3012.1 This Section sets forth the requirements for audits and reviews of FSMHC services and provider records. The Department, DHCF, and the D.C. Office of the Inspector General Medicaid Fraud Control Unit, among other entities, may conduct audits and reviews of FSMHC operations, including billing and treatment. The Department and DHCF shall perform regular audits of FSMHC providers to ensure that payments are consistent with efficiency, economy, quality of care, and are made in accordance with Federal and District conditions of payment, including programmatic duties, documentation, and reimbursement requirements under this chapter.
3012.2 The audit process shall utilize statistically valid sampling methods when the audit is based on claims sampling. The audit process may review all claims by type, time-period, and/or other criteria established by the Department, DHCF, or other entities. Statistically valid and commonly accepted standards methods for calculating overpayments will be followed.
3012.3 If DHCF or the Department denies a Medicaid claim during an audit, DHCF or the Department 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 and the Department shall issue a joint 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 FSMHC 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 FSMHC may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings (OAH), 441 4th Street, N.W., Suite 450 North, Washington, D.C. 20001; and(f) Filing an appeal with the OAH shall not stay any action to recover any overpayment.3012.4 If DHCF or the Department denies a locally-funded claim during an audit, DHCF or the Department 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) The Department shall issue an overpayment demand letter which sets forth the reasons for the recoupment, including specific reference to the particular sections of the statute, rule, or provider agreement, the amount to be recouped and the procedures for requesting an Administrative review;(b) The FSMHC shall have thirty (30) days from the date of the demand letter to request an Administrative Review and submit documentary evidence and written argument to DBH 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) The Department shall conduct an Administrative Review conducted by a group of independently licensed clinicians who have not previously examined the claims under review. The DBH Director will then make a final determination regarding the claims under review;(e) The Department shall mail a written determination relative to the Administrative Review not later than ten (10) days from the date of the written request for review. Any recoupment remaining after the Administrative Review will begin thirty (30) days following the date of the written determination;(f) Within fifteen (15) days of receipt, the FSMHC may appeal the written determination by filing a written notice of appeal with OAH; and(g) Filing an appeal with the OAH shall not stay any action to recover any overpayment.3012.5 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. DHCF or the Department shall retain the right to conduct announced or unannounced audits or reviews at any time and audits or reviews.
3012.6 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.
3012.7 The failure of a provider to release or to grant access to program documents and records to auditors in a timely manner, after reasonable notice by DHCF or the Department to the provider to produce the same, shall constitute grounds to terminate the Medicaid Provider Agreement. This provision in no way limits DHCF's ability to terminate any Medicaid Provider Agreement for any other reason, or for the Department to terminate an HCA for any other reason.
3012.8 As part of the audit process, providers shall grant access to necessary records to verify compliance with certification standards and conditions of payment, including but not limited:
(a) FSMHC financial records;(b) Statistical data to verify costs previously reported;(c) Program documentation;(d) A record of all service authorization and prior authorizations for services;(e) A record for all request for change in services;(f) Any records listed in §§ 3008 and 3009 in addition to any other records relating to the 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(s); and(g) Any record necessary to demonstrate compliance with rules, requirements, guidelines, and standards for implementation and administration of FSMHC services.3012.9 Nothing in this rule affects a provider's independent legal obligation under this chapter and Federal and District law to implement and enforce an internal auditing program that self-identifies overpayments and reimburses DHCF or other payers within sixty (60) days of discovery.
D.C. Mun. Regs. r. 22-A3012
Final Rulemaking published at 67 DCR 11929 (10/16/2020)