Recurring Findings

Health Care: Recurring Most severe Noncompliance
Federal Program Issue First Year Reported
Department's Assertion Page Number
Medical Assistance Program Health Care Services lacks sufficient internal controls to ensure only medically necessary claims are paid and to detect providers in violation of record retention requirements. 2005-06
Partially corrected. Health Care Services continues to work on implementing the corrective action steps outlined in the Medi-Cal Payment Error Study (MPES) of 2005-06. Through these continuous efforts Health Care Services is able to identify areas in the program that are the most susceptible and take additional steps to curtail any activity that may compromise the Medi-Cal program. 235
Medical Assistance Program Health Care Services lacks sufficient internal controls to ensure only medically necessary claims and eligible providers are paid. 2006-07
Partially corrected. Exceptions were noted for six claims. Letters requesting the recovery of the four claims determined not to be medically necessary or insufficiently documented will be sent to the providers. Exceptions involving two hospital claims will be recovered during the annual cost report review. Recovery letters will be sent during the week of August 13, 2009. Recovery for the institutional providers will take place during production year 2009-10. 233
Medical Assistance Program Health Care Services’ Provider Enrollment Division (PED) does not retain federally required provider agreements for non-facility providers (for example, doctors, pharmacies, and medical groups). In addition, Public Health’s Licensing and Certification Program (L&C) does not always retain federally required provider agreements for facility providers (such as, hospitals and long-term care facilities). 2006-07
Partially corrected. The (PED) continues to re-enroll providers on continuing basis in accordance with all federal and state statutes and regulations to ensure all providers have Medi-Cal Disclosure Statements and Provider Agreements on file. The PED is working continuously with Public Health to ensure all health facilities obtain the proper licensing for participation in Medi-Cal including the Medi-Cal Provider Agreement. 254
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