§ 32 — Functions, duties and responsibilities

New York § 32

• Jurisdiction: New York
• Law PBH: Public Health
• Title 3: Office of the Medicaid Inspector General
• Art. 1: Short Title and Definitions: General Provisions

Text

§ 32. Functions, duties and responsibilities. The inspector shall have\nthe following functions, duties and responsibilities:\n 1. to appoint such deputies, directors, assistants and other officers\nand employees as may be needed for the performance of his or her duties\nand may prescribe their duties and fix their compensation within the\namounts appropriated therefor;\n 2. to conduct and supervise activities to prevent, detect and\ninvestigate medical assistance program fraud and abuse amongst the\nfollowing: the department; the offices of mental health, alcoholism and\nsubstance abuse services, temporary disability assistance, and children\nand family services and the office for people with developmental\ndisabilities;\n 3. to coordinate, to the greatest extent possible, activities to\nprevent, detect and investigate medical assistance program fraud and\nabuse amongst the following: the department; the offices of mental\nhealth, alcoholism and substance abuse services, temporary disability\nassistance, and children and family services and the office for people\nwith developmental disabilities; the commission on quality of care and\nadvocacy for persons with disabilities; the department of education; the\nfiscal agent employed to operate the medical assistance information and\npayment system; local governments and entities; and to work in a\ncoordinated and cooperative manner with, to the greatest extent\npossible, the deputy attorney general for Medicaid fraud control; the\nwelfare inspector general, federal prosecutors, district attorneys\nwithin the state, the special investigative unit maintained by each\nhealth insurer operating within the state, and the state comptroller;\n 4. to solicit, receive and investigate complaints related to fraud and\nabuse within the medical assistance program;\n 5. to keep the governor, attorney general, state comptroller,\ntemporary president and minority leader of the senate, the speaker and\nthe minority leader of the assembly, and the heads of agencies with\nresponsibility for the administration of the medical assistance program\napprised of efforts to prevent, detect, investigate, and prosecute fraud\nand abuse within the medical assistance program, and to provide a\nquarterly briefing to the legislature on activities of the office;\n 6. to pursue civil and administrative enforcement actions against any\nindividual or entity that engages in fraud, abuse, or illegal or\nimproper acts or unacceptable practices perpetrated within the medical\nassistance program, including but not limited to: (a) referral of\ninformation and evidence to regulatory agencies and licensure boards;\n(b) withholding payment of medical assistance funds in accordance with\nstate and federal laws and regulations; (c) imposition of administrative\nsanctions and penalties in accordance with state and federal laws and\nregulations; (d) exclusion of providers, vendors and contractors from\nparticipation in the program; (e) initiating and maintaining actions for\ncivil recovery and, where authorized by law, seizure of property or\nother assets connected with improper payments; and entering into civil\nsettlements; and (f) recovery of improperly expended medical assistance\nprogram funds from those who engage in fraud or abuse, or illegal or\nimproper acts perpetrated within the medical assistance program. In the\npursuit of such civil and administrative enforcement actions under this\nsubdivision, the inspector shall consider the quality and availability\nof medical care and services and the best interest of both the medical\nassistance program and recipients;\n 6-a. to post on the department's internet website, within reasonably\nprompt fashion, all final administrative determinations issued by\nadministrative law judges in connection with any actions taken by the\noffice pursuant to this title;\n 7. to make information and evidence relating to suspected criminal\nacts which he or she may obtain in carrying out his or her duties\navailable to appropriate law enforcement officials and to consult with\nthe deputy attorney general for Medicaid fraud control, the welfare\ninspector general, and other state and federal law enforcement officials\nfor coordination of criminal investigations and prosecutions.\n The inspector shall refer suspected fraud or criminality to the deputy\nattorney general for Medicaid fraud control and make any other referrals\nto such deputy attorney general as required or contemplated by federal\nlaw. At any time after such referral, with ten days written notice to\nthe deputy attorney general for Medicaid fraud control or such shorter\ntime as such deputy attorney general consents to, the inspector may\nadditionally provide relevant information about suspected fraud or\ncriminality to any other federal or state law enforcement agency that\nthe inspector deems appropriate under the circumstances;\n 8. to subpoena and enforce the attendance of witnesses, administer\noaths or affirmations, examine witnesses under oath, and take testimony;\n 9. to require and compel the production of such books, papers, records\nand documents as he or she may deem to be relevant or material to an\ninvestigation, examination or review undertaken pursuant to