Report 2022-502 Recommendation 7 Responses

Report 2022-502: Follow-Up: Children in Medi‑Cal: The Department of Health Care Services Is Still Not Doing Enough to Ensure That Children in Medi‑Cal Receive Preventive Health Services (Release Date: September 2022)

Recommendation #7 To: Health Care Services, Department of

To ensure that health plan provider directories are accurate, 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 health 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 October 2024

CSA's recommendations align with DHCS' goals to implement improved processes to improve accuracy of provider directories, so Medi-Cal members have a current resource of providers available within the Plan's network. DHCS has reviewed internal processes pertaining to ensuring thresholds are met before approving the health plan's directory; however, our manual processes cannot feasibly implement CSA's recommendation, at this time.

EQRO's current sampling strategy ensures a maximum margin of error of +/- 5 percent and a 95 percent confidence level at the provider category level for each reporting unit. Therefore, DHCS has met that portion of the recommendation; however, this data is not currently provided to MCPs in a manner MCPs can act and update directories prior to DHCS' approvals. In the future, an automated processes would need to be developed for feedback to MCPs.

More importantly, the recommendation predates Medicaid and CHIP Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F) ("Managed Care Final Rule" (MCFR)) released by CMS in April 2024. MCFR seeks to modernize how Medicaid programs are defining, measuring, and enforcing standards pertaining to access to care broadly. In particular, MCFR contains provisions related to provider directory accuracy, requiring states to implement a Secret Shopper Survey (SSS) method to assess and determine the accuracy of the information in each Plan's provider directories. The results from SSS are to be provided to the Plans within three business days after any issues are identified with electronic provider directories and Plans must make corrections to the directory within 30 calendar days.

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

Provider directories are one of the primary means by which families can locate health care providers. Although DHCS states that it cannot feasibly implement our recommendation at this time, it also does not anticipate that it will begin using the Secret Shopper Survey method for assessing and determining the accuracy of provider directories until January 1, 2029. Consequently, our concern remains that DHCS potentially impedes families' access to providers by not ensuring that provider directories are accurate.

Annual Follow-Up Agency Response From December 2023

DHCS continues its manual process to ensure accuracy of provider directories. Internal conversations are concurrently occurring on how to best utilize the provider directory data obtained by the EQRO to ensure more accurate provider directories. EQRO's current sampling strategy ensures a maximum margin of error of +/- 5 percent and 95 percent confidence level at the provider category level for each reporting unit.

DHCS' Managed Care Contract Oversight Branch implemented a SharePoint Portal in October 2022. Since then, provider directories are received, reviewed, approved, and maintained in the Portal (See Attachment 10 in the Substantiation folder).

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

Per DHCS's response, it will not fully implement this recommendation until July 2024.

1-Year Agency Response

DHCS continues its manual process to ensure accuracy of provider directories Internal conversations are concurrently occurring on how to best utilize the provider directory data obtained by the External Quality Review Organization to ensure more accurate provider directories.

DHCS' Managed Care Contract Oversight Branch implemented a SharePoint Portal in October 2022. Since that date, provider directories have been received, reviewed, approved, and maintained in the Portal.

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

Per DHCS's response, it will not implement this recommendation until July 2024.

6-Month Agency Response

DHCS continues to work with multiple program areas to understand what role can be taken from a data oversight perspective to ensure accuracy of provider directories. EQRO continues validation efforts and DHCS is continuing the manual provider directory review process in tandem while internal conversations occur on how to utilize the EQRO data in the best way to ensure more accurate provider directories.

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

Per DHCS's response, it will not implement this recommendation until September 2023.

60-Day Agency Response

DHCS' EQRO resumed validation in January 2022, and provided two quarters' worth of results to DHCS. MCOD reviewed the data and will be working with other DHCS program areas to discuss MCP correction of identified errors and approval protocols in alignment across DHCS. MCOD met with other DHCS areas the week of October 10, 2022, to begin discussions on how to utilize the EQRO data in the best way to ensure more accurate Provider Directories.

On October 10, 2022, MCOD implemented a SharePoint portal, which will be used as a means for MCPs to submit deliverables (including Provider Directories) for review and approval. Having the SharePoint portal will allow for a repository of all Provider Directories for all MCPs.

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

Per DHCS's response, it will not implement this recommendation until September 2023.

All Recommendations in 2022-502

Agency responses received are posted verbatim.