Health Law Advisor

Behavioral health providers in the District of Columbia (“District” or “D.C.”) are operating in an environment of heightened government scrutiny. In recent months, federal and District authorities have signaled an intensified focus on Medicaid fraud in the behavioral health space, combining criminal prosecutions by the U.S. Attorney’s Office with aggressive program integrity actions by the D.C. Department of Health Care Finance (“DHCF”). These efforts have included criminal and civil investigations into alleged billing irregularities and, at an increasing rate, the suspension of Medicaid payments to providers based on suspected fraud. Such suspensions are implemented in almost all cases, as permitted by regulations, before any final determination on the merits. These developments raise significant legal, financial, and operational risks for behavioral health providers in D.C.

On January 5, 2026, the Office of Inspector General (“OIG”) for the Department of Health and Human Services published Advisory Opinion No. 25-12 (“AO 25-12”), an unfavorable opinion regarding sign-on bonuses offered to caregivers who provide in-home support services to Medicaid recipients.

In an indictment announced on October 26, 2023 in Miami, the U.S. Department of Justice, Criminal Division’s Fraud Section, working with the FBI and HHS-OIG, brought what may be only the second federal criminal charges directly related to the Medicare Advantage (Medicare Part C) risk adjustment payment methodology.  DOJ enforcement in the Medicare Advantage risk adjustment space overwhelmingly has proceeded civilly under the False Claims Act. Although the allegations suggest conduct far more troubling than prior civil cases under risk adjustment, these criminal charges ...

On February 1, 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule outlining its audit methodology and related policies for its Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program. The final rule codifies long-awaited regulations first proposed by CMS in 2018.