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DEPARTMENT OF HEALTH CARE FINANCE
NOTICE OF PROPOSED RULEMAKING
The Director of the Department of Health Care Finance (DHCF), pursuant to the
authority set forth in An Act to enable the District of Columbia to receive federal
financial assistance under Title XIX of the Social Security Act for a medical assistance
program, and for other purposes approved December 27, 1967 (81 Stat.774; D.C. Official Code § 1-307.02 (2006 Repl.)) and section 6(6) of the Department of Health Care Finance
Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6)(2008 Repl.)), hereby gives notice of the intent to adopt an amendment to chapter 50, Medicaid Reimbursement for Personal Care Services, of title 29, Public Welfare, of the District of Columbia Municipal Regulations (DCMR).
Personal care aide (PCA) services are basic health-related services that are provided by unskilled health care professionals to individuals who require services that range from bathing to meal preparation. These proposed rules will amend the previously published rules by requiring a preexisting relationship between beneficiaries and their primary care physicians or advanced practice registered nurses before a PCA prescription for services can be provided; expanding the opportunity of providing PCA services to individuals associated with Medicaid beneficiaries who are not family members; setting standards for staffing agencies that contract with home health agencies for the delivery of PCA services; expanding the requirements governing National Provider Identification (NPI) numbers in conjunction with the new federal standards; and amending the notice requirement for discharges to comply with federal and District law governing advance notice.
The Director also gives notice of the intent to take final rulemaking action to adopt this proposed rule in not less than thirty (30) days form the date of publication of this notice in the D.C. Register.
Chapter 50, MEDICAID REIMBURSEMENT FOR PERSONAL CARE SERVICES, of Title 29, PUBLIC WELFARE, of the DCMR is deleted in its entirety and replaced to read as follow:
CHAPTER 50 MEDICAID REIMBURSEMENT FOR PERSONAL CARE SERVICES
5000 GENERAL PROVISIONS
5000.1 These rules establish the standards and conditions of participation for home health agencies providing personal care services (Provider) under the District of Columbia Medicaid Program (Medicaid Program).
5000.2 The provisions shall be in support and furtherance of the following goals:
(a) To provide necessary hands-on personal care assistance with the activities of daily living that assist a beneficiary to safely reside in the home; and
(b) To encourage home-based care as a preferred and cost-effective alternative to institutional care.
5000.3 A Provider receiving reimbursement for personal care services shall be a home health agency and meet the conditions of participation for home health agencies set forth in Sections 1861(o) and 1891(e) of the Social Security Act and 42 CFR 484; shall be enrolled as a Medicare Provider; and shall comply with the requirements set forth in the Health-Care and Community Residence Facility Act, Hospice and Home-Care Licensure Act of 1983, effective Feb. 24, 1984 (D.C. Law 5-48; D.C. Official Code, §§ 44-501, et seq. (2005 Repl.; 2011 Supp.)), and implementing rules.
5000.4 An applicant seeking to participate as a personal care services Provider under the Medicaid Program shall submit a Medicaid Home Health Provider enrollment application to the Department of Health Care Finance (DHCF).
5000.5 Each Provider application shall contain, but not be limited to, the following:
(a) Name and address of the applicant’s organization and location of the applicant’s place of business. An applicant shall submit a separate application for each place of business from which the applicant intends to offer District of Columbia Medicaid program services;
(b) Answers to meet requirements as set forth in 42 C.F.R. § 455, subpart b: Disclosure of Information by Providers and Fiscal Agents;
(c) Names of all individuals providing personal care services, license numbers and National Provider Identifier (NPI) numbers from the National Plan and Provider Enumeration System (NPPES) as of the date of the application to become a District of Columbia Medicaid Provider;
(d) The applicant’s U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Medicare Supplier Letter issued pursuant to 42 C.F.R. § 424.510 to evidence enrollment of the applicant in the Medicare program;
(e) A copy or copies of all contracts held between the applicant and any staffing agency pertaining to the delivery of personal care services;
(f) A copy or copies of license(s) held by the employees of any staffing agency or agencies used by the Provider for the delivery of personal care services;
(g) The applicant’s NPI number as required by the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191);
(h) A copy of the applicant’s surety bond, pursuant to requirements set forth in §5002.2 of this title; and
(i) A copy of a Certificate of Registration or Certificate of Authority, if required by Title 29 of the D.C. Official Code.