this\nsection;\n 10. to examine and copy or remove documents or records of any kind\nrelated to the medical assistance program or necessary for the inspector\nto perform its duties and responsibilities that are prepared, maintained\nor held by or available to any state agency or local governmental entity\nthe patients or clients of which are served by the medical assistance\nprogram, or which is otherwise responsible for the control of fraud and\nabuse within the medical assistance program; provided, however, that any\nsuch information be afforded confidentiality protection as provided for\nunder state and federal law. The removal of records shall be limited to\nthose circumstances in which a copy thereof is insufficient for an\nappropriate legal or investigative purpose, provided that in such\ninstances the copying and return of such original, or copy where the\noriginal is required for an appropriate legal or investigative purpose,\nis expedited and such original or copy is readily accessible in\naccordance with the care and treatment needs of the patient,\n 11. to recommend and implement policies relating to the prevention and\ndetection of fraud and abuse; provided however, that the consent of the\nattorney general shall be obtained prior to the implementation of any\npolicy that shall affect the operations of the office of the attorney\ngeneral;\n 12. to monitor the implementation of any recommendations made by the\noffice to agencies or other entities with responsibility for\nadministration of the medical assistance program;\n 13. to prepare cases, provide testimony and support administrative\nhearings and other legal proceedings;\n 14. to review and audit contracts, cost reports, claims, bills and all\nother expenditures of medical assistance program funds to determine\ncompliance with applicable federal and state laws and regulations and\ntake such actions as are authorized by federal or state laws and\nregulations;\n 15. to work with the fiscal agent employed to operate the Medicaid\nmanagement information system to optimize the system;\n 16. to work in a coordinated manner with relevant agencies in the\nimplementation of information technology relating to the prevention and\nidentification of fraud and abuse in the medical assistance program,\nincluding the surveillance utilization review system and other automated\nsystems pursuant to paragraph (b) of subdivision eight of section three\nhundred sixty-seven-b of the social services law;\n 17. to conduct educational programs for medical assistance program\nproviders, vendors, contractors and recipients designed to limit fraud\nand abuse within the medical assistance program;\n 18. to, in conjunction with the commissioner, develop protocols to\nfacilitate the efficient self-disclosure and collection of overpayments\nand monitor such collections, including those that are self-disclosed by\nproviders. The provider's good faith self-disclosure of overpayments may\nbe considered as a mitigating factor in the determination of an\nadministrative enforcement action;\n 19. to receive and to investigate complaints of alleged failures of\nstate and local officials to prevent, detect and prosecute fraud and\nabuse in the medical assistance program;\n 20. to, consistent with provisions of this title, implement and amend,\nas needed, rules and regulations relating to the prevention, detection,\ninvestigation and referral of fraud and abuse within the medical\nassistance program and the recovery of improperly expended medical\nassistance program funds;\n 21. to conduct, in the context of the investigation of fraud and\nabuse, on-site facility and office inspections;\n 22. to take appropriate actions to ensure that the medical assistance\nprogram is the payor of last resort;\n 23. to annually submit a budget request, for the ensuing state fiscal\nyear, to the division of the budget, provided that the office's budget\nrequest shall not be subject to review, alteration or modification by\nthe commissioner or any other entity or person prior to its submission\nto the division of the budget;\n 24. to meet quarterly with representatives of social services\ndistricts to discuss the status of ongoing cooperative efforts between\nthe office of Medicaid inspector general and districts, including\ndemonstration programs authorized pursuant to section five-a of part C\nof chapter fifty-eight of the laws of two thousand five, the potential\nfor additional collaboration and/or for improved or innovative\ntechniques to be employed, and any issues of concern to such districts\nwith respect to the prevention and detection of fraud and abuse in the\nmedical assistance program;\n 25. to request submission of social services districts annual budget\nand audit workplans for purposes of planning for and executing the\ncounty demonstration program and for the creation of the office's annual\nworkplan and to include in the office's annual workplan a description of\nactivities that will be conducted in collaboration with social services\ndistricts;\n 26. to develop training materials with respect to the office's audit\nstandards and criteria for identifying fraud or waste, for use by social\nservices districts who are engaged with the office in demonstration\nprograms or other collaborative efforts; and\n 27. to perform any other functions that are necessary or appropriate\nto fulfill the duties and responsibilities of the office in accordance\nwith federal and state law.\n