State of New York Requires $60M Up Front From MCO’s

State of New York Requires $60M Up Front From MCO’s For Recovery Of Payments From Fraud, Waste and Abuse


Did you know this is happening?

Do you know that as part of the New York State 2016-2017 Budget, Medicaid Managed Care Organizations (MCO’s) are required to pay the state $60 million up front for the recovery of payments improperly paid through fraud, waste or abuse (FWA). This is a joint Department of Heath, Office of Health Insurance Programs (OHIP) and the Office of the Medicaid Inspector General (OMIG) effort to incentivize MCO’s in their FWA efforts.


This is how it’s going to affect you

This joint initiative will require both not-for-profit and for-profit plans responsible for providing quality, affordable, New York State-sponsored health insurance to institute practices to recover FWA payments to comply with the budget mandates. These practices will involve re-allocation of existing resources or the retaining of external resources to fully comply with the mandate. The ability of each MCO to meet their share of the budget mandate for recoveries will directly impact the capitation rate set by OHIP. OMIG will proactively monitor each MCO and require regular reporting.


Here’s what you can do about it

Pulselight, has extensive experience helping Medicaid programs implement best practices in policy to identify fraud, waste and abuse and also help recover payments while optimizing resources. Our payment integrity projects with public entities have a proven high return on investment (ROI) .