To improve the coordination between its divisions, branches, and units and ensure that it addresses allegations of fraud in a timely manner, Health Care Services should continue its efforts to develop its provider risk assessment model for the PSPP unit.
The DMC provider risk assessment model has been documented and 737 DMC provider sites have been scored with the developed weighted criteria. The scores will be reviewed and updated, where applicable, on a quarterly basis. Any DMC provider receiving a score over 10 points receives a high-risk designation and will be scheduled for a Post-service Post-payment utilization review before lower scoring providers.
DHCS provided a copy of its provider risk assessment model, which describes its process for assessing DMC providers as low, medium, or high risk.
SUD management is leveraging clinical support and expertise from DHCS' Medical Review Branch (MRB) to develop the model based upon MRB's experience and role as the DHCS' primary Medi-Cal anti-fraud unit. The categories of high, medium and low risk providers are based on multiple risk factors. Once provider risk levels are assessed, individuals and/or teams can be assigned responsibility for the reviews depending on the provider risk category. This methodology would mitigate the risk of fraud, waste and abuse within the DMC program, and give the Department some assurance that high risk providers are reviewed with a frequency that would not allow a return to fraudulent practices. Currently, this recommendation is partially implemented as PSPP reviews are occurring based on the data analytics and Strike Team recommendations.
The provider risk assessment model is currently being documented and tested with PSPP reviews commencing in January 2015.
In progress. The target date for completion and approval of the model is October 17, 2014.
Based on its response, the department has not yet implemented this recommendation.
Agency responses received are posted verbatim.