5000.6 A Provider shall submit a new Medicaid Provider enrollment application within thirty (30) days after any change in business ownership. Re-enrollment or continued enrollment in the Medicaid program after any change in business ownership shall be conditioned upon the Provider’s compliance with all applicable Federal and District requirements.
5000.7 A Provider shall submit a new Medicaid Provider enrollment application and successfully re-enroll in the D.C. Medicaid program at least every five (5) years from the date of its most recent enrollment or reenrollment.
5001 STAFFING AGENCIES
5001.1 A Provider may contract with a licensed staffing agency that will perform personal care services not to exceed a maximum of ten percent (10%) of the units of service provided in any given four (4) month period. Agreements between the Provider and the agency providing personal care staffing services shall be in writing and include at a minimum, the following:
(a) The staffing agency’s NPI number obtained from the National Plan and Provider Enumeration System (NPPES) and the NPI numbers of all staff supplied to the home health agency listed on all beneficiary documentation;
(b) A description of the services to be provided;
(c) Business address of each staffing agency location;
(d) The procedures used for managing, supervising, and evaluating the services delivered by agency personnel;
(e) Procedures for implementing plans of care; submitting clinical and progress notes; scheduling of visits; preparing beneficiary assessments; and other designated reports by agency personnel;
(f) The procedure identified for payments for services furnished and the terms of those payments;
(g) The duration of the agreement, including provisions for renewal, if applicable;
(h) Assurances that the agency shall comply with:
(1) All applicable home health Provider policies, including the assurance that contract personnel meet the qualifications and fulfill the responsibilities of agency employees in accordance with these rules;
(2) All insurance and bonding requirements as set forth in section 5002 of these rules; and
(3) All applicable federal and District laws and rules, including all relevant licensing requirements imposed by the District of Columbia;
5001.2 Each Home Health Provider contracting with a staffing agency for personal care services shall:
(a) Ensure that the staffing agency obtains NPI numbers for the agency and all personnel performing personal care services;
(b) Provide DHCF with a copy of any and all contract(s) entered into with a staffing agency for the delivery of all personal care services on behalf of the Provider. Each of these contracts shall contain the personal care staffing agency NPI number and a current list of NPI numbers for all individuals providing personal care services under the auspices of the personal care staffing agency;
(c) Require that each staffing agency providing personal care services conduct a performance assessment of each personal care aide after the first three (3) months of service under the auspices of the staffing agency and annually thereafter.
5001.3 Marketing and solicitation of Medicaid beneficiaries or their representatives by staffing agencies shall be prohibited. Those prohibited marketing and solicitation activities shall include, but not be limited to:
(a) Direct advertising or marketing to Medicaid beneficiaries;
(b) Representation of the staffing agency as the Medicaid Provider of personal care services; and
(c) Offering financial or other types of inducements to individuals for the referral of Medicaid beneficiaries, their names, or other identifying information to the staffing agency.
5001.4 Ownership rights between home health Providers and staffing agencies shall be prohibited. Ownership rights may include but not be limited to:
(a) A direct or indirect ownership or investment interest (including an option or non-vested interest) by the staffing agency in any home health agency. This interest may be in the form of equity, debt, or other means and includes any indirect ownership or investment interest;
(b) A direct or indirect ownership of investment interest (including an option or non-vested interest) by the home health agency in any staffing agency; or
(c) A compensation arrangement other than the contract between the home health agency and the staffing agency in performance of personal care services.
5001.5 A staffing agency providing personal care services shall be considered an agent of the Provider.
5001.6 All beneficiary records accumulated by a staffing agency in delivery of personal care services shall be the property of the home health Provider and maintained within the home health Provider’s office.
5002 INSURANCE
5002.1 Each applicant or Provider shall maintain the following minimum amounts of insurance coverage:
(a) Blanket malpractice insurance for all employees in the amount of at least one million dollars ($ 1,000,000) per incident;
(b) General liability insurance covering personal property damages, bodily injury, libel and slander of at least one million dollars ($ 1,000,000) per occurrence; and
(c) Product liability insurance, when applicable.
5002.2 Each applicant or Provider shall post a continuous surety bond in the amount of fifty thousand dollars ($50,000) against all personal care services claims, suits, judgments, or damages including court costs and attorney’s fees arising out of the negligence or omissions of the Provider in the course of providing services to a Medicaid beneficiary or a person believed to be a Medicaid beneficiary. The number of bonds required shall be predicated upon the
number of Provider offices enrolled by the applicant or Provider in the Medicaid program.
