The Surveillance/Utilization Branch
The Surveillance/Utilization Branch reviews providers’ patterns of care delivery and billing, reviews recipient utilization of resources’ patterns, undertakes corrective actions when needed, and educates providers on relevant laws, regulations, and other program requirements. Specifically, the Surveillance/Utilization Branch conducts audits and reviews of providers suspected of abnormal utilization or billing patterns within the District of Columbia's Medicaid program, recovers overpayments, issues administrative sanctions, and refer cases of suspected fraud for criminal investigation.
The Investigations Branch is responsible for conducting investigations of alleged violations of policies, procedures, rules or laws. Complaints may originate from the Office of Inspector General, the FRAUD Hotline, Agency staff, facilities and/or health care practitioners, the general public, data analysis, or other sources. Allegations of a criminal nature are referred to the appropriate law enforcement entity. When necessary, the Investigations Section works closely with the District of Columbia Medicaid Fraud Control Unit (MFCU) and other federal or local law enforcement.