NYAPRS Note: Managed Care brings a host of new challenges for oversight of fraud and abuse, particularly in regards to parity and eligibility for service delivery that is based more on socioeconomic necessity (such as employment, housing, education) than a straight line to health necessity. The specific guidelines for plans to follow lead some toward wasteful spending and others toward restrictive review practices. The delicate balance that health plans must achieve will not only be watched by OMIG but also advocates and state leaders that are transitioning increasing levels of expertise into managed care development and functioning.
OMIG’s Game Plan for Fighting Fraud
The New York State Office of the Medicaid Inspector General released its latest work plan for going after fraud and abuse. The plan, online here, covers April 1, 2014, to March 31, 2015.
The state has been moving many more Medicaid recipients into managed care. OMIG disclosed that its work in managed care “will expand this year and for the foreseeable future.” The agency will focus its reviews and personnel on managed care program integrity, expanding into certified home health agencies and personal care services, as well as supported employment services, according to the work plan.
OMIG has been in the spotlight because of pressure from California Republican Rep. Darrell Issa, chair of the House Committee on Oversight and Government Reform, whose office wrote a March 2013 report titled “Billions of Federal Tax Dollars Misspent on New York’s Medicaid Program.” Given that scrutiny, OMIG is under “unprecedented pressure to demonstrate its capacity to oversee the largest Medicaid program in the country—pressure that inevitably may result in a more aggressive stance in auditing and recovering Medicaid funds from health care providers,” according to an analysis of the new work plan by Manatt Phelps & Phillips.
For managed care, Manatt highlighted some of the issues OMIG will concentrate on. They include identifying duplicate payments consisting of out-of-network claims made to Medicaid for family planning and reproductive health services that were included in the capitated payment. As in the past, OMIG also will look for managed care claims with a date of service after the date of a patient’s death, or during a period of incarceration or institutionalization.
http://www.crainsnewyork.com/article/20140423/PULSE/140429965/omigs-game-plan-for-fighting-fraud