5003 ADMINISTRATION AND STAFFING
5003.1 NPI numbers for Providers, staffing agencies and all personnel delivering personal care services shall be included in all Medicaid billings.
5003.2 Each Provider shall have a current organizational chart that clearly describes the organizational structure, management responsibilities, staff responsibilities, and lines of authority.
5003.3 Each Provider shall maintain current copies of all fully executed contracts in the Provider’s home health agency office and make them available to DHCF, CMS, or their agents when requested.
5003.4 A Provider shall be prohibited from waiving liability or assigning contract authority to any other entity for covered services provided to Medicaid beneficiaries.
5003.5 Each Provider shall provide to all employees and contractors (such as, staffing agencies) a current policy manual which sets forth all of its policies and procedures.
5003.6 Each policy manual shall include, but not be limited to, the following information:
(a) A description of the services to be provided;
(b) Procedures for beneficiary care;
(c) The reimbursement methodology or fee schedules;
(d) Operational schedules;
(e) Quality assurance standards;
(f) A statement of beneficiary rights and responsibilities;
(g) Financial and record-keeping requirements;
(h) Procedures for emergency care, infection control and reporting of unusual incidents;
(i) A description of staff positions and personnel policies, which shall be reviewed annually, revised as necessary, and dated at time of review;
(j) Policies and procedures for employee hiring, assessments, grievances, and in-service training;
(k) Policies, procedures, and presentation materials for owners, managers, and employees for in-service education on the following subject matters:
(1) Compliance with federal and local False Claims Acts;
(2) Preventing, detecting, and reporting fraud, waste, and abuse; and
(3) Rights of employees to be protected as whistleblowers.
5003.7 Each Provider shall be staffed with individuals who are qualified to perform the following functions:
(a) Verify and document each beneficiary's Medicaid eligibility;
(b) Provide quality services in accordance with the plan of care, including the proper assignment and supervision of personal care aides; and
(c) Coordinate the provision of personal care services with home health services, as appropriate.
5003.8 Each Provider shall employ a registered nurse who is responsible for the following:
(a) Performing the initial assessment of the beneficiary and regularly reassessing the beneficiary's needs;
(b) Developing and reviewing the plan of care and preparing clinical and progress notes;
(c) Monitoring the quality of the personal care services on a regular basis;
(d) Supervising the personal care aides which shall include on-site supervision at least once every sixty-two (62) days;
(e) Coordinating services and communicating with primary care physicians and advanced registered practice nurses regarding changes in the beneficiary’s condition and needs;
(f) Gathering information regarding the beneficiary's condition and the need for continued care; and
(g) Counseling the beneficiary and the beneficiary’s family regarding nursing and related needs.
5003.9 The registered nurse shall visit each beneficiary within forty-eight (48) hours of initiating personal care services to monitor the quality of services, and no less than every sixty-two (62) days thereafter for assessment of the beneficiary and update of the plan of care.
5003.10 The registered nurse may provide an additional supervisory visit to each beneficiary if the situation warrants an additional visit, such as the assignment of a new personal care aide or change in the beneficiary's health status.
5003.11 Each Provider shall discontinue personal care services when such services are no longer required or have been determined inadequate to meet a beneficiary's needs.
5003.12 Each Provider shall notify DHCF and the beneficiary or beneficiary's representative, in writing, no less than fifteen (15) calendar days prior to discharge or referral. The beneficiary’s record shall contain documentation of the date the notice was mailed to the beneficiary and a copy of the notice to the beneficiary. An oral notice may be provided in lieu of the fifteen (15) day written notice if:
(a) The discharge or referral is the result of one (1) of the following:
(1) A medical emergency;
(2) A primary care physician's order to admit the beneficiary to a facility;
(3) A determination by the home health agency that the discharge or referral is necessary to protect the health, safety or welfare of agency staff; or
(4) A determination by a primary care physician that the beneficiary’s condition, that required the delivery of personal care services, no longer exists; and
(b) Documentation indicating a reason to omit the fifteen (15) day notice is included in the beneficiary’s record.
