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Audit Methodologies and Reporting

Data Analysis

What methodologies does the Division of Program Integrity use to select services to audit/review? 

 

  • Several methods are used to select services to audit. They include: 
  • Use of algorithms to identify billing aberrancies; 
  • 100% review of a provider’s paid claims for a specific time period; 
  • Select random or criteria-driven selection of specific procedure codes or claims paid during a specific time period (non-projected findings); 
  • Selecting random stratified sample from the universe of paid claims/procedures to extrapolate any aberrant findings.
  •  

Who might receive a copy of the audit/review report? 

As stakeholders in the provider audit and review process Department of Health and Human Services, Attorney General’s Office, and/or Medicaid Fraud Control Unit may receive copies of audit/review reports and overpayment notices. Section § 1312.1 of Chapter 13 of Title 29 DCMR allow referral for disciplinary or criminal action if warranted.