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Ana’s Pharmacy in Yonkers applied for enrollment in the Medicaid program. Office of the Medicaid Inspector General staff conducted an onsite visit and found expired drugs in the inventory, along with filthy conditions unsuitable for conducting this type of business. The pharmacy was dirty, had missing and water-stained ceiling tiles over the dispensing area, and was so cold that staff members had to wear heavy coats while working. In addition, the refrigerator was too cold to properly store medication. The pharmacy was denied enrollment under 18 NYCRR §504.5(a)(13).
OMIG has added some new features to our Consumer portal. One new feature is the addition of a copy of an Explanation of Medicaid Benefit (EOMB). OMIG sends out EOMBs every month to Medicaid consumers to check to see if services that were billed were actually provided. OMIG is posting the EOMB to make sure that Medicaid consumers know what an EOMB is and why they are getting one.
OMIG has also posted some new tips for Medicaid consumers. As an example, Medicaid consumers are reminded that they should check their income levels throughout the year. This tip, along with others will help consumers and other New York State residents to fight Medicaid fraud and abuse.

Governor Andrew M. Cuomo today announced the largest single year of recoveries of taxpayer dollars in the history of the Office of the Medicaid Inspector General (OMIG). Preliminary calculations show the administration recovered more than $851 million dollars for 2013. This brings the three-year total under Governor Cuomo to more than $1.73 billion recovered from Medicaid providers who inappropriately billed Medicaid and individuals who received services to which they were not entitled. This is a 34 percent increase over the previous three years. OMIG’s recoveries are the highest on record for any state Medicaid program integrity unit.

“With more than $851 million recovered from Medicaid abuses in 2013 alone – the most in the State’s history – New York is truly leading the nation in fighting fraud and protecting taxpayer dollars,” Governor Cuomo said. “Our focus on cleaning up the Medicaid program is showing record-breaking results, and OMIG’s efforts serve as a role model for other states to follow. Eliminating this kind of waste is vital to transforming New York’s healthcare system, and this year’s tremendous amount of recoveries shows that we are well on our way to building a healthier and fairer New York.”

“Fighting Medicaid fraud is a cornerstone of our efforts, and anyone who steals from Medicaid should know that we will find them. OMIG is proud of this record result,” said Medicaid Inspector General James C. Cox. “This is an extraordinary accomplishment, and an historical achievement. Through dedication and perseverance, our staff not only met but exceeded all expectations in recoveries for the year. Governor Cuomo’s support was crucial to our efforts.”

These results reflect the administration’s focus on eliminating or preventing fraud, waste, and abuse, particularly in the Medicaid program. OMIG has worked to eliminate fraud through aggressive responses to allegations of fraud in social adult day care, excluding unscrupulous providers, and focusing on ineligible individuals. Among the improvements in fraud and abuse prevention established under the Cuomo administration are the creation of pre-claim reviews – specialized reviews of home health claims and inventory reports – improved practices for reviewing pharmacy operations, and strong data sharing and coordination with federal, state, and local partners.

Some notable actions in 2013 included:

  • Cracking Down on Ineligible Individuals – OMIG investigated a ring of ineligible individuals who had been fraudulently enrolled in the Medicaid program in Brooklyn, New York. In these cases, members of an exclusive gated beachfront community had fabricated information on their Medicaid applications in order to bypass eligibility limits. One notable case included an individual who vacationed in Las Vegas and drove a Porsche, Aston-Martin, and a BMW. This work lead to six prosecutions by the Brooklyn District Attorney for welfare fraud, grand larceny, and offering a false instrument for filing.
  • Recovering Home Health Payments – OMIG reconciled Medicare and Medicaid payments for dual-eligible Medicaid consumers. When Medicaid consumers are eligible for both Medicare and Medicaid, home health care providers should first bill Medicare, and then bill Medicaid for whatever portion of the bill Medicare does not pay. OMIG’s work to review statewide home health payments identified instances where the Medicare program should have paid but did not. This work identified $496 million in inappropriate Medicaid billings. OMIG recovered $211 million in New York State’s share for taxpayers during 2013.
  • Ensuring that Medicaid Services Meet Quality Standards – OMIG audited Abbott House in Irvington, New York, to check compliance with Medicaid regulations regarding outpatient services. These services are furnished at clinic and day treatment facilities and through home- and community-based federal waiver programs. The audit found information was missing from Medicaid consumer records needed to support reimbursement for service. Auditors discovered that critical components of consumer records were absent, so they could not confirm whether a consumer had responded to treatment, or whether the treatment had been delivered in the first place. Additionally, Abbott House billed for more days of service than were documented, as well as for services when there was not a required residential habilitation plan. OMIG recovered the full amount – more than $254,000 – from this provider. The audit can be seen here.