5003.13 If the beneficiary seeks to change his or her personal care services Provider, the Provider shall assist the beneficiary in selecting a new Provider. Until the beneficiary is transferred to a new personal care services Provider, the Home Health Provider shall continue providing personal care services to the beneficiary until the transfer has been completed successfully and the beneficiary is receiving personal care services from the new Provider.
5003.14 Each Provider shall immediately terminate the services of a personal care aide and instruct the personal care aide to discontinue all services to the beneficiary, in any case where the Provider believes that the beneficiary's physical or mental well-being is endangered by the care or lack of care provided by the aide, or that the beneficiary's property is at risk.
5003.15 Each Provider shall conduct a performance assessment of each personal care aide after the first three (3) months of employment and annually thereafter.
5003.16 Each Provider shall develop contingency staffing plans to provide coverage for each beneficiary in the event the assigned personal care aide cannot provide the services or is terminated.
5004 PERSONAL CARE AIDE (PCA)
5004.1 Each PCA shall meet the following qualifications:
(a) Be at least eighteen (18) years of age;
(b) Be a citizen of the United States or an alien who is lawfully authorized to work in the United States;
(c) Complete a home health aide training program that includes at least seventy- five (75) hours of classroom training with at least sixteen (16) hours devoted to supervised practical training and pass a competency evaluation for those services which the PCA is required to perform consistent with the requirements set forth in 42 C.F.R. § 484.36;
(d) Be certified in cardiopulmonary resuscitation (CPR) and thereafter obtain CPR certification annually;
(e) Be able to read and write the English language at the fifth (5th) grade level and carry out instructions and directions in English;
(f) Be able to recognize an emergency and be knowledgeable about emergency procedures;
(g) Be knowledgeable about infection control procedures;
(h) Be acceptable to the beneficiary;
(i) Demonstrate annually that he or she is free from communicable disease as confirmed by an annual PPD Skin Test or documentation from a primary care physician or advanced practice registered nurse stating that the person is free from communicable disease;
(j) Pass a criminal background check pursuant to the Health-Care Facility Unlicensed Personnel Criminal Background Check Act of 1998, effective April 20, 1999 (D.C. Law 12-238; D.C. Official Code, §§ 44-551, et seq.(2005 Repl.; 2011 Supp.));
(k) Provide documentation of acceptance or declination of the Hepatitis vaccine; and
(l) Have an individual National Provider Identification (NPI) number obtained from the National Plan and Provider Enumeration System (NPPES).
5005 PROGRAM SERVICES
5005.1 Personal care aide services shall be prescribed by a primary care physician or advanced practice registered nurse who has had an existing relationship with the beneficiary that extended to an examination(s) provided in a hospital, primary care physician’s office or at the beneficiary’s home prior to the prescription of the personal care services.
5005.2 Each prescription for PCA services under this section shall include the prescriber’s NPI number obtained from NPPES;
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5005.3 PCA services shall be initiated no later than forty-eight (48) hours after completion of the initial assessment unless the beneficiary or the beneficiary's representatives agree to begin the services at a later date.
5005.4 An individual or family member other than a spouse, parent of a minor beneficiary, or any other legally responsible relative may provide personal care services. Each family member providing personal care services shall meet the requirements of these rules.
5005.5 Personal care services shall include, but not be limited to, the following:
(a) Performance of or assistance in performing routine activities of daily living (such as, bathing, transferring, toileting, dressing, eating and feeding self, maintaining bowel and bladder control [continence]);
(b) Assistance with bed pan use or changing urinary drainage bags;
(c) Assisting beneficiaries with a range of motion exercises;
(d) Assisting beneficiaries with self-administered medications;
(e) Reading and recording temperature, pulse, and respiration;
(f) Observing and documenting the beneficiary's status and reporting all services provided;
(g) Meal preparation in accordance with dietary guidelines and assistance with eating;
(h) Tasks related to keeping areas occupied by the beneficiary in a condition that promotes the beneficiary's safety;
(i) Accompanying the beneficiary to medically-related appointments or place of employment;
(j) Providing assistance at the beneficiary's place of employment;
(k) Shopping for items related to promoting the beneficiary's nutritional status and other health needs;
(l) Recording and reporting to the supervisory health professional, changes in the beneficiary's physical condition, behavior or appearance;
(m) Infection control; and
(n) Accompanying the beneficiary to recreational activities prescribed by the beneficiary’s primary care physician or advanced practice registered nurse.
