1937.1Each waiver provider of residential habilitation, host home, supported living, day habilitation, in-home supports, individualized day supports, respite, employment readiness and supported employment services shall report costs to the Department of Health Care Finance (DHCF), for the purpose of informing rate-setting parameters to be the most cost-effective for the government and to reimburse allowable costs for the providers, in accordance with the following requirements:
(a) A cost report shall be submitted no later than ninety (90) days after the end of the provider's cost reporting period, which shall correspond to the fiscal year used by the provider for all other financial reporting purposes, unless DHCF has approved an exception, on request;(b) A cost report shall be reported on a cost report template designated by DHCF and cover a period of twelve (12) months unless otherwise approved by DHCF;(c) In the absence of specific instructions or definitions contained in this section, cost report templates, cost report instructions, or DHCF guidance, the treatment and allowability of costs reported on a cost report shall be determined in accordance with the Medicare Principles of Reimbursement, 42 C.F.R. Part 413, and the interpretations found in the Medicare Provider Reimbursement Manual; and(d) The following categories of expenses shall be excluded from the allowable costs reported on a cost report: (1) Fundraising expenses in excess of ten percent (10%) of the amount raised;(2) Social activities not related to the services described in this chapter;(3) Personal telephone, radio, and television services;(5) Interest expenses and penalties due to late payment of bills or taxes, or for licensure violations;(6) Prescription drug costs; and1937.2A cost report that is not completed shall be considered an incomplete filing, and DHCF shall notify the waiver provider within thirty (30) days of the date on which DHCF received the incomplete cost report.
1937.3 All of the facility's accounting and related records, including the general ledger and records of original entry, and all transaction documents and statistical data, shall be permanent records and be retained for a period of not less than five (5) years after the filing of a cost report.
1937.4DHCF, or its designee, shall review each cost report for completeness, accuracy, compliance, and reasonableness. DHCF, the Office of the Chief Financial Officer, or DHCF's designee, shall evaluate expenditures subject to the requirements in Subsections 1937.1 " 1937.5 and 1937.15 through annual audit or review of cost reports.
1937.5At the conclusion of each cost report audit or review, a waiver provider shall receive an audited cost report including a description of each audit adjustment and the reason for each adjustment. A waiver provider that disagrees with the audited cost report may request an administrative review or hearing subject to the following requirements:
(a) Within thirty (30) days after receiving the audited cost report, a waiver provider may request an administrative review by submitting a written request to DHCF;(b) The written request for an administrative review shall include an identification of the specific audit adjustment to be reviewed, the reason for the request for review of each audit adjustment, and supporting documentation;(c) DHCF shall mail a formal response to the waiver provider's written request, as soon as practicable; and(d) Decisions made by DHCF and communicated in the formal response may be appealed, within thirty (30) days after the waiver provider receives DHCF's letter notifying the waiver provider of the decision, to the Office of Administrative Hearings.1937.6 Every five (5) years, for purposes of renewing the Waiver, DHCF shall rely on audited cost reports submitted by Waiver providers to DHCF. In the absence of audited cost reports, Waiver providers may submit unaudited costs reports or financial statements.
1937.7DHCF, Division of Program Integrity shall perform ongoing audits to ensure that the provider's services for which Medicaid payments are made are consistent with programmatic duties, documentation, and reimbursement requirements as required under this chapter. The audits shall be performed consistent with the audit processes in Subsections 1937.8 " 1937.15.
1937.8 The audit process shall be routinely conducted by DHCF to determine, by statistically valid scientific sampling, the appropriateness of services rendered to IDD Waiver program beneficiaries and billed to Medicaid.
