Report 2021-046 Recommendation 6 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 #6 To: Health Care Services, Department of

To prevent providers from billing for services performed by other providers that have been suspended, DHCS should, by June 2023, revise its policies and billing system to assess all service-rendering providers included in claim data and verify that they have not been suspended.

Annual Follow-Up Agency Response From October 2024

DHCS has completed the initial research and system analysis, which ended up being more complicated than initially envisioned and involved input from subject-matter experts across multiple teams within DHCS. Based on the work, DHCS now has a better understanding of the underlying issue, which appears quite narrow and involves how DHCS' system recognizes and processes restitution payments for suspended providers. Although internal work is ongoing to determine the most appropriate path forward, DHCS is actively working to implement any necessary edits in the system to ensure the issue is addressed but does not believe external-facing policy guidance is required.

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

1-Year Agency Response

Although DHCS was not able to identify any billing providers whom the Fiscal Intermediary paid while they were suspended, DHCS did identify that restitution payments did not check against providers under mandatory suspension. DHCS is conducting additional research to identify system checks used for restitution to learn where the breakdown occurred and will then issue policy guidance to implement edits, so that the system for restitution payments will check for suspended providers.

DHCS will also make an additional data run regarding identification of suspended rendering providers on claims prior to payment.

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.