Section 29-4613. AUDITS AND REVIEWS

 

4613.1MAA shall perform ongoing audits, on-site visits, and reviews of MCOTT Programs to ensure that Medicaid payments are consistent with efficiency, economy and quality of care and in accordance with federal regulations governing Medicaid.

 

4613.2The review process shall be routinely conducted by MAA to determine, by statistically valid scientific sampling, the appropriateness of services rendered and billed to Medicaid.

 

4613.3If MAA determines that claims are to be denied, MAA shall recoup, by the most expeditious means available, those monics erroneously paid to the Provider for denied claims, following the period of Administrative Review set out in Section 4614 of this chapter.

 

4613.4The recoupment amounts for overpayments 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 amount of the paid claims of the Provider during the period being audited. This fraction multiplied by the total amount of the paid claims during the period audited shall be the amount recouped. For example, if a sample of one hundred (100) client service records are audited in which one thousand dollars ($ 1,000) were Medicaid-paid claims and ten (10) of those paid claims are denied from reimbursement, then ten percent (10%) of the amount paid, or one hundred dollars ($ 100), would be recouped from the Provider.

 

4613.5Each Provider shall agree to facilitate audits and reviews of its MCOTT Program(s) by maintaining the required records and by cooperating with the MAA authorized personnel assigned to perform audits and reviews. These personnel are bound by law to fully respect and abide by all protections of the law regarding confidentiality of client information.

 

4613.6The failure of a MCOTT provider to timely release or grant access to program documents and records to MAA auditors, after reasonable notice from MAA to the MCOTT provider to produce the same, shall constitute grounds to terminate the Provider agreement.

 

source

Final Rulemaking published at 46 DCR 6122 (July 23, 1999).