5005.6 PCA services shall not include:
(a) Services that require the skills of a licensed professional, such as catheter insertion, procedures requiring the use of sterile techniques, and administration of medication; and
(b) Tasks usually performed by chore workers, such as cleaning of areas not occupied by the beneficiary and shopping for items not used by the beneficiary.
5005.7 PCA services shall be made available seven (7) days per week.
5005.8 Personal care services shall not be provided in a hospital, nursing facility, intermediate care facility for persons with intellectual and developmental disabilities (ICF/IDD), or any institutional setting.
5006 ELIGIBILITY REQUIREMENTS
5006.1 A Medicaid beneficiary who meets the following qualifications is eligible to receive PCA services:
(a) The Medicaid beneficiary has received an initial assessment from his or her primary care physician or advanced practice registered nurse and the assessment has found the beneficiary to be unable to independently perform one (1) or more activities of daily living for which personal care services are needed; and
(b) The referring primary care physician or advanced practice registered nurse has an expectation that the Medicaid beneficiary’s health care needs can be safely, adequately, and appropriately met while the beneficiary resides in the beneficiary's home.
5007 PLAN OF CARE
5007.1 Each Provider shall conduct an initial assessment of the beneficiary's functional status and needs within forty-eight (48) hours of receiving the referral for services.
5007.2 Each Provider shall develop a written plan of care within seventy-two (72) hours of the initial assessment of the beneficiary based upon the beneficiary's functional limitations.
5007.3 The plan of care shall specify the frequency, duration and expected outcome of the services rendered.
5007.4 The plan of care shall only be approved and signed by the beneficiary’s primary care physician or advanced practice registered nurse who has a prior relationship with the beneficiary and has examined the beneficiary in a hospital or primary care physician’s office or at the beneficiary’s home; and shall be re-certified no less than every six (6) months after the initial certification and each re-certification thereafter.
5007.5 The plan of care shall be re-certified by the primary care physician or advanced practice registered nurse after any interruption of service, including hospital admissions, greater than fourteen (14) calendar days.
5007.6 A registered nurse who is employed by the Provider shall review the plan of care at least once every thirty (30) days and shall update or modify the plan of care as needed. The revised plan of care shall be signed by the referring primary care physician or advanced practice registered nurse within thirty (30) days of prescription
5007.7 If a plan of care is revised by telephone order, the telephone order shall be immediately documented in writing and signed by the primary care physician or advanced practice registered nurse within thirty (30) days of its prescription.
5008 RECORDS
5008.1 Each Provider shall maintain complete and accurate records reflecting past and current findings, the initial and subsequent plans of care, and the ongoing progress of each beneficiary.
5008.2 Each Provider shall maintain complete and accurate records reflecting the specific personal care services provided to each beneficiary.
5008.3 Each Provider shall maintain beneficiary records that are confidential, complete and contain up-to-date information relevant to each beneficiary's care and treatment. For purposes of record confidentiality, the disclosure of treatment information by the Provider is subject to all the provisions of applicable District and Federal Laws.
5008.4 Each beneficiary's record shall include written documentation of the beneficiary's treatment needs and services. The documentation shall be written so that it is easily understood by a lay person.
5008.5 Each beneficiary's record shall be kept in a locked room or file maintained and safeguarded against loss or unauthorized use.
5008.6 Copies of all records for PCA services provided to beneficiaries by the Provider and/or the Provider’s contractors shall be maintained at the location of the Provider's place of business that is identified on the Provider’s Medicaid Provider application.
5008.7 Each Provider shall permit on-site inspections to be conducted by CMS, its agents, DHCF and its agents to determine Provider compliance with all applicable laws.
5008.8 Each Provider shall maintain beneficiary records for ten (10) years.
5008.9 Each beneficiary's record shall include, but is not limited to, the following information:
(a) Medical information, including the initial and annual assessments, and the initial certification and re-certifications of the plan of care;
(b) General information including the beneficiary's name, Medicaid identification number, address, telephone number, age, sex, name and telephone of emergency contact person, primary care physician's or advanced practice registered nurse’s name, address and telephone number;
(c) Description and dates of services rendered, including the name and NPI of the personal care aide performing the services;
(d) Documentation of each supervisory visit of the registered nurse including signed and dated clinical progress notes;
(e) Extended authorizations for services;
(f) Discharge summary, if applicable; and
(g) Any other appropriate identifying information that is pertinent to beneficiary care.
