upper room aids ministry, inc

f NEWYORKe3' STATE

Office of theMedicaid InspectorGeneral

ERIN E. IVESActing Medicaid Inspector General

Audit of Claims Billed with a Non-Enrolled orExcluded Ordering/Prescribing/Referring/Attending Provider Paid From January 1,

2015 to December 31, 2018Final Audit Report

Audit #: 2020Z67-031B

Upper Room AIDS Ministry, Inc.Provider ID #: 01741726

Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.

N EWYORK, STATEOffice of theMedicaid InspectorGeneral

ANDREW M. CUOMO ERIN E. IVESGovernor Acting Medicaid Inspector General

December 22, 2020

Upper Room AIDS Ministry, Inc.306 Lenox AvenueNew York, New York 10027

Final Audit ReportAudit #: 2020Z67-031BProvider ID #: 01741726

Dear Provider:

This is the Office of the Medicaid Inspector General's (OMIG) Final Audit Report for Upper Room AIDSMinistry, Inc. (Provider).

In accordance with Title 18 of the Official Compilation of the Codes, Rules and Regulations of the Stateof New York Section 517.6, the attached Final Audit Report represents the final determination on theissues found during OMIG's audit.

The Provider's December 16, 2020 response to OMIG's November 12, 2020 Draft Audit Report statedthat the Provider is in agreement with the Draft Audit Report findings. As a result, the overpaymentsidentified in this Final Audit Report remain unchanged from those cited in the Draft Audit Report. Thetotal amount due is $2,829.39, including interest to date.

OMIG has attached an exhibit of paid claims identified as overpayments. Please email if you have any questions or comments concerning this

report. Please refer to audit number 2020Z67-031B in all correspondence.

Attachment

Sincerely,

System Match and RecoveryDivision of Systems Utilization and ReviewOffice of the Medicaid Inspector General

800 North Pearl Street, Albany, New York 12204 www.omig.ny.gov

Audit #: 2020Z67-031B Final Audit Report

Table of ContentsBackground 1

Objective 1

Audit Scope 1

Audit Findings 2

Repayment Options 4

Hearing Rights 5

Contact Information 6

Remittance Advice

Exhibits:A - Claims Billed with a Non-Enrolled or Excluded Ordering/Prescribing/Referring/

Attending (OPRA) Provider Paid From January 1, 2015 to December 31, 2018


Background, Objective, and Audit Scope

Background

The New York State Department of Health (DOH) is the single state agency responsible for theadministration of the Medicaid program. As part of its responsibility as an independent entity withinDOH, the Office of the Medicaid Inspector General (OMIG) conducts audits and reviews of variousproviders of Medicaid reimbursable services, equipment, and supplies. These audits and reviews aredirected at assessing provider compliance with applicable laws, regulations, rules, and policies of theMedicaid program as set forth in New York Public Health Law, New York Social Services Law, theregulations of DOH (Titles 10 and 18 of the New York Codes Rules and Regulations), the regulationsof the Department of Mental Hygiene (Title 14 of the New York Codes Rules and Regulations), DOH'sMedicaid Provider Manuals and Medicaid Update publications.

Federal Rules and Regulations require all ordering and referring physicians or other professionalsproviding services to Medicaid Recipients be enrolled as participating providers. Section 6401(a) of theAffordable Care Act (ACA) establishes the requirements surrounding provider enrollment. 42 CFR,Section 455.410 requires providers to be enrolled in state Medicaid programs if they continue to orderor refer services reimbursed by the fee-for-service (FFS) Medicaid program.

Beginning January 1, 2014, physicians or other healthcare professionals who order, prescribe, refer, orattend (OPRA) Medicaid Services must be appropriately screened and enrolled in Medicaid. Medicaidclaims must include the OPRA Provider's National Provider Identifier (NPI).

The attending (ordering, referring and/or servicing) professional must be enrolled if the referring providerfield is blank on the institutional (8371) claim. This is because the attending provider is considered theordering/referring provider in the absence of a referring provider. If professionals are reported as theattending provider when they are the servicing provider only, the enrolled ordering/referring provider'sNPI is reported in the referring provider field on the claim.

