D.C. Mun. Regs. tit. 29, r. 29-5221

Current through Register 71, No. 45, November 7, 2024

Rule 29-5221 - AUDITS AND REVIEWS

5221.1

This section sets forth the requirements for audits and reviews of MHRS services. DHCF, or its designee, shall perform regular audits of MHRS providers to ensure that Medicaid payments are consistent with efficiency, economy, and quality of care, and made in accordance with Federal and District conditions of payment. The audits shall be conducted at least annually and when necessary to investigate and maintain program integrity.

5221.2

DHCF, or its designee, shall perform routine audits of claims, by statistically valid scientific sampling, to determine the appropriateness of MHRS services rendered and billed to Medicaid to ensure that Medicaid payments can be substantiated by documentation that meets the requirements set forth in this rule, and made in accordance with Federal and District rules governing Medicaid.

5221.3

The audit process shall utilize statistically valid sampling methods to ensure that a statistically valid sample is drawn 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 DHCF or other entities. Statistically valid and commonly accepted methods for calculating overpayments will be followed. 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 that includes a copy of the FNMOR 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 an overpayment.

5221.4

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 shall retain the right to conduct scheduled and unscheduled audits or reviews.

5221.5

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.

5221.6

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, 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.

5221.7

As part of the audit process, documents providers shall grant access to may include, but are not limited to the following:

(a) Relevant 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 § 5219 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 MHRS services.

5221.8

Nothing in this rule effects a provider's independent legal obligation under this Chapter and Federal and District law to self-identify overpayments and repay within sixty (60) days of discovery.

D.C. Mun. Regs. tit. 29, r. 29-5221

Final Rulemaking published at 69 DCR 12836 (10/21/2022)