Report 2014-134 Recommendation 5 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 #5 To: Health Care Services, Department of

To ensure that its review of provider directories is effective in identifying inaccurate information before it approves them for publication, Health Care Services should establish by September 2015 more detailed written policies and procedures for staff to follow that will provide evidence that staff are verifying the accuracy of provider directories. This verification process should include, at a minimum, the following elements:

- Developing a standard process for selecting a random sample, including procedures for selecting a sample size that is sufficient to identify errors in a provider directory and to enable Health Care Services to understand the accuracy of the entire directory. Health Care Services should then ensure that staff follow this process.

- Requiring staff to maintain for at least three years the documentation of their reviews and the verifications of the accuracy of provider directories.

- Retaining for three years Health Care Services' communications with the health plans about any errors found in the directories or about the approvals of the directories.

6-Month Agency Response

DHCS updated its Provider Directory review process and implemented the revised procedures effective September 2015. DHCS developed a standardized universal process to include sample size methodology, as well as a randomization mechanism to determine which providers to contact for verification of their respective PD listing. Staff were trained on the revised process and provided written procedures. DHCS updated the tools and record retention procedures for verification activities and plan communications.

  • Completion Date: September 2015
  • Response Date: December 2015

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

60-Day Agency Response

DHCS has assembled an internal workgroup to examine best practices to validate Medi-Cal managed care health plan (MCP) provider directory listings and develop a methodology for randomly sampling directories. Once identified, DHCS will update review tools, create compliance checklists, establish new policies and procedures, and train staff to ensure policies and procedures are complied with. These new processes will include sample sizes, which appropriately reflect the size of the MCP, and outreach to providers to confirm providers are listed correctly and are a part of the MCP's network. Additionally, DHCS will implement enhanced policies for review documentation and record retention. This activity is scheduled to implement by September 2015.

  • Estimated Completion Date: September 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.