1937.9 If DHCF denies a claim during an audit, DHCF shall recoup, by the most expeditious means available, those monies erroneously paid to the provider for denied claims, following the process for administrative review as outlined below:
(a) DHCF shall issue a Notice of Proposed Medicaid Overpayment Recovery (NPMOR), which sets forth the reasons for the recoupment, including the specific reference to the particular sections of the statute, rules, or provider agreement, the amount to be recouped, and the procedures for requesting an administrative review. (b) The Provider shall have thirty (30) days from the date of the NPMOR to submit documentary evidence and written argument to DHCF against the proposed action; (c) The documentary evidence and written argument shall include a specific description of the item to be reviewed, the reason for the request for review, the relief requested, and documentation in support of the relief requested; (d) Based on review of the documentary evidence and written argument, DHCF shall issue a Final Notice of Medicaid Overpayment Recovery (FNMOR); (e) Within fifteen (15) days of receipt of the FNMOR, the Provider may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings (OAH), 441 4th Street, N.W., Suite 450 North, Washington, D.C. 20001; and (f) Filing an appeal with the OAH shall not stay any action to recover any overpayment.1937.10 The recoupment amounts for denied claims may be determined by the following formula:
(a) A fraction shall be calculated with the numerator consisting of the number of denied paid claims resulting from the audited sample; and(b) The denominator shall be the total number of paid claims from the audit sample. This fraction will be multiplied by the total dollars paid by DHCF to the Provider during the audit period, to determine the amount recouped. 1937.11All participant, personnel, and program administrative and fiscal records shall be maintained so that they are accessible and readily retrievable for inspection and review by authorized government officials or their agents, as requested.
1937.12All records and documents required to be kept under this chapter and other applicable laws and regulations which are not maintained or accessible in the operating office visited during an audit shall be produced for inspection within twenty-four (24) hours, or within a shorter reasonable time if specified, upon the request of the auditing official.
1937.13The failure of a provider to release or to grant access to program documents and records to the DHCF auditors in a timely manner, after reasonable notice by DHCF to the provider to produce the same, shall constitute grounds to terminate the Medicaid Provider Agreement.
1937.14As part of the audit process, providers shall grant access to any relevant documents to DHCF Program Integrity personnel, which may include the following:
(a) A record of all service authorizations and prior authorizations for services;(b) A record of all requests for changes in services;(c) A written staffing plan, if applicable;(d) A schedule of the beneficiary's activities in the community, if applicable, including strategies to execute goals in the Individualized Service Plan, the date and time of the activities, and staff, as identified in the staffing plan;(e) Any records relating to adjudication of claims, including the number of units of the delivered service, the period during which the service was delivered and dates of service, and the name, signature, and credentials of the service provider;(f) Progress notes, as described in 29 DCMR § 1909; and(g) Any record necessary to demonstrate compliance with rules, requirements, guidelines, and standards for implementation and administration of the waiver.1937.15DHCF may conduct the audits or reviews in Subsections 1937.4 and 1937.7 at any time. Each waiver provider shall grant full access, during announced or unannounced on-site audits or review by DHCF, DHCF's designee, other District of Columbia officials, or representatives of the U.S. Department of Health and Human Services auditors, to relevant financial records, statistical data to verify costs previously reported to DHCF, program documentation, and any other documents relevant to the administration and provision of the waiver service.
1937.16 DHCF's Long Term Care Administration's Waiver Oversight and Monitoring team shall conduct monitoring reviews as follows:
(a) Quarterly oversight and monitoring reviews to ensure compliance with established federal and District regulations and applicable laws governing the operations and administration of the Waiver Program; and(b) Quarterly oversight and monitoring reviews to monitor progress and performance against quality measures.1937.17 As part of the oversight monitoring process, providers shall grant access to any of the following documents to the DHCF monitor, which may include, but shall not be limited to the following:
(a) Person-Centered Service Plan and Plan of Care/service delivery plan; (c) A signed, current copy of the Medicaid Provider Agreement; (d) Licensure information; (e) Policies and procedures; (f) Incident reports and investigation reports; and (g) Complaint related reports.D.C. Mun. Regs. tit. 29, r. 29-1937
Final Rulemaking published at 61 DCR 4406 (May 2, 2014); amended by Final Rulemaking published at 63 DCR 10445 (8/12/2016); as amended by Final Rulemaking published at 65 DCR 2190 (March 2, 2018); amended by Final Rulemaking published at 69 DCR 3538 (4/15/2022) Authority: An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2012 Repl. & 2013 Supp.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).