Section 29-4709. AUDITS AND REVIEWS

 

4709.1MAA shall perform ongoing audits to ensure that Medicaid payments are consistent with efficiency, economy and quality of care, and made in accordance with federal and District rules governing Medicaid.

 

4709.2The audit process shall be routinely conducted by MAA, to determine, by statistically valid scientific sampling, the appropriateness of services rendered and billed to Medicaid by CFSA.

 

4709.3If MAA determines that claims are to be denied, MAA shall recoup, by the most expeditious means available, those monies erroneously paid to CFSA for denied claims, following the period of Administrative Review set forth in section 4710 of these rules.

 

4709.4The recoupment amount for denied claims shall be determined by the following formula: A fraction shall be calculated with the numerator consisting of the number of denied claims from the audit 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 Medicaid to CFSA during the audit period, to determine the amount recouped. For example, if CFSA 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 10 claims out of 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.

 

4709.5MAA shall issue a Notice of Recoupment (NR) to CFSA, which sets forth the reasons for the recoupment, the amount to be recouped, and the procedures for requesting an administrative review.

 

source

Emergency Rulemaking published at 47 DCR 5257 (June 23, 2000) [EXPIRED]; as amended by Final Rulemaking published at 47 DCR 7084 (September 1, 2000).