CHA News Article

State Auditor Calls for Improved Monitoring of Medi-Cal Managed Care Plans
Indicates improved monitoring is necessary to better ensure access to care

The California State Auditor has released findings on the California Department of Health Care Services’ (DHCS) oversight of Medi-Cal managed care health plans. For the health plans reviewed, the audit found that DHCS did not verify the accuracy of data received before certifying the health plans’ network adequacy during the Healthy Families Program transition to Medi-Cal, and did not verify data for another health plan at the time the health plan entered the Medi-Cal program. Therefore, DHCS cannot ensure that the health plans it contracts with had an adequate network of providers to serve Medi-Cal members.

The report also revealed that DHCS did not verify the accuracy of the data it received from health plans and that it provided to the California Department of Managed Health Care (DMHC), with which it has an agreement to conduct quarterly network adequacy reviews. Furthermore, according to the audit, DHCS has not ensured that DHMC performed all quarterly reviews of the health plans’ required provider networks. The audit’s review of provider directories for three health plans – Anthem Blue Cross, Health Net and Partnership HealthPlan – found many errors, including incorrect telephone numbers and addresses, and information about whether providers were accepting new patients. However, DHCS’ review of these same directories had not identified these inaccuracies before it approved the directories for publication.

The report notes that thousands of calls from Medi-Cal members seeking assistance through DHCS’ Medi-Cal Managed Care Office of the Ombudsman have gone unanswered. Each month between February 2014 and January 2015 an average of 12,500 calls went unanswered. The report finds DHCS has not performed all statutorily required annual medical audits of Medi-Cal managed care health plans to determine whether the health plans meet their members’ needs. Notably, the audit found that DHCS did not perform any annual medical audits before 2012 and performed medical audits on less than half of the health plans in fiscal year 2013–14.

The audit report includes many recommendations for DHCS, including:

  • Establish a process to verify the accuracy of provider network data the health plan uses to demonstrate that it meets network adequacy standards.
  • Review each health plan’s process for ensuring the accuracy of directories, identify best practices and require health plans to follow those practices. It should also revise its provider directory review process to identify inaccuracies.
  • Upgrade or replace the ombudsman office’s telephone system to handle the volume of calls it receives.
  • Improve its oversight of managed health care and ensure it conducts quarterly reviews of health plans.
  • DMHC should determine if it can rely on DHCS’ annual audits to eliminate any duplicative work in reviewing health plans.

The full report is attached.