On August 21, 2023, the New York State Office of the Medicaid Inspector General (OMIG) revised the Self-Disclosure Program to provide two pathways for entities that must report, return and explain their receipt of Medicaid overpayments. Medicaid entities/providers may now use the new Abbreviated Self-Disclosure Process to report and explain overpayments that reflect routine or transactional errors and that have already been repaid through voids or adjustments of individual claims. This new guidance addresses a gap first identified when OMIG’s new regulations were released at the end of 2022. The new regulations and the guidance issued along with them in 2022 indicated that routine errors, typically corrected through voids and adjustments of individual claims, were “overpayments” that must be reported to OMIG using the standard Self-Disclosure process. The new guidance clarifies what is required when a Medicaid entity/provider is reporting and repaying a Medicaid overpayment arising from routine or transactional errors and affords a more streamlined process in such cases.
OMIG expects data for routine overpayments that are corrected via voids and adjustments to be collected for the month of September 2023 and the first monthly report to be made by October 5, 2023.
Medicaid entities/providers are required to report, return, and explain any Medicaid fee-for-service overpayments they have received via the OMIG Self-Disclosure Program within 60 days of identifying such overpayment, or the date any corresponding cost report is due, whichever is later. In the new guidance, OMIG explains that voiding or adjusting claims, alone, does not satisfy the Medicaid entity’s/provider’s obligation to report and explain the identified overpayment, in accordance with the regulations.
The updated Self-Disclosure Program Requirements Instructions and Guidelines, as well as the updated FAQ’s, provide the following examples of circumstances when a Medicaid entity/provider should use the new Abbreviated Self-Disclosure Process:
- Routine credit balance/coordination of benefits overpayments;
- Typographical human errors;
- Routine Net Available Monthly Income (NAMI) adjustments;
- Instance of missing or faulty authorizations for services due to human error;
- Instance of missing or insufficient support documentation due to human error;
- Inappropriate rate, procedure or fee code used, due to typographical or human error; and
- Routine recipient enrollment issues.
In addition, the information that must be submitted when using the Abbreviated Self-Disclosure Process is less detailed than the information which must be submitted when using the Full Self-Disclosure Process. For example, the Full Self-Disclosure Statement requires the Medicaid entity/provider to submit information, including reference to the rule that was violated, giving rise to the overpayment, identification of individuals involved in the error and in discovering the error, corrective measures that were put in place, a comprehensive claims data file or Mixed Payer Calculation (MPC) form, and confirmation that voided or adjusted transactions have been processed timely (if the Medicaid entity/provider has chosen to repay some/all of the identified overpayment in this manner).
By contrast, the Abbreviated Self-Disclosure Statement requires the Medicaid entity/provider to disclose its Federal Employer Identification Number (FEIN), the provider’s/entity’s name, a contact name, the overpayment identification period, the Transaction Control Numbers (TCNs) of voided or adjusted claims, the reason for the overpayment reflected by each voided or adjusted claim, and the total amount voided or adjusted during the identification period. OMIG also indicates that reporting all voided/adjusted claim for a particular “identification period” (i.e. time period) is advisable. Specifically, OMIG advises that:
“As a convenience and best practice, [Medicaid entities/providers] may aggregate their submissions in a monthly report which will be submitted by the 5th of the month following the month in which the claims were voided or adjusted.”
Please note that the self-disclosure process, and the information required to determine confirmation of the overpayment, is unique to the circumstances disclosed to OMIG and does not necessarily apply when other payors are involved. Upon receipt of a self-disclosure, OMIG will review the submission, determine the eligibility of the Medicaid entity under the New York Social Services Law § 363-d(7)(c) and notify the provider of same.