NYS Office of Medicaid Inspector General (OMIG) Audits

The NYS OMIG has conducted audits of restorative services in Crs and TAP.  Although all but one have been conducted outside of NYC and Long Island,  we expect them to go there eventually.  ACL was very involved in the Governor’s workgroup on OMIG and the formation of the restorative services audit protocols.  We have also had several major trainings on this topic at the conference and the management symposium. 

The link that follows is the PowerPoint presentation that was given by Joy DeVita of RSS at a meeting in Saratoga.  Joining her were Chris Syracuse and Lisa Corrigan of DePaul, with a lot of participation from audience members who have had recent audits.  It was a very rich discussion.  OMIG Audit Preparation and Response

Meanwhile, the following is a list of tips that you can use if you are facing an OMIG audit of restorative services in your Community Residence Programs to get you thinking about this. 

First – go to the OMIG website and print out the protocols at http://www.omig.ny.gov/data/images/stories/audit_protocols/omh_rehab_services_adult_protocol.pdf.   They will review your records and look for these things specifically.  I have their word that unless there is something very wrong (fraud or very, very sloppy work that could be negligent (waste)) they will stick to these items.

  • Second – decide which HIGH LEVEL staff you will assign to this task.  Have a couple of people assigned and only have them interact with the auditors.
  • Third – decide where you will work from.  You will need a dedicated room most likely.  This will be an exercise in your ability to stay organized.  If you have been given the names of the people and the claims, pull these. If not, get all the records for the designated period – usually 2 or 3 years – and put them in a room in an organized way. 
  • Fourth  – give them the information as they ask for it – do not give them access to the record room – but if they want the entire chart, you should give it to them.
  • Fifth – you may  be asked to make copies of items from the charts.  You need someone who can do that.  HOWEVER, they all seem to be bringing their own scanners and scanning the materials in so copies may  no longer necessary.
  • Sixth – there will be an exit interview.  The assigned staff should attend. 
  • Seventh – they will send a draft report with their findings.  Take this report very seriously.  They will accept alternative documentation to show that the item should not be disallowed. So, look at the disallowances (if any) and then go back into your records and try to find alternative documentation that might be used to mitigate the problem.  For example – if you billed for a medication  management goal but there is no staff signature you might have a medication management sheet that the staff initialed or signed at the time the meds were supervised that day.  If you have 3 or fewer problematic claims out of 100 claims you will owe nothing.  So getting it down to 3 is essential.

Each disallowance can cost a lot of money.  If they find 10% faulty claims out of the 100 that they look at, they will look to recoup 10% OF ALL YOUR MEDICAID BILLINGS FOR THE TIME PERIOD THAT THEY ARE LOOOKING AT – 2 – 3 years.  Every claim that you can mitigate will save a lot of money.

  • Eighth – pull together all of your alternative documentation – put it all in a report format claim by claim in a very organized way.  Give them as much information that might bear on the problem as you can find – even if it is a stretch. 
  • Ninth– Decide on whether or not you want an attorney who knows about these issues.  If you do, keep him/her involved. Even if you decide not to use one during the process, it is a good idea to run your final response by one and have an attorney send it in.
  • Finally, you know not to alter any record.  That is fraud and a very serious offense. 

Lastly – ACL had a high level meeting with OMH and DOH regarding exempt income.  It was decided that, if they do seek to take back money, it will be offset by any exempt income that you paid back in the year in question. 

Do not hesitate to call us if you get as notice of audit and need to talk about it with someone.  We can help but we can also put you in touch with those who have been through it successfully. 


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