N.Y. Public Health Law § 32: Functions, duties and responsibilities

§ 32. Functions, duties and responsibilities. The inspector shall have

the following functions, duties and responsibilities:

1. to appoint such deputies, directors, assistants and other officers

and employees as may be needed for the performance of his or her duties

and may prescribe their duties and fix their compensation within the

amounts appropriated therefor;

2. to conduct and supervise activities to prevent, detect and

investigate medical assistance program fraud and abuse amongst the

following: the department; the offices of mental health, alcoholism and

substance abuse services, temporary disability assistance, and children

and family services and the office for people with developmental

disabilities;

3. to coordinate, to the greatest extent possible, activities to

prevent, detect and investigate medical assistance program fraud and

abuse amongst the following: the department; the offices of mental

health, alcoholism and substance abuse services, temporary disability

assistance, and children and family services and the office for people

with developmental disabilities; the commission on quality of care and

advocacy for persons with disabilities; the department of education; the

fiscal agent employed to operate the medical assistance information and

payment system; local governments and entities; and to work in a

coordinated and cooperative manner with, to the greatest extent

possible, the deputy attorney general for Medicaid fraud control; the

welfare inspector general, federal prosecutors, district attorneys

within the state, the special investigative unit maintained by each

health insurer operating within the state, and the state comptroller;

4. to solicit, receive and investigate complaints related to fraud and

abuse within the medical assistance program;

5. to keep the governor, attorney general, state comptroller,

temporary president and minority leader of the senate, the speaker and

the minority leader of the assembly, and the heads of agencies with

responsibility for the administration of the medical assistance program

apprised of efforts to prevent, detect, investigate, and prosecute fraud

and abuse within the medical assistance program, and to provide a

quarterly briefing to the legislature on activities of the office;

6. to pursue civil and administrative enforcement actions against any

individual or entity that engages in fraud, abuse, or illegal or

improper acts or unacceptable practices perpetrated within the medical

assistance program, including but not limited to: (a) referral of

information and evidence to regulatory agencies and licensure boards;

(b) withholding payment of medical assistance funds in accordance with

state and federal laws and regulations; (c) imposition of administrative

sanctions and penalties in accordance with state and federal laws and

regulations; (d) exclusion of providers, vendors and contractors from

participation in the program; (e) initiating and maintaining actions for

civil recovery and, where authorized by law, seizure of property or

other assets connected with improper payments; and entering into civil

settlements; and (f) recovery of improperly expended medical assistance

program funds from those who engage in fraud or abuse, or illegal or

improper acts perpetrated within the medical assistance program. In the

pursuit of such civil and administrative enforcement actions under this

subdivision, the inspector shall consider the quality and availability

of medical care and services and the best interest of both the medical

assistance program and recipients;

6-a. to post on the department's internet website, within reasonably

prompt fashion, all final administrative determinations issued by

administrative law judges in connection with any actions taken by the

office pursuant to this title;

7. to make information and evidence relating to suspected criminal

acts which he or she may obtain in carrying out his or her duties

available to appropriate law enforcement officials and to consult with

the deputy attorney general for Medicaid fraud control, the welfare

inspector general, and other state and federal law enforcement officials

for coordination of criminal investigations and prosecutions.

The inspector shall refer suspected fraud or criminality to the deputy

attorney general for Medicaid fraud control and make any other referrals

to such deputy attorney general as required or contemplated by federal

law. At any time after such referral, with ten days written notice to

the deputy attorney general for Medicaid fraud control or such shorter

time as such deputy attorney general consents to, the inspector may

additionally provide relevant information about suspected fraud or

criminality to any other federal or state law enforcement agency that

the inspector deems appropriate under the circumstances;

8. to subpoena and enforce the attendance of witnesses, administer

oaths or affirmations, examine witnesses under oath, and take testimony;

9. to require and compel the production of such books, papers, records

and documents as he or she may deem to be relevant or material to an

investigation, examination or review undertaken pursuant to this

section;

