OMIG Audits Medicaid Claims for Patients with Medicare Advantage Plans

The Office of the Medicaid Inspector General (OMIG)
The Office of the Medicaid Inspector General (OMIG) is issuing letters to dentists advising that they may have received Medicaid payments improperly for patients with Medicare Advantage dental plans. Medicaid is the payer of last resort. Before submitting a claim for Medicaid benefits, claims must first be submitted to any other third party through which an enrollee has coverage, including Medicare Advantage.

At the end of 2018, the Office of the New York State Comptroller issued an audit report on improper Medicaid payments by the New York State Department of Health (NYSDOH) for services covered by Medicare Advantage (Medicare Part C) plans. This report included a substantial percentage of improper payments for dental services. As a result, the OMIG is auditing claims paid by Medicaid for enrollees who also have coverage through Medicare Advantage plans. These audits are being conducted by the OMIG’s Recovery Audit Contractor (RAC), Health Management Services, Inc. (HMS).

Some Medicare Advantage plans opt to cover dental; however, such benefit structures are plan specific. For this review, OMIG is asking those providers identified in the audit to confirm whether or not they participate with the plans identified in the review. Providers who do not participate with Medicare Advantage plans need to send in an attestation stating they do not participate with the plans identified in the review. Upon receipt of the attestation, the OMIG will close its review.

Providers who do participate with the plans identified in the review will need to show that they billed the plan and whether the claim was paid or denied. If claims were denied, OMIG will close out corresponding claims.

Questions regarding the audits may be directed to HMS, OMIG’s contractor, at:

Troy W. Burek
Data Systems Business Analyst I
Health Management Services, Inc.
2 Winners Circle, Suite 202
Albany, NY 12205
troy.burek@hms.com
518-724-7793