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 [2]. Tips can be completely anonymous, and OMIG investigates information from all calls.

The Governor's original press release can be seen here.

The 2014-15 OMIG Work Plan The New York State Office of the Medicaid Inspector General (OMIG) released its State Fiscal Year 2014-15 Work Plan, highlighting areas of focus in OMIG’s efforts to fight fraud, improve integrity and quality, and save taxpayer dollars.  This Work Plan details dozens of programs that will be reviewed over the period of April 1, 2014 through March 31, 2015.

 “Taxpayers depend on OMIG to fight fraud, improve integrity, and save taxpayer dollars. Our annual work plan is a roadmap to our efforts over the next 12 months,” said Medicaid Inspector General James C. Cox.

The work organizes OMIG’s work within business line teams (BLTs), an innovation Cox developed within OMIG during the early days of his tenure as Medicaid Inspector General.  BLTs consist of establishing teams of personnel with experience within the various parts of OMIG—auditors, investigators, clinicians, attorneys, and technicians—bringing together expertise to focus and expedite work production while simultaneously ensuring accuracy.   “BLTs help OMIG to operate with improved efficiency, conduct more thorough reviews and investigations, and tactically deploy resources where they are needed the most,” Cox added.  BLT coordination improves referrals to law enforcement and potential prosecution.

OMIG uses BLTs to focus on finding individuals who commit fraud and abuse.  Recent actions have included the identification of dozens of fraudulent providers and individuals who will face exclusion from participating in the Medicaid program or even criminal charges because of inappropriate and/or fraudulent acts.  

The BLT approach has paid financial dividends.  In calendar year 2013, preliminary OMIG recoveries topped $851 million dollars–a new record for OMIG, and the highest ever recovered in a single year by any state.

Recoveries do not tell the whole story of Medicaid program improvement.  New York State’s health care providers, as well as their compliance officers, and billing and coding staff, are following OMIG’s lead in strengthening their adherence to the rules of the Medicaid program.  “We are committed to ensuring fair consideration to New York’s providers, enrollees, and taxpayers as we fulfill the work outlined in this plan,” said Cox.

Available at the agency’s Web site, the Work Plan for State Fiscal Year 2014-15 reflects work that serves as the foundation for the state’s future efforts as the agency assures that providers meet program quality standards for Medicaid enrollees in a system free of waste, fraud, abuse, and improper payments.

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. Tips can be completely anonymous, and OMIG investigates information from all calls.

The mission of the Office of the Medicaid Inspector General is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.

#NYFightsFraud

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.

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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.

#NYFightsFraud

Report Fraud

Report FraudYou 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.

Check for Terminations and Exclusions

Check for Medicaid Terminations and ExclusionsThe 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.

Start a Self Disclosure

Start a Self DisclosureAnytime 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.

Latest News

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The New York State Office of the Medicaid Inspector General (OMIG) released its State Fiscal Year  [ ... ]

Governor Andrew M. Cuomo today announced the largest single year of recoveries of taxpayer dollars i [ ... ]

Thanks to an undercover site visit by the Office of the Medicaid Inspector General (OMIG), a Brookly [ ... ]

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