Division of Program Integrity

 

The mission of the Division of Program Integrity is to provide a reasonable and consistent system of oversight of the Medicaid program which effectively encourages:

  • Compliance
  • Accountability
  • Protection of public funds
  • Awareness and responsibility
  • Providers meeting participation requirements
  • Services being medically necessary
  • Payments in the correct amount for covered services

The goal is to reduce and eliminate fraud, waste, and abuse in the Medicaid Program.

The duties of Program Integrity include prevention; investigation; education; audit; recovery of improper payments; and cooperation with the Medicaid Fraud Control Unit (MFCU) and other federal/local law enforcement agencies.

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.

 

 Preliminary Investigations Policy  Preliminary Investigations Report
 Complaint and Referral Intake Policy   Suspension of Provider Payments
The Data Analysis and Research Team (DART) reviews claims data at the claims processing level. The process determines aberrant billing patterns and inappropriate reimbursements that may occur across a specific provider type, provider specialty, procedure code, diagnosis code or any other captured claims data element. When a potential issue is discovered, the DART staff performs thorough research and conducts payment studies to determine if overpayment of services occurred. When identified, the DATR staff may request that a provider submit medical or other records, including X-rays, to fully explain why services were rendered and billed to the Division of Program Integrity’s (DPI) Surveillance and Utilization Review Branch (SURS) for further evaluation and final determination of overpayment. This documentation must be sufficient to fully disclose the extent of the services provided. Providers must maintain medical records and other documentation for a period of ten (10) years from the date of service. A failure to provide medical records or other records when requested may constitute a violation of applicable District and/or Federal laws and regulations