Appendix A
California State Auditor’s Telephone Survey of Primary Care Providers in Three California Medical Assistance Program Managed Care Health Plans
To determine the accuracy of information included in provider directories for the California Medical Assistance Program (Medi‑Cal) managed care health plans (health plans), we selected for review the latest provider directories approved by the California Department of Health Care Services (Health Care Services) in 2014 for three health plans that serve Medi‑Cal beneficiaries. Specifically, we reviewed the accuracy of provider listings for primary care physicians in the October 2014 Anthem Blue Cross provider directory for Fresno County, the August 2014 Health Net provider directory for Los Angeles County, and the July 2014 Partnership HealthPlan of California (Partnership HealthPlan) provider directory for Solano County. As the Introduction discusses, a health plan makes its provider directory available to enrollees to assist them in making informed decisions when selecting their primary care physicians. Therefore, we limited our review to primary care physicians.
We randomly selected a statistically valid number of primary care physicians from each provider directory. Specifically, we consulted with a statistician to determine the appropriate sample size based on the total number of primary care providers included in each directory so that we could be 95 percent confident of our results. Because the directories of the three health plans had varying numbers of providers, the number of providers we surveyed differed for each health plan. We selected and called 77 of the 383 primary care providers listed in the Anthem Blue Cross directory for Fresno County, 93 of the 2,468 primary care providers listed in the Health Net directory for Los Angeles County, and 32 of the 47 primary care providers listed in the Partnership HealthPlan directory for Solano County. We contacted each provider’s office and asked the five questions shown in Table A below as well as any appropriate clarifying questions. If the listed telephone number for the provider was incorrect, we made a note of that error and tried to identify through Internet research the correct telephone number for the provider. If the answers to the survey questions indicated inaccuracies regarding information in a provider directory, we consulted the appropriate health plan’s website to determine whether the health plan had updated the information in its online directory subsequent to publishing the printed version of the provider directory. We discuss the results of our survey here in the Audit Results.
| Telephone Survey Questions |
If not the correct provider office, ask “Has this provider ever worked at your location?” If “No,” note that phone number listed was incorrect and end the call. If “Yes,” ask, “When did the provider stop working at this location?” Ask questions 2 and 3 only. If different from the listing, record the correct address and ask, “Has the office moved recently?” If unknown, conduct rest of survey but ask at the end for contact for missing information. If unknown, conduct rest of survey but ask at the end for contact for missing information. If “No,” ask, “Has the provider ever accepted Medi-Cal managed care coverage through [HEALTH PLAN NAME]?” If “No,” end the call. If “Yes,” ask, “When did you stop accepting this coverage?” Then end the call. If unknown, ask for contact for this information. If “No,” ask, “When did you [START or STOP] accepting new Medi-Cal patients with this coverage?” Then end the call. |
Source: California State Auditor’s script for the telephone survey of selected primary care providers for three California Medical Assistance Program managed care health plans.
Appendix B
California Medical Assistance Program Managed Care Health Plans’ Processes for Monitoring Their Provider Networks
In early 2015 we visited Anthem Blue Cross, Health Net, and Partnership HealthPlan of California—which offer the California Medical Assistance Program (Medi‑Cal) managed care health plans (health plans)—and reviewed the processes each employs to ensure that it provides beneficiaries with access to medical care and necessary assistance and that it recruits and retains appropriate providers. State regulations under the Knox‑Keene Health Care Service Plan Act of 1975 require all managed care health plans in California to ensure that their enrollees have access to quality medical care. Specifically, state regulations require health plans to ensure that services are readily available and accessible at reasonable times to each enrollee. To provide available and accessible services to their members, health plans must recruit and retain medical providers. We found that the three health plans employ similar processes. For example, each of the three health plans we reviewed has formal and informal processes to assist beneficiaries with locating providers. Further, all three health plans employ similar processes for recruiting primary care physicians to their provider networks and for retaining those providers. Table B below shows actions taken by health plans to ensure access and assistance to members, as well as for provider recruitment and retention.
