Matter of Poole: OMIG “System Match” Data Audits

Rejected as a Basis for Findings

March 13, 2021

Thanks to NYS Council member agency SPECTRUM Human Services and specifically, CEO Bruce Nisbet for sharing the following Alert from Barclay Damon that we hope will ultimately have bearing on current (and future) OMIG OPRA audits that are performed using data match processes that ignore ‘valid, contemporaneous provider documentation’ and that ‘rely solely on claims entry data’.

Needless to say, yesterday we asked our attorney Robert Hussar to thoroughly review this decision to ascertain whether it sets a precedent relating to the OMIG OPRA audits that we can use to change the OMIG OPRA audit determinations already made as well as future audits that rely on very limited data via what we commonly refer to as data matching ‘desk audits’.   Stand by!

Matter of Poole: OMIG “System Match” Data Audits Rejected as a Basis for Findings
Barclay Damon is very excited to report a key decision in our client’s favor after a hearing dealing with the core issues in all of our “coordinated” data match OMIG audits involving over $8 million in initial findings.

In a critical decision in a lead case issued after four days of hearing, our Barclay Damon Transportation Audit Team obtained a favorable decision that has now yielded clear precedent that will limit and even end the slew of audits that ignore valid, contemporaneous provider documentation and rely solely upon claims entry data that we and our experts believe is flawed and corrupted.

OMIG had pursued over 100 “system match” audits based solely upon claiming data, but refused to consider valid claiming documentation. In a trio of cases, binding upon OMIG and culminating in Poole, the agency’s ALJ’s have now foreclosed OMIG’s use of this lucrative, but highly controversial, auditing practice that threatened to render documentation requirements moot and cause a complete forfeiture of payments to providers based upon novel and immaterial inconsistencies or errors in electronic claiming data. This is good news for providers of all kinds who may resort to documentation kept per regulations to support claims upon audit.

If you are facing payer or governmental audit liabilities, contact the firm’s Health Care Controversies Audit Team for a free consultation as early as possible in the process to see how we can help.