas. On the provider side, OMIG will pursue audit and investigation activities relating to certain high-risk categories, such as pharmacy, durable medical equipment, and transportation. The following are some of the highlights.
Pharmacy
The 2024 Work Plan confirms that OMIG is prioritizing pharmacy compliance with existing Medicaid regulations and other laws, rules, and regulations applicable to pharmacy practice and operations. OMIG will continue to conduct fee-for-service pharmacy audits, which should come as no surprise given that New York State transitioned prescription drug coverage from Medicaid managed care plans to NYRx, a fee-for-service Medicaid pharmacy benefit program, in April 2023. The 2024 Work Plan states that OMIG will also continue its secondary review of pharmacy enrollment applications. This year, OMIG plans to conduct more frequent credential verification reviews (CVRs) of pharmacies throughout the state.
The 2024 Work Plan also lists pharmacy ownership and supervision as one of OMIG’s areas of focus. OMIG notes that pharmacy owners and supervising pharmacists are responsible for ensuring pharmacy compliance with applicable Medicaid and New York State laws and regulations. OMIG is choosing to concentrate on ownership and supervision to combat fraud, waste, and abuse caused by inadequate supervision.
Durable Medical Equipment
DME is another category in which OMIG will continue its audit and investigation efforts. Like pharmacies, DME suppliers will also be subject to a secondary review of provider enrollment applications and fee-for-service audits. OMIG also anticipates increasing medical reviews related to DME due to the shift of provider billing activity through managed care.
Transportation
OMIG will continue monitoring providers of nonemergency transportation services due to the significant amount of claims billed to Medicaid for these services, federal oversight of nonemergency transportation services, and provider turnover within the industry. In 2024, OMIG will also continue conducting fee-for-service audits for providers of ambulette, taxi, and livery services. OMIG will also perform system match audits for transportation providers. The system match audits will include a review of Medicaid fee-for-service transportation claims for ambulette services to determine whether the vehicle license number and driver’s license were authorized on the date of service.
Medicaid transportation providers will also be subject to CVRs and medical reviews. OMIG will conduct CVRs to assess whether providers are in compliance with all requirements in the Department of Health’s Transportation Manual Policy Guidelines. OMIG will collaborate with other state agencies and individual counties to support the reviews. Additionally, OMIG anticipates increasing medical reviews for transportation.
Other Audit Activities
While the 2024 Work Plan outlines several initiatives that have been present on previous work plans, OMIG has added new audit activities for 2024 to ensure that certain populations are appropriately served:
- Office of Mental Health (OMH) Personalized Recovery Oriented Services (PROS)
- OMH Telehealth Services
- Office of Persons With Developmental Disabilities (OPWDD) Community Habilitation
While the 2024 Work Plan outlines which OPWDD and OMH audits will be conducted, none of the newly added audit activities include audit protocols. This omission leaves providers in the dark regarding the scope of the audits and the standards with which OMIG will be evaluating providers’ compliance.
In addition to its emphasis on audits and investigations, OMIG wants to ensure that it continues to recover and save Medicaid funds. OMIG will work with its recovery audit contractor to verify that Medicaid is the last payor billed and all other forms of insurance coverage are utilized before Medicaid. OMIG plans to also work with its contractor on third-party retroactive recoveries, which may involve contacting Medicaid providers directly. OMIG will collaborate with its contractor to discover and recoup overpayments that likely would not be identified solely by the review of Medicaid claims data.
Providers should review the program integrity activities listed in OMIG’s 2024 Work Plan to determine which of the initiatives may affect them. Providers who are audited by OMIG benefit from involving counsel early in the audit process to ensure that all potential findings are fully addressed before the record is closed. Attorneys on Barclay Damon’s Health Care Controversies Team are experienced in assisting providers with audits, including billing and compliance program reviews.
If you have any questions regarding the content of this alert, please contact Linda Clark, Health Care Controversies Team co-leader, at lclark@barclaydamon.com; Amanda Rhodes, associate, at arhodes@barclaydamon.com; or another member of the firm’s Health Care Controversies Team.