On August 14, 2015, the New York Office of the Medicaid Inspector General (OMIG) posted six new audit protocols on its website. With the addition of the six new audit protocols, there are a total of 30 audit protocols currently available on the site. Each audit protocol is focused on a particular type of Medicaid provider or category of service and is designed to help Medicaid providers evaluate their compliance with Medicaid program requirements.

OMIG uses the audit protocols during audits to determine if a provider properly claimed Medicaid reimbursement for services. Specifically, the audits are designed to verify that: (i) Medicaid reimbursable services were rendered for the dates billed; (ii) the appropriate rate codes were billed for the services rendered; and (iii) claims were submitted in accordance with Medicaid rules, regulations, and provider manuals.

A sampling of some of the criteria in each of the new audit protocols is provided below. While these new protocols take effect immediately and any existing audits in these areas will likely be reviewed against the new protocols, OMIG should only apply those standards in place at the time the services were provided. Due attention should be given to the timing of any changes in relevant regulations or billing requirements.

Office of Mental Health (OMH) Outpatient Clinic Treatment Services Audit Protocol

This audit protocol includes 30 different criteria for evaluation by OMIG, including, but not limited to:

  • Missing Recipient Record: If the Medicaid recipient's record is not available for review, claims for all dates of service associated with the recipient record will be disallowed.
  • No Documentation of Clinic Service: If recipient records lack documentation that a face-to-face clinic treatment service was provided, the claim will be disallowed.
  • Excessive Preadmission Visit: Claims for preadmission visits in excess of the maximum allowed three preadmission visits will be disallowed. For services performed on October 1, 2010 and after, claims for service dates that involve more than one collateral preadmission visit for an adult recipient will be disallowed.
  • Missing Individual Service Plan: A written individual service plan must be completed within five visits after admission. Claims for services provided after the fifth visit from the admission date will be disallowed if the written individual service plan is missing.

OMH Continuing Day Treatment Audit Protocol

This audit protocol includes 19 different criteria for evaluation by OMIG, including, but not limited to:

  • Criteria, Similar to Those Listed above, relating to missing recipient records, lack of documentation of services, excessive preadmission visits and missing or incomplete individual treatment plans.
  • Missing Record of Attendance: There must be a record of all face-to-face contacts with the recipient, the type of service provided and the duration of the contact. The claim will be disallowed if documentation of attendance is missing.
  • Missing Progress Note: For continuing day treatment services, progress notes related to treatment plan goals must be recorded at least every two weeks. If the progress note is missing, claims will be disallowed for all visits within that specific interval for services that were to have been summarized by the progress note.
  • Failure to Meet Minimum Duration Requirements: Claims for visits of less than one hour in duration for continuing day treatment services, less than 30 minutes for collateral visits, or less than 60 minutes for group collateral visits will be disallowed. For services rendered 4/1/2009 and after, claims for visits of less than two hours in duration for continuing day treatment services, less than 30 minutes for collateral visits, or less than 60 minutes for group collateral visits will be disallowed.

OMH Day Treatment Programs Serving Children Audit Protocol

This audit protocol includes 18 different criteria for evaluation by OMIG, which are very similar to those for the OMH Continuing Day Treatment program. These include but are not limited to:

  • Criteria, Similar to Those Listed Above, relating to missing recipient records, lack of documentation of services, excessive preadmission visits, missing or incomplete individual treatment plans, missing records of attendance, missing progress notes, and failure to meet minimum duration requirements.
  • No Explanation of Benefit (EOB) for Third Party Health (TPHI) Covered Service (Excluding Medicare): If an EOB for a TPHI (commercial carrier) covered service is not found, the claim will be disallowed.
  • Failure to Bill Medicaid Managed Care: Claims will be disallowed for services billed to Medicaid that bypass the Medicaid Managed Care company responsible for payment.
  • Billing for Nonreimbursable Services: Educational-only services documented without the required additional billable day treatment service will be disallowed.

