Country / Language

New York Medicaid Claims Edits Impact Healthcare Industry


1/21/14

Background
 
The Affordable Care Act and subsequent federal regulations include provisions requiring additional screening of Medicaid providers to improve the integrity of the Medicaid Program and reduce fraud, waste, and abuse.  
 
Issue
 
To comply with these requirements effective January 1, 2014, New York Medicaid modified claim edits for non-enrolled Medicaid fee-for-service ordering/prescribing/referring/attending (OPRA) physicians and other healthcare professionals. The initiative originally required that claims be denied upon receipt when an OPRA provider was not enrolled as a fee-for-service provider. 
 
Effective January 1, 2014, claims will no longer be systematically rejected if the OPRA physician’s and other healthcare professionals’ enrollment application has not been processed, it will instead be adjudicated as a pend claim. This will allow the backlogged enrollment applications to be reviewed and processed. When the enrollment is approved, all previously pended claims will be released for processing and thereby adjudicated. If the OPRA professional is not enrolled after four weekly payment cycles, the claim will be released for processing and subsequently be denied.  
 
What Does CohnReznick Think?
Now is the time to complete an assessment to determine enrollment requirements of your professionals and to avoid future interruption of the services that providers order for their patients. Fee-for-service applications received and approved by the State between January through March 2014 will be granted a retroactive effective date of January 1, 2014. A review of your existing employment protocol should also be assessed at this time to ensure timely enrollment in the fee-for-service program is completed to avoid unnecessary claim denials.

Contact
 
For additional information, please contact Peter Epp, Co-Managing Director of CohnReznick’s Healthcare Industry Practice, at 646-254-7411.


Circular 230 Notice: In compliance with U.S. Treasury Regulations, the information included herein (or in any attachment) is not intended or written to be used, and it cannot be used, by any taxpayer for the purpose of i) avoiding penalties the IRS and others may impose on the taxpayer or ii) promoting, marketing, or recommending to another party any tax related matters.

This has been prepared for information purposes and general guidance only and does not constitute professional advice. You should not act upon the information contained in this publication without obtaining specific professional advice. No representation or warranty (express or implied) is made as to the accuracy or completeness of the information contained in this publication, and CohnReznick LLP, its members, employees and agents accept no liability, and disclaim all responsibility, for the consequences of you or anyone else acting, or refraining to act, in reliance on the information contained in this publication or for any decision based on it.

Search Our People

Search Our People

Look ahead. Gain insight. Imagine more. Is your business ready to break through?

View our new TV commercial..

Industry Outlooks

Industry Outlooks

Gain insight into what is ahead for the Commercial Real Estate, Technology and Middle Market Private Equity industries.

READ MORE

Learn about our upcoming events.

READ MORE

Working With Us

Working With Us

What makes CohnReznick different from others in our profession? And what should our clients come to expect when working with us? The answer is The CohnReznick Advantage. Contact us to learn how we can out the CohnReznick Advantage to work for your business.


People

The value of an organization is determined by the skills and qualities of its leaders. With more than 280 partners serving clients nationwide, CohnReznick is renowned for the diverse experiences, knowledge and backgrounds of its leadership.

Learn More

Services

We align our services in three segments: Accounting and Assurance, Tax, and Advisory. This approach allows us to provide holistic solutions to complex business problems and to seize upon opportunities requiring an integrated approach.

Learn More

Industries

Accounting and tax issues different significantly based on an organization's industry. We provide clients with expertise in nearly two dozen industries – we know the opportunities, the obstacles, the competitive landscape.

Learn more

Insights

CohnReznick professionals are thought leaders in their industries. Clients benefit from relevant and timely economic, legislative and industry insights that can keep them a step ahead of competition.

Learn More

Global Reach

Our involvement in the Nexia International network of firms enables us assist our clients wherever they do business-providing local expertise and connections wherever they needed. Nexia is comprised of 20,000 professionals operating in over 100 countries.

Learn More