Report 2014-134 Recommendation 3 Responses

Report 2014-134: California Department of Health Care Services: Improved Monitoring of Medi-Cal Managed Care Health Plans Is Necessary to Better Ensure Access to Care (Release Date: June 2015)

Recommendation #3 To: Health Care Services, Department of

To ensure that Managed Health Care reaches accurate conclusions during its quarterly assessments of the adequacy of provider networks, Health Care Services should establish by September 2015 a process to verify the accuracy of the provider network data it receives from health plans and forwards to Managed Health Care. For example, Health Care Services could verify, for a sample of physicians claimed as part of the health plans' provider networks, that health plans have current written agreements with the providers.

Annual Follow-Up Agency Response From November 2018

DHCS successfully transitioned to the new MCP provider file submission process. This new process contains stricter automated validation edits and enhanced response files, which have improved the quality of DHCS' provider network data. In addition, DHCS contracted with its external quality review organization to conduct an ongoing timely access study which will include an analysis of provider network data quality.

  • Completion Date: January 2017

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Health Care Services did not provide supporting documents to substantiate its claim of full implementation. Specifically, it did not provide documentation to support the contract with the external quality review organization it references in its response.

  • Auditee did not substantiate its claim of full implementation

1-Year Agency Response

DHCS is on schedule to implement a new MCP provider file submission process in late 2016. Phase one of MCP testing was completed on April 30, 2016. DHCS is conducting monthly webinars with all MCPs and individual MCP calls to discuss policy and technical issues. The new process contains stricter automated validation edits which will foster complete and accurate data.

  • Estimated Completion Date: December 2016
  • Response Date: June 2016

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS is on schedule to implement a new health plan provider file submission process in 2016. Testing of the new file will begin in the first half of 2016. Automatic quality checks of the data will be built into this system. The new quality check process will significantly strengthen the process that is in place today.

  • Estimated Completion Date: End of 2016
  • Response Date: December 2015

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS agrees with the audit finding. Currently, DHCS has a process for approving provider directories and certifying and monitoring health plan networks, but had self-identified the need for verifying data in the provider file prior to this audit commencing and has already taken steps to improve the data verification process. DHCS has started running all provider data through the Fee-For-Service validation process which checks the providers against national databases and determines if providers are in the network that should not be. A two-step quality check will also be implemented through the DHCS Network Adequacy Monitoring Project that is underway - provider file data will be submitted through a system that conducts a quality check on the data elements and then DHCS will perform a survey to ensure the provider is contracted with the Medi-Cal managed care health plan. This project has a projected implementation date of early 2016.

  • Estimated Completion Date: Winter 2016
  • Response Date: August 2015

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2014-134

Agency responses received are posted verbatim.