The District of Columbia Claimed Some Day Treatment Program Services That Were Not in Compliance With Federal or District Requirements

The District of Columbia's (District) Day Treatment Program (DTP) began in 1984 and was repealed in January 2016. District regulations defined the the DTP as "a nonresidential program operated for the purpose of providing medically supervised day treatment services for elderly persons, children from birth through age three (3), or adults with a developmental disability, and adults with mental disorders." Other OIG reviews showed that States' Medicaid claims for day treatment services did not always comply with Federal and State requirements.

We reviewed Federal and District requirements regarding day treatment services and also reviewed a random sample of 100 DTP claims paid to 13 providers. Our review covered 185,597 claims totaling $59.5 million ($42.3 million Federal share) that the District claimed for DTP services from 2011 through 2015. These claims were submitted by 27 providers for 2,428 beneficiaries.

While 80 of the 100 claims in our sample complied with Federal and District requirements, 20 of the sampled claims did not comply with either Federal requirements that claims have adequate supporting documentation or District requirements that claims include a physician's order, a participant plan of care, the beneficiary's attendance record, and daily progress notes. Specifically, 11 claims did not include any documentation to support that the beneficiaries received services on the claimed dates of service, 8 claims were submitted for beneficiaries who did not have a plan of care, and 1 claim was submitted for a beneficiary who was absent on the claimed date of service according to the attendance log. On the basis of our sample results, we estimated that this resulted in the District claiming at least $4.6 million in Federal reimbursement for unsupported and, therefore, unallowable DTP services.

We recommended the District refund to the Federal Government $4.6 million for DTP services that were not claimed in accordance with Federal and District requirements.

In written comments on our draft report, the District agreed to refund the full amount of questioned costs. In addition, the District noted that throughout our audit period, the District was operating under a Plan of Correction approved by the Centers for Medicare & Medicaid Services "to effectuate the orderly shutdown of this troubled program and to transition the beneficiaries safely to clinically appropriate alternative services."