Report 2023-103 Recommendation 4 Responses

Report 2023-103: The Comprehensive Perinatal Services Program: The Lack of Usage Data Prevents the State From Knowing How Often Medi‑Cal Members Receive Perinatal Care (Release Date: February 2024)

Recommendation #4 To: Health Care Services, Department of

To improve its current Medi-Cal monitoring and oversight systems, Health Care Services should do the following:
- Require managed care plans to conduct quality assurance reviews on perinatal service providers, such as OB-GYNs, at least once every three years, beginning by January 2025. If necessary, Health Care Services should seek resources to facilitate this change.
- Include the perinatal program in its risk assessment when determining where to target its annual medical audits.

Annual Follow-Up Agency Response From February 2026

As of August 1, 2025, DHCS has incorporated the perinatal program into its current State Fiscal Year (SFY) 2025-26 risk assessment. The scope has been designated as high-risk, which now necessitates mandatory review with every annual medical audit. The requirements for the scope are leveraged from the 2024 Boilerplate Contract. Additionally, DHCS' updated perinatal policies will continually undergo internal discussion to ensure future MCP audit scope reflects the commensurate level of risk, as well as provide appropriate lead time for the Plans to operationalize updated guidance.

DHCS continues to have resource constraints and will not expand the quality assurance review to include OB/GYN and other perinatal service providers who offer perinatal services, and who are not designated as primary care providers. Quality assurance reviews, referred to as Facility Site Reviews (FSR) and Medical Record Reviews (MRR), will continue to include only OB/GYN providers who have been selected as the member's primary care providers.

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

We consider this recommendation as partially implemented because DHCS noted they incorporated the perinatal program into its risk assessment for reviewing managed care plans; however, they have resource constraints related to adding additional OB/GYN providers to the quality assurance reviews and are not implementing that part of the recommendation.

1-Year Agency Response

The Facility Site Reviews (FSR) and Medical Record Reviews (MRR) are currently conducted for Obstetrician-Gynecologist (OB/GYN) providers who are selected to be the member's primary care providers only.

Due to resource constraints, DHCS did not expand the site review scope to include OB/GYN and other perinatal service providers who offer perinatal services but who are not designated primary care providers. Similarly, due to resource constraints for deploying training, certifying additional practitioners, and scheduling additional site visits to assess MCP compliance, DHCS will not implement the parts of this recommendation at this time.

However, DHCS conducts risk-based annual medical audits, which reviews provider and member grievances and captures OB/GYN issues.

Due to necessary updates in the audit process, DHCS' risk assessment will be approved by March 31, 2025. Once approved, the risk assessment (now including the perinatal program) will be implemented beginning July 1, 2025.

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

6-Month Agency Response

Within the past six months, DHCS has expanded the Facility Site Reviews (FSR) and Medical Record Reviews (MRR) (FSR/MRR) to include CPSP services. The revised FSR/MRR tools have been provided to the Medi-Cal Managed Care Plans (MCPs). DHCS continues to work on obtaining and identifying resources to expand site review scope to include obstetrician-gynecologists and other perinatal service providers who offer perinatal services but who are not designated primary care providers.

Additionally, DHCS continues to develop new requirements and guidance for deploying training, certifying additional practitioners, and scheduling site visits to ensure MCP compliance.

DHCS will include the perinatal program in the annual risk assessment by January 2025, for the purposes of targeting annual medical audits.

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

60-Day Agency Response

DHCS continues to work towards the expansion of required Facility Site Reviews (FSR) and Medical Record Reviews (MRR) to include all obstetrician-gynecologist (OB/GYN) providers. Instead of the currently required OB/GYN providers who elect to be primary care providers. DHCS is working towards identifying resources for expanded FSR/MRR scope, which entails issuing Medi-Cal Managed Care Plans (MCPs) guidance, building new requirements into the FSR tool, deploying training, and conducting the onsite reviews. Once resources are identified, staff will work towards expanding DHCS' site review scope, certifying additional practitioners, and scheduling site visits to ensure MCP compliance. Given additional resources, DHCS will revise the FSR scope and issue guidance to MCPs by June 2024, to be effective January 2025. MCPs will need 180 days to secure staffing, schedule additional visits with OB/GYN offices, and begin conducting visits. Additionally, DHCS will include the perinatal program in its annual risk assessment by January 2025.

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

All Recommendations in 2023-103

Agency responses received are posted verbatim.