To ensure that Health Care Services and its fiscal intermediaries reimburse providers only for services rendered to eligible beneficiaries, Health Care Services should coordinate with the appropriate fiscal intermediaries to recover inappropriate payments made for services purportedly rendered to deceased beneficiaries, if necessary.
This activity was fully implemented in February 2017 via Systems Development Notice 5005.
Although Health Care Services asserted that it implemented a system change to identify services to deceased beneficiaries, it has not provided adequate documentation supporting its assertion. Further, Health Care Services has not provided documentation demonstrating that it adequately reviewed the eligibility for the 153 beneficiaries identified in our review.
DHCS instructed its fiscal Intermediary, Delta Dental, to identify overpayments and recover these identified overpayments. However, the overpayments did not total to the $70,000 identified by the California State Auditor's (CSA) Office, rather Delta Dental was able to identify seven erroneous claims in the amount of $562.14. In addition, as of April 30, 2016, the Fiscal Intermediary Access to Medi-Cal Eligibility (FAME) file has been developed into a monthly deliverable in CD-MMIS for post-adjudicated claims for services provided after the beneficiary's DOD. As an additional proactive measure, Delta Dental has been tasked with making changes to the CD-MMIS in terms of the review of the monthly post-adjudicated claims for services provided after the beneficiary's DOD through an ad hoc process of post audit findings.
As of March 27, 2017, Health Care Service has not provided documentation demonstrating that it adequately reviewed the eligibility for the 153 beneficiaries identified in our review.
To validate the identified discrepancies, DHCS performed an in-depth identity verification process on the sample records. For a large number of the records, DHCS discovered data entry errors involving the Social Security Numbers (SSNs). Over 50 records have been corrected to reflect an accurate SSN. DHCS does not anticipate seeking recoveries for those individuals. For the sample records in which DHCS believes dental services were received under a false identity (belonging to a deceased individual), DHCS will evaluate the feasibility of conducting a second EPC to recoup the improper payments.
Additionally, DHCS has taken steps to improve its ability to prevent erroneous payments to providers and managed care plans for services and care that were never provided to the deceased beneficiaries:
-DHCS is actively working with County partners to ensure that they are following all policies and guidance on how to handle the disposition of SSN's that suggest an individual is deceased and actual deceased beneficiary cases and the needed updating of the appropriate eligibility status through MEDS.
-DHCS has obtained access to private data analytic services to identify deceased beneficiaries that do not appear on existing federal/state sources.
DHCS will meet regularly with staff in the Audits and Investigations Division to find ways to improve our death detection systems, report our findings, and prevent erroneous payments.
-DHCS will have Program Review Staff perform on-site County reviews of cases to validate the accuracy of county eligibility decisions and ensure the proper process to update records in MEDS, including those of deceased beneficiaries
DHCS issued an instruction letter to the Fiscal Intermediary to implement a process to recover from providers any identified inappropriate payments made for services purportedly rendered to deceased beneficiaries. This process is dependent on the ability to acquire the Date of Death (DOD) data from the Fiscal Intermediary Access of Medi-Cal Eligibility System. DHCS has also issued an erroneous payment correction to recover payments using stored DOD in the California Dental Medicaid Management Information System (CD-MMIS). The estimated date of completion is April 30, 2016.
DHCS will issue an instruction letter to the Fiscal Intermediary to implement a process to recover from providers any identified inappropriate payments made for services purportedly rendered to deceased beneficiaries. This process will be implemented by May 2015.
Agency responses received are posted verbatim.