DHCF maintains a strong commitment to identify improper payments, and potential fraud, waste and abuse to ensure that District and Federal tax dollars are spent appropriately. This commitment is driven by a firm intent to ensure that the right provider is receiving the right payment for the right services at the right time. 

 

The Division of Program Integrity strives for collaboration and partnership with its internal and external stakeholders to improve accountability for how health care funds are spent. The Division of Program Integrity must also be in compliance with Federal Medicaid audit and program integrity initiatives. Coordination of Medicaid fraud, waste and abuse activities requires partnership with every administration entrusted with taxpayer dollars. Program integrity is everybody’s business. 

 

The Division of Program Integrity also refers any quality of care concerns it discovers during the course of the audit/review process to the appropriate District authorities. 

 

Desk Audit-Review – An audit or review conducted at the Division of Program Integrity. A notification letter with request for records is sent to the provider and generally requires the provider to submit copies of the requested records, if necessary. Audit staff may conduct provider and/or provider personnel interviews by phone. Some examples of desk audits and reviews are clinical reviews, pharmacy third party liability (TPL) audits, hospital outpatient claims audits, and hospital credit balance reviews. 

 

Onsite/Field Audit – An audit conducted at a provider’s place of business. A letter of “intent to audit” or a notification letter can be provided by the Division of Program Integrity auditor to the provider prior to the onsite visit, or when the auditor arrives at the place of business, giving the provider information concerning the audit. Audit staff will make copies of the provider’s records when onsite, review provider’s billing protocols, and interview the provider and/or provider personnel. 

 

Surveillance/Utilization Branch Provider Review - A review of a provider’s billed services based on either a complaint received by the Surveillance and Utilization Review Section or anomalies in services identified through utilization reports and/or data mining. 

 

Data mining/Algorithm - A review applying rules-based filters (called algorithms) to claims payment data to identify overpayments within the District of Columbia’s Medicaid program. 

 

There are several Federal government audit/review and program integrity initiatives administered by the Centers for Medicare and Medicaid Services (CMS) or CMS contractors, and may include the Office of Inspector General (OIG). District of Columbia’s Medicaid providers may receive notification letters and record requests from CMS contractors advising them they have been selected for an audit or review.