D.C. Mun. Regs. tit. 29, r. 29-809
Federal laws and regulations governing the Medicaid program mandate the ongoing conduct of audits and reviews by the state agency to detect and deter provider fraud and Medicaid patient misutilization and abuse. For the Department of Human Services, the Medical Assistance Division shall carry out these responsibilities.
The Surveillance and Utilization Review Branch (SUR) of the Medical Assistance Division, shall perform ongoing audits, on-site visits, and reviews to ensure that Medicaid payments are consistent with efficiency, economy, and quality of care.
The review process shall be routinely conducted to determine, by scientific sampling, the appropriateness of services rendered and billed to Medicaid.
The SUR shall conduct routine onsite audits and reviews of each participating FSMHC to ensure that the FSMHC records fully, accurately, and properly document the provision of appropriate services to Medicaid patients that were billed to Medicaid during the period covered by the audit.
Using a scientifically acceptable sampling technique, the SUR shall examine the medicaid patient records to determine whether or not services billed to Medicaid were appropriate and properly documented in the patient record. Questionable billings found shall be reviewed and discussed with the appropriate FSMHC staff for possible clarification and acceptance.
If SUR determines that billings are to be denied, the Department of Human Services shall recoup, by the most expeditious means available, those monies erroneously paid to the FSMHC for denied billings.
The recoupment amounts shall be determined by a formula by which a percentage shall be arrived at representing the relationship between the total billings from the FSMHC during the period being audited and the number of denied billings resulting from the audited sample which shall be applied to the total Medicaid dollars paid the FSMHC during the period covered by the audit and shall determine the dollar amount to be recouped. For example, if one hundred (100) records are audited in which one thousand (1,000) were billed to Medicaid and ten (10) of those billed services are denied for reimbursement, this represents a one percent (1%) denial rate. If during the period being audited, Medicaid paid the FSMHC ten thousand dollars ($10,000), one percent (1%), or one hundred dollars ($100) would be recouped.
A participating FSMHC shall agree to facilitate audits and reviews by maintaining the required records and by cooperating with the authorized personnel assigned to perform audits and reviews. These personnel are bound by law to fully respect and abide by all protections of the law regarding confidentiality.
All prospective FSMHC providers shall be informed that because there is federal financial participation in Medicaid payment, penalties on substantiated fraudulent activities are twenty-five thousand dollars ($25,000) fines, imprisonment up to five (5) years, or both.
D.C. Mun. Regs. tit. 29, r. 29-809