175.998 Fraud and Abuse Audit Control Activities:
MSSNY is cognizant of the realities surrounding health insurance audit and utilization review activities to ensure justifiable expenditures of private or public funds for claimed medical services. The Society is, nevertheless, deeply concerned by reports of inappropriate and inequitable Medicaid fraud and abuse investigations in New York State.
MSSNY asserts that any such fraud and abuse investigations motivated by established recoupment targets and bonus incentives by investigating state and federal entities is highly unethical, immoral, and contrary to the principles of fairness that are inherent in the American administrative and judicial system, and that have come to be rightfully expected by the medical community and the public at large. In acknowledging that not all individuals seek to fulfill the highest aspirations of their particular professions, MSSNY believes that any such individuals in medical practice who subscribe to substandard principles of medicine and ethics in interacting with health insurance programs should be treated accordingly. However, since MSSNY is confident that such practitioners comprise a decided minority of the state’s medical community, the Society logically expects the New York State Department of Social Services (NYSDSS) Fraud and Abuse/Audit Control Divisions, the New York State Attorney General’s Office, and the Office of the Inspector General to conduct legitimate Medicaid fraud and abuse investigation in an ethical and moral manner that ensures: (1) Equitable and meaningful due process for those medical professionals whose services are under review or investigation; (2) Appropriate classification of Medicaid audits so that cases basically involving the following are not unduly labeled as fraudulent activities and, thus, pursued accordingly: (a) Lack of adequate documentation of services; (b) Simple billing irregularities; or (c) Other billing errors (3) Physician safeguards against occurrences of unwarranted prosecutions by investigating agencies through: (a) Utilization of medical experts to corroborate substandard medical practices and justify Medicaid investigations; (b) Provision of pertinent guidelines to physicians for proper conformance with Medicaid requirements; (4) Retention of sufficient physician participation in the Medicaid program to guarantee access to quality health care for medically needy recipient (5) Physician immunity against harassment and victimization by overzealous reviewers to the detriment of their well-being, community standing, and professional careers; with such reviewers being answerable for their unwarranted actions; (6) Physician immunity against undue harassment and pursuit by reviewers on the basis of state budgetary constraints or bureaucratically devised recoupment targets and bonus plan incentives; (7) Physician entitlement to reasonable compensation by the investigating state or federal agencies for legal costs incurred by exonerated practitioners for compelled involvement in arbitrary fraud and abuse or audit control activities. In summary, it is the position of the Medical Society of the State of New York that no medical practitioner in the State of New York be subjected to the traumatic, intimidating and career-threatening activities of state and federal agencies, or any other health insurance entities, unless there is absolute and unimpeachable evidence of serious wrongdoing to warrant such focused pursuit. (Council 1/31/91; Reaffirmed HOD 2014; Reaffirmed HOD 2024)
