View web version

Attention Providers! OMIG Audit Update: New Settlement Flexibility at Lower Confidence Payment Restored and DME Protocol Released

According to recently issued final audit reports, the New York State Office of the Medicaid Inspector General (OMIG) has revised its policy to give providers greater flexibility when responding to final audit reports. The new policy eliminates the previously deployed threat of a higher recoupment in the event the provider asked for a hearing per audit regulations, a policy that garnered significant criticism by the provider community as a penalty for seeking due process.

OMIG employs statistical sampling to extrapolate the results of a reviewed sample across the full universe of claims. Extrapolation is a method of estimating or projecting the total alleged overpayment based on a small sample of claims data. Within this framework, the result often yields a range of audit payments. The lower confidence interval (LCL) is the more conservative figure, whereas the middle confidence figure (MCL) is a more aggressive estimate. In practice, the LCL effectively serves as the “floor” of the estimate and is generally smaller than the point estimate that OMIG might otherwise seek to recover. Historically, OMIG only sought the higher repayment using the MCL if a provider lost at hearing. More recently, however, this flexibility to settle at the LCL before hearing was rescinded, giving providers only 20 days after the issuance of a final audit report to accept settlement at the LCL, thereby eliminating the ability to request a hearing and negotiate and further investigate the findings.

To read the full alert, click here.