D.C. Mun. Regs. tit. 29, r. 4255
The DHCF's Division of Program Integrity shall perform ongoing audits to ensure that the provider's services for which Medicaid payments are made are consistent with programmatic duties, documentation, and reimbursement requirements as required under this chapter.
The audit process shall be routinely conducted by DHCF to determine, by statistically valid scientific sampling, the appropriateness of services rendered to EPD Waiver program beneficiaries and billed to Medicaid.
Each EPD Waiver provider shall allow access, during an on-site audit or review (announced or unannounced) by DHCF, other District of Columbia government officials, and representatives of the United States Department of Health and Human Services, to relevant records and program documentation.
The failure of a provider to timely release or to grant access to program documents and records to the DHCF auditors, after reasonable notice by DHCF to the provider to produce the same, shall constitute grounds to terminate the Medicaid Provider Agreement.
If DHCF denies a claim during an audit, DHCF shall recoup, by the most expeditious means available, those monies erroneously paid to the provider for denied claims, following notice and the period of Administrative Review set forth in Subsection 4255.7 of this chapter.
The recoupment amounts for denied claims during audits shall be determined by the following formula:
In accordance with the formula referenced in Subsection 4255.6, DHCF would recoup ten percent (10%) of the amount reimbursed by Medicaid during the audit period, or one thousand dollars ($1000), if a provider received Medicaid reimbursement of ten thousand dollars ($10,000) during the audit period, and during a review of the claims from the audited sample, it was determined that ten (10) claims out of one hundred (100) claims are denied.
DHCF shall issue a Notice of Proposed Recovery for Medicaid Overpayment (NPRMO) which sets forth the reasons for the recoupment, including the specific reference to the particular sections of the statute, rules, or Provider agreement, the amount to be recouped, and the procedures for requesting an administrative review.
The timelines for responding to the NPRMO and the provider's appeal rights are governed by Section 4256.
The DHCF's Long Term Care Administration's EPD Waiver Oversight and Monitoring team shall conduct two (2) types of reviews as follows :
Each waiver services provider shall allow the EPD Waiver oversight and monitoring team access, during an on-site oversight/monitoring process (announced or unannounced).
As part of the oversight and monitoring process, providers shall grant access to any of the following documents, which may include, but shall not be limited to the following:
DHCF's EPD Waiver Oversight and Monitoring Team shall issue a Statement of Findings and Opportunities for Improvement Plan ("improvement plan") within fifteen (15) calendar days of the annual oversight and monitoring exit meeting. Providers shall subsequently submit a plan of correction within fifteen (15) calendar days of the date of receipt of DHCF's improvement plan.
DHCF's EPD Waiver Oversight and Monitoring team shall ge nerate a performance measures discovery/remediation report ("remediation report") within five (5) business days of completion of the quarterly performance measures-related review. Providers shall subsequently submit a performance measures-related remediation plan ("remediation plan") within ten (10) business days of receipt of the report.
The failure to provide an acceptable plan of correction, remediation plan or adherence to the improvement plan or remediation report may result in alternative sanctions such as a prohibition of new admissions and referral to the DHCF's Division of Program Integrity for further investigation.
D.C. Mun. Regs. tit. 29, r. 4255