Last Updated on: 13th October 2023, 01:54 pm

OMIG was actually established in New York Public Health Law, specifically Title 3 of Article 1. So they are enabled by state law to carry out their duties related to Medicaid oversight.

Some of OMIG’s main responsibilities include:

• Investigating fraud, abuse, and illegal acts involving Medicaid
• Recovering overpayments
• Imposing penalties
• Making referrals for criminal prosecutions

Common OMIG Investigations

OMIG conducts routine audits and inspections of Medicaid providers across New York. Some of the common issues they investigate include:

• Billing for services not provided
• Billing for unnecessary services
• Billing for services provided by unlicensed staff
• Billing at a higher reimbursement rate
• Duplicate billing

If OMIG identifies potential fraud or abuse, they have the authority to recoup Medicaid funds through various methods, like payment suspensions, pre-payment reviews, and more.

Self-Disclosures

Sometimes providers or facilities will uncover billing issues or overpayments themselves. In these cases, they may want to self-disclose to OMIG before an audit or investigation begins.

Self-disclosures can show OMIG that the provider is being proactive. OMIG recently updated the self-disclosure process, giving providers two options:

1. Self-disclosure portal – Providers submit overpayment info through an online portal.
2. Self-disclosure letter – Providers send a letter detailing the overpayment to OMIG.

Experienced OMIG lawyers can help providers through this process, including calculating the overpayment amount accurately.

Mandatory Compliance Programs

Certain Medicaid providers in New York are actually required to have compliance programs in place under state law and regulations. These help prevent, detect, and correct fraud, waste, and abuse.

OMIG recently overhauled the rules related to mandatory compliance programs. Some key changes include:

• More providers are now required to have a program.
• Programs must meet certain core elements.
• Providers have to designate a compliance officer.
• Compliance training is required for staff, executives, and boards.

An experienced OMIG attorney can help providers implement and maintain an effective compliance program that meets all of OMIG’s requirements.

Appeals and Hearings

If OMIG takes an enforcement action, like imposing penalties or suspending payments, the provider has the right to appeal. There is an established appeals process that involves administrative hearings.

Some key things to know:

• There are deadlines for filing appeals that must be met.
• Hearings allow providers to present evidence and examine OMIG’s findings.
• After the hearing, an administrative law judge issues a recommendation.
• Providers can go to court after exhausting the administrative process.

Having an experienced OMIG attorney represent you during the appeals process is extremely valuable, as they understand the procedures and can build the strongest case.

Criminal Prosecutions

In some serious fraud cases, OMIG may refer the matter to prosecutors for potential criminal charges. This can lead to felony Medicaid fraud charges.

If facing criminal prosecution, having an OMIG lawyer who also does criminal defense work is key. They can advocate during the investigation stage to avoid charges and negotiate with prosecutors. If charges are filed, they can defend at trial or negotiate a favorable plea deal.

Tips for Providers

Here are some quick tips for healthcare providers and facilities in New York when it comes to OMIG:

• Have a strong compliance program in place.
• Conduct regular audits to identify any overpayments quickly.
• Cooperate fully during any OMIG audit or investigation.
• Consider self-disclosure if you discover a problem.
• Consult an experienced OMIG attorney at the first sign of an investigation.

Finding the Right OMIG Lawyer

Don’t hesitate to ask candidates about their specific OMIG experience! This is a niche area, so you want someone who knows the ins and outs.

I hope this overview gives you a good sense of what an OMIG investigation involves and why working with an experienced OMIG lawyer is so important. Let me know if you have any other questions!

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