OPRA Audits

December 23, 2020

The NYS Council has obtained some important information we wanted to share with our members regarding a group of OMIG audits (underway, with some already completed) that, to this point, have impacted some 30 OASAS and/or OMH mental health and substance use disorder/addiction providers to include OASAS Article 32 and OMH Article 31 clinics, including county clinics.   We are advised by our friends as the NYS Conference of Local Mental Hygiene Directors that clinics that are serving children enrolled in Foster Care were also impacted because Foster Care is still in FFS.

The audit currently focuses on clinic Medicaid FFS claims paid between January 1, 2014 and December 31, 2018 that were billed with a non-enrolled or excluded Ordering/Prescribing/Referring/Attending (OPRA) provider.  The OMIG approach is similar to that being used by the Office of the State Comptroller recently where data mining is used to uncover whether or not the OPRA providers’ NPI on the claim was enrolled in Medicaid on the date of service, or if the provider was excluded on the date of service.

It is our understanding providers who received an audit letter from OMIG and that are the subject of this audit (so far) were originally given 30 days to respond to OMIG.  Today we learned OMIG has granted an extension until January 22, 2021.   It is our understanding that OMH and OASAS will be sending impacted providers a note to this effect, but until you receive that information, we urge you to follow the guidelines in the letter you received from the OMIG.  Note:  CASACs are not “enrolled providers” in the Medicaid program.

There are several hypotheses as to what may have transpired resulting in these audits.  These include (but are not limited to):

  •    The attending provider was not an enrollable provider type (e.g., LMSW), or unlicensed provider ID was used and the referring provider field was left blank.
  • Provider did not enter separate referring NPI, resulting in referring field left blank or automatically populated with the attending NPI.  This resulted in an un-enrollable provider type being listed in the referring field.
  • The attending provider was an enrollable provider type, however, they were not enrolled in Medicaid on the date of service.
  • The attending provider was not an enrollable provider type (i.e.; LMSW) and the referring provider on the claim was not enrolled in Medicaid on the date of service.
  • The OPRA provider was excluded from Medicaid on the date of service.

OMH and OASAS are in communication with representatives from the OMIG.  It would certainly help if providers were permitted to go back and fix claims that are the subject of this audit, but at this time there is no state sanctioned authority for providers to do so.  We urge you to consult your healthcare compliance attorney for advice before taking any actions whether you are the subject of this audit or not.

Attached please find a guidance document that was first discussed in a DoH Medicaid Update dated December 2013. The state has periodically reissued this guidance, once in 2017 and then again this summer.

Please note:  None of the information in this note should be construed as formal guidance.  Again, we urge you to consul a healthcare compliance attorney if you have any questions regarding this information..