Healthcare providers, physicians and pharmacies in particular, must be warned: 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.
Every healthcare provider claiming $500,000 per year or more from the NYS Medicaid program is required to adopt and implement an effective compliance program. Providers should be aware that the $500,000 in billings requirement includes claims submitted to the Medicaid program, whether billed directly or through various third-party managed care organizations. The Compliance Program applies to billings, payments, medical necessary and quality of care, governance, mandatory reporting, credentialing, and other risk areas that are or should with due diligence be identified by every healthcare provider. 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 that an adequate and effective Compliance Program has been implemented, which includes properly drafted policies and procedures that describe compliance expectations. The Compliance Program shall provide guidance to owners and employees on dealing with potential compliance issues, identify how to communicate these issues and describe how these problems are investigated and resolved. The Compliance Program must designate and employee responsible for its daily operations and it should provide for training & education of all affected employees on compliance issues, expectations, and the operation of the Compliance Program.
It is important for every NYS healthcare provider to remember that upon applying for enrollment in the NYS Medicaid Program and every December thereafter, a provider claiming over $500,000 per year must to the Department that an adequate Program is in place!
The Commissioner of Health and the Medicaid Inspector General will determine the adequacy of a provider's compliance program. In the event that the Commissioner or OMIG finds that a provider's compliance program is unsatisfactory or inadequate, the provider may face serious consequences.