NYS Comptroller’s Report re: OPRA

October 16, 2023

In 2020-2021, after learning that several of our member agencies were part of a larger group of agencies that had been (desk) audited by OMIG re: compliance with state OPRA requirements, the NYS Council retained legal counsel and went to work to advocate for all behavioral health providers.  The audit focused on Article 31 and Article 32-822 Outpatient Clinic Programs.  Medicaid managed care claims were not included – just Medicaid Fee-for-Service.

After numerous meetings with OMIG leaders and intense advocacy designed to show the state and the OMIG that the guidance for providers re: OPRA was unclear at best, and that eMedNY appeared to be editing claims coming into the system such that providers were not getting denials for claims that were not coded correctly, OMIG decided to turn the matter over to the Governor’s Office (May 2021).  Since then, and although we have inquired with DoH numerous times re: the status of the eMedNY system to ensure it is now functioning properly, we have had no confirmation of this.

According to leaders at the OMIG, the decision to conduct a relatively small sample audit of 32 agencies re: OPRA compliance was rooted in a federal OIG investigation into state-by-state compliance with OPRA requirements.  OMIG claimed that the federal OIG was applying pressure on the NYS Comptroller’s Office, and the Comptroller’s Office was pressuring OMIG to conduct the audits.  

Last week the NYS Council shared the following information that was published in a recent NYS Comptroller’s Update, with our Compliance listserv.  The Update discusses recent and past audits conducted by the Comptroller’s Office.  Click on the link below to read the Comptroller’s follow up on its prior audit of New York’s compliance with federal Ordering, Prescribing and Referring and Attending (OPRA) requirements.  

As you can see, the Comptroller is pushing the state to follow up on its recommendations.  According to the Comptroller’s Office, only one of 12 audit recommendations has been fully implemented, 3 were partially implemented, and 8 were not implemented.  

The NYS Council is currently working with our attorneys who are analyzing provider risks associated with the OPRA issue, and our concerns and questions pertaining to the updated OMIG Self-Disclosure guidance.  Stand by for more.



Department of Health: Medicaid Program – Improper Medicaid Payments for Claims Not in Compliance With Ordering, Prescribing, Referring, and Attending Requirements (Follow-Up) (2023-F-4)  

As of January 1, 2014, New York’s Medicaid program required health care professionals who order, prescribe, refer, or attend (OPRA) Medicaid services be appropriately screened and enrolled in Medicaid and their National Provider Identifier (NPI) – a unique identification number – to be included on Medicaid claims. A prior audit issued in August 2021 found Medicaid made over $1.5 billion in improper and questionable payments for claims that did not contain an enrolled or affiliated OPRA NPI as required or where the NPI was not properly validated by the Department of Health (DOH) at the time of payment, and $19.4 million in payments for claims that contained an OPRA NPI that should not be included on Medicaid claims or that should be further reviewed by DOH due to past misconduct. The follow-up found that none of the improper and questionable payments have been reviewed. Furthermore, DOH has not improved system controls to prevent improper use of an override option for pharmacy claims that were denied because they did not contain the NPI of an enrolled provider in the prescribing field, and, as a result, auditors identified another $11.3 million in improper pharmacy payments since the initial audit. Of the initial report’s 12 audit recommendations, one was implemented, three were partially implemented, and eight were not implemented.