• OMIG Reviews Impending Verification Requirements for Certain Home Health Agencies
  • July 1, 2011
  • Law Firm: Wilson Elser Moskowitz Edelman Dicker LLP - New York Office
  • The New York Office of Medicaid Inspector General (OMIG) held a webinar on May 25 to review recently enacted requirements for use of third-party verification organizations for certain home health services. One of the proposals put forth by the New York Medicaid Redesign Team was a long-term effort to improve Medicaid integrity by requiring select home health and personal care providers to comply with pre-claim verification requirements. The Legislature subsequently enacted this proposal in a new section 363-e of the Social Services Law.

    The requirements under section 363-e apply to certified home health agencies, long-term home health agencies and personal care providers with total Medicaid reimbursement exceeding $15 million per calendar year. While licensed home care services agencies (LHCSAs) are not subject to the new requirements, OMIG made a point of emphasizing that the entities subcontracting with LHCSAs remain liable for all services billed by such agencies. OMIG considers it in the best interests of agencies subject to section 363-e to have adequate systems in place to monitor subcontractors and to insist that subcontractors have robust compliance initiatives.

    The centerpiece of the new system is the requirement to have claims verified by a “verification organization,” a third-party entity that will use electronic means, including contemporaneous telephone or other electronic data, to verify whether a service or item was provided to an eligible Medicaid recipient. The verification organizations are required under the statute to capture (1) the identity of the individual providing services or items; (2) the identity of the Medicaid recipient; and (3) the date, time, duration, location and type of service or item. The contemporaneous electronic systems are meant to overcome the susceptibility of manual caregiver time entries to fraud or mistake. The system will also enable electronic cross-checking of claims to ensure a caregiver is not charging two agencies for the same time.

    Section 323-e also requires the verification organization to compile exception and conflict reports and supply them to the providers. An exception report will be an electronic report generated before a claim is submitted, detailing for the home health or personal care agency conflicts between services or items on the basis of the identity of the caregiver or item; the identity of the Medicaid recipient; and/or the time, date, duration or location of the service. For example, an exception report would note if a caregiver fails to comply with the scheduled time for electronic verification or fails to call in altogether. A conflict report, by contrast, occurs when a second claim submitted by another agency identifies an inconsistency in the schedule or location of the service or item. Because one claim will have already been paid, the conflict report will trigger the 60-day timeframe to repay the overpayment imposed under section 6402 of the Patient Protection and Affordable Care Act.

    OMIG indicated that it would not mandate that agencies subject to section 323-e comply with the requirements in the 2011-2012 fiscal year. Rather, OMIG will use experience with existing exception and conflict reports to hone its auditing procedures and issue compliance guidance in anticipation of implementation in 2012.

    The webinar can be found at http://www.omig.ny.gov/data/content/view/204/294