5009 BENEFICIARY RIGHTS AND RESPONSIBILITIES
5009.1 Each Provider shall develop a written statement of the beneficiary’s rights and responsibilities consistent with the requirements of this section, which shall be given to each beneficiary in advance of receiving services or during the initial assessment before the initiation of services.
5009.2 The written statement of the beneficiary’s rights and responsibilities shall be prominently displayed at the Provider’s business location and available at no cost upon request by a member of the general public.
5009.3 Each Provider shall develop and implement policies and procedures outlining the following beneficiary’s rights:
(a) To be treated with courtesy, dignity and respect;
(b) To control his or her own household and lifestyle;
(c) To participate in the planning of his or her care and treatment;
(d) To receive treatment, care and services consistent with the plan of care and to have the plan of care modified for achievement of outcomes;
(e) To receive services by competent personnel who can communicate with the beneficiary;
(f) To refuse all or part of any treatment, care or service and be informed of the consequences;
(g) To be free from mental and physical abuse, neglect and exploitation from persons providing services;
(h) To be assured that for purposes of record confidentiality, the disclosure of the contents of the beneficiary's records is subject to all the provisions of applicable District and federal laws;
(i) To voice a complaint or grievance about treatment, care, or lack of respect for personal property by persons providing services without fear of reprisal;
(j) To have access to his or her records; and
(k) To be informed orally and in writing of the following:
(1) Services to be provided, including any limits;
(2) Amount charged for each service, the amount of payment required from the beneficiary and the billing procedures, if applicable;
(3) Whether services are covered by health insurance, Medicare, Medicaid or any other third party sources;
(4) Acceptance, denial, reduction or termination of services;
(5) Complaint and appeal procedures;
(6) Name, address and telephone number of the Provider;
(7) Telephone number of the District of Columbia Medicaid fraud hotline;
(8) Beneficiary’s freedom from being forced to sign for services that were not provided or were unnecessary; and
(9) A statement, provided by DHCF, defining health care fraud and ways to report suspected fraud.
5009.4 Each beneficiary shall be responsible for the following:
(a) Treating all Provider personnel with respect and dignity;
(b) Providing accurate information when requested;
(c) Informing Provider personnel when instructions are not understood or cannot be followed; and
(d) Cooperating in making a safe environment for care within the home.
5009.5 Each Provider shall take appropriate steps to ensure that each beneficiary, including beneficiaries who cannot read or have a language or communication barrier, has received the information required pursuant to this section. Each Provider shall document in the records the steps taken to ensure that each beneficiary has received the information.
5010 REIMBURSEMENT
5010.1 Each Provider shall be reimbursed sixteen dollars and thirty cents ($ 16.30) per hour for services rendered by a personal care aide.
5010.2 Reimbursement for PCA services shall not exceed eight (8) hours of service per day per beneficiary. Reimbursement for services shall not exceed one thousand forty (1,040) hours during a calendar year, unless previously approved by DHCF or its agent.
5010.3 Each Provider shall agree to accept as payment in full the amount determined by DHCF as Medicaid reimbursement for the authorized services provided to beneficiaries. Providers shall not bill the beneficiary or any member of the beneficiary’s family for PCA services.
5010.4 Each Provider shall agree to bill any and all known third-party payers prior to billing Medicaid.
5010.5 All reimbursable claims for PCA services shall include the NPI numbers for the:
(a) Provider;
(b) Primary care physician or advanced practice registered nurse who ordered the personal care services;
(c) Staffing agency providing the personal care service, if the staff performing personal care services were obtained from a staffing agency; and
(d) Personal care aide who provided the personal care services.
5010.6 No more than ten percent (10%) of the billed units of service for PCA services, billed by date of service, in any given four (4) month period, may be claimed by a Provider for PCA services provided through the use of personnel from a staffing agency or agencies.
5010.7 Medicaid shall deny, pursuant to 42 C.F.R. § 424.22(d), home health services claims or recoup paid claims when Provider records or other evidence indicate that the primary care physician or advanced practice registered nurse ordering a beneficiary’s treatment has a significant ownership interest in, as defined in § 5010.8, or a significant financial or contractual relationship with, as defined in § 5010.9, the home health agency billing for the services.
