Section 29-1399. DEFINITIONS

 

1399.1For purposes of this chapter, the following terms shall have the meanings ascribed:

 

Abuse - the provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the program or in reimbursements for services that are not medically necessary or do not meet professionally recognized standards for health care. Abuse is characterized by, but not limited to, the presence of one (1) of the following conditions:

 

(a)The repeated submission of claims by a provider from which required material data is missing or incorrect. Examples include, but are not limited to, incorrect or missing procedure or diagnosis codes, incorrect mathemetical entries, and incorrect third party liability information;

 

(b)The repeated submission of claims by a provider which overstate the level or amount of health care provided;

 

(c)The repeated submission of claims by a provider for health care which is not reimbursable under the program, or the repeated submission of duplicate claims;

 

(d)Failure of a provider to develop and maintain patient care records which document the nature, extent, and evidence of the medical necessity of health care provided;

 

(e)Failure of a provider to use generally accepted accounting principles, or other accounting methods which relate entries on the medical or health care records to corresponding entries on the billing invoice, unless otherwise indicated by federal or District law or rules; or

 

(f)The repeated submission of claims by a provider for health care which is not medically necessary, of which is of unacceptable quality.

 

DHS - the Department of Human Services.

 

Director - the Director of the Department of Human Services.

 

Fraud - an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under the laws of the District of Columbia, Federal or State law.

 

HCFA - the Health Care Financing Administration of the U.S. Department of Health and Human Services.

 

Provider - an individual or entity furnishing Medicaid services under a provider agreement with DHS.

 

source

Final Rulemaking published at 31 DCR 3870 (August 3, 1984).