New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 521 - Fraud, Waste and Abuse Prevention
Subpart 521-3 - SELF-DISCLOSURE PROGRAM
Section 521-3.4 - Self-Disclosure Program
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 521-3.4
Current through Register Vol. 46, No. 39, September 25, 2024
(a) General. Pursuant to subdivision 7 of section 363-d of the Social Services Law, the OMIG's SelfDisclosure Program is the process by which persons who have identified an overpayment under the MA program report, return and explain overpayments to the MA program. Persons required to report, return and explain overpayments pursuant to section 521-3.3 of this SubPart shall submit information regarding the overpayment to OMIG and make repayment in the form and manner set forth in this section.
(b) Self-Disclosure Program - General Provisions.
(1) Eligibility. A person is
eligible to participate in the Self-Disclosure Program if:
(i) the person is not currently under audit,
investigation, or review by OMIG. If the person is under audit, investigation,
or review, but the overpayment being disclosed does not relate to the existing
audit, investigation, or review the person shall be eligible to participate,
with respect to the overpayment being disclosed. For purposes of this
paragraph, an audit, investigation, or review includes, but is not limited to,
Parts 515, 516, 517, 518 and 521 of this Title;
(ii) the person is disclosing an overpayment
and related conduct that OMIG has not identified at the time of the
disclosure;
(iii) the overpayment
and related conduct are reported by the deadline specified in paragraph (1) of
subdivision (b) of section
521-3.3 of this SubPart;
and
(iv) the person is not
currently a party to or the subject of any criminal investigation, related to
their participation in the MA program, being conducted by the MFCU or an agency
of the United States Government or any political subdivision thereof.
(2) For persons eligible to
participate in the Self-Disclosure Program, pursuant to paragraph (1) of this
subdivision, OMIG, in its sole discretion, after a written request from an
eligible person participating in the Self-Disclosure Program, may:
(i) waive the imposition of interest on the
amount of the overpayment, in whole or in part;
(ii) permit repayment through installments
pursuant to an SDCA;
(iii) in
accordance with the provisions of subdivision 18 of section 32 of the
Public Health Law, consider the person's reporting and returning overpayments
as a mitigating factor in the determination of an administrative enforcement
action; and
(iv) for persons
subject to the provisions of SubPart 521-1 of this Part and in accordance with
section 363-d of
the Social Services Law, consider the person's reporting and returning
overpayments as a factor in determining whether the person has adopted and
implemented an effective compliance program.
(3) Regardless of eligibility, if the person
has determined that they have received an overpayment pursuant to section
521-3.3 of this SubPart, the
person shall submit a SelfDisclosure Statement pursuant to subdivision (c) of
this section.
(4) If OMIG
determines that a person is ineligible, it shall notify the person of this
determination in writing, in accordance with the requirements of subdivision
(a) of section
521-3.6 of this SubPart.
(c) Self-Disclosure Statement.
(1) As a condition of participation in the
Self-Disclosure Program, the person shall apply by the submission of a
self-disclosure statement, cooperate and furnish any information requested,
including any additional data, documentation, or information requested by the
OMIG needed to confirm the overpayment.
(2) To participate in the Self-Disclosure
Program, a person shall submit a statement which shall contain the following
information:
(i) An estimate of the amount of
the overpayment. The person shall calculate the estimated overpayment and
provide information to OMIG which supports the calculated overpayment amount.
OMIG has the sole discretion to approve the methodology used for the
calculation and to determine the overpayment amount and interest if
applicable;
(ii) A detailed
explanation of the reason the person received the overpayment, which shall, at
a minimum include:
(a) a description and
explanation of the circumstances that gave rise to the overpayment;
(b) how the circumstances giving rise to the
overpayment were discovered;
(c)
the date the overpayment was identified;
(d) how the person calculated the amount of
the overpayment;
(e) the date(s)
the overpayment(s) were received; and
(f) the action taken to correct the error
which caused the overpayment.
(iii) the person's contact
information;
(iv) data file, in the
form and format specified by OMIG;
(v) whether the person is requesting to repay
through installment payments;
(vi)
whether the person is requesting the waiver of any applicable
interest;
(vii) the person's
agreement to return the full amount of the overpayment and interest if
applicable, as determined by OMIG; and
(viii) any other data, documentation, or
information OMIG shall require through the issuance of guidance or in response
to its review of the submission.
(3) The Self-Disclosure Statement shall be
signed by the person's compliance officer, where the person is a required
provider pursuant to SubPart 521-1 of this Part. Where the person is not a
required provider pursuant to SubPart 521-1 of this Part, the Self-Disclosure
Statement may be signed by one of the following, the person's chief executive
officer, chief operating officer, a senior manager of the person, or the
person, where the person is a sole practitioner.
(4) A person requesting to repay through
installment payments may be required to furnish OMIG with financial records and
other documentation in support of the request. OMIG shall approve or reject a
person's request based on a review of the person's financial documentation,
participation in the MA program, and any other factors OMIG
identifies.
(5) If OMIG determines
that no overpayment was made, it shall notify the person in writing of the
determination.
(6) A person who has
received and disclosed an overpayment or has received notice of the overpayment
amount due, and interest if applicable, pursuant to section
521-3.5 of this SubPart is
required to return the overpayment and interest if applicable, in accordance
with section
521-3.3 of this SubPart.
(d) Review of Accepted Self-Disclosures.
