Behavioral health providers in D.C. are facing a wave of government scrutiny unlike anything seen in recent years.
Payment suspensions are arriving before any finding of wrongdoing.
Sarah M. Hall and Chloe T. Hillard, Members of the Firm in the Health Care & Life Sciences practice of Epstein Becker Green, co-authored "Medicaid Behavioral Health Investigations and Payment Suspensions in D.C. Are Increasing – How Providers Can Limit Risk" in Healthcare Business Today.
The article addresses two converging enforcement tracks hitting D.C. behavioral health providers simultaneously. On the criminal side, the U.S. Attorney's Office, working with D.C.'s Medicaid Fraud Control Unit, has brought charges against at least nine individuals in three years, focusing on Community Support Workers who billed for services not rendered or overstated service time. On the civil side, D.C.'s Department of Health Care Finance can suspend Medicaid payments upon any "credible allegation of fraud," a deliberately low threshold, and suspensions continue through the full investigation, which commonly runs years. For providers paid exclusively by Medicaid, that combination can force closure before any final determination on the merits.
At a minimum, behavioral health providers should implement the following compliance initiatives:
- Assess risk regularly: Providers should conduct risk assessments on a regular basis that identify high, medium, and low risks given current regulatory priorities and industry trends.
- Conduct self-audits: Perform self-audits on the risks identified in the risk assessment, paying special attention to any irregular billing patterns. Remember that an effective self-audit includes follow-up and corrective actions for any issues identified.
- Take complaints seriously: Listen to complaints from consumers and staff and investigate accordingly.
- Designate a compliance leader: Regardless of the size of the provider, someone in the organization should be tasked with ensuring that management knows the applicable rules/regulations and is monitoring clinical and administrative staff's adherence to such rules and regulations.
- Create a compliance committee: Constitute a compliance committee of organization leaders to collaborate on how compliance with existing and new rules is being monitored, how adherence is incentivized, and how lack of adherence is penalized.
- Look beyond common red flags: Fraud is often subtle. Look at patterns of billing across time – for example, billing for an unreasonable number of days in a row, or consistently billing a high number of units without variation.
Attorney Clifford E. Barnes of Clifford E. Barnes, Esq. & Associates, LLC contributed to this article.
Get in Touch
To learn more about this topic, contact Sarah Hall at smhall@ebglaw.com or Chloe Hillard at chillard@ebglaw.com.
