New York State Medicaid Exclusion
New York’s Office of the Medicaid Inspector General exists to “to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting a high quality of patient care.” It was established as an autonomous entity within the New York State Department of Health, consisting within its organizational structure the following offices:
- Agency Coordination and Communications
- Bureau of Compliance
- Bureau of Quality Control and Risk Management
- Division of Administration
- Division of Medicaid Audit
- Division of Medicaid Investigations
- Division of System Utilization and Review
- Office of Counsel
These offices make up the OMIG’s Business Line Teams tasked to look into the processes and operations of healthcare-related industries and services including and oversee:
- Delivery System Reform Incentive Payment Program
- Home and Community Care Services
- Hospital and Outpatient Services
- Managed Care
- Managed Long Term Care
- Medical Services in an Educational Setting
- Mental Health, Chemical Dependence, and Developmental Disabilities Services
- Pharmacy and Durable Medical Equipment
- Physicians, Dentists, and Laboratories
- Residential Health Care Facilities
In order to efficiently mobilize its mission, the New York OMIG conducts and supervises all prevention, detection, audit, and investigation efforts in coordination with the following offices:
- Department of Health
- Office of Mental Health
- Office for People With Developmental Disabilities
- Office of Alcoholism and Substance Abuse Services
- Office of Temporary and Disability Assistance
- Office of Children and Family Services
- Justice Center for Protection of People with Developmental Disabilities
- Department of Education
Also, the Medicaid Inspector General and the Attorney General’s Medicaid Fraud and Control Unit (MFCU) work closely to further empower the existing partnerships with local and federal law enforcement agencies.
Examples of fraudulent activities which the New York OMIG is consistently on the lookout for include the following:
- Billing for Medicaid services that were not provided
- Giving out, or billing for, unnecessary services
- Selling prescriptions
- Ordering unnecessary tests
- Giving money or presents to consumers in return for agreeing to get medical care from someone
- Lending a Medicaid Identification card to another person;
- Forging or altering a prescription or fiscal order;
- Using multiple Medicaid ID cards;
- Intentionally receiving duplicative, excessive, contraindicated, or conflicting health care services or supplies; and
- Re-selling items provided by the Medicaid program.
Some New York State OIG Exclusion facts:
- 178 exclusions during 2015 (that’s more than 10% less than 2014 which had 200 total exclusions)
- OIG exclusions in NY include among others:
- Conviction of program-related crimes.
- Conviction relating to patient abuse or neglect
- Felony conviction relating to health care fraud
- Felony conviction relating to controlled substance
- Specialties that were excluded include among others:
- Pharmacy technician
- Ambulance companies
- Skilled Nursing
- 761 OIG exclusions in the State of New York over the years 2011-2015
- 639 total OIG exclusions in the State of NY from the years 2006-2010 which is about 15% less than the following 5 years. Does this mean that the OIG is more on top of the situation and handling all of this better? Does this mean that healthcare & medicaid fraud is getting worse?
To report suspected fraud, or for self-disclosure:
please report it via the internet
- or call toll free:
Reports should include the following details:
- Nature of suspected fraudulent activity
- Details such as: Who is involved; when it occurred; whether there are witnesses to the misconduct.
Anonymous reports are welcome although the New York Office of the Medicaid Inspector General (OMIG) encourages that whistleblowers agree to identify themselves should the case require further questions be answered.
To file fraud allegations, follow the instructions on this link:
For more on state medicare and medicaid exclusions visit our OIG Exclusion list and State exclusion database page here.
To learn more about State Medicaid compliance, visit our MEDICAID PROVIDER EXCLUSION LIST page.