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.