OMIG Issues Guidance on Medicaid Compliance Requirements

The New York State Office of the Medicaid Inspector General (OMIG) issued guidance on its requirements for Medicaid compliance, effective October 26, 2016.  This Compliance Program Review Guidance (“Guidance”) will assist the Medicaid Required Provider (“Required Provider”) community in developing and implementing compliance programs that meet the requirements of Social Services Law Section 363-d (“SSL 363-d”) and title 18 New York Codes of Rules and Regulations Part 521 (“Part 521”).

For the purposes of this Guidance, “Required Provider” means a provider meeting any of criteria listed: (a) persons subject to the provisions of articles twenty-eight or thirty-six of the public health law; (b) persons subject to the provisions of articles sixteen or thirty-one of the mental hygiene law; or (c) other persons, providers or affiliates who provide care, services or supplies under the medical assistance program or persons who submit claims for care, services, or supplies for or on behalf of another person for which the medical assistance program is or should be reasonably expected by a provider to be a substantial portion of their business operations.

The comprehensive Guidance addresses all requirements under each of the eight program elements. Invariably in compliance program guidance there are seven key elements of an effective compliance program which are as follows: written policies and procedures, compliance oversight, effective training/ education, effective communication, internal monitoring and auditing, enforcement of standards and corrective action with the OMIG Guidance adding an eight element in the form of a policy on non-intimidation and non-retaliation.

In addition, the Guidance addresses the seven prime risk areas. The seven prime risk areas include billing, payment, medical necessity and quality of care, governance, mandatory reporting, credentialing, and other risk areas.

This Guidance is not intended to replace any prior Guidance offered by OMIG, but rather to be supplemental. Further, it does not constitute rulemaking by OMIG and may not be relied on to create a substantive or procedural right or benefit enforceable, at law or in equity, by any person. In addition, this Guidance does not encompass all the current requirements for compliance programs to meet the requirements of SSL 363-d and Part 521 and therefore, are not a substitute for a review of the statutory and regulatory law.

Nonetheless, the Guidance represents a constructive tool that provides insight into OMIG’s perspective on compliance. Thus, it is highly advisable for NY providers which qualify as Required Provider, as well as their council, to review the Guidance when constructing their compliance programs.

The new OMIG Guidance on Medicaid compliance requirements, can be found using this link:

For more information about this topic, please contact Carey F. Kalmowitz, Esq., Adrienne Dresevic, Esq., or Abby Pendleton, Esq.  at 248-996-8510, or by e-mail at,, or


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