Provider Quality

Fidelis Care has received notice from the Office of the Medicaid Inspector General (OMIG) of new compliance program requirements for Medicaid participating providers.

Effective April 2020, for New York State (NYS) Social Services Law (SSL) §363-d, and effective December 28, 2022, for the corresponding regulations at 18 New York Codes, Rules and Regulations (NYCRR) Subpart 521-1, NYS Medicaid providers shall adopt, implement, and maintain effective compliance programs aimed at detecting fraud, waste, and abuse in the NYS Medicaid program.

Who is Required to Have a Compliance Program?

NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules and Regulations (18 NYCRR) SubPart 521-1 defines those factors that require providers to have a compliance program.

If you answer YES to any of the following questions, you are required to have a compliance program in New York State.

1. Is your organization subject to Article 28 or Article 36 of the NYS Public Health Law (PBH)?
2. Is your organization subject to Article 16 or Article 31 of the NYS Mental Hygiene Law?
3. Notwithstanding the provisions of § 4414 of the NYS PBH, is your organization a managed care provider, as defined in SOS § 364-j, which includes managed long-term care plans?
4. Does your organization claim —and/or can be reasonably expected to claim—Medicaid services or supplies of at least $1,000,000 in any consecutive 12-month period?
5. Does your organization receive Medicaid payments—and/or can be reasonably expected to receive payments—either directly or indirectly, of at least $1,000,000 in any consecutive 12-month period?  Indirect Medicaid reimbursement is any payment that you receive for the delivery of Medicaid care, services, or supplies that comes from a source other than the State of New York.  For example, if you provide covered services to a Medicaid beneficiary who is enrolled in a Medicaid Managed Care Plan, the payment you receive from the Managed Care Organization is considered an indirect payment.

What Should a Compliance Program Include?

A compliance program should include, at a minimum, the following seven elements:

1. written policies and procedures;
2. the designation of a compliance officer and compliance committee;
3. compliance training and education;
4. lines of communication to the provider's compliance officer or compliance function;
5. disciplinary policies to encourage good faith participation in the compliance program;
6. auditing and monitoring compliance risk areas; and
7. responding to compliance issues.

Effective compliance programs, in meeting the above seven elements, are expected to establish systemic checks and balances to detect and prevent inaccurate billing and inappropriate practices in the NYS Medicaid program; address the requirement to self-disclose, explain, and repay identified overpayments; address the responsibility of the provider to check for excluded persons who may be involved in the provision of NYS Medicaid services; and other obligations that may be specific to the size, complexity, resources, and culture of the provider. The OMIG Bureau of Compliance regularly conducts reviews of providers to ensure they have a compliance program, if required, and that the compliance program is effective.

How Do Providers Submit a Compliance Certification?

Effective immediately, providers are no longer required to complete the annual December certification, commonly referred to as the "SSL Certification," using the form located on the Office of the Medicaid Inspector General's (OMIG) website. Instead, a provider adopting and maintaining an effective compliance program will now record (attest to) this as part of their annual "Certification Statement for Provider Billing Medicaid." This annual certification shall occur on the anniversary date of the provider's enrollment in Medicaid. 

Providers can find their anniversary dates on their initial Medicaid enrollment welcome letters. Additionally, each year, approximately 45-60 days before the anniversary of a provider’s enrollment, the NYS Department of Health (NYSDOH) sends by mail a package of information and materials to the provider, which includes the Certification of Statement for Provider Billing Medicaid Form. This Form must be completed and returned to NYSDOH by the enrollment anniversary date.

Providers also need to send a copy of the completed compliance certification to Fidelis Care.  Please email a copy of the certification to: MedicaidComplianceCertification@fideliscare.org.

Additional guidance and information on compliance requirements can be found on the OMIG website. Providers can also subscribe to the OMIG LISTSERV, to receive agency updates and announcements.