Report 2007-122 Recommendations and Responses in 2012-041

Report 2007-122: Department of Health Care Services: Although Notified of Changes in Billing Requirements, Providers of Durable Medical Equipment Frequently Overcharged Medi-Cal

Department Number of Years Reported As Not Fully Implemented Total Recommendations to Department Not Implemented After One Year Not Implemented as of Most Recent Response
Department of Health Care Services 4 3 2 0

Recommendation To: Health Care Services, Department of

To maintain control over the cost of reimbursements, Health Care Services should develop an administratively feasible means of monitoring and enforcing current Medi-Cal billing and reimbursement procedures for medical equipment. If unsuccessful, Health Care Services should consider developing reimbursement caps for medical equipment that are more easily administered.

Response

The California Department of Health Care Services (DHCS) continues to maintain control over the cost of reimbursement through the application of edits and audits to claims for payment submitted to the fiscal intermediary consistent with Medi-Cal policy. Additionally, DHCS conducts a variety of post-payment audits to monitor and enforce Medi-Cal billing and reimbursement procedures for medical equipment. As a result of these efforts it is not necessary to implement reimbursement caps for medical equipment.

  • California State Auditor's Assessment of Status: Fully Implemented
  • Completion Date: October 2012
  • Response Date: October 2012

Recommendation To: Health Care Services, Department of

If Health Care Services continues using audits to ensure that providers comply with Medi-Cal billing procedures for medical equipment, including the upper billing limit, it should design and implement a cost-effective approach that adequately addresses the risk of overpayment and ensures that all providers are potentially subject to an audit, thereby providing a deterrent for noncompliance.

Response

Audits & Investigations (A&I) has completed all Upper Billing Limit (UBL) reviews except for which which is in progress. The UBL audits were effective in identifying providers who were out of compliance with the billing requirements and in identifying for recovery amounts overpaid. All identified providers received Civil Money Payment letters which identified the billing errors and the consequences of future non-compliance. All providers will be subject to re-audit in six months to verify compliance. Providers who are not in compliance with the billing requirements will be subject to administrative and financial sanctions. A&I considers this matter as being resolved.

  • California State Auditor's Assessment of Status: Fully Implemented
  • Completion Date: October 2012
  • Response Date: October 2012

Current Status of Recommendations

All Recommendations in 2012-041