Report 2021-046 Recommendation 5 Responses

Report 2021-046: Proposition 56 Tobacco Tax: The Department of Health Care Services Is Not Adequately Monitoring Provider Payments Funded by Tobacco Taxes (Release Date: November 2022)

Recommendation #5 To: Health Care Services, Department of

To comply with state law, reduce the amount of time it takes to suspend providers from delivering Medi-Cal services, and better protect Medi-Cal beneficiaries from potentially ineligible providers, DHCS should, by June 2023, begin issuing temporary provider suspensions or temporary payment suspensions when permissible or required by state law while it engages in the process of issuing a mandatory provider suspension.

Annual Follow-Up Agency Response From October 2024

DHCS' Mandatory Suspension Desk (MSD) has finalized updates to the desk manual. The updates include the processes when MSD receives notifications of loss of license or criminal convictions. MSD staff reviews each notification for suitability of a temporary or payment suspension while the mandatory suspension process is pending.

MSD and Audits & Investigation (A&I) are communicating regularly on relevant cases to ensure referrals for temporary and payment suspensions are taking place.

Additionally, MSD and A&I shall have quarterly meetings to discuss matters referred between MSD and A&I to ensure current P&Ps are effective in complying with the DHCS mandate to reduce the time to suspend providers and ensure Medi-Cal beneficiaries are better protected from ineligible providers.

DHCS is currently communicating and coordinating with the DOJ's Division of Medi-Cal Fraud and Elder Abuse (DMFEA) regarding DMFEA's investigation and charging of Medi-Cal providers.

The DHCS MSD revised the suspension process by the estimated implementation date of March 30, 2024, and the coordination with other divisions to memorialize the process took until September 6, 2024.

See Attachment 3 in the Substantiation - Part 1 of 2 folder, which contains the relevant updates highlighted in yellow. Pages 1 through 7 outline the "MSD Desk Manual - Temporary Suspension Policy". Pages 7 through 11 are the "Implementation of the Temporary Suspension Policy". Lastly, pages 12 through 15 are the "Payment Suspension/ Temporary Suspension Request Form."

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

DHCS has fully implemented the recommendation by updating its desk manual to require the issuance of temporary provider suspensions or temporary payment suspensions while it engages in the process of issuing a mandatory provider suspension.

1-Year Agency Response

The DHCS MSD has revised its suspension process. When MSD receives a notification of loss of license or conviction, MSD personnel will determine whether the activity contained in the notification constitutes a basis for the imposition of a temporary provider suspension under the statute. If it does, the information will be referred to the sanctions section within A&I for priority processing as a temporary suspension.

DHCS has met with the Department of Medi-Cal Fraud and Elder Abuse (DMFEA) and reached agreement to implement notifications to DHCS when charges are filed against a Medi-Cal provider. DHCS and DMFEA are currently formalizing this process for inclusion into each department/division's respective policies and procedures.

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

6-Month Agency Response

Health Care Services did not submit a response to this recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

60-Day Agency Response

Health Care Services did not submit a response to this recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

All Recommendations in 2021-046

Agency responses received are posted verbatim.