MAY 2017 COMPLIANCE UPDATES

PROVIDER COMPLIANCE

The Centers for Medicare and Medicaid Services (CMS) has implemented a series of videos for the Medicare Learning Network (MLN) to help providers of all types improve in areas identified with a high degree of noncompliance.

These videos are referred to as Provider Minute Videos as the recordings last anywhere from one to three minutes and are an educational resource to the provider community.

To locate the videos, please access the Provider Compliance section of CMS’s website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

and click on: CMS Provider Minute YouTube playlist

OFFICE OF THE MEDICAID INSPECTOR GENERAL 2017-2018 WORK PLAN

In mid-April, the NYS Office of the Medicaid Inspector General (OMIG) announced the release of its 2017-2018 Work Plan. The Plan details OMIG’s program integrity focus areas in the Medicaid Program for the State Fiscal year 4/1/17 through 3/31/18.

This Work Plan is focusing on the following to help fight Fraud, Waste and Abuse in the Medicaid Program.

  • Physician Excessive Ordering – OMIG’s Recipient Investigation Unit (RIU) will review recipient data to identify physicians prescribing excessive amounts of controlled substances or providing unnecessary services. Identified providers are then referred for investigation to the Provider Investigations Unit (PIU).
  • Network Provider Review of Managed Care Organizations (MCO) – The Network Provider Review Project Team continues to conduct audits of network providers in MCO’s. The audits will ensure accuracy of claim submissions and confirm that provider records are in regulatory and contractual compliance. OMIG will identify improper claims that contribute to inflate capitation payments. OMIG will coordinate with the MCO’s and their Special Investigation Units in its audit efforts.
  • Provider Investigations – OMIG’s undercover investigators receive services from Medicaid providers and record the provider’s conduct during the undercover operation. The provider’s subsequent claims are reconciled with the investigator’s written report and evidence obtained by the investigator. These undercover operations are conducted t o identify quality-of-care issues and billing problems. They can also identify systemic fraud, such as paying recipients to undergo unnecessary medical tests. These investigations gather important intelligence on how providers/organizations operate and the types of drugs/services being abused. These investigations will continue in the course of OMIG’s program integrity efforts.
  • Recovery Audit Contractor (RAC) – The Medicaid RAC contractor in NYS is Health Management Systems Inc. (HMS). HMS reviews provider’s claims for services rendered to Medicaid recipients through fee-for-service or Medicaid Managed Care. HMS is responsible to identify both overpayments and underpayments. OMIG and HHS collaborate and coordinate their recovery initiatives with several other state agencies and CMS contractors. Audits include review of claims submitted for recipients that are dually eligible for Medicaid and Medicare, retroactive member disenrollment and recovery of capitation payments for beneficiaries who are no longer enrolled or eligible for Medicaid Managed Care coverage.

OMIG’s 2017-2018 Work Plan can be reviewed at:

https://omig.ny.gov/images/stories/work_plan/SFY_2018_OMIG_Work_Plan_FINAL.pdf

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com

 

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