| Medical Assistance Program |
Health Care Services lacks adequate internal controls to obtain and track the enrollment presumptive eligibility identification numbers issued to prevent unauthorized use of identification numbers. Health Care Services does not perform procedures to authenticate the existence of the recipient, prevent duplicate issuances, and reconcile the presumptive eligibility numbers with the recipient enrollment listing filed during the claims adjudication process. |
2005-06 |
| Remains uncorrected. Health Care Services lacks the necessary resources to develop and implement automated systems to address this finding at this time.
The Patient Protection and Affordable Care Act (PPACA) of 2010 provides an opportunity to implement a solution to this problem. As required by the PPACA and with the passage of SB 900 (Chapter 659, Statutes of 2010) and AB 1602 (Chapter 655, Statutes of 2010), California will establish the California Health Benefits Exchange (Exchange). A component the Exchange has is the ability to screen for and enroll eligible individuals into the Medi- Cal program, utilizing a web-based enrollment portal and streamlined eligibility processes. The Exchange provides an opportunity to allow Presumptive Eligibility (PE) Qualified Providers to complete the PE enrollment for eligible pregnant women using an internet-based application that will provide real-time validation with the Statewide Medi-Cal Eligibility Data System. This will result in the assignment of a Client Index Number for tracking and billing purposes; thereby eliminating the possibility of duplicate issuances of identification numbers and will provide a means of authentication of enrolled individuals.
Currently, Health Care Services is analyzing the Medicaid provisions of PPACA and is awaiting guidance from the federal Centers for Medicare and Medicaid Services and implications for modernizing current PE processes for pregnant women. Health Care Services is in the process of revising the current enrollment form to include instructions for providers to inform pregnant women of additional options available to apply for Medi-Cal by telephone or use a web-based application to remove the requirement for this population to submit the application in-person or the mail. The additional options could reduce the length of time this population is served under PE. |
97 |
| Medical Assistance Program |
Health Care Services does not ensure that drug utilization data are provided to drug manufacturers/labelers on a timely basis. |
2006-07 |
| Fully corrected. Health Care Services has modified the Rebate Accounting Information System (RAIS) on October 30, 2009, to allow the invoicing process to be more efficient and require less manual reviewing, thus allowing for timely mailing of the invoices. Health Care Services is now meeting the deadlines for submitting the Utilization reports to the drug manufacturers. However, though the Centers for Medicare and Medicaid Services (CMS) Guidelines use a sixty-day window after the quarter for submission of the utilization reports to drug manufacturers, the States continue to be penalized when CMS is late in submitting or making available the quarterly drug rebate files to the States. These factors should be considered when an audit is performed to ensure that CMS is submitting the quarterly drug rebate files within 45 days of the end of the quarter which then gives the States 15 days after receipt of the file as stated in the guidelines. |
88 |
| Medical Assistance Program |
Health Care Services did not conduct site visits of local government agencies (LGAs) as required. Only one LGA site visit was conducted during the current fiscal year when 22 site visits should have been performed as the previous visits were more than four years ago. |
2009-10 |
| Partially corrected. It was the intent of the County Based Medi-Cal Administrative Activities(CMAA) Unit to conduct 16 LGA site visits during fiscal year 2010-11 to comply with Medicaid funding requirements which indicate LGA site visits must be conducted at least once every four years. However, due to the delayed passage of the State Budget in November 2010 and a Governor’s order restricting non-essential travel in May 2011, the CMAA Unit only had five months to work towards compliance. The CMAA Unit was able to conduct and complete 11 of the planned 16 LGA site visits in fiscal year 2010-11; however, due to the aforementioned issues, five of the LGA site visits were not conducted. Currently the CMAA Unit staff is developing a desk review process that will meet the Medicaid funding requirements and not require travel. It is the intent of the CMAA Unit to complete the outstanding site visits in fiscal year 2011-12 through the desk review process and still achieve compliance with the LGA monitoring policy by June 30, 2012. |
99 |
