Report 2009-112 Recommendations and Responses in 2012-041

Report 2009-112: Department of Health Care Services: It Needs to Streamline Medi-Cal Treatment Authorizations and Respond to Authorization Requests Within Legal Time Limits

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 2 3 2 2

Recommendation To: Health Care Services, Department of

To ensure that Medi-Cal recipients receive timely access to prescribed drugs, Health Care Services should abolish its policy of responding to drug TARs by the end of the next business day and should instead ensure that prior-authorization requests to dispense drugs are processed within the legally mandated 24-hour period. Alternatively, it should seek formal authorization from CMS to deviate from the 24-hour requirement, and should seek a similar modification to state law. In addition, Health Care Services should begin recording the actual time it receives paper TARs so that it can begin to measure accurately its processing times.

Response

The recommendation has two parts. The first is to abolish the policy of adjudicating drug TARs by the next business day and instead ensure prior authorization requests to dispense drugs are processed within the mandated 24-hour period. As an alternative, Health Care Services should seek formal authorization from the Centers for Medicare and Medicaid Services (CMS) to use the next business day timeframe and should modify existing state law accordingly. The second is to begin recording the time that Health Care Services receives paper TARs. As indicated in the previous update, Health Care Services will implement the second component, but not the first.

Record Time of Paper TAR Receipt

Health Care Services will begin to record the time of paper TAR receipt when Xerox, the new CA-MMIS contractor, develops and implements the new TAR submission and adjudication system. As noted in previous status reports, the current system does not have the capacity to record the time of TAR receipt, and it would be costly and time intensive to make the changes that would enable it to do so.

Next Business Day Adjudication of Drug TARs

As indicated in prior status reports, it is not feasible for Health Care Services to process drug TARs within 24 hours of receipt because its offices are not staffed or budgeted for 24-hour/seven-day-per-week operations. Emergency drug supplies are available to Medi-Cal beneficiaries as needed and do not require prior authorization. Health Care Services has received few complaints from providers and beneficiaries regarding the timely processing of drug TARs.

Health Care Services has not sought formal authorization from CMS to deviate from the 24-hour requirement. CMS is aware of Health Care Services' “next business day” practice and the availability of emergency drug supplies for Medi-Cal beneficiaries.

  • California State Auditor's Assessment of Status: Will Not Implement
  • Response Date: October 2012

Recommendation To: Health Care Services, Department of

To ensure that Medi-Cal recipients are receiving timely medical services from providers, Health Care Services should start tracking prior-authorization medical TARs separately and should ensure that such TARs are processed within an average of five working days. Although state law and regulations specifically require prior authorization for certain medical services, Health Care Services generally does not require prior authorizations in practice. Consequently, Health Care Services should seek legislation to update existing laws and amend its regulations to render them consistent with its TAR practices.

Response

As indicated in previous status reports, Health Care Services has implemented a process to separately track paper prior-authorization medical TARs. Health Care Services will separately track electronic prior-authorization medical TARs when Xerox, the new CA-MMIS contractor, develops and implements the new TAR submission and adjudication system. The current system does not have the ability to track prior-authorization TARs, and it would be costly and time intensive to make the modifications that would enable it to do so.

As noted in previous status reports, Health Care Services is not currently seeking legislation to update existing laws and regulations to make them consistent with the TAR process. The reason is that the continuing implementation of the Affordable Care Act will lead to considerable changes in the Medi-Cal program and California's entire health care system in the coming months and years, and this will likely lead to significant, as yet unknown, changes to the TAR process. Given current uncertainties and the likelihood of significant change, it would not be advisable to make this kind of modification of existing TAR related laws or regulations at this time.

  • California State Auditor's Assessment of Status: Will Not Implement
  • Response Date: October 2012

Current Status of Recommendations

All Recommendations in 2012-041