Report 2014-134 Recommendation 6 Responses

Report 2014-134: California Department of Health Care Services: Improved Monitoring of Medi-Cal Managed Care Health Plans Is Necessary to Better Ensure Access to Care (Release Date: June 2015)

Recommendation #6 To: Health Care Services, Department of

If Health Care Services finds significant errors in a health plan's provider directory, it should work with that health plan to identify reasons for the inaccuracies and require the health plan to develop processes to eliminate the inaccuracies.

Annual Follow-Up Agency Response From October 2021

The Managed Care Plan (MCP) contracts were updated to require MCPs to update paper and electronic provider directories in accordance with 42 CFR 438.10(h)(3). The updated contract language specifically identifies the required information which needs to be included in provider directories for Primary Care Physicians, Specialists, hospitals, pharmacies, behavioral health providers and any other Providers contracted for Medi-Cal Covered Services. The DHCS reviews the provider directory every six months utilizing a review tool to ensure the provider directory meets 42 CFR 438.10(h) and Health and Safety Code 1367.27. If the DHCS finds any errors in the MCPs provider directory during the review process, per Exhibit A, Attachment 13, E, 5 under Member Services, MCP Boilerplate Contract, the MCP is required to immediately address findings identified during the DHCS review process. The MCP is required to re-submit the Provider Directory for review and document how the error(s) in question was addressed.

In addition to DHCS' six-month review, DHCS' External Quality Review Organization (EQRO) established a process for conducting provider directory validation and will be providing quarterly results to DHCS based on outbound calls to Providers included in the Provider Directory. Results from the Provider Directory review will be retained on SharePoint by Health Care Plan. Initial requirements for the Provider Directory review have been established and DHCS' EQRO began making outreach calls to validate provider information in the first quarter of 2020. However; due to the COVID-19 pandemic, the work through DHCS' EQRO is delayed. DHCS expects to resume the work efforts in the first quarter of 2022.

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

Annual Follow-Up Agency Response From November 2020

The contract amendment previously pending with CMS was approved as of March 12, 2020. Considering the last requirement indicated above was the pending approval of the Final Rule contract amendment, DHCS considers the recommendation fully implemented. The approval letters are included as substantiation.

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

Health Care Services did not provide necessary documentation to demonstrate that the Final Rule it references contained language that would address our recommendation.

Annual Follow-Up Agency Response From October 2019

DHCS has implemented contractual requirements from the Final Rule. Health Plans implemented the Final Rule requirements into their provider directories. DHCS has also updated the review tool used to review provider directories to ensure consistency and accuracy as well as compliance with the Final Rule requirements. In addition, DHCS is working with an outside vendor to make outbound calls to providers to increase the confidence level when verifying provider information.

CMS is currently reviewing the contract amendment that includes the Final Rule. The date of when the contract approval from CMS will be provided is pending. Once approved, DHCS will consider this implemented.

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

Annual Follow-Up Agency Response From June 2019

DHCS has implemented contractual requirements from the Final Rule. Health plans continue to utilize the new provider directory template. The contract amendment is in its final stage of being reviewed by CMS. There is no date at this time as to when the contract approval from CMS will be provided. Once approved, DHCS will consider this implemented.

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

Annual Follow-Up Agency Response From November 2018

DHCS has implemented contractual requirements from the Final Rule. Health Plans are now utilizing the new provider directory template. Each health plan submitted its directory for review and approval by DHCS. The contract amendment is currently being reviewed by CMS. There is no date at this time as to when the contract approval from CMS will be provided. Once approved, DHCS will consider this implemented.

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

1-Year Agency Response

In May 2016, CMS released new regulations for Medicaid managed care. These regulations have requirements specific to provider directories that the Department is currently reviewing to determine implications. However, initial reviews show that the requirements exceed those set forth in SB 137. Knox Keene licensed health plans are required to come into compliance with the first set of SB 137 requirements by July 1, 2016. Health plans are currently in the process of updating their policies and procedures to reflect these requirements.

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

6-Month Agency Response

DHCS updated its Provider Directory review process and implemented the revised procedures effective September 2015. DHCS developed a standardized universal process to include sample size methodology, as well as a randomization mechanism to determine which providers to contact for verification of their respective PD listing. Staff were trained on the revised process and provided written procedures. DHCS updated the tools and record retention procedures for verification activities and plan communications.

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

Health Care Services' revised procedures for provider directory review states that if the review results in numerous inconsistencies, staff should inquire about how the health plan follows best business practices for ensuring accurate provider directory information. However, the revised procedures do not require the health plan to develop processes to eliminate the inaccuracies. After we followed up with Health Care Services, it stated that with the enactment of SB 137, Chapter 649, Statutes of 2015 (SB 137), Managed Health Care will be establishing and implementing universal standards and practices for health plans and their provider directories, which will be designed to establish and implement a system of best practices to eliminate provider directory inaccuracies. Health Care Services noted that it will align its policies and procedures for internal functions and for operations pertaining to external entities with Managed Health Care standards and practices.

60-Day Agency Response

DHCS has assembled an internal workgroup to examine best practices to validate Medi-Cal managed care health plan (MCP) provider directory listings and develop a methodology for randomly sampling directories. Once identified, DHCS will update review tools, create compliance checklists, establish new policies and procedures, and train staff to ensure policies and procedures are complied with. These new processes will include sample sizes, which appropriately reflect the size of the MCP, and outreach to providers to confirm providers are listed correctly and are a part of the MCP's network. Additionally, DHCS will implement enhanced policies for review documentation and record retention. This activity is scheduled to implement by September 2015.

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

All Recommendations in 2014-134

Agency responses received are posted verbatim.