OMIG has released its 2016-17 Work Plan, detailing the areas of focus in the Medicaid program for State Fiscal Year April 1, 2016 to March 31, 2017.
According to OMIG, this year’s Work Plan continues a focus on organizing work according to categories of service. Building on the 2015-16 Work Plan, OMIG continues to utilize its Business Line Teams across a number of areas, including but not limited to the Delivery System Reform Incentive Payment Program (DSRIP), Managed Long Term Care, Transportation, Home and Community Care Services, and Managed Care.
Further, OMIG will continue to emphasize provider outreach and education, particularly focusing on providers having proactive compliance programs that will prevent or, when necessary, detect and address abusive practices.
The 2016-17 WorkPlan, and plans from previous years, are at: https://www.omig.ny.gov/index.php/information/work-plan. It outlines several areas of focus in home care, LTHHCP and CHHA rates, compliance program review and managed care.
The following are some areas of OMIG focus in the 2016-17 Work Plan follow. Agencies should use these targeted activities, along with the OMIG audit protocols and other materials on the OMIG’s website, to strengthen their ongoing compliance work.
Home Health Verification Project
OMIG will continue to monitor the data collected by the Verification Organizations (VOs) and the compliance reports produced by the VOs, identifying outlier behaviors and non-compliant providers and individual caregivers. Staff will also ensure that the VOs are conducting their annual reviews in a timely manner and will continue to work with the VOs to improve the quality and accessibility of the data in their systems.
- OMIG will analyze claims to determine if services that require supervision were provided, that staff rendering services were properly qualified, licensed and trained, and that other personnel requirements were met.
- OMIG will analyze claims to determine if an approved patient care plan exists, plan services were deemed necessary, services were rendered consistent with the patient care plan, and hours billed were authorized by the care plan.
- OMIG will determine if the home care provider processes the spend-down requirements correctly in cases where the respective county assigns responsibility for monitoring the spend down to the provider.
- OMIG will identify home health and personal care providers who bill while the consumer is not at home, but instead is in a hospital or resides in an institutional setting where the billed services are covered by the facility rate.
- OMIG will examine overlapping payments for consumers who are dually eligible for Medicare and Medicaid and are receiving home health services. OMIG will determine if Medicaid, as the payer of last resort, paid an excessive amount for home health aide services.
LTHHCP and CHHA Rates
OMIG will review Long Term Home Health Care Program (LTHHCP) and Certified Home Health Agency (CHHA) cost reports to verify per-visit and hourly rates calculated for the various ancillary services provided, with an emphasis on both high Medicaid utilization and rate capitations. OMIG will also review rate add-ons, including funds dedicated to worker recruitment, training, and retention.
Medicare Home Health Maximization
OMIG and its contractor, the University of Massachusetts Medical School, will continue to work collaboratively to pursue reimbursement for dual-eligible recipients who have received home health services paid for by Medicaid that should have been paid for by Medicare.
OMIG will review hospice payments to ascertain whether patients and/or family members voluntarily elected hospice care, a certification of terminal illness was obtained, qualifying services were authorized on the plan of care, and all required documentation supporting continued hospice care was in the patient file.
Compliance Program Reviews
OMIG will conduct compliance program reviews of Medicaid providers. These reviews will include, but will not be limited to, providers who do not meet annual certification requirements and those who have repeated issues with OMIG or other regulating agency requirements. OMIG will continue conducting compliance program reviews of Managed Care Organization (MCO) compliance programs and reviews of MCOs’ performance under New York State’s mandatory compliance program requirements, as well as the program integrity requirements found in federal laws and regulations.
Audits will verify that services billed to Medicaid were actually delivered to the Consumer Directed Personal Assistance Program (CDPAP) participant. OMIG will also ensure that consumer-directed personal assistants comply with personnel requirements.
OMIG will examine Nursing Home Transition and Diversion Waiver (NHTD) claims to determine compliance with program requirements. Reviews will primarily focus on verification that services were provided, that services billed were included in the service plan, that service plans were updated in a timely manner, and that services were provided by qualified staff.
Assisted Living Program
OMIG will identify goods and services delivered to Assisted Living Program (ALP) residents by other providers and billed to the Medicaid program that were also included in the ALP payment rates.
- In an effort to provide meaningful incentives for Managed Care Organizations (MCOs) to pursue fraud, waste and abuse, DOH’s Office of Health Insurance Programs (OHIP) and OMIG are proposing a joint initiative establishing recovery targets that are designed to incentivize MCOs in their recovery efforts. A framework of the plan is being developed, and industry targets will be set. Once the plan is launched, OMIG will monitor each MCO and provide support as needed.
- OMIG will review various aspects of the cost reports, including the underlying data to identify whether disallowed costs are included in the report.
- OMIG will continue to conduct comparative analytics of encounter data and other plan-submitted data sources to evaluate the consistency and completeness of reporting by MCOs.
- The Managed Care Plan Review Project Team will focus on further enhancing OMIG program integrity efforts in a continuously developing Medicaid managed care environment. Team resources will be devoted to auditing Medicaid Managed Care Operating Reports (MMCORs), assessing Clinical Risk Groups (CRGs), and analyzing the annual fraud and abuse prevention plan reports submitted by MCOs.
- OMIG will match base audits of claims for managed care enrollees who had a date of services following their date of death, or during a period of incarceration or institutionalization.
- OMIG will review Medicaid managed care payments for the same enrollee with multiple client identification numbers.
- OMIG will continue to track enrollees who are retroactively disenrolled from managed care based on what is reported to OMIG by local social service districts, the NYC Human Resources Administration (HRA) and DOH. OMIG will audit those MCOs who have received capitation payments to provide care to enrollees who were subsequently retroactively disenrolled.
- OMIG will review fee-for-service (FFS) payments made for managed care consumers to determine if the services were already included in the managed care benefits package.
Managed Long Term Care
- OMIG will review the enrollment records to determine if the MLTC plans properly determined eligibility for enrollment and provided proper care management to selected members.
- In addition to the independent investigations of social adult day care centers (SADC), OMIG will continue to jointly investigate SADCs with the New York State Attorney General’s Medicaid Fraud Control Unit (MFCU), the New York City Buildings Department and New York City Department for the Aging (DFTA). OMIG will also coordinate with DOH and the State Office for the Aging (SOFA) to improve system controls over SADCs, including implementing the state certification process and aligning with DFTA’s new registration process. OMIG will also continue to verify the documentation that SADCs are required to maintain for certification and continue to meet quarterly with MLTCs and DFTA to coordinate efforts to identify ongoing issues in SADCs.
Early Intervention Services
OMIG will review early intervention providers who received reimbursement from Medicaid.
Office for People With Developmental Disabilities
OMIG will review day habilitation providers, Medicaid Service Coordination and individual residential alternative habilitation services to determine whether services were provided in accordance with Medicaid requirements.