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Are You Being Investigated? What to Expect

Magnifying Glass Over Audit

How will providers know if they are being audited or reviewed by the Division of Program Integrity? 

 
Provider audits may be unannounced as authorized by Medical Assistance Program Transmittal # 95-47, which states some on-site reviews will be performed without prior notice. If announced, the Division of Program Integrity sends an intent to audit/notification letter to providers announcing the audit and the time frame of the audit; or The Division of Program Integrity sends an overpayment notice or letter when a review has identified overpayments. For PERM reviews & MIC audits see the Federal audit section of this guide for more details. 
 

What types of records will the Division of Program Integrity request during an audit or review?

Providers must retain documentation that supports the services billed to Medicaid. The Division of Program Integrity may request the following types of information and records; please note that this is not an all-inclusive listing
  • Prescription records
  • Office visit/hospital visit notes
  • Patient care plans 
  • Medication administration records/sheets 
  • Diagnostic test results (e.g. lab reports, radiology/nuclear medicine reports, etc.)
  • Financial reports/accounting/billing records, charge masters, service level descriptions
  • Dental x-ray films 
  • Third party insurance documents
  • Physician/practitioner orders/ Plans of Care
  • Credit balance reports Surgical, recovery & anesthesia records
  • Appointment books/patient sign-in sheets 
  • Durable & non-durable medical equipment/product delivery documents 
  • Ownership agreement/business license and professional staff licenses/certificates 
  • Treatment records Office/facility policies/employment records 
  • Transfer records/referral documents 
  • Complete hospital medical records
 

How long must a provider keep records for audit or review purposes?

The majority of Medicaid providers must maintain appropriate documentation in the client's medical or health care service records for  a minimum of 6 years to verify the level, type, and extent of services provided.  Providers must: (a) Keep legible, accurate, and complete charts and records to justify the services provided to each client; (b) Assure charts are authenticated by the person who gave the order, provided the care, or performed the observation, examination, assessment, treatment or other service to which the entry pertains; and (c) Make charts and records available to DHCF, its contractors, and the U.S. Department of Health and Human Services upon request, for six years from the date of service or longer if required specifically by federal or state law or regulation. Refer to the DCMR http://www.dcregs.dc.gov/ for specific regulation and for additional provider requirements. Refer to section 1902 (a) (27) of the Social Security Act for Federal record keeping requirements. 
 
Per the DHCF Provider Agreement, providers shall retain all original records and documents that support services billed and paid by DHCF for 10 years. 
 
Please note: If a provider is being audited all records need to be retained until the audit is completed and all issues are resolved, even if the period of retention extends beyond the required 6 year period.
 
No original provider records and/or information will be removed by the auditors when conducting an onsite audit. Audit staff will either make copies or request copies be made of original provider records and/or information.