New York State Office of the Medicaid Inspector General SFY 2009-2010 OMIG Medicaid Work Plan David A. Paterson Governor James G. Sheehan Medicaid Inspector General www.omig.state.ny.us Fraud Hot Line: 1-877-87-FRAUD April 24, 2009 NYS OMIG 2009-2010 WORK PLAN TABLE OF CONTENTS STATEMENT FROM NEW YORK’S GOVERNOR.......................................................................1 INTRODUCTION...............................................................................................................................2 EXECUTIVE INITIATIVES..............................................................................................................5 BUREAU OF ALLEGATIONS AND COMPLAINTS....................................................... 5 COMPLIANCE GUIDANCE .............................................................................................. 5 CORPORATE INTEGRITY AGREEMENTS ................................................................... 6 FOCUS ON ORDERING PHYSICIANS ............................................................................ 6 AUDIT ASSESSMENT SURVEY ....................................................................................... 7 MARKETING AND ORDERING OF PRESCRIPTION DRUGS AND MEDICAL DEVICES ............................................................................................................................. 7 MONITORING NEW YORK STATE’S SHARE OF THE FEDERAL STIMULUS MEDICAID FUNDS............................................................................................................. 8 EXTERNAL COMMUNICATIONS................................................................................... 8 Web Site............................................................................................................................. 9 External Outreach.............................................................................................................10 REVIEW OFF-LINE MEDICAID EXPENDITURES ......................................................10 DIVISION OF MEDICAID AUDIT.................................................................................................10 AUDIT PROCESS ..............................................................................................................11 Selection of Audit Subject Areas, Providers and Methods ..................................................12 Project Notification...........................................................................................................12 Entrance Conference.........................................................................................................12 Statistical Sampling...........................................................................................................13 Audit Field Work...............................................................................................................14 Exit and Draft Reports ......................................................................................................14 ADULT DAY HEALTH CARE..........................................................................................14 Clinical Audit....................................................................................................................15 Rate Audit.........................................................................................................................15 ASSISTED LIVING FACILITIES.....................................................................................15 CONSUMER-DIRECTED PERSONAL ASSISTANCE PROGRAM..............................16 COUNTY AUDIT/INVESTIGATION DEMONSTRATION PROJECT .........................16 CROSSOVER PAYMENT MATCHES.............................................................................16 DIAGNOSTIC AND TREATMENT CENTERS...............................................................17 DURABLE MEDICAL EQUIPMENT AND SUPPLIES ..................................................17 EARLY INTERVENTION .................................................................................................17 FREESTANDING AMBULATORY SURGERY SERVICES ..........................................18 HOME HEALTH SERVICES............................................................................................18 Adult Home Setting ...........................................................................................................18 Certified Home Health Agency - Rate................................................................................18 Claims Audits....................................................................................................................18 Medical Surpluses.............................................................................................................18 HOSPICE SERVICES ........................................................................................................19 HOSPITALS .......................................................................................................................19 Ambulatory Surgery Services ............................................................................................19 Credit Balances ................................................................................................................19 Duplicate Clinic Claims Audit...........................................................................................19 Fee-for-Service Payments When Patient Enrolled in Medicaid Managed Care ..................20 Hospital Newborn Fee-for-Service –Managed Care Crossover Payments.........................20 Ninety-Day Billing Exception Codes .................................................................................20 Payment for Medicare Coinsurance and Deductibles ........................................................20 4/27/2009 Page i of 69 NYS OMIG 2009-2010 WORK PLAN Physician and Hospital Financial Relationships................................................................21 Review of DRG Coding .....................................................................................................21 HUMAN IMMUNODEFICIENCY VIRUS SERVICES ...................................................22 Case Management Services...............................................................................................22 Drug Resistance Testing....................................................................................................22 Pre-Test Counseling..........................................................................................................22 LABORATORY SERVICES..............................................................................................23 Independent Laboratories .................................................................................................23 Payment for Medicare Coinsurance and Deductibles ........................................................23 MANAGED CARE .............................................................................................................23 Capitation Payments Made When Enrollees are Institutionalized in a Skilled Nursing Facility .............................................................................................................................23 Compliance Review of Medicaid Managed Care and Family Health Plus Contracts..........23 Family Planning Chargeback to Managed Care Organizations .........................................24 Family Planning Chargeback to Managed Care Organization Network Providers.............24 Improper Multiple Client Identification Numbers for One Enrollee Payments....................24 Improper Retroactive Supplemental Security Income Capitation Payments........................24 Payments for Deceased Enrollees......................................................................................25 Payments for Incarcerated Enrollees.................................................................................25 Prior to Date of Birth Payments ........................................................................................25 Recovery of Capitation Payments for Retroactive Disenrollment Transactions ..................25 Review of Reported Costs by Managed Long Term Care Organizations.............................25 Review of Reported Costs by MCO Plan Companies..........................................................26 Supplemental Capitation Payments Made Without Corresponding Encounter Data ...........26 Supplemental Newborn and Maternity Payment Errors .....................................................26 Supplemental Payments to Federally Qualified Health Centers with No Encounter Data...26 MEDICAID IN EDUCATION............................................................................................27 OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES (OASAS)..........27 Chemical Dependence Inpatient Rehabilitation Services - Clinical....................................28 Chemical Dependence Inpatient Rehabilitation Services - Rates........................................28 Ninety-Day Billing Exception Codes .................................................................................28 Outpatient Chemical Dependence Services........................................................................29 OFFICE OF CHILDREN AND FAMILY SERVICES .....................................................29 OFFICE OF MENTAL HEALTH......................................................................................29 Clinic Restructuring..........................................................................................................30