The Office of Medicaid Inspector in New York State
("OMIG") has been aggressive in pursuing fraud claims
against providers, targeting the problems that fee for service
reimbursement create – over utilization, lack of medical
necessity, upcoding and so forth.
OMIG is also stepping up its enforcement efforts with managed
care organizations ("MCOs"). In the managed care
environment, underutilization and lack of access to appropriate
services can result from an MCO's overly restrictive policies.
OMIG will review MCOs to determine whether they have conducted
adequate outreach and education so enrollees know how to utilize
OMIG will also look at the following:
Medicaid payments being made for the same enrollee with
multiple client identification numbers
Duplicate fee for service billing that resulted in Medicaid
paying separately for services that should have been included in
Quality of Care Issues – whether appropriate services
were provided and in accordance with applicable standards of
Cost Reports – the underlying data that is used to
set capitation rates will be examined to ferret out false encounter
data, appropriateness of costs, dually-eligible billing issues,
billing for costs of preventable health care acquired conditions to
justify rates, and provision of medically unnecessary services and
OMIG's charge is to ensure that taxpayer dollars are used
efficiently to provide needed health care services. In the case of
managed care, the challenge is to identify plans that are
inappropriately taking Medicaid payments and then withholding
needed care or inflating costs to obtain higher premiums.
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