Report 2014-134 Recommendation 10 Responses

Report 2014-134: California Department of Health Care Services: Improved Monitoring of Medi-Cal Managed Care Health Plans Is Necessary to Better Ensure Access to Care (Release Date: June 2015)

Recommendation #10 To: Health Care Services, Department of

To ensure that Health Care Services complies with state law, it should increase its oversight of Managed Health Care to ensure that it completes the quarterly assessments required under the agreements.

Annual Follow-Up Agency Response From June 2019

DHCS and DMHC have mutually agreed not to renew the interagency agreements that delegated certain monitoring and oversight activities to DMHC. As a result, DHCS has assumed the monitoring and oversight responsibilities previously prescribed in the interagency agreement and would no longer be required to ensure that the work is completed by DMHC.

California State Auditor's Assessment of Annual Follow-Up Status: Resolved

Annual Follow-Up Agency Response From November 2018

DHCS continues oversight of interagency agreements in the areas of medical surveys and quarterly assessments. The Contract Compliance Unit continues to track the completion of medical surveys and the Managed Care Operations Unit continues to partner with DMHC to send joint network adequacy letters to Medi-Cal managed health plans on a quarterly basis. Both units coordinate with DMHC on a weekly basis.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Health Care Services appears to be confused about our finding and related recommendation. During the audit, we were aware of Health Care Services' oversight of the interagency agreements. In its response, Health Care Services references two units' focus on oversight of and work associated with its agreements with Managed Health Care. The medical surveys and the related corrective action plans that Health Care Services cites were not related to the quarterly network adequacy reviews that Managed Health Care performs and were not significant to the scope of our audit, which focused on the adequacy of provider networks and accuracy of provider directories. Further, we did review the joint efforts of Health Care Services and Managed Health Care to follow up on the results of the quarterly network adequacy reviews that Managed Health Care performed. However, our finding beginning on page 35 of the report and related recommendation focus on the quarterly reviews that Managed Health Care did not perform as required under one of the two agreements between the two departments. Health Care Services is ultimately responsible for ensuring that its contractor provides the required services covered under both its agreements. Therefore, we stand by our recommendation on page 42 of the report that Health Care Services increase its oversight of Managed Health Care to ensure that it completes the quarterly assessments required under the agreements.

1-Year Agency Response

DHCS continues oversight of interagency agreements in the areas of medical surveys and quarterly assessments. The Contract Compliance Unit continues to track the completion of medical surveys and the Managed Care Operations Unit continues to partner with DMHC to send joint network adequacy letters to Medi-Cal managed health plans on a quarterly basis. Both units coordinate with DMHC on a weekly basis.

California State Auditor's Assessment of 1-Year Status: Will Not Implement

Health Care Services appears to be confused about our finding and related recommendation. During the audit, we were aware of Health Care Services' oversight of the interagency agreements. In its response, Health Care Services references two units' focus on oversight of and work associated with its agreements with Managed Health Care. The medical surveys and the related corrective action plans that Health Care Services cites were not related to the quarterly network adequacy reviews that Managed Health Care performs and were not significant to the scope of our audit, which focused on the adequacy of provider networks and accuracy of provider directories. Further, we did review the joint efforts of Health Care Services and Managed Health Care to follow up on the results of the quarterly network adequacy reviews that Managed Health Care performed. However, our finding beginning on page 35 of the report and related recommendation focus on the quarterly reviews that Managed Health Care did not perform as required under one of the two agreements between the two departments. Health Care Services is ultimately responsible for ensuring that its contractor provides the required services covered under both its agreements. Therefore, we stand by our recommendation on page 42 of the report that Health Care Services increase its oversight of Managed Health Care to ensure that it completes the quarterly assessments required under the agreements.

6-Month Agency Response

DHCS continues oversight of interagency agreements in the areas of medical surveys and quarterly assessments. The Contract Compliance Unit continues to track the completion of medical surveys and the Managed Care Operations Unit continues to partner with DMHC to send joint network adequacy letters to Medi-Cal managed health plans on a quarterly basis. Both units coordinate with DMHC on a weekly basis.

California State Auditor's Assessment of 6-Month Status: Will Not Implement

Health Care Services appears to be confused about our finding and related recommendation. During the audit, we were aware of Health Care Services' oversight of the interagency agreements. In its response, Health Care Services references two units' focus on oversight of and work associated with its agreements with Managed Health Care. The medical surveys and the related corrective action plans that Health Care Services cites were not related to the quarterly network adequacy reviews that Managed Health Care performs and were not significant to the scope of our audit, which focused on the adequacy of provider networks and accuracy of provider directories. Further, we did review the joint efforts of Health Care Services and Managed Health Care to follow up on the results of the quarterly network adequacy reviews that Managed Health Care performed. However, our finding beginning on page 35 of the report and related recommendation focus on the quarterly reviews that Managed Health Care did not perform as required under one of the two agreements between the two departments. Health Care Services is ultimately responsible for ensuring that its contractor provides the required services covered under both its agreements. Therefore, we stand by our recommendation on page 42 of the report that Health Care Services increase its oversight of Managed Health Care to ensure that it completes the quarterly assessments required under the agreements.

60-Day Agency Response

DHCS disagrees with the audit finding. DHCS had little to no discussion with the audit team relative to oversight of interagency agreements between DHCS and DMHC. DHCS has two separate Units focused on oversight of and work associated with the interagency agreements, the: 1) Contract Compliance Unit in the Managed Care Quality and Monitoring Division (MCQMD) ensures that DMHC Medical Surveys are completed and has a robust tracking tool to ensure interagency provisions are complied with, and 2) Managed Care Operations Unit in MCQMD partners with DMHC to send joint network adequacy letters to Medi-Cal managed care health plans on a quarterly basis. This process was established in November 2014

California State Auditor's Assessment of 60-Day Status: Will Not Implement

Health Care Services appears to be confused about our finding and related recommendation. During the audit, we were aware of Health Care Services' oversight of the interagency agreements. In its response, Health Care Services references two units' focus on oversight of and work associated with its agreements with Managed Health Care. The medical surveys and the related corrective action plans that Health Care Services cites were not related to the quarterly network adequacy reviews that Managed Health Care performs, and were not significant to the scope of our audit, which focused on the adequacy of provider networks and accuracy of provider directories. Further, we did review the joint efforts of Health Care Services and Managed Health Care to follow up on the results of the quarterly network adequacy reviews that Managed Health Care performed. However, our finding beginning on page 35 of the report and related recommendation focus on the quarterly reviews that Managed Health Care did not perform as required under one of the two agreements between the two departments. Health Care Services is ultimately responsible for ensuring that its contractor provides the required services covered under both its agreements. Therefore, we stand by our recommendation on page 42 of the report that Health Care Services increase its oversight of Managed Health Care to ensure that it completes the quarterly assessments required under the agreements.

All Recommendations in 2014-134

Agency responses received are posted verbatim.