Mandatory Compliance Program and Certification Obligations

Delivery System Reform Incentive Payment (DSRIP)
Program Performing Provider System (PPS) Leads

  • Presentation is also available in Portable Document Format (PDF)

February 26, 2015


Welcome

New York State Office of the Medicaid Inspector General (OMIG) appreciates your interest in the mandatory compliance program obligations that apply to PPS Leads within the DSRIP Program.

The Fine Print

These slides are not intended to provide legal advice; do not represent the opinion of the Office of the Medicaid Inspector General (OMIG); do not represent the opinion of Centers for Medicare and Medicaid Services (CMS), Office of Inspector General (OIG) or any other State or federal agency; and shall not bind OMIG in any way.


Goals of this Webinar

  • NYS´s Mandatory Compliance Program Requirements and Certification (SSL):
    • Overview of NYS´s mandatory compliance program requirement;
    • Overview of the certification requirement for mandatory compliance programs; and
  • Deficit Reduction Act (DRA) of 2005 Requirements and Certification:
    • Overview of the federal DRA obligation for Medicaid providers; and
    • Overview of the certification requirement in NYS for those providers subject to the DRA requirements.

Office of the Medicaid Inspector General

Compliance Program Requirement

Required of all Providers where Medicaid is a "substantial portion of business operations"

  • Social Services Law §363–d subd. 4 and 18 NYCRR §521.1(c)
  • 18 NYCRR §521.2(b) defines "substantial portion of business operations"
    • person, provider or affiliate who receives, has received or should be reasonably be expected to receive at least $500,000 in any consecutive 12–month period

What Are the Elements of a Mandatory Compliance Program?

Element 1: Written Policies and Procedures that describe compliance expectations as embodied in a code of conduct or code of ethics...

Element 2: Designation of Compliance Officer – an employee vested with responsibility for the day– to–day operation of the compliance program...

Element 3: Training and Education of all affected individuals on compliance issues, expectations and the compliance program...

Element 4: Communication Lines to the Compliance Officer that are accessible to all affected individuals to allow compliance issues to be reported...

Element 5: Disciplinary Policies to encourage good faith participation in the compliance program

Element 6: System for Routine Identification of Compliance Risk Areas and Non–Compliance...

Element 7: System for Responding to Compliance Issues when raised, for investigating and correcting problems...

Element 8: Policy of Non–Intimidation and Non–Retaliation for good faith participation in the compliance program...

SSL §363–d subd. 2 and 18 NYCRR §521.3(c)


Application of Mandatory Compliance Programs

  • Compliance Programs must be applicable to:
    1. Billing
    2. Payment
    3. Medical necessity and quality of care
    4. Governance
    5. Mandatory reporting
    6. Credentialing
    7. Other risk areas that are – or should – with due diligence be identified

18 NYCRR §521.3(a)

Medicaid Provider Compliance Obligations

Mandatory Compliance Program Certification Requirement

18 NYCRR §521.3
(b) Upon applying for enrollment in the medical assistance program, and during the month of December each year thereafter, a required provider shall certify to the department, using a form provided by the Office of the Medicaid Inspector General on its Web site, that a compliance program meeting the requirements of this Part is in place....

Certification for Mandatory Compliance Programs

  • Certification is only available electronically on OMIG´s website.
  • OMIG has separate Webinars that address how the certification can be accomplished.

Office of the Medicaid Inspector General

42 USC 1396a(a)(68) Obligations

The DRA requires health care entities which receive or make $5 million* or more in Medicaid payments during a federal fiscal year (October 1 to September 30) to do the following:

  • Establish written policies and procedures that provide detailed information to its employees, management, contractors, and agents about federal and state false claims acts, whistleblower protections, and its policies and procedures for detecting and preventing fraud, waste, and abuse.
  • Include in an employee handbook (if one exists) specific discussion on federal and state false claims acts, whistleblower protections, and the provider´s policies and procedures for detecting and preventing fraud, waste, and abuse.

*DRA´s FAQs identify $5 million in direct Medicaid payments received from the state for providers or for $5 million in Medicaid payments made.

Certification for DRA

  • Required for all Medicaid providers subject to the DRA requirements.
  • Required by OMIG in December immediately following the end of the federal fiscal year that the provider becomes subject to the DRA.
  • Required annually for each year that the DRA applies.
  • Certification is only available electronically on OMIG´s website.
  • OMIG has separate Webinars that address how the certification can be accomplished.
  • Health care entities subject to the DRA´s requirements must certify that:
    • they maintain written policies;
    • any employee handbook includes materials, required under the DRA mandate;
    • the materials have been properly adopted and published by the health care entity; and
    • the materials have been disseminated to employees, contractors, and agents.

OMIG has guidance on its website: www.omig.ny.gov

Compliance tab
  • Certification
  • Compliance Library

Compliance Resources

OMIG website: www.omig.ny.gov

  • Compliance Library
    • Compliance Authorities
    • OMIG Compliance Publications
    • Forms
    • OMIG Assessment Results
    • FAQs
    • Compliance–related Webinars
    • Other Compliance Resources
  • Bureau of Compliance dedicated e–mail address – compliance@omig.ny.gov
  • Bureau of Compliance dedicated telephone number – 518.408.0401

Questions

  • For those on the call...
  • After the call...

Thank You