The Bureau of State Audits (BSA) presents the tenth in a series of semiannual reports evaluating the way the Department of Health Services (department) processes reimbursement requests for certain prescribed drugs under the California Medical Assistance Program (Medi-Cal). These requests are known as drug treatment authorization requests (TARs).
This report focuses on the drug TARs processed during the six months from June 1995 through November 1995. During this six-month period, the department's processes for compiling drug TAR statistics were accurate. The department received 354,855 drug TARs from June to November 1995. This figure represents an increase of 276,357 (352 percent) received over the first sixmonth review period of June through November 1990 and is the highest level of activity since the beginning of these reviews. This increase was primarily due to changes in the governing code and a 41 percent increase in the number of people eligible to obtain drugs through Medi-Cal (from 3,675,000 to 5,165,590).
Of the drug TARs received from June 1995 through November 1995, the department processed 354,702. This figure represents an increase of 30,558 (10 percent) over the prior six-month period from December 1994 through May 1995. In November 1990, the department's backlog consisted of 2,311 unprocessed drug TARs. In comparison, the backlog in November 1995 was only 1,266 drug TARs.
Both of the department's drug units (located in Stockton
and Los Angeles) met the state requirement for processing mailed-in drug TARs in one working day. Based on samples
of mailed-in drug TARs randomly selected at each drug unit, we found that the drug units met the requirement 100 percent of the time.
We also found that the drug units generally met the state requirement for processing fax and Voice Drug TAR System (VDTS) drug TARs within one working day. Based on samples of fax drug TARs randomly selected at each drug unit, we found that the Stockton drug unit met the requirement 99 percent of the time and the Los Angeles drug unit met the requirement 98 percent of the time. Based on a sample of VDTS drug TARs randomly selected at the Los Angeles drug unit, we found that the drug unit met the requirement 100 percent of the time. The Stockton drug unit did not process any VDTS drug TARs during the review period. We also found that the department's methods of measuring the time it takes to process a drug TAR were accurate.
From June 1995 through November 1995, 201 fair hearing requests to appeal denials of drug TARs were submitted to the Department of Social Services. This figure represents an increase of 117 (139 percent) over the prior review period, from December 1994 to May 1995. Of the 201 requests submitted, 151 (75 percent) were withdrawn or dismissed, 14 were denied, and 15 were approved. The decisions on the remaining 21 were still pending at the time of our review.