Report 2006-110 Recommendations

To ensure that it does not prevent or delay some eligible providers from delivering services to Medi-Cal beneficiaries, the branch should ensure that it promptly notifies applicants that it has automatically enrolled them as provisional Medi-Cal providers when the branch has not processed the applications within the required time periods.

The branch should modify PETS data to track the length of time applications it recommends for denial remain in the policy section for review, to ensure that it does not automatically enroll or pay the claims of ineligible providers when the review does not occur in a timely manner.

Branch management should include in the secondary reviews of applications periodic reviews to ensure that staff are accurately and consistently entering the correct dates the branch received, processed, or returned the application into PETS.

To protect the integrity of PETS data, the branch should remove all staff training and branch testing data from PETS and include it in an environment that simulates PETS, thus protecting the integrity of the production data.

To ensure that the branch does not unnecessarily increase its workload or prolong the enrollment process for eligible applicants, it should increase its efforts to notify applicants that they must use the current and appropriate application forms to avoid being denied enrollment into Medi-Cal.

The department should seek legislation to revise state law to extend the 35-day time period applicants have to remedy deficiencies in their applications to 60 days.

The department should seek legislation to revise state law to eliminate preferred provider status. However, if it chooses to keep this status and to increase the number of applicants that could benefit from the shorter processing period that preferred provider status offers, the department should increase its efforts to notify applicants of the reasons it denies applications during the prescreening for preferred provider status.

The branch, with direction from the department, should align the reasons available in PETS for which it may refer an application with its fraud indicators and high-risk checklists to better track the appropriateness of its high-risk checklists and update the fraud indicators as trends in fraud change over time.

To ensure that it is referring those applicants at greatest risk of committing fraud and not preventing eligible Medi-Cal providers from providing services to beneficiaries, the branch and the Medical Review Branch, with direction from the department, should reevaluate the appropriateness of the branch's high-risk fraud indicators periodically by consistently communicating and collaborating with one another.

The branch and the Medical Review Branch, with direction from the department, should place increased emphasis on processing those applications referred for further review within a reasonable time period, to ensure that some eligible Medi-Cal providers are not unreasonably delayed from providing services to beneficiaries.

The branch should monitor the implementation of Medicare's revalidation process in which it verifies the enrollment information for all its providers to identify opportunities for streamlining its application and verification procedures, and should make modifications as appropriate for Medicare providers seeking enrollment in Medi-Cal.

The branch should continue its plans to reenroll all its Medi-Cal providers and add any resources freed up by its streamlining of its enrollment process.