This Legal Alert discusses some important developments of which providers should be aware regarding the activities of the Office of the Medicaid Inspector General (OMIG).
- OMIG has released Compliance Alert 2012-01, which discusses Medicaid provider certification of its Compliance Program. This certification is due in December. Providers should ensure to review this document if they are unsure as to whether a Compliance Program is required or of their certification requirements. The Compliance Alert recommends that providers conduct a self-assessment of its Compliance Program as early in the year as possible so that corrections may be made prior to the certification, and that results of the self-assessment be provided to senior leadership and the governing body of the organization.
- OMIG has also released its 2012-2013 Work Plan. The Work Plan introduces OMIG's new Business Line Teams and discusses the focus of OMIG, including its auditing activities, for the period. Providers should review the document to focus its own internal reviews. We understand that OMIG is not auditing providers until the relevant protocols are finalized.
- OMIG released a new guidance regarding self-disclosure. Under the new guidance, disclosures may be made directly to OMIG or through its contracted agent HMS, which maintains the online OMIG PORTal. The guidance states that once an inappropriate payment is discovered, providers must determine whether it warrants a self-disclosure or whether it would be better handled through the void process. The factors to analyze are similar to those in prior guidance, although missing from this guidance is any reference to a hard dollar threshold that would mandate self-disclosure. Providers should review this document and discuss self-disclosures with health care counsel.
- Final regulations regarding withholding of payments were released and set forth that the Department may withhold Medicaid payments when it has determined that a provider has "abused the program or has committed an unacceptable practice." This determination may consist of preliminary findings by the Department's audit or utilization review staff of unacceptable practices or significant overpayments, information from a State professional licensing or certifying agency of an ongoing investigation of a provider involving fraud, abuse, professional misconduct or unprofessional conduct, or information from a State investigating or prosecutorial agency or other law enforcement agency of an ongoing investigation of a provider for fraud or criminal conduct involving the Program. The Department may withhold payment of current and future claims to the provider and any affiliate. The Department must withhold payments under the Program when it has determined or has been notified that a provider is the subject of a pending investigation of a "credible allegation of fraud" unless the Department finds good cause not to withhold payments in accordance with federal regulations. A "credible allegation of fraud" is an allegation that has indicia of reliability and has been verified by the Department, or the Medicaid Fraud Control Unit, or another State agency, or law enforcement organization. Providers should contact counsel whenever they receive notice of a withholding.
- OMIG has released compliance program guidance for hospitals. The guidance is useful for any type of provider to review as some of the information provided is general and even the specific hospital references will provide guidance as to what OMIG will be emphasizing when reviewing other provider types.
- For those who will be covered by the much-publicized legislation seeking increased protection for individuals with special needs and disabilities, OMIG will be informed of substantiated reports of abuse or neglect by Medicaid providers by the Justice Center when it may be relevant to an investigation of unacceptable practices.
Should you have any questions regarding these matters or pending audits before OMIG, please contact Melissa M. Zambri, Chair of the Firm's Health Care and Human Services Practice Area, David Glasel, Chair Emeritus, or any other member of our Firm's Health Care and Human Services Practice Area.