Among its successes in this year’s legislative session, the Assembly passed legislation aimed at combating Medicaid fraud by creating the Office of Medicaid Inspector General. This agency will identify cases of waste and tackle the rising problem of Medicaid fraud and abuse in New York.
Current estimates are that fraud accounts for 10 percent or more of the state’s $40 billion plus Medicaid program.
The Medicaid inspector general, to be appointed by the governor, must have at least 10 years of professional experience in the areas of law (with a prosecutorial background), auditing, health care fraud and fraud investigation.
The office falls under the jurisdiction of the state Department of Health, is responsible for reviewing and establishing fraud and abuse prevention procedures, and must work to prevent Medicaid fraud. The inspector general will accomplish the objectives by referring information and evidence to regulatory agencies, initiating actions for civil recovery and recovering illegally spent Medicaid funds. The inspector general also is to report suspected fraud or abuse cases to the deputy attorney general for Medicaid fraud control.
The inspector general also is responsible for:
- Conducting on-site investigations.
- Issuing subpoenas and enforcing witness attendance at various proceedings.
- Reviewing and auditing contracts, cost reports, claims bills and any other Medicaid expenditures to determine compliance.
- Reviewing and investigating complaints of alleged failures of state and local officials to prosecute fraud.
- Developing, testing and implementing new methods to strengthen the capability of the Medicaid payment information system to detect and control fraud and improve expenditure accountability.
- Developing a surveillance utilization review system that detects and identifies improper Medicaid use.
- Conducting educational programs for providers.
- Developing protocols to facilitate efficient self-disclosure and collection of overpayments, and fostering good faith behavior through these mechanisms.
This legislation also urges Medicaid providers to implement programs that would avoid or correct billing mistakes and quickly resolve payment problems. Office personnel will also use the Internet to create guidelines for all established provider compliance programs.
The state insurance superintendent is required to annually report health care fraud to the governor and state Legislature regarding the inspector general’s activities and successes in combating Medicaid fraud and abuse. The law also establishes and sets forth specific penalties for health care fraud.
My colleagues and I worked diligently during this year’s legislative session to pass measures to protect hardworking state taxpayers. This legislation indicates our success in this particular area, and we will work to return integrity and honesty to New York’s Medicaid system.
If you have any questions or comments regarding the Medicaid program, do not hesitate to contact me in my district office by calling (315) 866-1632 or, in Johnstown, (518) 762-6486.