Report 2009-112 Recommendations and Responses in 2013-041
Report 2009-112: Department of Health Care Services: It Needs to Streamline Medi-Cal Treatment Authorizations and Respond to Authorization Requests Within Legal Time Limits
| Department | Number of Years Reported As Not Fully Implemented | Total Recommendations to Department | Not Implemented After One Year | Not Implemented as of 2012-041 Response | Not Implemented as of Most Recent Response |
|---|---|---|---|---|---|
| Department of Health Care Services | 3 | 3 | 2 | 2 | 2 |
Recommendation To: Health Care Services, Department of
To ensure that Medi-Cal recipients receive timely access to prescribed drugs, Health Care Services should abolish its policy of responding to drug TARs by the end of the next business day and should instead ensure that prior-authorization requests to dispense drugs are processed within the legally mandated 24-hour period. Alternatively, it should seek formal authorization from CMS to deviate from the 24-hour requirement, and should seek a similar modification to state law. In addition, Health Care Services should begin recording the actual time it receives paper TARs so that it can begin to measure accurately its processing times.
Response
Recording time of paper TAR receipt:
The actual time of paper TAR receipt will begin being recorded when Xerox, the CA-MMIS contractor, develops and implements the new TAR submission and adjudication system. The implementation of new TAR system is projected to begin early 2015. As in previous status update, modifying the current system would be costly and time intensive and not a prudent use of limited resources.
Next Business Day Adjudication of Drug TARs:
As indicated in previous status updates, it is not feasible for Health Care Service to process drug TARs within 24 hours of receipt because its offices are not staffed nor budgeted for 24-hour/seven-day-per-week operations. Emergency drug supplies are available to Medi-Cal beneficiaries as needed. In addition, Health Care Services has received few complaints from providers or beneficiaries regarding the timely processing of drug TARs. For these reasons, Health Care Services intends to continue its practice of adjudicating drug TARs by the next business day. Health Care Services has not sought formal authorization from CMS to deviate from the 24-hour requirement because CMS is aware of Health Care Services' "next business day" practice and that the emergency drug supplies are available to Medi-Cal beneficiaries as needed.
- California State Auditor's Assessment of Status: Not Fully Implemented
- Completion Date: not available
- Response Date: October 2013
Recommendation To: Health Care Services, Department of
To ensure that Medi-Cal recipients are receiving timely medical services from providers, Health Care Services should start tracking prior-authorization medical TARs separately and should ensure that such TARs are processed within an average of five working days. Although state law and regulations specifically require prior authorization for certain medical services, Health Care Services generally does not require prior authorizations in practice. Consequently, Health Care Services should seek legislation to update existing laws and amend its regulations to render them consistent with its TAR practices.
Response
A process was developed, and has been implemented, to track and adjudicate prior authorization TARs received in paper form. The ability to implement such a process for TARs received electronically is part of a replacement TAR processing system currently under development by Xerox State Healthcare, LLC. Changes to the existing system would be costly and time-intensive and not a prudent use of limited resources. Due to current uncertainties and the likelihood of significant change to the TAR process with the implementation of the Affordable Care Act, Health Care Services is not seeking legislation to update existing laws and/or regulations to make them consistent with the TAR process.
- California State Auditor's Assessment of Status: Will Not Implement
- Response Date: October 2013