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When New York Medicaid providers must have compliance plans

Providers that have $500,000 or more in revenues from NY Medicaid within a consecutive year are required to have a compliance program in effect under New York law (18 NYCRR §521.2(b)).

It is up to the provider to determine if they are required to have a compliance program and to certify to the New York State Office of the Medicaid Inspector General (OMIG) that a program is in place every December.

What is required of mandatory compliance programs

There are eight elements that are required of a mandatory compliance program (SSL §363-d subd. 2 and 18 NYCRR §521.3(c)). These elements include:

  • Written policies and procedures that cover the expectations of compliance, how the program should operate and how to deal with potential compliance issues.
  • Designating an employee as Compliance Officer who has responsibility over the day-to-day operation of the program.
  • Training and educating on compliance issues and the program.
  • Making sure all potential compliance issues can be reported to the Compliance Officer.
  • Disciplinary policies that encourage good-faith participation in the program.
  • System for routinely identifying compliance risk-areas and non-compliance.
  • System for responding to compliance issues, including investigating and correcting problems.
  • Policy to prohibit intimidation and retaliation for good-faith participation in the program.

Additionally, the mandatory compliance program must apply to the following:

  • Billing
  • Payment
  • Medical necessity and quality of care
  • Governance
  • Mandatory reporting
  • Credentialing
  • Other risk areas that are identified or should be identified with due diligence

As you can see, implementing a compliance program is a complicated and time-consuming endeavor, which is why many providers seek help from an experienced health care lawyer, who can make sure that a compliance program is effective and meets all requirements.

What the certification obligation requires

Providers are required to certify to the New York State Office of the OMIG that a compliance program meeting all of the above is in place using a form provided by the OMIG, which can only be found on its website.

This certification must be done upon applying for enrollment in the medical assistance program and again during the month of December every year thereafter. More information about mandatory compliance programs can be found on the OMIG's website: www.omig.ny.gov.

For immediate assistance with implementing a mandatory compliance program, contact our law firm online or call 212-541-2451

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