Objective

The objective of this audit was to assess the Provider's adherence to applicable laws, regulations, rules,and policies governing the New York State Medicaid program and to identify claims where:

the OPRA provider NPI on the claim was not enrolled in Medicaid on the date of service; andthe OPRA provider NPI on the claim was excluded from Medicaid on the date of service.

Audit Scope

An audit of paid claims billed with a non-enrolled or excluded OPRA provider for payment dates includedin the period beginning January 1,2015 and ending December 31, 2018 was completed.

Please note that due to the implementation of the National Provider Identifier (NPI) on September 1,2008, there may be multiple Provider Identification Numbers associated with the Primary ProviderIdentification Number. The NP1 is linked to the Primary Provider Identification Number. The PrimaryProvider Identification Number is used for correspondence and recoupment.

Office of the Medicaid Inspector General 1


Audit Findings

OMIG issued a Draft Audit Report to the Provider on November 12, 2020 that identified $2,829.39 inMedicaid overpayments. The Provider's December 16, 2020 response to the Draft Audit Report statedthat the Provider is in agreement with the Draft Audit Report findings. As a result, the overpaymentsidentified in this Final Audit Report remain unchanged from those cited in the Draft Audit Report.

One or more of the following audit criteria resulted in an audit finding and overpayment determination,as outlined below and in the enclosed exhibit.

1. Claims Billed with a Non-Enrolled or Excluded OPRA Provider

By enrolling the provider agrees...to prepare and to maintain contemporaneous recordsdemonstrating its right to receive payment under the medical assistance program and to keep for aperiod of six years from the date the care, services or supplies were furnished, all records necessaryto disclose the nature and extent of services furnished and all information regarding claims forpayment submitted by, or on behalf of, the provider and to furnish such records and information,upon request, to the department, the Secretary of the United States Department of Health andHuman Services, the Deputy Attorney General for Medicaid Fraud Control and the New York StateDepartment of Health.

18 NYCRR 504.3(a)

By enrolling the provider agrees...that the information provided in relation to any claim for paymentshall be true, accurate, and complete.

18 NYCRR 504.3(h)

By enrolling, the provider agrees...to comply with the rules, regulations and official directives of thedepartment.

18 NYCRR 504.3(0

A person who is excluded from the program cannot be involved in any activity relating to furnishingmedical care, services or supplies to recipients of medical assistance for which claims are submittedto the program, or relating to claiming or receiving payment for medical care, services or suppliesduring the period.

18 NYCRR 515.5(c)

An overpayment includes any amount not authorized to be paid under the medical assistanceprogram, whether paid as the result of inaccurate or improper cost reporting, improper claiming,unacceptable practices, fraud, abuse or mistake.

18 NYCRR 518.1(c)

The State Medicaid agency must require all ordering or referring physicians or other professionalsproviding services under the State plan or under a waiver of the plan to be enrolled asparticipating providers.

42 CFR 455.410(b)

Physicians and other healthcare professionals ordering/referring services provided under the stateplan or under a waiver of the state plan must enroll in Medicaid.

Medicaid Update July 2013Medicaid Update December 2013



Exhibit A is a list of claims billed with a non-enrolled or excluded OPRA provider. As a result, OMIG hasdetermined that $2,528.34 was inappropriately billed to Medicaid, resulting in Medicaid overpayments.

Pursuant to 18 NYCRR Parts 517 and 518, OMIG, on behalf of DOH, may recover such overpayments.In accordance with 18 NYCRR Section 518.4, interest may be collected on any overpayments identifiedin this audit and wil l accrue at the current rate f rom the date of the overpayment. Interest on theoverpayments identif ied in this Draft Audit Report was calculated from the date of each overpaymentthrough the date of the Draft Audit Report, using the Federal Reserve Prime Rate. For the overpaymentsidentif ied in this audit, OMIG has determined that accrued interest of $301.05 (Exhibit A) is now owed.

Based on this determination, the total amount due to DOH, as defined in 18 NYCRR Section 518.1, is$2,829.39 (Exhibit A), including interest to date.

Do not submit claim voids or adjustments in response to this Final Audit Report. Repaymentinstructions are outlined on the next page.



