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June 14, 2016

Home Care Providers Beware: OMIG May Be Knocking on Your Door

The New York State Office of the Medicaid Inspector General (“OMIG”) lists home health services as one of the areas in its work plan for 2016-2017 and is making good on that action item.   As a result, audits of home health care services, particularly personal care services are on the increase.

OMIG will analyze claims for the provision of services, supervision and qualification of staff and personnel requirements, the consistency of following patient care plans, if spend down requirements are properly processed, and overlapping payments for dually eligible consumers, among other things.  Protocols are available online and have been recently revised for Certified Home Health Agencies (Revised 4/27/16), Independent Provider of Private Duty Nursing Services (Revised 6/3/16), and Personal Care Aides (5/11/15).   These protocols focus on the sufficiency of the documentation, the completeness of the documentation of hours and services provided, consistency of services with the orders, and credentialing and other regulatory requirements for staff.

Since the documentation for these audits is fairly extensive, the fieldwork usually takes 3-4 days onsite.  Once the field work for the claims is completed, OMIG may need to return to check staff credentials and requirements.  As with other audits, OMIG will then issue summary preliminary findings and schedule an Exit Conference.  Thereafter, a Draft Audit Report will be issued.  In order to preserve any arguments, the provider MUST include all objections, defenses and documents in response to the Draft Audit Report.  OMIG will review and then issue its Final Audit Report and the provider will have the opportunity to request an administrative hearing if it wishes to challenge those findings.

With any audit, ongoing compliance efforts should focus on the protocols and the related regulatory requirements.  We recommend that providers conduct periodic internal audits to ensure compliance.  Moreover, since the potential for large financial recoveries exists, providers need to know their rights, understand the process, and retain legal counsel to represent it during these audits.  Without this, home care providers could be facing financial hardship if OMIG seeks recovery of claims for services provided.

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