Health Law Blog

FOR A LIMITED TIME ONLY, WE ARE OFFERING A DISCOUNT OF $250 ON OUR COMPREHENSIVE COMPLIANCE PACKAGES FOR HEALTHCARE PROVIDERS


If you are a HEALTH CARE PROVIDER IN THE STATE OF NEW YORK, you MUST BE AWARE that every healthcare provider billing or ordering over $500,000 per year from the NYS Medicaid program (including claims billed indirectly through third-party managed care organizations (“HMOs”) is required to adopt and implement an effective compliance program.  The requirement pertains to services billed directly by the provider as well as any indirect claims such as orders or referrals for ancillary services, claims for which are submitted to Medicaid, including but not limited to laboratory, radiology, and ambulette services. The Compliance Program applies to billings, payments, medical necessity and quality of care, governance, mandatory reporting, credentialing, staffing and other risk areas that are or should, with due diligence, be identified by every healthcare provider.

All providers are cautioned: A provider may be subject to sanctions and penalties, including revocation of enrollment in the NYS Medicaid Program, for failing to implement an adequate compliance program.  Putting together a Compliance Program that meets the requirements of the NYS Department of Health and the Office of Medicaid Inspector General involves a comprehensive professional review of your operations and compiling an extensive set of requisite documentation.

The NYS Medicaid Compliance Program must satisfy specific requirements set forth in relevant NYS codes and regulations.  When applying for initial provider enrollment in the NYS Medicaid program, in transfer of ownership applications and once per year thereafter, during the month of December, every NYS healthcare provider must demonstrate and certify to the Office of the Medicaid Inspector General that an adequate and effective Compliance Program has been implemented, which includes properly drafted policies and procedures that describe compliance expectations. 

December 2012 is an IMPORTANT DEADLINE!! Every NYS healthcare provider claiming over $500,000 per year must CERTIFY to OMIG that an adequate Program is in place by DECEMBER 31, 2012!

Experienced attorneys at the healthcare law firm of Sauchik Law Group, P.C. will take time to address any of your questions pertaining to implementation and certification of an effective Medicaid Compliance program as well as address any other healthcare legal issues you may be facing. 

CALL US today at 718-787-9500, visit our website at ww.mdrxlaw.com or email us at This email address is being protected from spambots. You need JavaScript enabled to view it.

March 2012 Medicaid Update, npscfe8.pdf, discusses major changes to the Medicaid Fee-For-Service and Managed Care programs.  Some of the topics discussed in the update are:

• Policy and Billing Guidance
  • New Benefit Year Begins April 1 for Medicaid Fee-for-Service (FFS) Enrollees - discusses when the current service year for purposes of service limits begins for Medicaid Enrollees
  • New York Medicaid Transportation Management for Fee-For-Service Enrollees in New York City  - discusses major changes to the transportation program for Medicaid Enrollees
  • New Edits for Original and Adjusted Delayed Claims  - discusses changes to the Delay Reason Codes
     
• Pharmacy Updates
  • Family Planning Benefits for Fidelis Care New York Members Billing Update  - discusses the availability of family planning coverage for Fidelis managed care enrollees under the Medicaid Fee-for-Service program
  • Preferred Drug Program and Frequency/Quantity/Duration (F/Q/D) Edits  - discusses various codes that are returned by eMedNY for rejections due to FQD program implementation
  • Clarifying Information for Medicaid Fee-for-Service (FFS} and Managed Care Pharmacy Providers  - contains questions and answers regarding the co-existence of Medicaid Fee-for-Service and Managed Care pharmacy benefits and the responsibilities of managed care plans and Medicaid

If you have any questions concerning these changes or other concerns regarding New York Medicaid Program, please contact our attorneys at 212-634-3650 or 718-787-9500, or email us at This email address is being protected from spambots. You need JavaScript enabled to view it.

The New York State Department of Health (“DOH”) has issued a Request for Applications (“RFA”) to establish new or expand existing Certified Home Health Agencies (“CHHAs”) in New York State. This is the first time in many years that CHHA applications will be accepted.  A CHHA is a licensed home health agency allowed to bill the Medicare and Medicaid.

As we have previously written, and as many of you may know, NY mandatory Medicaid compliance law requires that providers who bill, receive or order more than $500,000 from Medicaid must have a compliance program in place.  The Office of the Medicaid Inspector General ("OMIG") requires all affected providers to certify in December of each year that an effective compliance program is in place. 

Recently, OMIG began to conduct "effectiveness reviews"  where it contacts a provider who is supposed to have an effective compliance program, and requires them, sometimes on an expedited basis, to complete the relevant OMIG effectiveness questionnaire and provide other documentation to the compliance effectiveness review team. A site visit may occur, which includes interviews of board members, management and staff and can last a week.  If the effectiveness review team determines that the program is not effective and is not being used, the provider may be found in violation of the compliance law with penalties ranging from fines to potential exclusion.

It is therefore exceptionally important to have a compliance program in place, to follow all certification requirements, and to complete the relevant questionnaire in case of an effectiveness review.  We can help with every step of this process.