Skip Repetitive Navigation Links
California State Auditor Logo COMMITMENT • INTEGRITY • LEADERSHIP

Department of Health Care Services
It Paid Billions in Questionable Medi-Cal Premiums and Claims Because It Failed to Follow Up on Eligibility Discrepancies

Report Number: 2018-603


Appendix A

Health Care Services’ Payments for Beneficiaries with Questionable Eligibility by County

Health Care Services’ Payments for Beneficiaries with Questionable Eligibility by County Health Care Services paid at least $4 billion in questionable Medi‑Cal premiums and claims from January 2014 through December 2017 because it failed to ensure that it was providing benefits only to eligible beneficiaries. As the Audit Results discusses and Table A shows, we found more than 453,000 beneficiaries with eligibility discrepancies in Health Care Services’ eligibility system when compared to the three systems counties use to track beneficiaries—CalWIN, Consortium IV system (C‑IV), and the LEADER Replacement System (LRS). Further, our analysis identified questionable payments in all 58 counties and across both managed care and fee for service.

 

Table A
Health Care Services’ Questionable Payments by County
January 2014 Through December 2017
      QUESTIONABLE PAYMENTS
COUNTY COUNTY ELIGIBILITY SYSTEM NUMBER OF BENEFICIARIES WITH QUESTIONABLE ELIGIBILITY MANAGED CARE PREMIUMS FEE-FOR-SERVICE
CLAIMS
TOTAL PERCENTAGE OF TOTAL QUESTIONABLE PAYMENTS
Alameda CalWIN 16,576 $102,076,949 $39,202,592 $141,279,541 3.5%
Alpine C-IV 18 111,776 3,198 114,974 0
Amador C-IV 17 150,769 91,505 242,274 0
Butte C-IV 1,269 8,674,341 1,885,072 10,559,413 0.3
Calaveras C-IV 311 2,429,671 899,317 3,328,988 0.1
Colusa C-IV 36 87,892 20,999 108,891 0
Contra Costa CalWIN 7,920 49,935,252 33,879,863 83,815,115 2.1
Del Norte C-IV 211 1,577,960 140,628 1,718,588 0
El Dorado C-IV 105 616,193 87,021 703,214 0
Fresno CalWIN 5,297 18,709,439 5,568,238 24,277,677 0.6
Glenn C-IV 40 294,679 45,276 339,955 0
Humboldt C-IV 79 318,614 231,436 550,050 0
Imperial C-IV 550 3,353,730 710,360 4,064,090 0.1
Inyo C-IV 16 43,300 181,053 224,353 0
Kern C-IV 2,357 10,421,757 2,854,656 13,276,413 0.3
Kings C-IV 163 779,034 327,911 1,106,945 0
Lake C-IV 463 3,273,444 855,301 4,128,745 0.1
Lassen C-IV 69 387,951 58,094 446,045 0
Los Angeles LRS 229,248 1,532,680,994 585,660,939 2,118,341,933 52.4
Madera C-IV 119 864,046 1,989,151 2,853,197 0.1
Marin C-IV 827 8,859,327 627,725 9,487,052 0.2
Mariposa C-IV 67 299,716 285,105 584,821 0
Mendocino C-IV 748 3,748,953 2,149,447 5,898,400 0.1
Merced C-IV 86 341,869 152,196 494,065 0
Modoc C-IV 20 47,371 16,239 63,610 0
Mono C-IV 112 504,847 399,282 904,129 0
Monterey C-IV 2,563 18,387,622 3,430,382 21,818,004 0.5
Napa C-IV 595 6,741,645 3,225,622 9,967,267 0.2
Nevada C-IV 396 1,311,998 407,463 1,719,461 0
Orange CalWIN 34,891 323,964,900 34,352,740 358,317,640 8.9
Placer CalWIN 1,393 7,298,676 1,648,104 8,946,780 0.2
Plumas C-IV 162 660,807 121,101 781,908 0
Riverside C-IV 29,018 180,213,715 60,838,585 241,052,300 6
Sacramento CalWIN 11,251 68,144,496 9,930,744 78,075,240 1.9
San Benito C-IV 495 1,536,023 1,210,685 2,746,708 0.1
San Bernardino C-IV 5,907 27,007,104 13,326,250 40,333,354 1
San Diego CalWIN 70,080 474,787,181 130,309,308 605,096,489 15
San Francisco CalWIN 366 1,377,952 1,496,221 2,874,173 0.1
San Joaquin C-IV 1,747 6,954,016 985,090 7,939,106 0.2
San Luis Obispo CalWIN 982 5,244,684 1,614,122 6,858,806 0.2
San Mateo CalWIN 4,015 38,392,429 2,351,471 40,743,900 1
Santa Barbara CalWIN 3,507 21,179,178 3,601,565 24,780,743 0.6
Santa Clara CalWIN 3,931 32,825,284 8,542,892 41,368,176 1
Santa Cruz CalWIN 1,240 9,838,597 5,370,235 15,208,832 0.4
Shasta C-IV 70 420,248 1,960,819 2,381,067 0.1
Sierra C-IV 24 122,038 24,143 146,181 0
Siskiyou C-IV 400 2,047,409 570,499 2,617,908 0.1
Solano CalWIN 3,784 36,185,927 3,590,391 39,776,318 1
Sonoma CalWIN 2,009 8,882,768 4,753,208 13,635,976 0.3
Stanislaus C-IV 768 4,558,082 1,247,585 5,805,667 0.1
Sutter C-IV 555 3,193,302 312,170 3,505,472 0.1
Tehama C-IV 65 171,574 35,906 207,480 0
Trinity C-IV 33 161,649 76,513 238,162 0
Tulare CalWIN 4,016 15,727,846 5,214,699 20,942,545 0.5
Tuolumne C-IV 49 256,429 80,509 336,938 0
Ventura CalWIN 901 5,596,056 1,954,286 7,550,342 0.2
Yolo CalWIN 809 6,254,162 714,797 6,968,959 0.2
Yuba C-IV 645 3,325,283 746,105 4,071,388 0.1
  Totals* 453,391 $3,063,358,954 $982,366,814 $4,045,725,768 100%

Source: Analysis of the counties’ and Health Care Services’ eligibility data, and Health Care Services’ payment data.

* The percentage of total questionable payments does not total 100 percent due to rounding.



Back to top