A recent report from the New Jersey Office of the State Comptroller indicates an expansion of the efforts of its Medicaid Fraud Division (MFD) to investigate fraud, waste and abuse in the New Jersey Medicaid Program. The report also highlights MFD’s expanded effort to exclude providers from the Medicaid Program.
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Healthcare practitioners should be aware of important updates and changes to Medicare and Medicaid Programs of New York and New Jersey. We summarize some of these changes in the article that follows. The Centers for Medicare & Medicaid Services (CMS) has once again proposed new rules which would enhance the screening requirements for providers and suppliers. The rule proposals would ratchet up the scrutiny on provider enrollments and toughen suspension and revocation penalties. The mission of the Medicaid Fraud Division (MFD) within the Office of the State Comptroller is to prevent, detect, audit and investigate fraud, waste and abuse by New Jersey providers and recipients. As we look forward to the New Jersey Medicaid Fraud Division 2015 work plan, we look back at the agency’s activities in 2014. Deniza Gertsberg, Esq. will be speaking during “Elements of Fraud and Abuse Investigation” presentation. The event focuses on the basics of a New Jersey Medicaid fraud and abuse investigation. The topics that will be discussed include responding to subpoenas, self disclosure and the use of statistical sampling in audits. The Deputy Director of New Jersey Medicaid Fraud Division, Mark Moskovits and former Director of the Medicaid Fraud Control Unit, Riza I. Dagli will also be presenting. Deniza Gertsberg, Esq. is one of the organizers of this New Jersey State Bar Association event which is open to all members of the NJSBA’s Health Law Section. Pursuant to the requirements imposed by the Affordable Care Act (ACA), New Jersey Division of Medical Assistance and Health Services is beginning a revalidation process of all NJ FamilyCare (NJFM) fee-for-service (FFS) providers. Can a provider bill a beneficiary all or part of the difference between the provider’s charged fees and the payment received from NJ Medicaid or managed care plan? The NJ Department of Human Services, Division of Medical Assistance & Health Services (Department) recently answered that question. Providers beware – even an unintentional omission on a New Jersey Medicaid enrollment application can lead to denial of enrollment. Such was the holding of a recent New Jersey Court of Appeals decision. New York State Medicaid Program posted new applications on April 1, 2013 for non-billing providers that order, prescribe, and/or refer beneficiaries with fee-for-service Medicaid coverage. New Jersey Medicaid required all such providers to be enrolled an “non-billing” providers by Jan. 1, 2013. Documenting each patient encounter not only benefits the patient but it is also good preventative medicine for the doctor against claims of professional negligence, failure to meet certain professional standards, and investigations by government agencies. The position taken by most licensing boards and law enforcement agencies is that if an item or service is not documented in a patient’s medical record “it didn’t happen.” Below we discuss the minimum documentation requirements imposed by New Jersey Medicaid on participating providers. There are at least 27 different basis for exclusion or denial of provider enrollment application in the New Jersey Medicaid Program. Some are not so obvious. Every year, the New Jersey Medicaid Fraud Division (MFD), the watchdog agency for New Jersey’s Medicaid program, releases a workplan which informs providers, suppliers and their advisers about the agency’s focus for the up-coming year. MFD’s 2012 workplan outlines a comprehensive audit and review agenda. We have summarized the agency’s audit criteria to help New Jersey Medicaid providers become aware of and stay prepared for scrutiny in 2012. The Affordable Care Act (ACA) imposed certain enhanced Medicaid enrollment requirements for State Medicaid programs to follow. Recently, the NJ Medicaid Fraud Division Unit (MFD), in consultation with the NJ Division of Medical Assistance and Health Services (DMAHS), described how it plans to comply with the ACA’s enhanced provider screening requirements. One of the changes brought about by the Affordable Care Act (ACA) is the enhanced enrollment and revalidation screenings for providers and suppliers not only under Medicare but also Medicaid and CHIP healthcare programs. The New Jersey Medicaid and New Jersey FamilyCare programs insures more than one million New Jersey residents. Review responsibilities of the different units within the Medicaid Fraud Division, the State’s “watchdog” agency over these programs. |
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