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May 02, 2008

OMIG Continues Vigorous Enforcement Efforts: Compliance Programs to be Required for Additional Providers

The New York State Office of the Medicaid Inspector General (OMIG) recently issued its 2008-2009 Workplan. This plan sets forth the government's vigorous efforts in enforcement of the Medicaid laws and promises to review and audit virtually every type of provider. This plan reinforces the need for healthcare providers to be even more vigilant in their compliance efforts. Moreover, recently proposed regulations by OMIG indicate that the requirement for the implementation of a Compliance Program will now apply to almost all Medicaid providers.

The proposed regulations will extend the Compliance Program requirement to any "provider or an affiliate of the provider" that claims and/or receives, or has claimed and/or received, or should be reasonably expected to claim and/or receive at least $500,000 in a consecutive 12-month period from the Medicaid program. The proposed regulations also state that a provider or affiliate that receives $500,000 indirectly from the Medicaid program would also be required to implement such a program. Lastly, the regulations would require Compliance Programs be implemented by persons that submit or have submitted claims for care, services or supplies to the Medicaid program on behalf of another person in the aggregate of at least $500,000 in a consecutive twelve-month period. Providers will be required to certify that it has a program meeting the OMIG's requirements. Providers that do not have a satisfactory program may be subjected to sanctions or penalties, including revocation of the provider's agreement to participate in the Medicaid program.

Thus, having a Compliance Program which was once highly recommended of providers is now mandatory for almost all.

An effective Compliance Program assists providers in establishing systems designed to maintain statutory and regulatory compliance; and it also helps to identify and then correct non-compliance as soon as practicable. Importantly, an effective Compliance Program also demonstrates to government enforcement agencies a provider's good faith compliance efforts. In that regard, Federal and State criminal and civil enforcement agencies place strong emphasis on the presence or absence of a Compliance Program which conforms to their particular standards in deciding how to deal with providers.

Hiscock & Barclay, LLP has extensive experience developing compliance plans, and in responding to audits, investigations and reviews. Attorneys in the Practice Area include the former Deputy Commissioner & General Counsel of the New York State Department of Social Services and its former Director of the Bureau of Program Integrity, a former Assistant Medicaid Inspector General, and a former Assistant Counsel to the New York State Department of Health. The breadth of knowledge and experience in the Firm's Health Care and Human Services Practice Area invests us with special expertise in helping providers implement a compliance program that meets regulatory requirements, is tailored for the provider's size and industry segment, and works within the structure of the particular provider. Members of our team have extensive experience in drafting plans, revising plans, and training Boards of Directors, executive team members and staff of providers. Our Practice Area has worked with all types of providers - both big and small - to implement an effective Compliance Program. Please contact us for further details.

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