NYSDA Alerts

Medicaid Audit Sweep Hits Crisis Point

The New York State Office of the Medicaid Inspector General (OMIG) is an independent entity within the New York State Department of Health charged with improving and preserving the integrity of the Medicaid program by conducting and coordinating fraud, waste and abuse control activities for all State agencies responsible for services funded by Medicaid. The OMIG conducts and supervises all prevention, detection, audit and investigation efforts.

It has come to NYSDA’s attention that investigative efforts have reached a crisis point because OMIG is resorting to any technical claims error made by a participating dentist to demand refunds from the dentist.

OMIG is conducting preliminary audits reviewing claims records for the past five years focusing primarily on the following:

• Fillings replaced within three years of original treatment.
• Claims for D9310, “consultation – diagnostic service provided by a dentist or physician other than the requesting dentist or physician” that do not include the name and NPI or license # of the referring doctor.
• Claims for rebase, reline or repair service within six months of delivery of new dentures.
• Inappropriate billing after completion of upper or lower dentures.
• Claims submitted for patients residing in skilled nursing facilities.

One of the most prevalent manifestations of these recent audits is the alleged failure by dentists to properly complete the New York Medicaid claim form requiring the name and National Provider Identifier (NPI), or license number, of the referring dentist when there are consultation billings. Claim forms must be completed properly or OMIG will deem it to be a billing abuse and seek recovery on the claim. NYSDA urges all Medicaid providers to immediately establish that all Medicaid filings are complete and accurate.

NYSDA is working to address various policy issues with the New York State Department of Health (DOH) pertaining to these audits and to resolve disparities between the DOH’s policies for reimbursement and the criteria used by the OMIG to determine if payments were improperly made. OMIG asserts that it need not follow DOH’s policies it deems to be incorrect, allowing OMIG to recover money even when claims meet guidance issued by the DOH. Sometimes, only expensive litigation by providers with OMIG can drive OMIG away from their more extreme policy interpretations.

If you are contacted by OMIG, consult a knowledgeable attorney immediately to handle the matter from the outset. OMIG is a prosecuting agency and their investigations can lead to serious civil and/or criminal charges that could affect your ability to earn your livelihood from the practice of dentistry.

Dentists are urged to never rely on verbal responses to inquiries about Medicaid policies and claim requirements. If a policy in the MMIS Manual is unclear, write to DOH’s Office of Health Insurance Programs and get a written clarification in return.

New York State Department of Health
Office of Health Insurance Programs
Riverview Center
150 Broadway, #6E
Albany, NY 12204-2736