Section 29-4236. PROGRAM SERVICES:CHORE AIDE SERVICES

 

4236.1The MAA shall perform ongoing audits to ensure that the provider's services for which Medicaid payments are made are consistent with efficiency, economy, quality of care, and made in accordance with federal and District rules governing Medicaid.

 

4236.2The audit process shall be routinely conducted by MAA to determine, by statistically valid scientific sampling, the appropriateness of services rendered and billed to Medicaid and that services were only rendered to Medicaid-eligible individuals.

 

4236.3Each provider of waiver services shall allow access, during an on-site audit or review (announced or unannounced) by MAA, other District of Columbia government officials, and representatives of the United States Department of Health and Human Services, to relevant records and program documentation.

 

4236.4The failure of a provider to timely release or to grant access to program documents and records to the MAA auditors, after reasonable notice by MAA to the provider to produce the same, shall constitute grounds to terminate the provider agreement.

 

4236.5If MAA denies a claim, MAA shall recoup, by the most expeditious means available, those monies erroneously paid to the provider for denied claims, following the period of Administrative Review set forth in § 4237.5 of this chapter.

 

4236.6The recoupment amounts for denied claims shall be determined by the following formula: A fraction will be calculated with the numerator consisting of the number of denied paid claims resulting from the audited sample. The denominator shall be the total number of paid claims from the audit sample. This fraction will be multiplied by the total dollars paid by MAA to the provider during the audit period to determine the amount recouped. For example, if a provider received Medicaid reimbursement of ten thousand dollars ($10,000) during the audit period, and during a review of the claims from the audited sample, it was determined that ten (10) claims out of one hundred (100) claims are denied, then ten percent (10%) of the amount reimbursed by Medicaid during the audit period, or one thousand dollars ($1000), would be recouped.

 

4236.7The MAA shall issue a Notice of Recoupment (NR), 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.

 

source

Final Rulemaking published at 50 DCR 9025 (October 24, 2003).