Report 2014-130 Recommendation 3 Responses

Report 2014-130: California Department of Health Care Services: It Should Improve Its Administration and Oversight of School‑Based Medi-Cal Programs (Release Date: August 2015)

Recommendation #3 To: Health Care Services, Department of

Until the Legislature implements our recommendation in Chapter 2, Health Care Services should immediately resolve weaknesses in its oversight of local educational consortia and local governmental agencies to ensure that these entities sufficiently meet their responsibilities under the administrative activities program and meet the terms of their contracts with Health Care Services. Health Care Services should update its site review and desk review procedures to include the following steps:
* A risk-based approach to selecting entities for review.
* Verification that local educational consortia and local governmental agencies are adequately meeting the oversight and administrative responsibilities described in their contracts with Health Care Services.
* Verification that contracts between local educational consortia or local governmental agencies and their claiming units do not include provisions that could result in disallowed costs, such as allowing Health Care Services' participation fee to be included in the claim calculations.
* Examination of local educational consortia and local governmental agencies' records to ensure that:
-- Costs they claim for federal reimbursement are necessary and reasonable.
-- The entities are not inappropriately earning a profit based on the fees they collect from claiming units.
-- The coding performed by local educational consortia that charge claiming units a percentage of their federal reimbursement is reasonably accurate.

Annual Follow-Up Agency Response From November 2020

DHCS developed and finalized new desk review/site visit procedures based on the RMTS methodology as of December 2019. The desk reviews/site visits utilizing the new procedures were set to begin in April 2020. However, due to the COVID-19 pandemic desk review/site visits have been delayed. Desk reviews will begin in December 2020 and site visits will begin upon the termination of the pandemic.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2019

SMAA is currently developing a new desk review/site visit procedure based on the random moment time survey (RMTS) methodology. Desk reviews will begin in early 2020, and these desk reviews will inform the site visit procedure which will begin in mid 2020.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From August 2019

A. DHCS did develop a risk-based approach for selecting entities for review. This criteria for determining high-risk claiming units was added to section 6-23 of the SMAA Manual at: http://www.dhcs.ca.gov/provgovpart/Documents/ACLSS/Manuals/SMAA-Manual/SMAA_Manual.pdf

B. Site visits will resume once back-casting has been completed. DHCS anticipates resuming site visits in September 2019, the quarter following the completion of back-casting.

C. DHCS has reviewed all LEC/LGA contracts with Local Educational Agencies (LEA). These contracts do not contain provisions that could result in disallowed costs.

D. Although site visits have not yet resumed;

a. DHCS reviews all costs contained on LEC/LGA invoices submitted for reimbursement.

b. All fees charged to LEAs are based on the LEC/LGAs actual cost for administering the program.

c. DHCS conducts a 10 percent random sample review of all coded moments each quarter.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2018

(A)DHCS did develop a risk-based approach for selecting entities for review. This criteria for determining high-risk claiming units was added to section 6-23 of the School-Based Medi-Cal Administrative Activities (SMAA) Manual at: http://www.dhcs.ca.gov/provgovpart/Documents/ACLSS/Manuals/SMAA-Manual/SMAA_Manual.pdf

(B)Site visits will resume once backcasting has been completed. DHCS anticipates resuming site visits in September 2019, the quarter following the completion of backcasting.

(C)DHCS has reviewed all LEC/LGA contracts with Local Educational Agencies (LEA). These contracts do not contain provisions that could result in disallowed costs.

(D)Although site visits have not yet resumed;

a.DHCS reviews all costs contained on LEC/LGA invoices submitted for reimbursement.

b.All fees charged to LEAs are based on the LEC/LGAs actual cost for administering the program.

c.DHCS conducts a 10 percent random sample review of all coded moments each quarter.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Annual Follow-Up Agency Response From September 2017

DHCS anticipates beginning site visits in January 2018. The delay from previous updates is due to unanticipated workload for Fiscal Year (FY) 2017-18 Quarter (Q) 2, which includes processing FY 2015-16 Q2 invoice payments, FY 2009-10 and FY 2010-11 backcasting invoice payments. All of these claims must be processed before December 1, 2017; therefore, staffing resources are currently fully directed to processing these claims.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

DHCS developed criteria that will identify high-risk entities and provided it to the CSA on June 29, 2016. New site visit protocols will be implemented once coding has been finalized and invoices begin to be submitted. It would not be practical for the Department to begin site visits until we are able to review invoices that have been submitted via the new RMTS methodology. DHCS issued PPL 16-007 on April 8, 2016, informing LECs and LGAs about the participation fee and added this step to the site visit protocols. DHCS anticipates beginning sites visits in October of 2017.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

6-Month Agency Response

DHCS reviews LEC/LGA oversight responsibilities during regularly scheduled site visits. As site visits have recently resumed, a new site visit protocol is being developed to include: a risk-based approach for identifying high-risk claiming units; a thorough review of sub-recipient contracts to verify the lack of provisions for claiming participation fees; and a detailed review of all assigned codes for moment responses. DHCS will develop a set of criteria that can be used to identify high-risk claiming units and help facilitate a revised site visit protocol based on the new Random Moment Time Survey (RMTS) methodology.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS will work with audit staff in Audits and Investigation to review current risk-based practices to develop an approach for selecting entities for review. DHCS has requested copies of all contracts with the LEC/LGAs and LEAs and will review to determine the oversight and administrative responsibilities and verify these activities are being accomplished.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2014-130

Agency responses received are posted verbatim.