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Medicaid's Annual Certification Requirement

March 22, 2011

Question:

Jennifer,

Thank you for helping me integrate a compliance plan into my practice. Now that I have the plan, do I have to send it in to Medicaid for approval?

Thanks again,

Dr. C

Answer:

No, you do not need to send the whole plan into Medicaid for review, however, if you do qualify under 18 NYCRR 521.2 - as receiving a "substantial portion" of reimbursement from straight Medicaid, Medicaid HMOs or you order reimbursable services from Medicaid in excess of $500,000 annually - you are required to certify that you have adopted a compliance plan.

For those interested in the actual language of the statute:

(b) “Substantial portion” of business operations means any of the following:

(1) when a person, provider or affiliate claims or orders, or has claimed or has ordered, or should be reasonably expected to claim or order at least five hundred thousand dollars ($500,000) in any consecutive twelve-month period from the medical assistance program;

(2) when a person, provider or affiliate receives or has received, or should be reasonably expected to receive at least five hundred thousand dollars ($500,000) in any consecutive twelve-month period directly or indirectly from the medical assistance program; or

(3) when a person, provider or affiliate who submits or has submitted claims for care, services, or supplies to the medical assistance program on behalf of another person or persons in the aggregate of at least five hundred thousand dollars ($500,000) in any consecutive twelve-month period. 18 NYCRR 521.2(a)

As specified above, OMIG includes those billing on behalf of providers, so YES, if you use an external billing company, they too are required to adopt a compliance plan and are also required to be registered with Medicaid as "Service Bureaus". Medicaid has indicated that it will be targeting medical practices by investigating billing company compliance in the initial instance, and getting that companies list of clients to check compliance, which is another reason to ensure your billing company and your practice are up to speed.

To certify, visit the OMIG website - see http://omig.ny.gov/data/.

Failing to certify on an annual basis that you have adopted a compliance plan, if required by your practice, may result in OMIG imposing administrative sanctions, up to and including exclusion from the program. See http://www.omig.ny.gov/data/content/view/167/65.

 

For additional information on this topic, contact Jennifer Kirschenbaum at (516)-747-6700 ext. 302 or at Jennifer@Kirschenbaumesq.com.

 

Copyright © 2011 by Kirschenbaum & Kirschenbaum, P.C.
All Rights Reserved. This email is provided for news and information purposes only and does not constitute legal advice or an invitation to an attorney-client relationship. While every effort has been made to ensure the accuracy of the information contained herein, Kirschenbaum & Kirschenbaum PC does not guarantee such accuracy and cannot be held liable for any errors in, any reliance upon this, or losses caused by the information. Under New York’s Code of Professional Responsibility, this material may constitute attorney advertising. Prior results do not guarantee a similar outcome.


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