D.C. Mun. Regs. tit. 29, r. 29-9012

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-9012 - COST REPORTS, AUDITS, AND OVERSIGHT MONITORING

9012.1

Each Waiver provider of day habilitation, in-home supports, individualized day supports, respite, employment readiness, and supported employment services shall report costs to DHCF no later than ninety (90) days after the end of the provider's cost reporting period, which shall correspond to the fiscal year used by the provider for all other financial reporting purposes, unless DHCF has approved an exception, on request. Such cost reporting will be for the purpose of informing rate setting parameters to be the most cost-effective for the government and to reimburse allowable costs for the providers. All cost reports shall cover a twelve (12) month cost reporting period.

9012.2

A cost report that is not completed shall be considered an incomplete filing, and DHCF shall notify the waiver provider within thirty (30) days of the date on which DHCF received the incomplete cost report.

9012.3

All of the facility's accounting and related records, including the general ledger and records of original entry, and all transaction documents and statistical data, shall be permanent records and be retained for a period of not less than five (5) years after the filing of a cost report.

9012.4

DHCF shall evaluate expenditures subject to the requirements in this Section through annual review of cost reports.

9012.5

DHCF, or its designee, shall review each cost report for completeness, accuracy, compliance, and reasonableness.

9012.6

Every five (5) years, for purposes of renewing the Waiver, DHCF shall rely on audited cost reports submitted by Waiver providers to DHCF. In the absence of audited cost reports, Waiver providers may submit unaudited costs reports or financial statements.

9012.7

DHCF, 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.

9012.8

The audit process shall be routinely conducted by DHCF to determine, by statistically valid scientific sampling, the appropriateness of services that are rendered to the IFS Waiver program beneficiaries and billed to Medicaid.

9012.9

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 the process for administrative review as outlined below:

(a) DHCF shall issue a Notice of Proposed Medicaid Overpayment Recovery (NPMOR), 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;

(b) The Provider shall have thirty (30) days from the date of the NPMOR to submit documentary evidence and written argument to DHCF against the proposed action;

(c) The documentary evidence and written argument shall include a specific description of the item to be reviewed, the reason for the request for review, the relief requested, and documentation in support of the relief requested;

(d) Based on review of the documentary evidence and written argument, DHCF shall issue a Final Notice of Medicaid Overpayment Recovery (FNMOR);

(e) Within fifteen (15) days of receipt of the FNMOR, the Provider may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings (OAH), 441 4th Street, NW, Suite 450 North, Washington, DC 20001; and

(f) Filing an appeal with the OAH shall not stay any action to recover any overpayment.

9012.10

The recoupment amounts for denied claims shall be determined by the following formula:

(a) A fraction shall be calculated with the numerator consisting of the number of denied paid claims resulting from the audited sample; and

(b) The denominator shall be the total number of paid claims from the audit sample. This fraction shall be multiplied by the total dollars paid by DHCF to the Provider during the audit period, to determine the amount recouped.

9012.11

All participant, personnel, and program administrative and fiscal records shall be maintained so that they are accessible and readily retrievable for inspection and review by authorized government officials or their agents, as requested.

9012.12

All records and documents required to be kept under this chapter and other applicable laws and regulations which are not maintained or accessible in the operating office visited during an audit shall be produced for inspection within twenty-four (24) hours, or within a shorter reasonable time if specified, upon the request of the auditing official.

9012.13

The failure of a provider to release or to grant access to program documents and records to the DHCF auditors in a timely manner, after reasonable notice by DHCF to the provider to produce the same, may constitute grounds to terminate

the Medicaid Provider Agreement, in accordance with the notice and process requirements set forth in 29 DCMR § 9400.

9012.14

DHCF shall retain the right to conduct audits or reviews at any time. Each waiver provider shall grant full access, during announced or unannounced on-site audits or review by DHCF, DHCF's designee, other District of Columbia officials, and representatives of the U.S. Department of Health and Human Services auditors, to relevant financial records, statistical data to verify costs previously reported to DHCF, program documentation, and any other documents relevant to the administration and provision of the Waiver service.

9012.15

As part of the audit process, providers shall grant access to any of the following documents to DHCF Program Integrity personnel, which may include, but are not limited to the following:

(a) A record of all service authorization and prior authorizations for services;

(b) A record for all request for change in services;

(c) A written staffing plan, if applicable;

(d) A schedule of the beneficiary's activities in the community, if applicable, including strategies to execute goals in the Individualized Service Plan, the date and time of the activities, and staff, as identified in the staffing plan;

(e) Any records relating to adjudication of claims, including, the number of units of the delivered service, the period during which the service was delivered and dates of service, and the name, signature, and credentials of the service provider;

(f) Progress notes, as described in 29 DCMR § 9006; and

(g) Any record necessary to demonstrate compliance with rules, requirements, guidelines, and standards for implementation and administration of the Waiver.

9012.16

DHCF's Long Term Care Administration's Waiver Oversight and Monitoring team shall conduct monitoring reviews as follows:

(a) Quarterly oversight and monitoring reviews to ensure compliance with established federal and District regulations and applicable laws governing the operations and administration of the Waiver Program; and

(b) Quarterly oversight and monitoring reviews to monitor progress and performance against quality measures.

9012.17

As part of the oversight monitoring process, providers shall grant access to any of the following documents to the DHCF monitor, which may include, but shall not be limited to the following:

(a) Programmatic records including Person-Centered Service Plan, Plan of Care/service delivery plan and documents supporting service delivery;

(b) Employee records including training records;

(c) A signed, current copy of the Medicaid Provider Agreement;

(d) Licensure information;

(e) Policies and procedures;

(f) Incident reports and investigation reports; and

(g) Complaint related reports.

D.C. Mun. Regs. tit. 29, r. 29-9012

Final Rulemaking published at 69 DCR 10229 (8/12/2022)