BRG Healthcare Compliance & Ethics Leadership Forum Stakeholder Expectations: The New York Medicaid Program

Tom: Brett, thanks for carving out time for our conversation. What is the role of the New York Office of the Medicaid Inspector General, and how has it evolved?

Brett: From a leadership standpoint in compliance program standards, New York is one of the few states with a mandatory compliance program requirement for the vast majority of healthcare providers, including managed care plans.

About fifteen years ago, the New York State Legislature passed the Social Services Law, Section 363-D, requiring the establishment of compliance programs. That mandate affords OMIG unique and significant authority for compliance oversight
of New York’s Medicaid program.

When I stepped into a State Medicaid role in 2019, I could see that the relationship between OMIG and the larger Medicaid program needed nurturing. In my role, we developed stronger alignment and initiated forward-looking conversations on topics like Medicaid system interoperability, big data, and artificial intelligence to address long-term program integrity operations.

Tom: With the benefit of your experience at the State, how would you compare OMIG to the US Department of Health and Human Services Office of Inspector General (OIG)?

Brett: Like the OIG, which works to promote efficiency and dissuade fraud and abuse, OMIG works to protect the integrity of the Medicaid system in New York. The OMIG communicates expectations and standards, which helps create structure
for healthcare providers that are required to comply with the State’s compliance program. This didn’t happen overnight, but when you think about where New York State was fifteen to twenty years ago regarding prioritizing compliance, the State
has made tremendous progress, largely due to OMIG’s vision and initiatives.

OMIG has also continued to evolve its thinking around compliance program efficacy in a way that has helped to improve healthcare in New York. This flexibility has resulted in the organization providing better guidance and a focus on quality.

Tom: There is no question that it is crucial to focus on the continuum among compliance, ethics, and quality of care. Failure to understand the nexus between those three pillars will inevitably undermine a program’s efficacy.

Tom: OMIG’s work certainly underscores the need for robust compliance, ethics, and quality of care programs. Quite apart from the reporting lines of the roles, what is the optimal relationship between the chief compliance officer and general counsel, and how should they work together and collaborate to create enterprise value?

Brett: Tom, that is a great question. They are two very different leadership roles. Both focus on risk assessment and mitigation: one from a compliance perspective, the other from a legal perspective.

In response to your question about what the relationship should look like, it’s important to ensure these leaders are aligned on the appropriate approach for risk mitigation and risk assessment, while respecting their respective core responsibilities.

Tom: I agree with you. Irrespective of where these functions reside in an organization, a certain dynamic tension coalesces to create enterprise value when an organization’s compliance officer and general counsel are collaborating effectively.

Tom: How critical are underlying cultural values, tone at the top, and governance and oversight in determining program effectiveness?

Brett: Organizational compliance issues often stem from boards lacking expertise to hold leadership accountable for compliance. Almost everything you need to know about the health of a compliance program can be learned by observing
the relationship between the compliance officer and the chair of the board committee responsible for compliance oversight. Effective compliance requires a dedicated board committee overseeing compliance and a strong working relationship
between the compliance officer and the committee chair; this connection is crucial for establishing the right culture and tone at the top.

Recently, we’ve seen the pendulum swing back a little, with some organizations looking to consolidate compliance functions within other committee charters, such as audit or quality. But having a clear and fulsome, dedicated, and chartered oversight responsibility conveys the importance of compliance to the organization and enables the compliance officer to tackle difficult issues with confidence and without fear of retribution.