On January 29, the New York State Office of the Medicaid Inspector General (OMIG) published its 2025 Work Plan, which provides a preview of the OMIG’s program integrity initiatives for the upcoming year. While this post highlights several areas that the OMIG will focus on, Medicaid providers should refer to the Work Plan for a complete list of the OMIG’s priorities for the year.
As an initial matter, the OMIG will continue to conduct compliance program reviews to assess whether a provider’s compliance program satisfies the OMIG’s requirements. In 2025, the OMIG anticipates completing approximately 100 compliance program reviews. The OMIG also reminds providers of the Self-Disclosure Program and Abbreviated and Full Self-Disclosure processes, which are used to assist fee-for-service providers in meeting the requirement of timely and appropriately reporting, returning, and explaining any overpayments.
The Work Plan made clear that nursing homes and Assisted Living Programs (ALPs) remain an area of focus to ensure that residents receive appropriate services and that those services are properly documented. More specifically, nursing home administrators can expect rate audits and minimum data set (MDS) reviews to continue. Similarly, the OMIG will continue its oversight of Home and Community-Based Services, including, among others, personal care services, private duty nursing, and Medicaid Waiver programs like the Nursing Home Transition and Diversion and Traumatic Brain Injury programs.
The OMIG is also actively developing and updating audit protocols for providers rendering services in Office of Mental Health (OMH), Office of Addiction Services and Supports (OASAS), and Office for People With Developmental Disabilities (OPWDD) programs. OMH providers can expect a new audit protocol this year for OMH Telehealth Services, and OPWDD providers should be on the lookout for a new Community Habilitation audit protocol. In general, Medicaid providers should routinely monitor updates to audit protocols to ensure their services comply with all documentation requirements.
Pharmacies and non-emergency transportation providers can also anticipate fee-for-service audits to continue. For pharmacies, the OMIG’s focus will be to largely ensure compliance with existing Medicaid regulations and appropriate authorization of payment for controlled substance claims. Ambulette and taxi/livery services will also remain a focus. The OMIG will also continue audits related to Health Care Worker Bonus (HWB) claims that were filed for eligible employees and encourages providers to use the Employer Self-Disclosure process to report any overpayments of HWB funds.
Lastly, Medicaid providers should be aware that the OMIG’s recently established Advanced Analytics Team will use data analysis techniques to proactively identify suspicious patterns and irregularities in claims data, such as abnormally high billing frequencies from a single provider or unusual service combinations, or outliers that significantly deviate from expected trends. Algorithms will be used to predict potential fraud. The use of analytics is likely to broaden the OMIG’s fraud, waste, and abuse detection and enforcement efforts.
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