Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.

MISSION STATEMENT Our mission 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.

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. We Have A Statewide Presence Regional Offices:  Capital District  Western NY (2)  Central NY  Westchester  New York City (2)  Long Island

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Costs Tax Payers > $52 Billion  Nearly 5 Million Recipients  Over 60,000 Active Providers  Processes over 350 Million Claims Per Year  Medicaid is the Payer of Last Resort Facts About NY State Medicaid

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Executive Office: James C. Cox, Medicaid Inspector General  Bureau of Agency Coordination & Communication  Bureau of Compliance  Bureau of Risk Management  Bureau of Quality Assurance OMIG Administration

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Office of Counsel  Office of Administration  Division of Medicaid Investigations  Division of Medicaid Audit  Division of Technology and Business Automation OMIG’S Organizational Structure

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Managed Care  Medical Services in an Educational Setting  Home and Community Care Services  Hospital and Outpatient Clinic Services  Mental Health, Chemical Dependence, and Developmental Disabilities Services  Pharmacy and Durable Medical Equipment  Physicians, Dentists and Laboratories  Residential Health Care Facilities  Transportation Business Line Teams (BLTs)

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Coordination between the divisions  Combines staff knowledgeable in their field  Improved efficiency  More thorough reviews and investigations  Reduced time to conclusion Why Business Line Teams

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Investigate fraud, waste and abuse in the Medicaid program  Deter improper behavior  Ensure that Medicaid recipients receive quality care  Foster cooperation with internal and external partners Division Mission * PI-Program Integrity Deterrence Cooperation PI* Quality of Care Fraud, Waste & Abuse

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Provider and Undercover Investigations Unit  Recipient Fraud Unit  Pharmacy Investigations Unit  Administrative Remedies Unit  Enrollment and Reinstatement Unit  Recipient Restriction Unit Division Structure

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. “Waste and abuse” are defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices; and that constitute an overutilization of Medicaid- covered services and result in an unnecessary cost to the Medicaid program What is Medicaid Waste and Abuse?

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  A provider ordering or performing unnecessary tests  Ordering unnecessary transportation  Ordering unnecessary durable medical equipment  Waste and abuse can lead to fraud Types of Waste and Abuse

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. “Fraud means an intentional deception or misrepresentation made with the knowledge that the deception could result in an unauthorized benefit to the provider or another person and includes the acts prohibited by section 366-b of the Social Services Law.” – 18 NYCRR 515.1(b)(7) What is Provider Fraud?

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Services Not Rendered  Unnecessary Services  Unbundling  Kickbacks and Bribes  Upcoding Types of Medicaid Fraud

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Verify: Did you actually receive the service? Did it take place on the date noted on the EOB?  Is the provider (e.g., physician, therapist, dentist, etc.) actually the person you saw?  OMIG sends out explanation of benefits (EOBs) to recipients  Were you transported from point A to point B on the date noted? Services Not Rendered

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. Examples:  Restorative dental care for people who have no teeth  Monthly capitation fees for deceased managed care patients  Pre- and post-natal care for girls under the age of 10 or women over the age of 55  Custom-fitted shoes for double amputees Unnecessary Services

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. Fraud schemes called “unbundling” involve instances in which a provider bills separately for the component parts of a product or service, resulting in a significantly larger payment to the provider. For instance, a durable medical equipment provider company was found to have billed for the component parts of a wheelchair separately, thus receiving four or five times more than if the wheelchair alone had been billed as a single item. Unbundling Supplies and/or Services

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Providers cannot receive compensation in goods, money, or services in exchange for referring Medicaid recipients to other providers  It is illegal to pay a Medicaid recipient a fee to go to a medical practice to receive services  It is illegal to pay a “finder” to convince Medicaid recipients to choose a specific Medicaid provider Kickbacks and Bribes

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. You are medical billers and coders. You know that you cannot do things such as:  Bill for a full stroke when a Medicaid recipient (or anyone, for that matter) has a transient ischemic attack (TIA) (mini-stroke)  Bill for a Cesarean section when the patient had a vaginal delivery Upcoding

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. A recipient knowingly makes or causes to be made a false or misleading statement or representation for use in obtaining benefits from the medical assistance program What is Recipient Fraud?

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Eligibility  Drug diversion  Card lending  Selling drugs, supplies, or equipment obtained with Medicaid funds Types of Recipient Fraud

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. Providers:  Impose Sanction  Exclusion  Censure  Termination  Payment withholds  Referrals to the Attorney General’s Medicaid Fraud Control Unit and/or other law enforcement entities. Recipients:  Criminal charges/prosecution  Medicaid restriction/administrative remedies OMIG Actions for Fraud, Waste and Abuse

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Majority of providers are honest  Criminals have infiltrated the health insurance system  Medicaid is part of the health insurance system  Bad providers prey on the most vulnerable  Everyone is a potential victim  Be a “HERO”: If you see something, say something Operating Principles

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.  Thanks for listening  Thanks for your diligence and achievements in serving those in your community  Thanks for working to improve program integrity Thank You

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. We Want to Hear from YOU  Our new, improved Web site:  Join our Listserv  Follow us on  Dedicated  More than 4,000 final audit reports  Audit protocols  And much, much more!

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars. Contact Information Christopher Bedell Medicaid Investigator 2 New York State Office of the Medicaid Inspector General 250 Veterans Memorial Highway, Room 4A12 Hauppauge, NY