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Medicaid Inspector General Provides Fraud Guidance

Ben Amirault, May 5, 2009

The New York State Office of Medicaid Inspector General (OMIG) last week released its 2009 work plan, which details the processes used by the agency to root out Medicaid fraud.

In the work plan's introduction, Medicaid Inspector General James Sheehan describes the document as a "road map" for the agency "reflecting OMIG's mission, developing competencies and carefully reviewing New York Medicaid expenditures and vulnerabilities."

The 2009 work plan is the second such document released by the New York OMIG, which continues to be among the most active Medicaid enforcement agencies. Within the work plan, the OMIG stated it also plans to publish compliance guidance for hospitals and managed care organizations in 2009.

However, according to experts, the work plan provides helpful guidance in its own right.

"New York state Medicaid work plan is a useful resource providers can certainly consider when identifying risk in the Medicaid program," says Sarah Kay Wheeler Sarah Kay Wheeler, partner at King & Spalding in Atlanta.

According to Wheeler, the work plan offers a transparent look into how the OMIG operates, which can be valuable to providers in any state. Providers can look to the work plan when determining possible Medicaid vulnerabilities. This is particularly important now because evidence indicated Medicaid enforcement efforts have been on an upswing.

Last week, New York State Attorney General Andrew Cuomo announced the state's Medicaid Fraud Control Unit (MFCU) recovered more than $263.5 million in fraud and abuse settlements in 2008. That total is more than double what the state recovered in 2007. New York's federal fiscal year 2009 goal is set at $322 million and if history is any indication, the state should meet that goal.

But New York agencies are not the only ones cracking down on Medicaid abuse. The federal Office of Inspector General also targeted Medicaid in its 2009 work plan.

"For those of us that have been following the law, this is not a surprise," says Wheeler.

According to Wheeler, the uptick in Medicaid enforcement has been in the works since 2006 when the Federal Deficit Reduction Act aimed to establish more resources to ensure the integrity for the Medicaid dollar.

The act increased funding at the federal level to establish data-mining, enact employee education provisions, encourage states to establish their own version of the False Claims Act, and created the Medicaid Integrity Contractors (MIC).

MICs are a quieter cousin to the Recovery Audit Contractors (RAC). Wheeler says MICs have not gotten as much attention as the RACs because MICs have not been as active. But Wheeler predicts MICs will be more active in 2009 than they have in previous years, and she wouldn't be surprised if this turns out to be a record year.


Ben Amirault is an Editorial Assistant for the revenue cycle division of HCPro. He manages the Compliance Monitor e-newsletter and has developed a number of online learning modules. He can be reached at bamirault@hcpro.com.

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