Report 2018-603 Recommendation 6 Responses
Report 2018-603: Department of Health Care Services: It Paid Billions in Questionable Medi-Cal Premiums and Claims Because It Failed to Follow Up on Eligibility Discrepancies (Release Date: October 2018)
Recommendation #6 To: Health Care Services, Department of
To assist counties in addressing discrepancies, Health Care Services should reevaluate and update its guidance to the counties related to prioritizing MEDS alerts by December 31, 2018.
In preparation for the resumption of county oversight monitoring activities in June 2024, DHCS published All County Welfare Department Letter 23-14 in July 2023. The letter informs counties of the prioritization of MEDS Alerts based on the impact to eligibility.
- Completion Date: July 2023
California State Auditor's Assessment of Status: Fully Implemented
DHCS issued updated guidance in July 2023 related to processing MEDS alerts.
DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high-volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to Recommendation 3 referencing DHCS' response to the COVID-19 pandemic.
Otherwise, no changes from the 48 Month update submitted to CSA on August 4, 2022.
- Estimated Completion Date: 03/01/2024
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until March 2024.
The estimated implementation date was extended by four months to 3/1/2024, due to an extension of the PHE for COVID-19. No changes from 45-Month Program Update.
- Estimated Completion Date: 3/1/2024
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not implement this recommendation until March 2024.
The Estimated Implementation Date was extended by four months due to an extension of the PHE for COVID-19. Otherwise, no change from previous response:
DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 PHE, efforts are now suspended. Please refer to the response to Recommendation 3 referencing DHCS' response to the COVID-19 pandemic.
- Estimated Completion Date: 11/1/2023
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until November 2023.
DHCS plans to move forward with the implementation plan provided in the previous update upon termination of the public health emergency with no modifications to the original plan. Response is unchanged from 39-Month Update. DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
-Reducing discrepancies between systems.
-Capturing records in a hold status for an extended period.
-Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to Recommendation 3 referencing DHCS' response to the COVID-19 pandemic.
- Estimated Completion Date: 07/01/2023
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until July 2023.
Response is unchanged from the 36-Month update. DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to Recommendation 3 referencing DHCS' response to the COVID-19 pandemic.
However, due to the extension of the original termination date of the federal public health emergency, the estimated implementation date is now 12/31/2022.
- Estimated Completion Date: 12/31/2022
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until December 2022.
Response is unchanged from 33-Month Update. DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to Recommendation 3 referencing DHCS' response to the COVID-19 pandemic.
However, due to the extension of the original termination date of the federal public health emergency, the estimated implementation date is now 12/31/2022.
- Estimated Completion Date: 12/31/2022
California State Auditor's Assessment of Status: Pending
Per Health Care Services' response, it will not fully implement this recommendation until December 2022.
Response is unchanged from 30-Month Update. DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high-volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to Recommendation 3 referencing DHCS' response to the COVID-19 pandemic.
- Estimated Completion Date: December 31, 2021
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until December 2021.
Response is unchanged from 27-Month Update. DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to Recommendation 3 referencing DHCS' response to the COVID-19 pandemic.
- Estimated Completion Date: December 31, 2021
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until December 2021.
Response is unchanged. DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to recommendation three referencing DHCS' response to the COVID-19 pandemic.
- Estimated Completion Date: June 2021
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until June 2021.
Response is unchanged. DHCS is working with the pilot counties to identify caseworker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to recommendation three referencing DHCS' response to the COVID-19 public health emergency.
- Estimated Completion Date: June 2021
California State Auditor's Assessment of Status: Pending
Per the department's response, it will not fully implement this recommendation until June 2021.
Response is unchanged. DHCS is working with the pilot counties to identify case worker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period of time.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritize MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to recommendation three referencing DHCS' response to the COVID-19 pandemic.
- Estimated Completion Date: Unknown
California State Auditor's Assessment of Status: Pending
DHCS is working with the pilot counties to identify case worker actions resulting in specific, high volume alerts. DHCS works collaboratively with the pilot counties to develop and implement business practices to reduce the overall number of alerts produced on a monthly basis, and leverage pilot activities to identify MEDS alerts most effective in:
- Reducing discrepancies between systems.
- Capturing records in a hold status for an extended period of time.
- Capturing records no longer meeting eligibility criteria for the assigned aid code.
DHCS' pilot activities will assist in developing updated guidance to prioritizes MEDS alerts and provide guidance on actions counties may take to reduce the creation of MEDS alerts.
Due to the COVID-19 public health emergency, efforts are now suspended. Please refer to the response to recommendation three referencing DHCS' response to the COVID-19 pandemic.
- Estimated Completion Date: June 2021
California State Auditor's Assessment of Status: Pending
The prioritization of MEDS alerts is a separate effort; however, the pilot will be leveraged to identify MEDS alerts that are most effective in:
- Reducing discrepancies between systems.
- Capturing records that remain in a hold status for an extended period of time.
- Capturing records that no longer meet the eligibility criteria for the assigned aid code.
DHCS will then work with stakeholders to prioritize these alerts. Upon completion of this process, DHCS will issue updated guidance on the prioritization of MEDS alerts.
- Estimated Completion Date: June 2020
California State Auditor's Assessment of Status: Pending
According to Health Care Services' response, implementation of this recommendation is still pending.
DHCS will leverage the MEDS alerts pilot to identify the MEDS alerts that are the most effective in:
 Reducing discrepancies between systems.
 Capturing records that remain in a hold status for an extended period of time.
 Capturing records that no longer meet the eligibility criteria for the assigned aid code.
DHCS will then work with stakeholders to prioritize these alerts. Upon completion of this process, DHCS will issue updated guidance on the prioritization of MEDS alerts.
- Completion Date: June 2019
California State Auditor's Assessment of Status: Pending
Although Health Care Services noted that it fully implemented the recommendation in June 2019, its response notes that it has not yet completed this process or issued updated guidance on the prioritization of MEDS alerts.
- Auditee did not substantiate its claim of full implementation
- Auditee did not address all aspects of the recommendation
In July 2019, DHCS will implement the MEDS alerts pilot project that was originally scheduled for implementation on May 31, 2019.
DHCS delayed the implementation of the MEDS alerts pilot project to ensure that the reports used for this effort:
- Captured the correct alerts.
- Are formatted to ensure readability.
- Have sort/filter functionalities.
- May be used by DHCS to monitor counties' progress, by developing a secondary report that tracks the number of resolved alerts, ongoing (unresolved) alerts, and the number of new alerts on a monthly basis.
- Estimated Completion Date: End of fall 2019
California State Auditor's Assessment of Status: Pending
According to Health Care Services' response, implementation of this recommendation is still pending.
In May 2019, DHCS will deploy a MEDS alerts pilot program. Part of this pilot includes regularly scheduled meetings between counties and DHCS program and Information Technology staff who specialize in MEDS functionality. DHCS will leverage these meetings to obtain counties' input to develop updated guidance on prioritizing MEDS alerts.
- Estimated Completion Date: May 31, 2019
California State Auditor's Assessment of Status: Pending
DHCS is in the initial phase of contacting internal and external partners to engage in discussions that will assist in prioritizing MEDS alerts. DHCS is on target to release updated guidance to counties by April 30, 2019.
- Estimated Completion Date: April 30, 2019
California State Auditor's Assessment of Status: Pending
All Recommendations in 2018-603
Agency responses received are posted verbatim.