Repayment Options

In accordance with 18 NYCRR Part 518, which regulates the collection of overpayments, yourrepayment options are described below.

Option #1: Make a full payment by check, money order, or OMIG's Online Payment Portal within 20days of the date of the Final Audit Report.

The check should be made payable to the New York State Department of Health, shouldinclude the audit number on the memo line, and be mailed with the attached remittanceadvice to:

New York State Office of the Medicaid Inspector GeneralBureau of Collections Management

800 North Pearl StreetAlbany, New York 12204

If you elect to pay electronically through OMIG's Online Payment Portal, please visithttps://omig.ny.gov/online-payment-portal or contact OMIG's Bureau of CollectionsManagement by telephone or email, at the above number or address.

Option #2: Enter into a repayment agreement with OMIG. If your repayment terms exceed 90 daysfrom the date of the Final Audit Report, recoveries of amounts due are subject to interest charges atthe prime rate plus 2%. OMIG's acceptance of a repayment agreement is based on your repaying theMedicaid overpayment as agreed. OMIG will adjust the rate of recovery, or require payment in full, ifyour unpaid balance is not being repaid as agreed. If you wish to enter into a repayment agreement,please contact the Bureau of Collections Management within 20 days, by telephone or email, asprovided above.

Should you fail to select a payment option above within 20 days of the date of this Report, OMIG willinitiate recoupment by withholding all or a part of your payments otherwise payable, in accordance with18 NYCRR 518.6. Additionally, OMIG reserves the right to use any remedy allowed by law to collectthe amount due. Pursuant to the State Finance Law Section 18(5), a collection fee equal to twenty twopercent (22%) of the amount due, including interest, may be added to the amount owed.



Hearing Rights

The Provider has the right to challenge this action and determination by requesting an administrativehearing within sixty (60) days of the date of this notice. In accordance with 18 NYCRR Section519.18(a), "The issues and documentation considered at the hearing are limited to issues directlyrelating to the final determination. An appellant may not raise issues regarding the methodology usedto determine any rate of payment or fee, nor raise any new matter not considered by the departmentupon submission of objections to a draft audit or notice of proposed agency action."

If the Provider wishes to request a hearing, the request must be submitted in writing within sixty (60)days of the date of this notice to:

General CounselNew York State

Office of the Medicaid Inspector GeneralOffice of Counsel


Questions regarding the request for a hearing should be directed to Office of Counsel, at

If a hearing is held, the Provider may have a person represent it or the Provider may represent itself. Ifthe Provider chooses to be represented by someone other than an attorney, the Provider must supplyalong with its hearing request a signed authorization permitting that person to represent the Provider atthe hearing; the Provider may call witnesses and present documentary evidence on its behalf.

For a full listing of hearing rights please see 18 NYCRR Part 519.



Contact Information

Office Address:

New York StateOffice of the Medicaid Inspector General

Division of Systems Utilization and Review800 North Pearl Street

Albany, New York 12204

Mission

The mission of the Office of the Medicaid Inspector General is to enhance the integrity of the New YorkState Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices withinthe Medicaid program and recovering improperly expended Medicaid funds while promoting high qualitypatient care.

Vision

To be the national leader in promoting and protecting the integrity of the Medicaid program.


I N E WYORKSTATE

Office of theMedicaid InspectorGeneral

REMITTANCE ADVICE

Upper Room AIDS Ministry, Inc.306 Lenox AvenueNew York, New York 10027

Amount Due: $2,829.39

Provider ID #: 01741726

Audit #: 2020Z67-031B

AuditType

I=1Managed Care

Fee-for-Service

El Rate

Checklist

1. To ensure proper credit, please enclose this form with your check.

2. Make checks payable to: New York State Department of Health.

3. Record the audit number on your check.

4. Mail the check to:

New York State Office of the Medicaid Inspector GeneralBureau of Collections Management


If you elect to pay electronically through OMIG's Online Payment Portal, please visithttps://omig.ny.gov/online-payment-portal or contact OMIG's Bureau of Collections Managementby telephone or email, at the above number or address.

upper room aids ministry, inc

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