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Thanks

Compliance Challenges
2013: Sixth Annual
Conference for
Providers Serving
Individuals with
Disabilities

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Today’s Agenda

WHY WE FOCUS ON COMPLIANCE
YOU ARE ON THE FRONT LINES
OMIG WORK PLAN 2013-14
CONCLUSION

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MISSION STATEMENT

Our mission is 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.

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Corporate Compliance and Ethics
Week starts in a few days. Be sure to

follow OMIG on Twitter
(@NYSOMIG) for helpful compliance

information.

5/3/2013 Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. 5

WHY WE FOCUS ON COMPLIANCE

5/3/2013 6

OMIG Gets Results

We produce a significant number of audit
reports:

o 1,659 final audit reports in our last reporting year
o We generate hundreds of millions in collections:

$410 million in our last reporting year

We prevent billions in expenses:

More than 2.5 Billion in our last reporting year

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We Have A Statewide Presence

Regional Offices:
Capital District
Western NY (2)
Central NY
Westchester
New York City (2)
Long Island

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Recent Developments

 Published 2013-14 Work Plan
 Premiered new, user-friendly Web site
 Published several new audit protocols (now have a

total of eleven in effect)
 Second year of Business Line Teams (BLTs)

o The BLT of most interest to this group is Mental Health,
Chemical Dependence, and Developmental Disabilities
Services

o Other BLTs of interest: Managed Care, Home and
Community Care Services, Pharmacy and Durable Medical
Equipment, Physicians, Dentists, and Laboratories, and
Transportation

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One Recent Case

OMIG learned about attempts to bribe a
sitting state legislator

The alleged bribers operated a social adult day
care program

We started to look into what exposure existed
within the program

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We Act Deliberately…

OMIG contacted the State Department of
Health and State Office for the Aging

OMIG reached out to a spectrum of managed
care plans

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We Act Deliberately…

Consistent with Public Health Law § 32(3) we
worked with agency and law enforcement
partners

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…With All Due Speed

Based on the federal complaint OMIG issued a
Notice of Immediate Agency Action (April 15,
2013)

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None of This Answers the
Question…..

….Why Focus on Compliance?

5/3/2013 FiFgihgthitninggFFrarauudd. . ImImpprroovviinng IntegriittyyaannddQQuuaaliltiyt.y.SSaavvininggTTaaxxppaayyeerrDDoollallarsr.s. 14

New York Is a Leader

New York was the first state to require
compliance programs

Created at the same time as OMIG in statute
Federal government adopted this approach as

part of the Affordable Care Act

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Compliance Tells Us A Lot

Our efforts are a different mode of review:

Ensuring that providers improve
Encouraging independent work to drive results

What do we get out of compliance

Understanding the Medicaid program
Taking action where appropriate

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Compliance Gets Results

Here’s a Little Story:

July 2011
First onsite compliance review issued
Organization had certified through the required

OMIG on-line process

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A Program on Paper Is Not Enough

Bronx Health Care Provider
On paper, compliance officer and program
However – here’s what we found

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This is What we Found

Program was on paper but incomplete
Documented training was nearly non-existent

Day before we showed up, facility held
compliance training
In interviews, nobody knew anything about
compliance or even who the compliance officer
was
Confusion over HIPAA compliance, quality
assurance compliance, DOH surveillance
obligations, and DRA obligations

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What we Determined

What we found:

We determined they did not have compliance
program that met requirements

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So OMIG Took Action

What We Did:
DOH terminated, we issued a NOPAA
Why – Under 18 NYCRR 521.1, to be eligible

to provide services and supplies, you must
adopt and implement a compliance program
Point is – these folks did not have one

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YOU ARE ON THE FRONTLINE

5/3/2013 22

 Most of you are compliance officers – you are trying to
ensure that you have good, strong systems

 Eight elements of an effective compliance program

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Elements of a Mandatory Compliance
Program

Compliance Programs shall include the following eight
elements:

SSL §363-d. sub 2 and 18 NYCRR § 521.3 (c)

 Element 1: Written Policies and Procedures -
Code of Conduct/Ethics

 Element 2: Designation of Compliance Officer –
Employee Vested with Responsibility

 Element 3: Training and Education

 Element 4: Communication Lines to the
Compliance Officer/Function

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Elements of a Mandatory Compliance
Program (continued)

Element 5: Disciplinary Policies

Element 6: Identification of Compliance Risk
Areas and Non-Compliance

Element 7: Responding to Compliance Issues

Element 8: Policy of Non-Intimidation and
Non-Retaliation

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 If you are in this room – you are a likely to be familiar
with the next few slides as well. They outline the legal
requirements on compliance programs.

