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HomeHealth LawConsideration New York Medicaid Suppliers: It’s Time to Improve Your Compliance Program

Consideration New York Medicaid Suppliers: It’s Time to Improve Your Compliance Program


On January 31, 2023, the New York State Workplace of the Medicaid Inspector Basic (OMIG) launched three steering paperwork to help Medicaid suppliers in assembly the necessities of not too long ago adopted laws governing (i) the implementation and upkeep of an efficient compliance program for sure suppliers; (ii) Medicaid managed care fraud, waste and abuse prevention applications; and (iii) OMIG’s Self-Disclosure Program for overpayments.

New Subpart 521-1: Compliance Applications

The adopted laws signify substantial adjustments to 18 N.Y.C.R.R. Half 521 governing the implementation and operation of efficient compliance applications for sure “required suppliers,” together with, now for the primary time, Medicaid managed care organizations (MMCOs).[1] Though the laws had been adopted on December 28, 2022, and have become efficient instantly, OMIG introduced within the Compliance Program Steering that required suppliers can have till March 28, 2023, to undertake and implement the required adjustments to their compliance applications.

OMIG’s new Compliance Program Steering outlines a number of greatest practices and supplies examples of documentation that OMIG believes Medicaid required suppliers ought to keep to show that the they’ve adopted, carried out and keep efficient compliance applications that meet every of the 7 parts specified within the laws.

OMIG’s Compliance Program Steering additionally outlines the steps that it’ll comply with in conducting its opinions of supplier compliance applications. These steps embody:

  • Written notification of the evaluate to the required supplier;
  • Requiring the supplier to obtain a module from OMIG’s web site, full the module and submit supporting documentation to OMIG inside 30 days for OMIG’s evaluate; and
  • OMIG’s written compliance program evaluation, suggestions for enchancment and a numerical scorecard indicating whether or not the required supplier satisfactorily met the Half 521-1 necessities for every month of the evaluate interval (to not exceed 12 months).

OMIG’s introduction of month-to-month scorecards underlines the significance of required suppliers changing into and staying up-to-date with all compliance program necessities, as OMIG is permitted to impose financial penalties of as much as $5,000 monthly on required suppliers that wouldn’t have an efficient compliance program. For a second violation, OMIG might enhance the penalty to $10,000 monthly.

New Subpart 521-2: Necessities for MMCOs

New Subpart 521-2 requires every MMCO to undertake, implement and keep a compliance program that satisfies the entire provisions in Subpart 521-1. As well as, every MMCO should develop a fraud, waste and abuse prevention plan and submit it to OMIG inside 90 days of the efficient date of the brand new guidelines or upon signing a brand new contract with the New York State Division of Well being to start participation as an MMCO. 

New Subpart 521-3: Self-Disclosure Program

New Subpart 521-3 implements the long-standing requirement that all enrolled Medicaid suppliers report, return and clarify overpayments acquired from the Medicaid program by means of OMIG’s Self-Disclosure Program. Whether or not or not a supplier is topic to the necessary compliance program obligations, underneath each Federal and State regulation, all suppliers are required to report, return, and clarify any overpayments acquired from Medicaid inside 60 days of identification, or by the date any corresponding price report was due, whichever is later. Medicaid suppliers must also use the Self-Disclosure Program to report broken, misplaced or destroyed data that help their proper to obtain Medicaid funds.

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Required suppliers might want to evaluate and replace their Requirements of Conduct and Compliance Program insurance policies and procedures to make sure they meet the brand new regulatory necessities, which cowl a broad spectrum of operational adjustments starting from compliance coaching to dissemination of insurance policies to capabilities such because the formation of compliance committees, accountability and duties of the Compliance Officer and extra.

When you require help in revising, updating or adopting a Compliance Program that meets the brand new regulatory requirements, or if you happen to want help with a submission to the OMIG Self-Disclosure Program, the attorneys at Sheppard Mullin can be found to help you.


[1] Different required suppliers topic to the Half 521-1 laws are the next: hospitals, residential well being care services, dwelling care providers companies, suppliers of developmental incapacity providers, suppliers of psychological incapacity providers, and suppliers that declare or obtain $1 million or extra immediately or not directly (equivalent to managed care community collaborating suppliers) from the Medicaid program.




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