Required to Comply?
If you receive or order more than $500,000 in any consecutive twelve-month period from Medicaid, you are required to have a written compliance plan in place at your practice. Importantly, the $500,000 precipice includes: (1) straight Medicaid and Medicaid HMO monies; and (2) the amount of “ordered” services, not just monies received by a practice are included in the tally, capturing a wide-array of practices into the compliance requirement that may otherwise have been immune. The Compliance Program you are required to have must address the following, but not limited to, areas: billing, payments, medical necessity and quality of care, etc.; and elements: be in writing, address governance and training at the practice, designate a compliance officer, etc.

How do I certify?
If you are qualify as requiring a compliance plan, you are also required to certify with the Office of Medicaid Inspector General that you have a compliance plan by December 31, 2011. OMIG has made certification available on its website (www.omig.ny.gov).

Who will know if I do not comply?
OMIG. OMIG has openly marketed its compliance tactic – it will simply go down the list of providers required to have compliance plans (because it has all of that data since it is the payor!) and audit/sanction/fine those practitioners not complying.

What happens if I do not comply?
Should the commissioner of health or OMIG find that a required provider does not have a satisfactory compliance program, or no program at all, applicable law states that “the required provider may be subject to any sanctions or penalties permitted by federal or state laws and regulations, including revocation of the provider’s agreement to participate in the medical assistance program.” Further, OMIG has intimated that it will be utilizing the compliance program requirement as a window into practices. Should your practice appear on OMIG’s radar as a potentially noncompliant practice, you run the risk of being targeted by OMIG for a retrospective review of claims or being placed on prepayment review, which is a process that requires you send in patient records prior to receiving reimbursement for any services. Either process – a retrospective review or prepayment review – create dire ramifications for many practices, requiring legal representation, diminished reimbursement and the potential to have to pay back monies received or anticipated to be received by the practice.

What are the benefits of complying?
In addition to staying off of OMIG’s radar, there are benefits to OMIG’s compliance plan requirement that are immediate and rewarding, which is why mandatory compliance can be a good thing. Of note, many practitioners report an increase in their reimbursement upon adopting a compliance plan; because their staff have a written policy to follow when performing billing, practitioners find that fewer errors are occurring and the result is increased reimbursement.

Where do I get a compliance plan?
Here.  We wrote one for you – https://www.kirschenbaumesq.com/healthcareorder.htm.