What the state expects from providers
In New York, Medicaid program integrity is overseen largely by the Office of the Medicaid Inspector General, known as OMIG, which audits providers, investigates billing, and publishes guidance on what an effective compliance program should contain. Providers above certain billing or licensing thresholds are required to adopt such a program and to certify it, while smaller providers are still expected to bill accurately and keep records that support every claim. Medicaid managed care adds another layer, because plans run their own audits and special investigations units. A compliance program on paper is not the same as one that works, and reviewers look at whether training, auditing, and follow-up actually happen. Medicaid compliance is ongoing work rather than a document filed once.
Overpayments and self-disclosure
Billing errors happen in every organization, and the legal risk often turns less on the error than on what happens after someone notices it. Federal law requires identified Medicaid and Medicare overpayments to be reported and returned within a set period, and keeping money past that point can create liability under the False Claims Act. New York runs a self-disclosure program through OMIG for providers who find problems on their own. Before disclosing, it usually makes sense to understand the scope of the issue, which may call for a sample or look-back review done under counsel's direction. Keep claims data, documentation policies, and records of past audits organized so that the review can move quickly.
Where a compliance review begins
Our starting point is how your organization bills, who codes and signs claims, and which services carry the most documentation risk, such as home care hours, transportation, or time-based therapy. We also ask what the hotline, prior audits, and plan reviews have already flagged. From there we look at whether the written program matches what OMIG expects for your type of provider and whether it is working in practice. If an issue has already been identified, the conversation shifts toward measuring it and deciding how and when to raise it with the program. You leave with a sense of priorities rather than a generic checklist.
