New Proposed OMIG Regulations

July 26, 2022

Update:  The NYS Council is working with our colleagues at COMPA, to continue our forward progress in bringing fairness and balance to the OMIG audit process.  We have drafted a sign on letter addressed to the Governor, urging enactment of the OMIG Reform legislation that passed in both houses last month.  Currently the letter has 27 different associations signed on, and all represent providers and consumers of healthcare services here in NY.  We will issue the letter at the end of next week, and we will need all hands on deck to compel Governor Hochul to call up the bill from the legislature, and to sign it.

In other OMIG-related news, the article at the bottom of this email from today’s Crain’s Health Pulse describes a proposed rule issued by the NYS OMIG that would require MMC plans to have more robust special investigations units, focused on rooting out fraud and abuse, to ‘protect the fiscal integrity of the Medicaid program’.

Background:  On July 13, the Office of Medicaid Inspector General (OMIG) published proposed regulations implementing 2020 changes to law relating to provider compliance programs, Medicaid managed care fraud, waste and abuse prevention programs, and OMIG’s self-disclosure program. The proposed changes will significantly impact both payers and providers alike.

RESOURCE:  NYS Council Healthcare Compliance Attorney Robert Hussar sent us notice of an upcoming webinar his firm is offering free of charge on this important topic.  We shared the announcement with all members several weeks ago. Links that take you to a write up of the webinars and that provide a way to register are provided here:

Click here to register for the July 27 session.
Click here to register for the July 28 session.
The Zoom link will be provided upon registration.

(Crain’s Health Pulse, 7/26)
Medicaid managed care plans would face heftier compliance standards under state proposal

A proposed rule issued this month by the state’s Office of the Medicaid Inspector General would require Medicaid managed care plans to have more robust special investigations units, which focus on rooting out fraud and abuse.

The objective of the regulations is “to protect the fiscal integrity of the Medicaid program,” officials said in a notice in the July 13 state register.

The proposal would lower the threshold for plans required to have a special investigations unit from 10,000 members to 1,000. 
Each unit would need one full-time lead investigator and one director, plus an additional staffer for every 60,000 plan enrollees or every 6,000 enrollees in the case of managed long- term care plans.

Randi Siegel, partner at consultancy and law firm Manatt Health, said the provisions would result in a significant hiring blitz of compliance professionals, who are already hard to come by. She said the state should be flexible and allow good-cause exemptions to the staffing requirements if the rules were adopted.

“It’s very hard to hire a compliance professional or a fraud, waste and abuse investigator,” Siegel said. “There’s a much higher demand for the job than there are individuals who are qualified or interested.”

The proposed rules also add compliance-related documentation requirements for plans and Medicaid-enrolled providers and explicitly specify that contractors are subject to compliance programs. The threshold for providers required to adopt a compliance program would increase from $500,000 to $1 million in Medicaid revenue.

“The proposed rules are making sure your compliance program isn’t just on paper and that you’re actually implementing and evaluating the program as a whole,” Siegel said.

The proposed changes stem from the state’s enacted fiscal 2021 budget and the Medicaid Redesign Team II.

The state is accepting public comments on the proposed rule through September. —Maya Kaufman