Health Care: Recurring Significant Internal Control Deficiencies
||First Year Reported
|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. However, Health Care Services is pursuing an automated process to post the presumptive eligibility identification numbers to the MediCal eligibility system so records for these recipients can be accessed to authenticate, reconcile, and prevent duplicate issuances of the presumptive eligibility number during the claims adjudication process.
|Partially Corrected. Health Care Services lacks the necessary resources needed to develop and implement automated systems to address this finding. However, they believe the Patient Protection and Affordable Care Act (PPACA) of 2010 provides an ideal opportunity to implement a solution to this problem. As required by PPACA and with the passage of Senate Bill 900 (Chapter 659, Statutes of 2010) and Assembly Bill 1602 (Chapter 655, Statutes of 2010), California is required to develop a Health Benefits Exchange (Exchange). A component of the Exchange 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. Under PPACA, for purposes of Medi-Cal eligibility, Health Care Services is required to develop and implement streamlined eligibility and enrollment processes for individuals seeking Medi-Cal covered services. 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 realtime validation with the Statewide Medi-Cal Eligibility Data System (MEDS). Health Care Services is working in collaboration with the Health Benefit Exchange Board in the development of the Exchange, which is required to be operational by 2014. As an interim measure, Health Care Services will begin using a new print vendor as of November 15, 2011 for purposes of automating the process of issuing the presumptive eligibility identification numbers. The new vendor will automate the ordering process to validate presumptive eligibility identification numbers issued to providers. This quality assurance effort reduces the chance of duplicating presumptive eligibility identification numbers issued to providers.
|Medical Assistance Program
||A sample of fee-forservice (FFS) claims was selected to ascertain if each expenditure was for an allowable service rendered and was supported by medical records or other evidence, which indicates the service was actually provided and consistent with the medical diagnosis. In the sample of 50 FFS claims reviewed, 6 did not appear to be for an allowable service.
|Partially Corrected. Audits were conducted on the detected overpayments to confirm these findings and recovery demands were issued.