(1) OMIG shall acknowledge
receipt and review the Self-Disclosure Statement and consider any written
requests made pursuant to paragraph (2) of subdivision (b) of this section and
shall complete a preliminary review within twenty (20) days of the submission.
The deadline to report, return and explain shall be tolled, in accordance with
the provisions of subdivision (b) of section
521-3.3 of this SubPart, from the
date the submission was acknowledged by OMIG until completion of OMIG's
preliminary review. Upon completion of its preliminary review, OMIG shall
notify the person, in accordance with the notice provisions of subdivision (a)
of section
521-3.6 of this SubPart, and
either accept the submission or return the submission as incomplete and
identify the information and data needed to complete the submission. Only a
submission that is acknowledged and accepted shall continue to toll the
deadline to report, return and explain, in accordance with the provisions of
subdivision (b) of section
521-3.3 of this SubPart, from the
date the submission was acknowledged by OMIG. OMIG's acceptance of the person's
submission of a Self-Disclosure Statement is conditioned upon the person's
cooperation with OMIG under the Self-Disclosure Program, including any request
for additional information or data under paragraph (2) of this
subdivision.
(2) OMIG may, at any
time, request additional information or data from the person who submitted the
Self-Disclosure Statement. Such requests will be made in writing in accordance
with subdivision (a) of section
521-3.6 of this SubPart. The
person shall respond with such information and data within fifteen (15) days of
the date of OMIG's notice.
(i) OMIG may extend
the period to respond for good cause. Any request by the person to extend the
period to respond shall be made in writing to OMIG and any approval or denial
of the extension request shall be made by OMIG, in writing, in accordance with
the provisions of subdivision (a) of section
521-3.6 of this SubPart.
(ii) Failure by the person to respond within
fifteen (15) days or by any extended deadline will result in the submission
being deemed not accepted and returned to the person as incomplete, and any
tolling of the deadline to report, return and explain shall be terminated. OMIG
will notify the person in writing, in accordance with the provisions of
subdivision (a) of section
521-3.6 of this SubPart, that the
submission has not been accepted, and the notice shall include the date on
which the submission was deemed not accepted and the tolling of the deadline to
report, return and explain was terminated.
(3) Once OMIG has accepted the submission of
a self-disclosure statement and determined that the submission is complete,
OMIG will review and verify the amount of the overpayment and issue a
notification, in accordance with subdivision (a) of section
521-3.6 of this SubPart, to the
person of the overpayment amount due, including interest if applicable, and
instructions for repayment.
(e) Self-Disclosure and Compliance Agreement.
(1) The SDCA is a binding contract between
the person and OMIG. A person may be eligible for an SDCA based on the conduct
being disclosed and/or where the person has requested to repay the determined
overpayment amount through installments. The overpayment amount shall include
interest unless interest is waived, in the sole discretion of OMIG.
(2) The SDCA shall include, at a minimum, the
following terms and conditions:
(i) Agreement
by the person to repay the amount of the overpayment and interest if
applicable, as determined by OMIG, which is the subject of the
disclosure.
(ii) If approved by
OMIG for installment payments, agreement to make all installments payments on
time, and in accordance with the repayment schedule.
(iii) Identification of, and agreement by the
person to implement any corrective actions to prevent the issues which caused
the person to receive an overpayment from the MA program from
recurring.
(3) The
person shall execute and return the SDCA, which must be received by OMIG within
fifteen (15) days of the person receiving said agreement from OMIG, or such
other timeframe as OMIG may permit, provided that such period shall not be less
than fifteen (15) days.
(4) If the
person fails to execute and return the SDCA to OMIG within the timeframe
specified in paragraph (3) of this subdivision the person's participation in
the Self-Disclosure Program shall be terminated. Notice of such termination
shall be provided in accordance with paragraph (2) of subdivision (f) of this
section.
(5) OMIG shall have the
authority to enter into an SDCA with a person making a SelfDisclosure, in its
sole discretion.
(f) Termination of participation.
(1) In
accordance with subparagraph (4) of paragraph (f) of subdivision 7 of section 363-d of
the Social Services Law a person's participation in the Self-Disclosure Program
shall be immediately terminated if:
(i) the
person provides false material information or omits material information in
their Self-Disclosure Statement or other communications with OMIG;
(ii) the person attempts to defeat or evade
an overpayment due pursuant to the SDCA or notification of an overpayment due,
and interest if applicable, pursuant to section
521-3.5 of this SubPart;
or
(iii) the person fails to
execute and return the SDCA in accordance with the timeframes specified in
subdivision (e) of this section.
(2) If OMIG terminates a person's
participation in the Self-Disclosure Program it shall issue a notice to the
person within five (5) business days of its determination. The notice shall be
mailed to the person's designated payment address or correspondence address or
address provided on the Self-Disclosure Statement submitted pursuant to
subdivision (c) of this section. The notice shall contain:
(i) the reason for the termination and the
legal authority for the action taken;
(ii) the effective date of the
termination;
(iii) the overpayment
amount and interest due;
(iv) the
due date of the overpayment amount and interest;
(v) the date on which the tolling of the
return of the overpayment amount ends;
(vi) notification that the overpayment and
interest amount may be recovered in accordance with Part 518 of this Title;
and
(vii) notification that failure
to return the overpayment and interest amount by the due date may result in
monetary penalties pursuant to section 145-b (4) of the Social
Services Law and Part 516 of this Title, and any other sanction or penalty
authorized by law.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