10. to examine and copy or remove documents or records of any kind

related to the medical assistance program or necessary for the inspector

to perform its duties and responsibilities that are prepared, maintained

or held by or available to any state agency or local governmental entity

the patients or clients of which are served by the medical assistance

program, or which is otherwise responsible for the control of fraud and

abuse within the medical assistance program; provided, however, that any

such information be afforded confidentiality protection as provided for

under state and federal law. The removal of records shall be limited to

those circumstances in which a copy thereof is insufficient for an

appropriate legal or investigative purpose, provided that in such

instances the copying and return of such original, or copy where the

original is required for an appropriate legal or investigative purpose,

is expedited and such original or copy is readily accessible in

accordance with the care and treatment needs of the patient,

11. to recommend and implement policies relating to the prevention and

detection of fraud and abuse; provided however, that the consent of the

attorney general shall be obtained prior to the implementation of any

policy that shall affect the operations of the office of the attorney

general;

12. to monitor the implementation of any recommendations made by the

office to agencies or other entities with responsibility for

administration of the medical assistance program;

13. to prepare cases, provide testimony and support administrative

hearings and other legal proceedings;

14. to review and audit contracts, cost reports, claims, bills and all

other expenditures of medical assistance program funds to determine

compliance with applicable federal and state laws and regulations and

take such actions as are authorized by federal or state laws and

regulations;

15. to work with the fiscal agent employed to operate the Medicaid

management information system to optimize the system;

16. to work in a coordinated manner with relevant agencies in the

implementation of information technology relating to the prevention and

identification of fraud and abuse in the medical assistance program,

including the surveillance utilization review system and other automated

systems pursuant to paragraph (b) of subdivision eight of section three

hundred sixty-seven-b of the social services law;

17. to conduct educational programs for medical assistance program

providers, vendors, contractors and recipients designed to limit fraud

and abuse within the medical assistance program;

18. to, in conjunction with the commissioner, develop protocols to

facilitate the efficient self-disclosure and collection of overpayments

and monitor such collections, including those that are self-disclosed by

providers. The provider's good faith self-disclosure of overpayments may

be considered as a mitigating factor in the determination of an

administrative enforcement action;

19. to receive and to investigate complaints of alleged failures of

state and local officials to prevent, detect and prosecute fraud and

abuse in the medical assistance program;

20. to, consistent with provisions of this title, implement and amend,

as needed, rules and regulations relating to the prevention, detection,

investigation and referral of fraud and abuse within the medical

assistance program and the recovery of improperly expended medical

assistance program funds;

21. to conduct, in the context of the investigation of fraud and

abuse, on-site facility and office inspections;

22. to take appropriate actions to ensure that the medical assistance

program is the payor of last resort;

23. to annually submit a budget request, for the ensuing state fiscal

year, to the division of the budget, provided that the office's budget

request shall not be subject to review, alteration or modification by

the commissioner or any other entity or person prior to its submission

to the division of the budget;

24. to meet quarterly with representatives of social services

districts to discuss the status of ongoing cooperative efforts between

the office of Medicaid inspector general and districts, including

demonstration programs authorized pursuant to section five-a of part C

of chapter fifty-eight of the laws of two thousand five, the potential

for additional collaboration and/or for improved or innovative

techniques to be employed, and any issues of concern to such districts

with respect to the prevention and detection of fraud and abuse in the

medical assistance program;

25. to request submission of social services districts annual budget

and audit workplans for purposes of planning for and executing the

county demonstration program and for the creation of the office's annual

workplan and to include in the office's annual workplan a description of

activities that will be conducted in collaboration with social services

districts;

26. to develop training materials with respect to the office's audit

standards and criteria for identifying fraud or waste, for use by social

services districts who are engaged with the office in demonstration

programs or other collaborative efforts; and

27. to perform any other functions that are necessary or appropriate

to fulfill the duties and responsibilities of the office in accordance

with federal and state law.