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Is Your Compliance Program in Conformity with Recent Changes to New York State Law?

The New York State Office of the Medicaid Inspector General (“OMIG”) issued final regulations on December 28, 2022, overhauling the mandatory compliance program requirements imposed on certain Medicaid providers, including Article 28 and Article 36 entities, as well as those that bill or order at least $1,000,000 in Medicaid reimbursable services in any given year (up from the previous threshold of $500,000).  In addition, in late January 2023, OMIG released guidance on what the agency will be looking for when assessing whether providers are in compliance with the new requirements (both linked below).  Enforcement of these new regulations will commence on March 28, 2023.

Notably, the guidance highlights the consequences, including but not limited to financial penalties, for providers that fail to satisfy the new requirements.  Among these requirements, the new regulations make having an “effective” compliance program a “condition of payment”, meaning a provider’s receipt of Medicaid reimbursement could be jeopardized if OMIG finds that its compliance program is not “effective”.   A provider may also be subject to monetary penalties of up to $5,000 for each month during which the provider failed to adopt, implement, and maintain an effective compliance program – an amount which increases to $10,000 per month with a second violation. OMIG may also recoup monies paid to the provider, terminate the provider’s enrollment in the Medicaid program, or impose sanctions, such as exclusion from the Medicaid program.

The new regulations require significant changes to providers’ existing compliance programs, call upon providers to focus on measuring “effectiveness”, and mandate annual effectiveness evaluations.

18 NYCRR Part 521 Fraud, Waste and Abuse Prevention – Effective Date: 12/28/2022

Compliance Program Guidance with Addendums A and B_0 (3).pdf 

If you have questions about these changes or would like to speak to one of our attorneys, please complete the contact form below.

Are You Prepared? We Can Help.

Because of the magnitude and importance of Medicaid funding to healthcare providers, we are working in conjunction with MicroscopeHC to help clients gear up for the new requirements. Our cooperation will afford our clients coordinated legal, compliance, coding, billing and reimbursement knowledge and support to educate, assess effectiveness, and otherwise help clients prepare for this new enforcement era.*

Services We Provide

  • Preparation/Readiness for Effectiveness Reviews
  • Compliance Program Document Reviews
  • Annual Effectiveness Assessments
  • Auditing
  • Coding and Billing Reviews
  • Education and Training

The Microscope Team

Learn more about the Microscope Healthcare Compliance team here.

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*In compliance with state rules on the practice of law, clients will have direct contracts with Hancock Estabrook for any legal services provided. Disclaimer.  ATTORNEY ADVERTISING. Prior results do not guarantee a similar outcome.