Whenever I stumble upon something regarding regulatory compliance I try to make sure I share this with everyone. I have been posting links and articles from OMIG and OPWDD as appropriate. Here is a rather lengthy note about provider certification with OMIG.
Mandatory Compliance Program
Social Services Law (SSL) § 363-d, and Part 521 of Title 18 of the New York State Codes, Rules and Regulations (NYCRR), both entitled Provider Compliance Programs, has been actively enforced by the Office of the Medicaid Inspector General (OMIG) since 2009. This regulation requires all Medicaid providers who fall under the following categories to certify in December of each year that they have adopted and implemented an effective compliance program.
* persons subject to the provisions of Articles 28 or 36 of the New York State Public Health Law;
* persons subject to the provisions of Articles 16 or 31 of the New York State Mental Hygiene Law;
* other persons, providers or affiliates who provide care, services or supplies under the Medicaid program, or persons who submit claims for care, services or supplies for or on behalf of another person or provider for which the Medicaid program is or should be reasonably expected by a provider to be a substantial portion of their business operations.
Under 18 NYCRR § 521.2 (b), “substantial portion” of business operations means any of the following:
* when a person, provider or affiliate 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 the medical assistance program;
* when a person, provider or affiliate 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 the medical assistance program; or
* when a person, provider or affiliate who submits or has submitted claims for care, services, or supplies to the medical assistance program on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period.
Each compliance program must contain the eight elements required under SSL § 363-d and 18 NYCRR § 521.3 (c). Upon applying for enrollment in the medical assistance program, and during the month of December each year thereafter, 18 NYCRR 521.3 (b) requires providers to certify to the Department and OMIG that a compliance program meeting the requirements of the regulation is in place. The regulation, certification form, and FAQ’s are available on the OMIG Web site at: http://www.omig.ny.gov.
Additionally, New York State’s Medicaid providers are advised to review OMIG’s Web site and review the Compliance Alerts that are published under the Compliance tab on OMIG’s home page. The following Compliance Alerts may be helpful to Medicaid providers as they consider their obligations under this requirement:
* Compliance Alert 2010-02: Effectiveness of Medicaid Provider’s Compliance Program;
* Compliance Alert 2011-01: Annual Certification 2010 and
* Compliance Alert 2011-05: Compliance Program Requirement for New Medicaid Providers.
Lastly, OMIG will be updating New York’s Medicaid Provider Certification of Effective Compliance Program during 2011 for use during December 2011. When the new form becomes available, it will be announced in the Medicaid Update and on the OMIG’s Web site. One of the new features of the 2011 certification form will be questions on whether a Medicaid provider uses the services of a Service Bureau for billing, coding and eligibility determinations. The Bureau of Compliance intends to issue a Compliance Alert during 2011 on Service Bureaus as a supplement to OMIG’s Webinar #6, which is available under the Resources tab on OMIG’s home page. New York’s Medicaid providers are recommended to sign up for e-mail notices from OMIG by subscribing to OMIG’s listserv. Anyone can become a subscriber at no cost by signing up on OMIG’s home page. The listserv is a great way to keep informed of new compliance tools and information on compliance. Questions? Please contact the OMIG’s Bureau of Compliance at (518) 473-3782 or via e-mail at: firstname.lastname@example.org.