Fraud and Abuse Retractions

If overpayments related to fraudulent or abusive billing has been identified, MedStar Family Choice-DC may retract payments made to providers. In addition, MedStar Family Choice-DC may be required to notify the DHCF and/or other District of Columbia agencies of the retraction.

Providers will be notified of the retraction. The notification will include the following:

  • The reason for retractions of payments
  • The amount to be retracted
  • A list of claims that will be retracted
  • Notification of the providers right to appeal

Providers will have ninety (90) business days to appeal. The appeal must be submitted to in writing and to the following address:

MedStar Family Choice-DC
4000 Connecticut Avenue, N.W.
POD3N
Washington, D.C. 20008
Attn: Compliance Director

If additional documentation is available to support the reversal of the denied services, these should be submitted at this time. MedStar Family Choice-DC will send a written acknowledgement to the provider of receipt of the appeal within two business days. MedStar Family Choice-DC will notify the provider of the determination of the appeal, in writing, within 30 calendar days of the receipt of appeal.

Should the provider remain dissatisfied with the decision issued, the provider may submit a request for reconsideration to the Chief Executive Officer , MedStar Family Choice-DC or his/her designee. A written request must be filed within 30 calendar days of MedStar Family Choice-DC's notice of decision of the first level of appeal. MedStar Family Choice-DC makes a decision and notifies the provider within 30 calendar days. Should the provider remain dissatisfied with the decision issued, the terms in the Provider's Agreement, regarding Dispute Resolution, shall apply.

Information current as of: 10/20/20