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Requirement for Compliance
Programs

New York State Social Services Law (SSL) §363-d
subd. 1

18 New York Code of Rules and Regulations
(NYCRR) § 521.1

Create compliance program requirements for
certain Medicaid providers

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Who Must Have a Compliance
Program?

Providers:

• subject to Public Health Law Article 28 or 36;

• SSL §363-d subd. 4 and 18 NYCRR §521.1(a)

• subject to Mental Hygiene Law Article 16 or 31; or

• SSL §363-d subd. 4 and 18 NYCRR §521.1(b)

• for which Medicaid is a substantial portion of their business
operations.

• SSL §363-d subd. 4 and 18 NYCRR §521.1(c)

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Who Must Have a Compliance
Program (continued)

“Substantial portion of business operations” means any of the
following:

• 18 NYCRR §521.2(b)

(1) Claims or orders, or has claimed or has ordered or should be
reasonably expected to claim or order at least $500,000 in any
consecutive 12-month period from Medicaid; or

(2) Receives or has received, or should be reasonably expected to
receive at least $500,000 in any consecutive 12-month period,
directly or indirectly from Medicaid; or

(3) Submits or has submitted claims for care, services or supplies to
Medicaid on behalf of another person or persons in the aggregate
of at least $500,000 in any consecutive 12-month period.

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OMIG Develops
Tools to Assist

Providers

OMIG’s has developed self-
assessment tools for
providers to use within their
own environments to
improve on their compliance
efforts.
On the new Web site, these
are found under the
Compliance tab at the top, in
the Compliance Library,
under the Forms section.

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Compliance Programs Apply To:

18 NYCRR § 521.3 (a)

Compliance programs shall be applicable to:
(1) billings;
(2) payments;
(3) medical necessity and quality of care;
(4) governance;
(5) mandatory reporting;
(6) credentialing; and
(7) other risk areas that are or should with due

diligence be identified by the provider

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Requirement for SSL Certification

SSL §363-d subd. 3

 a newly enrolling Medicaid provider shall certify
that its compliance program satisfactorily meets the
requirements of §363-d

18 NYCRR §521.3(b)

 upon applying for enrollment and
 during December each year…
a required Medicaid provider must certify that its
compliance program meets the requirements of Part
521

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Federal Deficit Reduction Act of 2005

State Plan Amendment

1. Certification Requirement
• Must be complete on or before January 1 following the end of
the Federal Fiscal Year
• Applies to Medicaid providers receiving or paying $5 million or
more during the Federal Fiscal Year
• Certification on OMIG’s Web site – www.omig.ny.gov

42 USC §1396a (a)(68)

2. Basic Requirements
• Maintenance of the written policies
• Any employee handbook includes the mandated language
• Policies and procedures have been properly adopted, published
and distributed among employees, contractors and agents

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Federal Deficit Reduction Act of 2005
(continued)

3. Employee Education Requirement on:
• Federal False Claims Act
• New York State False Claims Act
• Whistleblower protections
• Policies and procedures for detecting and preventing fraud,
waste, and abuse

4. Employee Handbook Requirements (if any)
• Specific discussion of laws described in the policies
• Rights of employees to protection of whistleblowers
• Discussion of policies and procedures for detecting and
preventing fraud, waste, and abuse

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2013-14 OMIG WORK PLAN

5/3/2013 35

2013-14 OMIG Work Plan

The Mental Health, Chemical Dependence,
and Developmental Disabilities Services BLT
works in close collaboration with:

o The Office for People with Developmental
Disabilities (OPWDD)

o The Commission on Quality of Care and Advocacy
for Persons with Disabilities

o We will also be working with the Justice Center
once it is fully operational later this year

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2013-14 Work Plan (continued)

Priorities:
Medicaid service coordination
Consolidated support services
Residential habilitation
Day habilitation
Day treatment
Prevocational services
Supported employment

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2013-14 Work Plan (continued)

OMIG will continue to review all of these
priorities to determine whether services were
provided in accordance with Medicaid
requirements.
The complete OMIG 2013-14 Work Plan is
available on our Web site.

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CONCLUSION 39

5/3/2013

How You Can Work With Us

40

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We Want to Hear from YOU

Our new, improved Web site: www.omig.ny.gov
Join our Listserv
Follow us on Twitter: @NYSOMIG
Dedicated e-mail: [email protected]
For compliance: [email protected]
More than 4,000 final audit reports
Audit protocols
And much, much more!

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Contact Information

James C. Cox

Medicaid Inspector General
New York State Office of the Medicaid Inspector

General
800 North Pearl Street

Albany, NY 12204
518-473-3782

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