NY Medicaid Exclusion

Posted by Frank Strafford on April 14, 2016 in Exclusion Reinstatement, Exclusion Screening, Exclusions, Self Disclosure,

New York State Medicaid Exclusion

New York’s Office of the Medicaid Inspector General exists to “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 a high quality of patient care.” It was established as an autonomous entity within the New York State Department of Health, consisting within its organizational structure the following offices:

Agency Coordination and Communications
Bureau of Compliance
Bureau of Quality Control and Risk Management
Division of Administration
Division of Medicaid Audit
Division of Medicaid Investigations
Division of System Utilization and Review
Office of Counsel

These offices make up the OMIG’s Business Line Teams tasked to look into the processes and operations of healthcare-related industries and services including and oversee:

Delivery System Reform Incentive Payment Program
Home and Community Care Services
Hospital and Outpatient Services
Managed Care
Managed Long Term Care
Medical Services in an Educational Setting
Mental Health, Chemical Dependence, and Developmental Disabilities Services
Pharmacy and Durable Medical Equipment
Physicians, Dentists, and Laboratories
Residential Health Care Facilities
Transportation

In order to efficiently mobilize its mission, the New York OMIG conducts and supervises all prevention, detection, audit, and investigation efforts in coordination with the following offices:

Also, the Medicaid Inspector General and the Attorney General’s Medicaid Fraud and Control Unit (MFCU) work closely to further empower the existing partnerships with local and federal law enforcement agencies.

Examples of fraudulent activities which the New York OMIG is consistently on the lookout for include the following:

Providers:

Billing for Medicaid services that were not provided
Giving out, or billing for, unnecessary services
Selling prescriptions
Ordering unnecessary tests
Giving money or presents to consumers in return for agreeing to get medical care from someone

Enrollees:

Lending a Medicaid Identification card to another person;
Forging or altering a prescription or fiscal order;
Using multiple Medicaid ID cards;
Intentionally receiving duplicative, excessive, contraindicated, or conflicting health care services or supplies; and
Re-selling items provided by the Medicaid program.

Some New York State OIG Exclusion facts:

178 exclusions during 2015 (that’s more than 10% less than 2014 which had 200 total exclusions)
OIG exclusions in NY include among others:
- Conviction of program-related crimes.
- Conviction relating to patient abuse or neglect
- Felony conviction relating to health care fraud
- Felony conviction relating to controlled substance
Specialties that were excluded include among others:
- Pharmacy technician
- Paramedics
- Ambulance companies
- Skilled Nursing
761 OIG exclusions in the State of New York over the years 2011-2015
639 total OIG exclusions in the State of NY from the years 2006-2010 which is about 15% less than the following 5 years. Does this mean that the OIG is more on top of the situation and handling all of this better? Does this mean that healthcare & medicaid fraud is getting worse?

Fraud Disclosure

To report suspected fraud, or for self-disclosure:

please report it via the internet

or call toll free:

1-877-87-FRAUD (1-877-873-7283)

Reports should include the following details:

Nature of suspected fraudulent activity

Details such as: Who is involved; when it occurred; whether there are witnesses to the misconduct.

Anonymous reports are welcome although the New York Office of the Medicaid Inspector General (OMIG) encourages that whistleblowers agree to identify themselves should the case require further questions be answered.

To file fraud allegations, follow the instructions on this link:

https://www.omig.ny.gov/index.php/fraud/file-an-allegation

https://omig.ny.gov/index.php/information/about-omig

https://omig.ny.gov/images/stories/work_plan/2015-16_work_plan.pdf

https://omig.ny.gov/index.php/fraud/file-an-allegation

http://oig.hhs.gov/fraud/enforcement/cmp/cmp-ae.asp

For more on state medicare and medicaid exclusions visit our OIG Exclusion list and State exclusion database page here.

To learn more about State Medicaid compliance, visit our MEDICAID PROVIDER EXCLUSION LIST page.

Check out this great resource for all questions on OIG Exclusion of the State of New York and the New York OIG Exclusion List.