5010.8 A primary care physician or advanced practice registered nurse shall be considered to have a significant ownership interest in a home health agency if either of the following conditions apply:
(a) The primary care physician or advanced practice registered nurse has a direct or indirect ownership of five percent (5%) or more in the capital, stock, or profits of the home health agency; or
(b) The primary care physician or advanced practice registered nurse has an ownership of five percent (5%) or more of any mortgage, deed of trust, or other obligation that is secured by the agency, if that interest equals five percent (5%) or more of the agency's assets.
5010.9 A primary care physician or advanced practice registered nurse is considered to have a significant financial or contractual relationship with a home health agency if any of the following conditions apply:
(a) The primary care physician or advanced practice registered nurse receives any compensation as an officer or director of the home health agency;
(b) The primary care physician or advanced practice registered nurse has indirect business transactions, such as contracts, agreements, purchase orders, or leases to obtain services, supplies, equipment, space, and salaried employment with the home health agency; or
(c) The primary care physician or advanced practice registered nurse has direct or indirect business transactions with the home health agency that, in any fiscal year, amount to more than twenty-five thousand dollars ($25,000) or five percent (5%) of the agency's total operating expenses, whichever is less.
5010.10 Claims resulting from referrals, marketing (such as, face-to-face solicitation at doctors’ offices, home visits), requests for beneficiary Medicaid numbers, or otherwise directing beneficiaries to any Medicaid Provider shall not be reimbursed.
5011 AUDITS AND REVIEWS
5011.1 DHCF shall perform 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.
5011.2 The audit process shall be routinely conducted by DHCF to determine, by statistically valid scientific sampling, the appropriateness of services rendered and billed to Medicaid. These audits shall be conducted on-site or through an off-site, desk review.
5011.3 Each Provider shall allow access, during an on-site audit or review by DHCF, other District of Columbia government officials and representatives of the United States Department of Health and Human Services, to relevant records and program documentation.
5011.4 If DHCF denies a claim, DHCF shall recoup, by the most expeditious means available, those monies erroneously paid to the Provider for denied claims, following the period of Administrative Review as set forth in §5011 of these rules.
5011.5 The recoupment amounts for denied claims shall be determined by the following formula:
(a) A fraction shall 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; and
(b) This fraction shall be multiplied by the total dollars paid by DHCF 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.
5011.6 DHCF shall issue a Notice of Proposed Medicaid Overpayment Recovery (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.
5012 APPEALS FOR PROVIDERS AGAINST WHOM A RECOUPMENT IS MADE
5012.1 The Provider shall have sixty (60) days from the date of the NR to request an administrative review of the NR. The request for administrative review of the NR shall be submitted to Program Manager, Office of Program Integrity, Department of Health Care Finance.
5012.2 The written request for administrative review 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.
5012.3 DHCF shall mail a written determination relative to the administrative review to the provider no later than one hundred twenty (120) days from the date of the written request for administrative review pursuant to §5012.1.
5012.4 Within forty-five (45) days of receipt of the Medicaid Program’s written determination, the Provider may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings (OAH), 441 4th Street, NW, Suite 450 North, Washington, DC 20001.
5012.5 Filing an appeal with the OAH shall not stay any action to recover any overpayment.
5099 DEFINITIONS
5099.1 When used in this chapter, the following terms and conditions shall have the following meanings:
Activities of Daily Living - The ability to bathe, transfer, dress, eat and feed self, engage in toileting, and maintaining bowel and bladder control (continence).
Advanced Practice Registered Nurse - A person who is licensed or authorized to practice as an advanced practice registered nurse pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201, et seq. (2007 Repl.; 2011 Supp.)).
Family - Any person related to the client or beneficiary by blood, marriage, or adoption.
Primary care physician - A person who is licensed or authorized to practice medicine pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code, §§ 3-1201, et seq. (2007 Repl.; 2011 Supp.)).
Registered Nurse - A person who is licensed or authorized to practice registered nursing pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code, §§ 3-1201, et seq. (2007 Repl.; 2011 Supp.)).
Comments on the proposed rules shall be submitted, in writing, to Dr. Linda Elam, Medicaid Director, Department of Health Care Finance, 899 North Capitol Street, N.E., Sixth Floor, Washington, DC 20002, or online at www.dcregs.dc.gov, within thirty (30) days after the date of publication of this notice in the D.C. Register. Copies of the proposed rules may be obtained from the above address.
