The New York State Office of the Medicaid Inspector General (“OMIG”) recently released its Compliance Program Guidance for General Hospitals.   While the OMIG had previously released a Compliance Program Assessment Tool, the new Guidance document provides a far greater level of detail as to the expectations of a hospital’s compliance program.

New York State law (Social Services Law Section 363-d and 18 NYCRR Section 521.3) requires that hospitals and most other Medicaid providers adopt and implement “effective compliance programs” in order to participate in New York’s Medicaid program.  If a Medicaid provider fails to implement an effective compliance program, that provider may be ineligible to bill or receive Medicaid payments, and the provider’s participation in the Medicaid program could be revoked.

Eight Elements of an Effective Compliance Program

The compliance program implemented by Medicaid providers must apply to billings, payments, medical necessity and quality of care, governance, mandatory reporting, credentialing and other risk areas that are or should, with due diligence, be identified by the provider.  The Guidance provides OMIG’s views on the eight elements for effective compliance programs.  In brief, the eight elements are as follows:

(1)  Written Policies and Procedures
(2)  Designation of Compliance Officer
(3)  Training and Education
(4)  Communication Lines to the Compliance Officer
(5)  Disciplinary Policies
(6)  Identification of Compliance Risk Areas and Non-Compliance
(7)  Responding to Compliance Issues
(8)  Policy of Non-Intimidation and Non-Retaliation

The Guidance breaks down each element into multiple requirements, and the provides numerous specific recommendations for each requirement.  For example, under Element #2, Requirement #2, these can be as broad as “the compliance officer advises on compliance related contract provisions” and as specific as which committee meetings the Compliance Officer might attend (quality assurance, risk management, billing and coding, and credentialling).

The OMIG continues to conduct compliance program effectiveness reviews, and has stated that adherence to the Guidance document recommendations will be one measure of an effective program.

Not Just for Hospitals

While directly relevant and specific to acute care hospitals in New York, the Guidance is recommended reading for all other Medicaid providers.  Non-acute care providers will gain insight into items OMIG will look for in a compliance program, and may elect to proactively amend their compliance programs.  In addition, providers who service hospitals are likely to find language in their contracts mandating that they abide by the hospitals’ compliance programs.