OMH Intensive Psychiatric Rehabilitation Treatment Audit Protocol

This audit protocol includes 14 different criteria for evaluation by OMIG, including, but not limited to:

  • Criteria, Similar to Those Listed Above, relating to missing recipient records, lack of documentation of services, excessive preadmission visits, missing or incomplete individual service plans, and failure to meet minimum duration requirements.
  • No Documentation of Initial Referral by a Licensed Practitioner:Claims will be disallowed if documentation of the initial referral by a licensed practitioner is missing.
  • No Documentation of a Renewal of Authorization: A written renewal of authorization is needed within four months after admission and quarterly thereafter. Claims will be disallowed if documentation of the required renewal of authorization for services by the referring licensed practitioner or another licensed practitioner who is not affiliated with the intensive psychiatric rehabilitation treatment program is missing.
  • Reimbursement in Excess of the Allowable Hours of Service:Claims for services provided in excess of 72 hours per recipient per month and/or in excess of 720 hours per recipient per year will be disallowed.

OMH Partial Hospitalization Audit Protocol

This audit protocol includes 20 different criteria for evaluation by OMIG, including, but not limited to:

  • Criteria, Similar to Those Listed Above, relating to missing recipient records, lack of documentation of services, excessive preadmission visits, missing or incomplete individual treatment plans, missing progress notes, and failure to meet minimum duration requirements.
  • Improper Medicaid Billings for TPHI Recipients (Excluding Medicare): If Medicaid's co-payment is incorrect, the amount of the claim disallowed will be the difference between Medicaid's incorrect co-payment billed and the correct co-payment amount.
  • Duration of Visit Not Documented: There must be a record of all face-to-face contacts with the recipient, the type of service provided and the duration of the contact. If the duration of the partial hospitalization visit is not documented in the recipient's records, the claim will be disallowed.
  • Incorrect Collateral Billings: Collateral persons are defined as (1) members of the recipient's family or household; (2) significant others identified in the treatment plan; or (3) significant others identified in preadmission notes. Claims billed for individuals not meeting the definition of collateral persons or for collateral persons not listed on the recipient's treatment plan or preadmission notes will be disallowed.

Traumatic Brain Injury Audit Protocol

This audit protocol includes 29 different criteria for evaluation by OMIG, including, but not limited to:

  • Criteria, Similar to Those Listed Above, relating to lack of documentation of services and missing or incomplete individual treatment plans.
  • Services Performed by Unqualified Service Coordinator Staff: If the Service Coordinator does not meet the requirements for qualification of the position (education/experience) at the date of service, all paid claims provided by the unqualified Service Coordinator will be disallowed.
  • Services Performed by Unqualified Independent Living Skills Training (ILST) and Development Staff: If the provided service was performed by staff that did not meet the standards required for the ILST position (education/experience) at the date of service, the paid claims provided by the unqualified staff will be disallowed.
  • Services Performed by Unqualified Behavioral Specialist: If the provided service was performed by staff that did not meet the standards required for the Behavioral Specialist position (education/experience) at the date of service, the paid claims provided by the unqualified staff will be disallowed.

Conclusion

With the release of these new audit protocols, healthcare providers that participate in the service categories above can expect that OMIG will likely perform audits of these service categories in the relatively near future. When undergoing an audit by OMIG, it is important to keep in mind that, although OMIG's audit protocols have been reviewed by the relevant Medicaid program office (e.g. the NY State Department of Health, the NY State Office for People with Developmental Disabilities and OMH), OMIG's findings in an actual audit can often successfully be challenged on a number of fronts, including timeliness and procedural violations. Manatt regularly advises providers on identifying acceptable secondary documentation and/or developing successful audit defense strategies.

We recommend that healthcare providers perform frequent self-audits, using OMIG's protocols, to ensure that they are complying with Medicaid's various requirements. Performing self-audits is an effective way to protect against a real audit by OMIG and demonstrate compliance program effectiveness. Plans and providers are reminded that findings contrary to the audit protocols leading to overpayments must be disclosed and returned within 20 days of identification.