Report 97012 Summary - August 1997

Department of Health Services:

Some Drug Treatment Authorization Requests Are Not Processed Promptly

The Bureau of State Audits presents the thirteenth 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).

The department received 437,253 drug TARs from December 1996 through May 1997, an increase of 358,755 (457 percent) over the number received during our first six-month review period of June through November 1990. Major reasons for this significant increase include the rise in the number of people eligible to obtain drugs through Medi-Cal and changes in the governing code that require more drug TARs in specific situations.

The department processed 440,302 drug TARs from December 1996 through May 1997, an increase of 363,020 (470 percent) over the number processed during the first six-month period we reviewed. The current number represents the highest level of activity for any period we reviewed.

Although the number of processed drug TARs has risen substantially since June 1990, the percentage of unprocessed drug TARs compared to drug TARs received continues to remain at a low level. The average month-end backlog for the review period December 1996 through May 1997 was just 5 percent of all drug TARs received.

The department's Stockton drug unit consistently complied with state policy, which requires that all drug TARs be processed within one working day. However, the Los Angeles drug unit did not always comply with state policy, taking longer than one working day to fully process 117 (31 percent) of the 375 drug TARs sampled that were either mailed or submitted via Voice Drug TAR System (VDTS). In contrast, samples of facsimile (fax) drug TARs received by the Los Angeles unit, as well as samples of faxes and mailed-in drug TARs received at the Stockton unit, showed both units processed all 1,383 TARs within the required time frame.

We found that the number of fair-hearing requests went down during this latest review period. From December 1996 through May 1997, beneficiaries submitted to the Department of Social Services 71 fair-hearing requests appealing denials of drug TARs. This figure represents a decrease of 26 (27 percent) over the prior review period of June 1996 to November 1996.