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.
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.
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.
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.
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.
Agency responses received are posted verbatim.