Report 2014-134 Recommendation 4 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 #4 To: Health Care Services, Department of
To improve the accuracy of provider directories, by December 2015 Health Care Services should revise its processes for monitoring health plans' provider directories. Specifically, Health Care Services should review how each health plan updates and verifies the accuracy of the directory. In addition, Health Care Services should identify best practices and require the plans to adopt those practices.
Annual Follow-Up Agency Response From October 2019
Since the 2015 audit report, DHCS has updated and streamlined the provider network validation process as well as updated the provider directory review tool used by contract managers to validate the accuracy. DHCS developed a methodology to create a random sample and ensure we follow a standard process and appropriately identify errors in our review of the provider directory. If any errors are identified, the MCP is notified and required to make the corrections.
In 2017, based on the release of the Medicaid Managed Care Final Rule, DHCS updated the validation process and review tool to incorporate the Final Rule requirements. To ensure all requirements of the Final Rule were met, MCPs were required to submit an updated provider directory for review and approval. Although DHCS does not review how each MCP updates and verifies the accuracy of the provider directory, the updated provider directory review tool ensures MCP consistency and compliance in accordance with the Final Rule. DHCS will continue to update the process as necessary to incorporate any new policy changes or best practices as necessary.
- Completion Date: January 2017
California State Auditor's Assessment of Annual Follow-Up Status: Resolved
Although Health Care Services did not implement this recommendation, the actions it has taken resolve the underlying finding to revise its processes for monitoring health plans' provider directories to ensure accuracy.
Annual Follow-Up Agency Response From June 2019
Since the 2015 audit report, DHCS has updated and streamlined the provider network validation process as well as updated the provider directory review tool used by contract managers to validate the accuracy. DHCS developed a methodology to create a random sample and ensure we follow a standard process and appropriately identify errors in our review of the provider directory. If any errors are identified, the MCP is notified and required to make the corrections.
In 2017, based on the release of the Medicaid Managed Care Final Rule, DHCS updated the validation process and review tool to incorporate the Final Rule requirements. To ensure all requirements of the Final Rule were met, MCPs were required to submit an updated provider directory for review and approval. DHCS will continue to update the process as necessary to incorporate any new policy changes.
- Completion Date: January 2017
California State Auditor's Assessment of Annual Follow-Up Status: Pending
Health Care Services' response does not address our recommendation to review how each plan updates and verifies the accuracy of the directory to identify best practices and require all plans to adopt those practices.
- Auditee did not address all aspects of the recommendation
Annual Follow-Up Agency Response From November 2018
DHCS has updated and streamlined the provider network validation process in a formal procedure. The formal provider network validation process is utilized every time that DHCS reviews and approves a MCP's provider directory. The process ensures DHCS is monitoring the plans directory for accuracy across all plans. Plans have adopted DHCS' best practices identified, some of which include providing the directory in an excel format to aid in review accuracy as well as updating their internal policies and procedures to ensure they are receiving updated information to be included in the directories.
- Completion Date: January 2017
California State Auditor's Assessment of Annual Follow-Up Status: Pending
Health Care Services response does not address our recommendation. Specifically, it does not address reviewing each health plan's practice for updating and verifying the accuracy of the directory. Further, although its response states that plans have adopted best practices that Health Care Services has identified, it did not provide any documentation to substantiate this claim.
- Auditee did not substantiate its claim of full implementation
- Auditee did not address all aspects of the recommendation
1-Year Agency Response
In May 2016, CMS released new regulations for Medicaid managed care. These regulations include provider directory requirements that appear to exceed the requirements set forth in SB 137. The Department is currently reviewing the regulations to determine its implications. The first set of SB 137 requirements are effective July 1, 2016; MCPs are still in the process of updating policies and procedures. DHCS and DMHC are updating and reviewing their own internal review process to capture the requirements of both the new federal regulation and state law.
- Estimated Completion Date: July 2017
- Response Date: June 2016
California State Auditor's Assessment of 1-Year Status: Pending
6-Month Agency Response
With the passage of Senate Bill 137, Chapter 649, Statutes of 2015, the DHCS internal workgroup determined that the provisions of SB 137 satisfies the mandates of the CSA audit. SB 137 requires substantial revision of the plan's provider directory monitoring process, in addition to developing uniform provider directory standards to ensure consistency in directories. SB 137 also provides comprehensive requirements for how and when plans should update and verify the accuracy of their directories. During the development and implementation of SB 137 provisions, DHCS will continue to have ongoing discussions and reviews with the plans to enact the policies and procedures as will be set forth by SB 137.
- Completion Date: December 2015
- Response Date: December 2015
California State Auditor's Assessment of 6-Month Status: Pending
Senate Bill 137, Chapter 649, Statutes of 2015 (SB 137) includes various provisions requiring health plans to implement specific procedures for verifying the accuracy of provider directories. However, as it indicates in its response, Health Care Services plans to continue to have ongoing discussions and reviews with the plans to enact the policies and procedures set forth in SB 137. Further, in our follow-up discussions with Health Care Services, it indicated some planned activities for working with the plans to enact the new requirements. Because the activities are noted as planned and have not yet been completed, we assessed the status of this recommendation as pending.
- Auditee did not substantiate its claim of full implementation
60-Day Agency Response
DHCS has assembled an internal workgroup to examine and analyze current Medi-Cal managed care health plan (MCP) policies and procedures regarding provider directory updates and verification of listings and proper methodology for randomly sampling directories. DHCS will evaluate MCPs' business practices to determine those functions that yield the most accurate listing results. Once these best practices are identified, DHCS will institute a standardized policy and subsequently monitor compliance with the requirements. Issuance of the policy is scheduled to implement by December 2015.
- Estimated Completion Date: December 2015
- 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.