The New York State Office of the Medicaid Inspector General (OMIG) maintains a Certification Program to ensure Medicaid providers are continuing proper compliance. This program works to eliminate any environment in a Medicaid provider’s system that may encourage fraud, waste, or abuse, as well as ensuring errors have the potential for self-correction if mistakes are located before the Medicaid program is billed. Providers who meet OMIG’s requirements must submit a certification at the time of enrollment and every December thereafter. This includes any Medicaid providers who have submitted $500,000 in Medicaid claims or those who may reach that goal in any consecutive 12-month time period, regardless of calendar year.
OMIG has identified seven compliance areas that must be covered by the Compliance Program:
- Billings
- Payments
- Medical necessity and quality of care
- Governance
- Mandatory reporting
- Credentialing
- Other risk areas that are or should with due diligence be provided by the provider
There are an additional eight elements that also need to be included in the plan. The necessary elements can be found on OMIG’s website that details Compliance Plan information, linked above.
The 2018 Compliance Requirements, which included several updates, a number of which will have a potentially material impact on the providers who are required to recertify. The first category of these updates is the change to the number of Certification Categories. In previous years, these comprised of three categories; however, this year, that number has increased to five, which include:
- Annual Certification
- Enrolling Provider Certification
- Revalidating Provider Certification
- Certification after correcting insufficiencies identified in a compliance program review
- Certification after receiving notice of regulatory action for failing to complete your annual certification
Arguably, the most significant change in the 2018 certification process is that OMIG now requires the Provider ID and the National Provider Identifier Number (NPI), in addition to the Provider Name and the Federal Employer Identification Number (FEIN), which were required in years past.
The one change for the Compliance Officer/Certifying Official is the new requirement for the official’s address to be included.
The Compliance Questions have been omitted as a discrete section, but have been substantially retained into the Certification Section. This section now includes a compliance self-assessment form that OMIG suggests each Certification Official conduct prior to completing the Certification Form.
Each Medicaid provider must demonstrate that its Compliance Plan meets all eight elements OMIG has identified. If any provider fails to do so, a certification will not be administered and immediate corrections must be made in order to ensure the provider satisfies all requirements set forth by OMIG for a suitable Compliance Plan.
Although there were certain changes to the 2018 OMIG Compliance Certification Program, the overall purpose remains the same: to ensure every Medicaid provider has taken the proper steps to maintain compliance in order to remain certified. The 2018 form must be completed during the month of December and can be accessed via the above link beginning Monday, December 3, 2018.
For help with creating a satisfactory OMIG Compliance Certification or for more information, please contact Adrienne Dresevic, Esq. (adresevic@thehlp.com), Carey F. Kalmowitz, Esq. (ckalmowitz@thehlp.com), or Abby Pendleton, Esq. (apendleton@thehlp.com) at The Health Law Partners, (248) 996-8510.