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 complete the oversight reviews for any remaining high-risk local educational consortia or local governmental agencies by June 30, 2016, and post the results to its website.
DHCS did not receive approval for the revised coding structure until October 31, 2016. This created a delay in the completion and submission of the FY 2014-15 Q3 and Q4 invoices. Consequently, this altered the timeline for the submission of backcasting invoices, which will delay DHCS' ability to implement site visits until January 2018
Changes to the coding structure were submitted to CMS in August 2016 for their consideration. These changes were made in collaboration with the LECs and LGAs. Therefore, the coding has not been finalized for the invoices from the RMTS methodology. Once CMS approves the revised structure, coding will be finalized and invoices will be submitted, DHCS will then apply the risk-based criteria and begin to implement site visits. DHCS expects to begin site visits by October 2017.
The RMTS sample for SFY 2014/15 Q4 was completed on June 30, 2015. LECs and LGAs are in the process of finalizing the coding of the moment responses. Once the coding is complete, the SMAA Unit will compile the time survey data and use this information to work with A&I staff to determine a comprehensive set of risk-based audit criteria. In March 2016, DHCS determined the criteria to use to identify high risk claiming units under the RMTS methodology.
In July 2016, Health Care Services identified to us the specific criteria it will use to identify high risk claiming units. However, it did not identify the status of its reviews for the remaining local educational consortia or local governmental agencies not reviewed as part of its implementation of Recommendation #4 (for example, the number of reviews planned, started or in progress, completed, etc.). Health Care Services also stated that it would not post the results of its reviews on its website.
On January 1, 2015, the DHCS/SMAA Unit implemented the Random Moment Time Survey (RMTS) to capture the amount of time the LEAs were spending on Medi-Cal administrative activities. DHCS is currently working with the LEC/LGAs to finalize the coding for SFY 2014/15 Q3 and Q4 time surveys. Once the coding has been finalized, the Unit will compile the time survey data to review and use as a component to begin the discussions with the A&I staff to determine risk-based audit criteria. After this process is in place, DHCS will revise its site visit protocols and schedule site visits. The estimated completion date to establish a risk-based process and prepare a site visit schedule is April 2016.
Agency responses received are posted verbatim.