Appendix B
Methodology and Limitations of Our Review of Medi‑Cal Eligibility Data
To identify Medi‑Cal beneficiaries with eligibility discrepancies between the State’s and counties’ data, we obtained Health Care Services’ MEDS files covering the period from January 2014 through December 2017. We also obtained Medi‑Cal eligibility data from the three county systems—CalWIN, LRS, and C‑IV—for the same period. We then identified the beneficiaries whose eligibility status in the county systems was inconsistent with the MEDS records as of December 2017. Because of the volume of data related to Medi‑Cal eligibility, we focused our review on a portion of the population that had eligibility discrepancies in December 2017. Specifically, we reviewed the history of eligibility for this population and limited our analysis to beneficiaries with discrepancies for consecutive months starting in December 2017 and going as far back as January 2014. To allow a reasonable time for Health Care Services and the counties to resolve the discrepancies, we excluded beneficiary records with eligibility discrepancies lasting for less than three months. Figure B depicts these and other beneficiaries who we did not include in our analysis—including beneficiaries who received Medi‑Cal eligibility based on their eligibility for other entitlement programs, such as CalWORKs.
To identify Medi‑Cal beneficiaries with eligibility discrepancies between the State’s and counties’ data, we obtained Health Care Services’ MEDS files covering the period from January 2014 through December 2017. We also obtained Medi‑Cal eligibility data from the three county systems—CalWIN, LRS, and C‑IV—for the same period. We then identified the beneficiaries whose eligibility status in the county systems was inconsistent with the MEDS records as of December 2017. Because of the volume of data related to Medi‑Cal eligibility, we focused our review on a portion of the population that had eligibility discrepancies in December 2017. Specifically, we reviewed the history of eligibility for this population and limited our analysis to beneficiaries with discrepancies for consecutive months starting in December 2017 and going as far back as January 2014. To allow a reasonable time for Health Care Services and the counties to resolve the discrepancies, we excluded beneficiary records with eligibility discrepancies lasting for less than three months. Figure B depicts these and other beneficiaries who we did not include in our analysis—including beneficiaries who received Medi‑Cal eligibility based on their eligibility for other entitlement programs, such as CalWORKs.
To calculate managed care premiums and fee‑for‑service claims associated with the beneficiaries whose eligibility was inconsistent between MEDS and the counties’ systems, we obtained Health Care Services’ Medi‑Cal payment information. We then calculated the total amount Health Care Services paid for beneficiaries with eligibility discrepancies between the systems in December 2017 and in prior consecutive months. Because health care providers may continue submitting fee‑for‑service claims after the date of service, we included claims that were processed from January 2014 through February 2018. Although Health Care Services may have adjusted some payments, it was cost‑prohibitive for us to calculate all of these adjustments because Health Care Services does not maintain all adjustment records for individual beneficiaries. Further, as noted above, our analysis did not include beneficiaries who qualify for Medi‑Cal based on their enrollment in other entitlement programs; thus, our calculations do not include payments for these beneficiaries. Because our analysis focuses on a portion of the population that had discrepancies in December 2017, we have the most complete payment data for that month. For example, as Figure B describes in scenario 4, we did not include beneficiaries who only had discrepancies before our December 2017 starting point. Thus, additional discrepancies likely exist outside of the portion of the population that we reviewed. The total questionable payments from the month of December 2017 was $139 million, and projecting that amount across the 12 months of a year, we estimate that Health Care Services could avoid about $1.7 billion per year in questionable payments if it resolved these discrepancies.
Figure B
Medi-Cal Eligibility Data Discrepancies Discussed in Our Report
Source: Analysis of MEDS and SAWS.
* We did not include discrepancies that persisted for less than three months to allow for Health Care Services and the counties to resolve discrepancies through their reconciliation process. We also excluded discrepancies related to temporary Medi-Cal benefits if they occurred within the allowable time frames for determining eligibility.