Compliance/Enforcement - Development and Implementation of Effective Compliance Plans

New York is one of the few states in the country that requires virtually all Medicaid providers and Medicaid Managed Care Plans to maintain effective compliance plans, and to annually certify their adoption and implementation to the New York State Office of the Medicaid Inspector General (OMIG). While the elements required to be included in compliance plans in New York largely track those contained in the Federal Sentencing Guidelines promulgated by the United States Sentencing Commission, several unique elements are required as well. In addition, OMIG has made clear that its audit focus will evolve from merely assuring that the required annual compliance plan certification has been submitted, to a focus on determining whether a provider or health plan’s compliance plan is effective based on outcome metrics tied to various elements of its compliance systems.

At the federal level, Medicare Advantage Plans are subject to separate compliance plan requirements. Moreover, the recently enacted federal Patient Protection and Affordable Care Act (PPACA) contains provisions that will impose additional compliance plan requirements on other types of providers. PPACA also contains a significant new requirement that overpayments be reported and returned to the Medicare/Medicaid programs, which will require incorporation in all compliance plans.

In this regulatory environment, it is critical that Medicaid and Medicare participating providers and health plans keep abreast of compliance plan requirements, and timely implement all required elements. Hinman Straub's fraud and abuse group can assist clients in all phases of the development and implementation of required compliance plans. Our services include:

  • Review of existing compliance plans;
  • The development of compliance plans for all types of providers and health plans to assure compliance with New York's mandatory compliance plan requirements, as well as the most recent requirements of the Federal Sentencing Guidelines;
  • Best practice recommendations based on, among things, OIG’s model compliance plans, and OIG/OMIG Corporate Integrity Agreements;
  • The development of relevant internal audit strategies designed to address high risk areas as identified through the annual OMIG Work Plan, the annual OIG Work Plan, OMIG Compliance Alerts, OIG Special Fraud Alerts, significant recent OMIG and OIG audit activity, and OMIG Final Audit Reports;
  • Incorporation of appropriate overpayment reporting and repayment policies and procedures, including the use of OMIG and OIG self disclosure protocols; and
  • The development and implementation of relevant self-audit tools.

Practice Area Professionals

Sean Doolan

Mara Ginsberg

Raymond Kolarsey

Philip Murphy

Stephanie Piel

Jennie Shufelt

To learn more about our Health services, please contact Raymond Kolarsey.