| Oversight Area | Actions | California Medical Assistance Program (Medi-cal) Managed care Health plan (Health Plan) | ||
|---|---|---|---|---|
| Anthem Blue Cross | Health Net | Partnership HealthPlan of california (Partnership Healthplan) | ||
| Ensuring that Medi‑Cal beneficiaries have adequate access to providers | Review network adequacy at least annually, including the following components: | Action Taken | Action Taken | Action Taken |
| • Beneficiary-to-provider distance | Action Taken | Action Taken | Action Taken | |
| • Beneficiary-to-provider ratio | Action Taken | Action Taken | Action Taken | |
| • Percent of providers open to new patients | Action Taken | Action Taken | Action Taken | |
| • Grievance trends related to beneficiaries access to care | Action Taken | Action Taken | Action Taken | |
| • Wait time to see providers | Action Taken | Action Taken | Action Taken | |
| Assisting Medi‑Cal beneficiaries who have trouble locating a provider | Operate a call center to respond to member complaints and aim to resolve issues within 24 hours. | Action Taken | Action Taken | Action Taken |
| Maintain a formal grievance process and resolve grievances within 30 days, as required by the contract with the State. | Action Taken | Action Taken | Action Taken | |
| Ensuring provider recruitment and retention | Identify shortages of key specialists. | Action Taken | Action Taken | Action Taken |
| Maintain a provider relations unit and regional offices to assist in provider recruitment and retention. | Action Taken | Action Taken | Action Taken | |
| Reach out to and encourage all Medi-Cal fee-for-service providers to participate in its network. | NA* | NA† | Action Taken | |
| Provide financial support to participating medical groups for their recruiting efforts. | NO ACTION TAKEN | Action Taken‡ | Action Taken | |
| Reach out to all specialists in service area and encourage them to participate in its network. | Action Taken§ | NA† | Action Taken | |
| Contract with specialists, even when they refuse Medi-Cal reimbursement rates. | NAll | Action Taken‡ | Action Taken | |
| Maintain a dedicated help line to resolve problems that providers may encounter. | Action Taken | Action Taken | Action Taken | |
| Provide education and training for providers and their staff to adapt to new processes implemented by the health plan. | Action Taken | Action Taken | Action Taken | |
| Provide incentive programs and performance bonuses to providers. | Action Taken | Action Taken‡ | Action Taken | |
| Use automatically renewing contracts with providers. | Action Taken# | Action Taken | Action Taken | |
| Conduct annual satisfaction survey of providers to identify and address provider concerns. | Action Taken | Action Taken | Action Taken | |
Sources: California State Auditor’s analysis of interviews with key managers at Anthem Blue Cross, Health Net, and Partnership HealthPlan and supporting documentation.
NA = Not applicable
* The regional vice president for provider engagement and contracting for Anthem Blue Cross reported that in Fresno County, Anthem Blue Cross uses a delegated model and has no direct outreach to primary care providers. Instead, Anthem Blue Cross relies on medical groups to maintain an adequate network of primary care physicians in Fresno County.
† Health Net’s Medi-Cal compliance manager reported that in Los Angeles County it uses a delegated model and has no direct outreach to providers. Instead, staff reported that Health Net relies on medical groups to maintain an adequate network of physicians.
‡ Health Net’s director of compliance and Medi-Cal compliance officer noted that Heath Net performs these actions subject to specific circumstances.
§ Anthem Blue Cross’s director of business integration and contract administration (contract director) noted that Anthem Blue Cross reaches out to needed specialists in its service area and encourages them to participate in its network.
ll Anthem Blue Cross’s contract director will enter into single‑case agreements with providers with respect to continuity of care and allowing access to hard‑to‑find specialists.
# Anthem Blue Cross’s provider agreements do not include a termination date.