Behavioral health providers in the District of Columbia are operating under heightened government scrutiny, with federal and District authorities intensifying their focus on Medicaid fraud. Criminal prosecutions by the U.S. Attorney’s Office for the District of Columbia are being combined with aggressive program integrity actions by the D.C. Department of Health Care Finance (DHCF). These enforcement efforts include criminal and civil investigations into alleged billing irregularities and, at an increasing rate, suspensions of Medicaid payments to providers based on suspected fraud.
Criminal Investigations
The U.S. Attorney’s Office for the District of Columbia, often working with the District’s Office of Inspector General and Medicaid Fraud Control Unit (MFCU), has filed criminal charges against at least nine individuals in the past three years. Cases typically involve similar allegations, primarily relating to billing by Community Support Workers (CSW). The government has focused on CSWs who bill for services they did not provide or who overstate the time duration of their services, including situations where CSWs bill for services while consumers were out of state, hospitalized, or incarcerated, or bill for encounters with multiple consumers simultaneously. Penalties for these crimes are significant, including possible jail time and restitution in the hundreds of thousands of dollars.
Payment Suspension Process
When DHCF determines there is a “credible allegation of fraud”—a low standard that can encompass nearly any allegation of fraudulent behavior—it can suspend all Medicaid payments to a provider. Payment suspensions typically last several months in the best case scenario or, more commonly, years. This process devastates providers, especially Mental Health and Rehabilitative Services providers who tend to be paid exclusively by Medicaid. Providers can request administrative review or appeal to an administrative law judge, but because the government’s burden of proof is low, ALJs typically do not overturn suspensions while investigations remain open.
Compliance Recommendations
Providers should implement strong compliance programs including regular risk assessments identifying high, medium, and low risks, conducting self-audits with attention to irregular billing patterns, taking complaints seriously, designating a compliance leader, creating a compliance committee, and looking beyond common red flags. These steps can help providers proactively catch fraud and demonstrate to the government that they are good corporate actors.
This article is an AI-assisted summary. All facts and figures are drawn from the original report: https://natlawreview.com/article/medicaid-behavioral-health-investigations-and-payment-suspensions-dc-are-increasing