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The OMIG Exclusion and Reinstatement Process. William Gilbert Assistant Medicaid Investigator in Charge of Investigations Moderator. About OMIG. Established in 2006 as an independent program integrity entity within the Department of Health (DOH) - PowerPoint PPT Presentation
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o Established in 2006 as an independent program integrity entity within the Department of Health (DOH)
o Our mission: To enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices in the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care
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o Julia McPherson, Management Specialist 3o Sean Parker, Management Specialist 1o Peter Zayicek, Management Specialist 2o John Sitterly, Management Specialist 3o Anita Dowse, Hospital Nursing Service Consultant
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To protect the Medicaid program and recipients from providers who pose a risk. OMIG has authority to sanction individuals and entities
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18 NYCRR 515.3Upon a determination that a person has engaged in an unacceptable practice, the department may impose one of the following sanctions:
o Exclusiono Censureo Limited Participation
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18 NYCRR 504.7(d) If an enrolled provider loses his or her license, the provider’s enrollment in New York State Medicaid
is terminated.
Provider is no longer enrolled in Medicaid.
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o Immediate Sanctions 515.7• Indictment• Conviction• Imminent Danger• Professional Misconduct
o Mandatory Exclusion 515.8• HHS/OIG Medicare Exclusion
o Sanctions Based on Unacceptable Practices 515.2• 18 unacceptable practices defined in the regulations
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18 NYCRR 515.7
Indictment
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o 18NYCRR 515.7
o Indictmento Conviction
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o 18 NYCRR 515.7
o Indictmento Conviction
o Imminent Danger
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o 18 NYCRR 515.7
o Indictmento Conviction
o Imminent Dangero Professional Misconduct
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o Whether the determination was based upon a mistake of fact
o Whether any crime charged in an indictment, or conviction of a crime, resulted from furnishing or billing for medical care, service, or supplies
o Whether the sanction imposed was reasonable
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o 18 NYCRR 515.8
o Federal Medicare Exclusion
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o Unacceptable Practices 515.2
o 18 Unacceptable practices as defined in the regulations
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o Consent Order/Determination and Ordero Indictment/Convictiono Federal Exclusiono Affiliation
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18 NYCRR 515.5(c)“A person who is excluded from the program cannot be involved in any activity relating to
furnishing medical care, services or supplies to recipients of medical assistance for which claims
are submitted to the program, or relating to claiming or receiving payment for medical care,
services or supplies during the period.”
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o HHS Center for Medicare and Medicaid Services (CMS)o Verify that a person is not excluded when they are hiredo Verify every 30 days that current employees have not been
excludedo Search the HHS/OIG List of Excluded Individuals and Entities
(LEIE)o Search the OMIG list of restricted or excluded individuals or
entities on OMIG Web site
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Medicaid providers found to be in violation are placed on the OMIG list of restricted and excluded individuals and entities available on the OMIG Web
site, which enables any organization access to review for disqualified providers.
http://omig.ny.gov/data
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o Applications on www.emedny.org siteo Submit to Computer Sciences Corporation (CSC)o Applications reviewed by New York State
Department of Health (DOH) prior to review by OMIG
o Secondary review by OMIG/Enrollment Assessment Unit (EAR)
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o Placeholder: www.emedny.org screen shot for application for reinstatement.
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o A reinstatement application is made as an application for enrollment
o Reinstatement may only be granted if it is reasonably certain that the violations will not be repeated
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o Answer the four “yes/no” questions on the application
o Prior conduct questionnaire
o Cover letter addressing the reasons for exclusion and give assurances
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Assurances may include:oCourses or continuing educationoSubstance abuse or other counselingoRestitutionoThird-party monitoring of billingoCompliance Plan – www.omig.ny.gov/data oAny other assurances can be submitted
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o OMIG may ask for information and documentation regarding the conviction
o The applicant is responsible for obtaining the information
o Applicant will be given at least 30 days to submit information
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o An individual excluded from Medicare may not be reinstated into the Medicaid program
o Apply for Medicare reinstatement first:www.oig.hhs.gov/fraud/exclusions/reinstatement.asp
o Exception – Medicare exclusions based solely on Medicaid exclusion
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o All reviews done on a case-by-case basiso Medicaid reinstatement decision is
separate from Medicare, OPD, or OPMC decision
o Law allows 90-day time frame for review
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o Nature of violationo Error or intentionalo Length of time since violationo Patterns/repeated violationso Voluntary corrective actions takeno Acceptance of responsibility for actionso Monitoring or supervisiono Not limited to these factors
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o OMIG will inform applicant of approval or denialo If reinstatement is approved, the individual or
entity’s provider number will be reactivatedo Reinstated parties removed from exclusion listo Individual or entity may be reinstated with
limitations
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A physician was excluded after he showed up once to work while intoxicated. No patients were harmed. Applied two years later for reinstatement.oSubmitted documentation of participation in Committee on Physicians Health of Medical Society of State of New YorkoSubmitted a letter from alcohol rehabilitation counseloroAttends AA regularlyoHas license back; no problems since exclusionoOMIG approved MD for reinstatement
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A physician was excluded after billing Medicaid for $100,000 in false claims. License restored after six months. Applied for reinstatement two months later.oDenies charges – was just a “misunderstanding”oHas since been indicted for false billings to a health insurance companyoStates he will never agree to having someone monitor his practiceoOMIG denied MD for reinstatement
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o Excluded parties that do not want to enroll in Medicaid may request only removal from exclusion list
o Removal without reinstatement does not allow party to directly bill Medicaid
o Removal allows applicant to provide Medicaid services that an employer can be reimbursed for
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o Can be done as a letter to OMIGo Include name, address, contact information,
license numbero Letter must specifically state that the request is
for removal from exclusion listo Letter should explain reasons for exclusion and
address the reasons for proposed removal
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Requests for removals can be sent to:John Sitterly
Division of Medicaid Investigations800 North Pearl Street
Albany, NY 12204
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Applicant may submit:oCourses or continuing educationoSubstance abuse or other counselingoStatement as to where applicant plans to work if removed from listoLetters from employer or other supporting documentsoAny other assurances can be submitted
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o All reviews done on a case-by-case basiso Decision on removal is separate from Medicare,
OPD or OPMC decisionso Law allows 90-day timeframe for reviewo Because letter goes directly to OMIG, process
may be quicker than reinstatement process
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o Error or intentionalo Length of time since violationo Patterns/repeated violationso How does removal affect New York State
Medicaid?o Involved with Medicaid recipients?o Does applicant need removal just to participate with
third-party payers?o Working out of state?
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o OMIG will inform applicant of decisiono If removal is approved, will be removed from
exclusion listo Removal allows employer to bill for services
applicant provideso Can still request reinstatement
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A nurse was excluded for taking drugs from a locked area in a nursing home for her own use. Applied two years later for removal from exclusion list.oRight after exclusion, she got involved with PAPoSuccessfully completed rehabilitation programoSubmitted current statement from her counseloroAdmitted she stole the medication/very sorryoOMIG approved removal from exclusion list
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A home care provider stole a Medicaid recipient’s credit card and charged more than $2,000 on the card in various stores, forging the recipient’s name. Applied for removal seven weeks after exclusion.oApplicant’s letter downplays incidentoStates only that exclusion harms her financiallyoWants to continue to work in home care in New York StateoOMIG denied request for removal from list
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o If a denial is based on prior conduct, applicant may not reapply for two years
o Denials may be appealedo Denial letters give information regarding
appeal rights
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o 45 days after denial to appealo Appeal reviewed by an Appeals Committee
within 60 dayso Decision after appeal is the final decision of
Medicaid
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