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.
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.
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.
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.
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.
Agency responses received are posted verbatim.