To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately direct its investigations division to further enhance its analysis of program claims data to identify the type of high-risk payments we identified on a monthly basis.
A&I's data analytics contractor has implemented flags for all criteria stated on the 6 month update, except for the "Provider Services Multiple Beneficiaries at Same Address" but added flags for beneficiaries sharing the same address.
DHCS provided documentation demonstrating that it has incorporated flags for high-risk payments into its Pondera system.
Audits and Investigation (A&I) has worked with its data analytic contractor to implement flags indicating when providers bill Medi-Cal for
-Holiday Dates of Service
-Excessive Drug Medi-Cal Visits Per Week
-A High Percentage of Beneficiaries Who Receive More Than One Visit Per Week
-Provider Excessive Weekly Dates of Service, Provider Services Multiple Beneficiaries at Same Address, and
-Excessive Denied Claims.
The contractor will deploy the flags beginning January 30, 2015. A&I staff will continuously review the flags to determine if A&I should initiate an investigation of any provider identified by the flags.
A&I continues to work closely with its data analytics contractor to expand and improve the algorithms used in its data analytics tool. At the same time, A&I is continually updating its audit programs and field review checklists to better identify areas of greatest risk within the program including those identified by the CSA. For example, Drug Medi-Cal providers will now receive a high risk-score if the claims data indicates concurrent substance use disorder and inpatient hospital billings. Through these efforts, claims data will continue to be monitored each month to ensure that the providers are submitting accurate claims and are not exceeding program allowances.
Health Care Services indicated that it will not implement this recommendation until February 2015.
Agency responses received are posted verbatim.