Thanks to an undercover site visit by the Office of the Medicaid Inspector General (OMIG), a Brooklyn pharmacy won’t be allowed to enroll in the state’s Medicaid program.
During the site visit to New Life Pharmacy in Brooklyn, the provider filled a prescription that was later billed to Medicaid by another provider. New Life Pharmacy was denied enrollment under 18 NYCRR §504.5(a)(13).
“Site visits are crucial to determining the viability of health care providers,” said Medicaid Inspector General James C. Cox. “We detected a problem in one instance where a pharmacy that wasn’t enrolled in Medicaid was using a pharmacy that was a ‘front’ for its billing. That simply constitutes fraud."
In order to become a participating provider in the Medicaid program, a health care provider must go through a lengthy process that begins with filling out an on-line application followed by the submission of documentation to the New York State Department of Health. Once that process is complete, OMIG investigators conduct site visits similar to the one performed at New Life Pharmacy to ensure the organization’s viability. On-site observations are critical to making a final determination on the need, effectiveness, and availability of services for Medicaid consumers.
New Yorkers can assist the Office of the Medicaid Inspector General in fighting fraud, waste, and abuse by reporting potentially suspicious behavior or incidents. OMIG encourages anyone who observes instances of potential Medicaid fraud, waste, or abuse to contact OMIG’s fraud hotline at 1-877-87-FRAUD or visit the Web site at www.omig.ny.gov. Tips can be completely anonymous, and OMIG investigates information from all calls.
Our mission is 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.
Webinar # 19, “Governing Body's Role in Program Integrity,” is now available for viewing and listening. Click here to view.
You can help stop Medicaid fraud: Call OMIG’s Fraud Hotline at 1-877-87 FRAUD (1-877-873-7283), or click here to file a complaint electronically.
The OMIG may sanction some providers by excluding them from participating in the Medicaid program. These providers are excluded from offering services to Medicaid enrollees and also cannot be paid with Medicaid dollars. Prior to adding new staff members, employers should check to see if prospective employees have been excluded from Medicaid. To make it easier to perform such a check, OMIG set up a dedicated service to check the status of any exclusion.
Anytime a health care organization discovers that it was paid more than it was due, this should be reported to OMIG. Our Self-Disclosure section provides information for health care organizations to complete the recently revamped self-disclosure process.
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