Report 2018-111 Recommendation 13 Responses

Report 2018-111: Department of Health Care Services: Millions of Children in Medi-Cal Are Not Receiving Preventive Health Services (Release Date: March 2019)

Recommendation #13 To: Health Care Services, Department of

To ensure that plan provider directories are accurate, by September 2019 DHCS should begin using a 95 percent confidence level and not more than a 10 percent margin of error on its statistical sampling tool and should require at least 95 percent accuracy before approving a plan's provider directory. In addition, DHCS should ensure that its staff adhere to its policy to retain all documentation related to its review of provider directories for at least three years.

Annual Follow-Up Agency Response From September 2022

There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).

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

DHCS is exploring having its external reviewer verify select health plans' provider directory information using a new approach, which would include a larger sample size. DHCS plans to continue to perform the directory reviews for two of the health plans and is considering increasing its sample size once it transfers the other reviews to the external reviewer. However, DHCS does not have a timeline for when it will transfer the verification process to the external reviewer. Further, DHCS has approved provider directories despite finding significant errors in them.

Annual Follow-Up Agency Response From October 2021

While DHCS had expected to resume the Provider Directory Validation work through the EQRO in 2021, DHCS halted work entailing outbound calls so that providers can focus on the COVID-19 pandemic. DHCS expects to resume the work efforts in the first quarter of 2022. When work efforts resume, the EQRO will use the established process for conducting provider directory validation and will provide quarterly results to DHCS based on outbound calls to Providers that are included in the Provider Directory. MCPs will be required to rectify findings that result from the validation.

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

When DHCS resumes its efforts, we will look to determine whether it is using the confidence level, margin of error, and accuracy rate included in this recommendation.

Annual Follow-Up Agency Response From November 2020

DHCS' EQRO established a process for conducting provider directory validation and will be providing quarterly results to DHCS. Requirements for the provider directory review and validation have been established and DHCS' EQRO began making outreach calls to validate provider information in the first quarter of 2020. However, due to the COVID 19 pandemic, the work through DHCS' EQRO is delayed. DHCS expects to reinstate provider directory validation processes in 2021. As requested, documentation showing the methodology used by the EQRO in the first quarter of 2020 to assist with the provider directory review is included. The same methodology will be used when the provider directory review process by the EQRO is re-instated later in 2021 once timing is determined after the COVID-19 pandemic has concluded.

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

1-Year Agency Response

DHCS' EQRO has established a process for conducting provider directory validation and will be providing quarterly results to DHCS. Results from the Provider Directory review will be retained on a SharePoint by Health Care plan.

California State Auditor's Assessment of 1-Year Status: Pending

DHCS did not provide documentation of its new process or its document retention efforts.

6-Month Agency Response

DHCS' EQRO is establishing a process for conducting provider directory validation and will be providing quarterly results to DHCS. Results from the Provider Directory review will be retained on a SharePoint by Health Care Plan. Initial requirements for the Provider Directory review have been established; the targeted implementation timeframe of January 1, 2020, is currently still anticipated.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

DHCS' EQRO is establishing a process for conducting provider directory validation quarterly. Initial requirements are being discussed; the targeted implementation timeframe of January 1, 2020 is currently still anticipated.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing the progress DHCS has made to implement the recommendation to both increase the validation level and ensure staff adhere to its policy to retain documentation related to its provider directory reviews with DHCS' 6-month and 1-year responses.

All Recommendations in 2018-111

Agency responses received are posted verbatim.