New York State Contract Reporter #RFP # OMIG 26-23

New York OMIG Home Health Care Medicare Appeals and Recovery Services

New York OMIG is seeking a contractor to recover Medicare payments for Medicaid-funded home health services and operate its Home Health Care Medicare Maximization program. - Buyer: New York State Office of the Medicaid Inspector General (OMIG), Division of Medicaid Audit, Bureau of Provider Audit; procurement administered by the Bureau of Budget and Fiscal Management. - Solicitation: RFP OMIG 26-23. No OEMs, commercial vendors, or manufacturers are named in the solicitation materials. - Services requested: Case analysis and selection; Medicare appeals and recovery; provider coordination and education; audits and demand-billing compliance monitoring; recovery reconciliation; reporting, recordkeeping, technology support, quality control, and administrative-proceeding support. - Expected workload: Approximately 1,700 cases annually and capacity for more than 100,000 claims annually. Claims are counted at the line level, with an expected six-month lookback; work may expand to Medicaid Managed Care. - Program scope: Appeals and coverage determinations for skilled nursing, home health aide, physical therapy, occupational therapy, speech-language pathology, and medical social services. OMIG will provide Medicaid-paid claims and related data semiannually in text-file format. - Notable requirements: At least five years of relevant organizational experience; qualified multidisciplinary staff, including medical professionals and legal staff with at least one New York-licensed attorney; work and data handling within the United States; annual SOC 1 and SOC 2 reports; and advance written OMIG approval for any AI use. - Provider support and recovery: Phone and email support during weekday business hours, with responses within 24 hours or as directed by OMIG. Compensation is tied to a fixed percentage of recovered funds; audit contingency fees currently apply to specified demand-billing and remittance failures. The contractor monitors the State-owned lockbox but cannot withdraw funds.

Description

The New York State Office of the Medicaid Inspector General seeks a contractor to provide Home Health Care Medicare Maximization Services under the direction of its Bureau of Provider Audit. The work supports Medicare coverage appeals for dual-eligible recipients whose home health services were paid by Medicaid, along with provider coordination, audits, and recovery activities. Responsibilities include data analysis and case selection, appeals processing, recovery support, reporting, provider education, and related operations. The contract term is three years, with two optional one-year extensions.

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