Healthcare Law Blog

We wish to remind our clients who receive more than $500,000 from New York Medicaid that they are obligated to adopt a written compliance plan and certify to the New York Office of the Medicaid Inspector General ("OMIG") that the plan has been adopted and is effective.  The deadline to certify to OMIG was December 31, 2011, but providers are encouraged to certify as soon as possible even if they missed the deadline.  Certification is mandatory, and providers who fail to certify are subject to sanctions up to and including exclusion from the Medicaid program. Providers must certify the following with OMIG:

• Effective Provider Compliance Certification Form

This form must be completed in December of each year by all Medicaid providers who order, receive or bill $500,000 or more in Medicaid services or supplies within a 12-month period, as well as any Medicaid provider operating under Articles 28 or 36 of the Public Health Law or Articles 16 or 31 of the Mental Hygiene Law. By submitting this certification, a provider attests that it has adopted, implemented and maintained an effective compliance program that meets the requirements of New York State Social Services Law § 363-d and 18 NYCRR Part 521.

• Federal Deficit Reduction Act Certification Form - January 1, 2012 Deadline

Providers who receive or make $5 million or more in Medicaid payments during the federal fiscal year are required to annually certify that they are in compliance with the Federal Deficit Reduction Act (DRA) of 2005, which requires such providers to establish and implement written policies and procedures informing their employees, contractors and agents about federal and state false claim acts and whistleblower protections.

For more information about certification or if you have any questions pertaining to compliance with the New York State Mandatory Medicaid Compliance Program or the Federal Deficit Reduction Act, please contact us at (718) 787-9500 or by email at This email address is being protected from spambots. You need JavaScript enabled to view it.

To all Medicaid providers:

In accordance with new federal rules and regulations, the New York State Medicaid program will be rolling out the provider revalidation process.

Revalidation will include attestation of credentials as well as the agreement to abide by the rules and regulations of the Medicaid program. Certain provider types will be required to pay a fee for revalidation. A revalidation process will be initiated by the New York Department of Health in the fall of 2012.  Revalidation will be rolled out by provider type. Correspondence will be sent to providers, advising them of their need to revalidate their enrollment. Providers will then have 150 days from receipt of the notice to complete the process. Failure to comply with the revalidation and attestation within the timeframe will result in provider disenrollment.

Our firm will assist new and existing clients with Medicaid revalidation.  Further updates will be provided when they become available, including a preliminary list of required documentation.

Providers are reminded that they are obligated to complete a compliance package if they bill more than $500,000 to NY Medicaid program annually (including through third-party Medicaid HMOs).  We expect that one of the required documents for Medicaid revalidation will be a certification of compliance.  We will provide a 20% discount to all clients who retain our firm to prepare a compliance package within the next 30 days after the publication of this announcement (through March 3, 2012).  Please contact us as soon as possible if you do not have a compliance package in place as this might result in substantial penalties, puts you at a much higher risk of Medicaid audit, and will prevent you from revalidating your Medicaid enrollment.

Our client, a registered nurse, was charged with professional misconduct for allegedly falsifying prescriptions and using it for her own use.  Following an interview with the office of Professional Discipline and presentation of written and oral evidence, the investigation against our client was terminated with no consequences to our client.

Please register on our website and access Member-Only "Documents and Files" to read this comprehensive article on combating derogatory online comments and attacks on doctors and other healthcare professionals

Medicare contractors will begin prepayment reviews of certain Medicare claims starting in January 2012 in several states, including New York. 

The first of the three-year demonstration programs -- all beginning in January 2012 -- will allow Medicare recovery audit contractors to conduct prepayment reviews of certain claims in 11 states, including NY. RACs currently examine claims after they have been paid. Auditors will begin the pilot program by focusing on inpatient hospital claims, especially those for short stays, and conduct the reviews before payment is authorized, said Deborah Taylor, director of the Office of Financial Management at the Centers for Medicare & Medicaid Services.

The second demonstration program will require prior authorization for powered mobility devices in seven states (including NY). It will begin with prepayment reviews for every claim, then transition to prior authorization within a year.

The third demonstration program will provide hospitals a new avenue to recover inpatient Medicare claims that were denied because the wrong site of service was listed. Hospitals will be allowed to resubmit these inpatient bills as outpatient claims at a slightly reduced rate and avoid the existing appeals process that CMS said can be costly and time-consuming.

It is unclear at this point to what extent individual physicians will be targeted by these pilot programs.