Report 2009-112 Recommendations and Responses in 2014-041

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 2013-041 Response Not Implemented as of Most Recent Response
Department of Health Care Services 4 3 2 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

CAASD had previously stated that a change as recommended would not be forthcoming until the new system being developed by CA-MMIS and Xerox was implemented. A change in the paper TAR process will likely implement prior to the implementation of the new system. A DHCS-sponsored bill, AB 1457, was recently signed into law by Governor Brown. This bill mandates the use of e-TAR for all fee-for-service treatment requests and eliminates the use of paper TARs. This mandate takes effect as of July 1, 2016. The implementation of the e-TAR mandate will render this recommendation moot. CAASD will develop a transition plan for providers who use paper TARs and related provider stakeholder groups to aid in the transition to e-TAR.

Next Business Day Adjudication of Drug TARs:

As indicated in the 2013 status update, it is not feasible for Health Care Service to process drug TARs within 24 hours of receipt because its offices are not staffed nor budgeted for 24-hour/seven-day-per-week operations. Emergency drug supplies are available to Medi-Cal beneficiaries as needed. In addition, Health Care Services has received few complaints from providers or beneficiaries regarding the timely processing of drug TARs. For these reasons, Health Care Services intends to continue its practice of adjudicating drug TARs by the next business day. Health Care Services has not sought formal authorization from CMS to deviate from the 24-hour requirement because CMS is aware of Health Care Services' "next business day" practice and that the emergency drug supplies are available to Medi-Cal beneficiaries as needed.

  • California State Auditor's Assessment of Status: Will Not Implement
  • Response Date: October 2014

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

A process was developed, and has been implemented, to track and adjudicate prior authorization TARs received in paper form. The ability to implement such a process for TARs received electronically is part of a replacement TAR processing system currently under development by Xerox State Healthcare, LLC. Changes to the existing system would be costly and time-intensive and not a prudent use of limited resources. Due to current uncertainties and the likelihood of significant change to the TAR process with the implementation of the Affordable Care Act, Health Care Services is not seeking legislation to update existing laws and/or regulations to make them consistent with the TAR process.

  • California State Auditor's Assessment of Status: Will Not Implement
  • Response Date: October 2013

Current Status of Recommendations

All Recommendations in 2014-041