Report 2013-125 Recommendation 23 Responses

Report 2013-125: California Department of Health Care Services: Weaknesses in Its Medi-Cal Dental Program Limit Children's Access to Dental Care (Release Date: December 2014)

Recommendation #23 To: Health Care Services, Department of

To ensure that Health Care Services and its fiscal intermediaries reimburse providers only for services rendered to eligible beneficiaries, Health Care Services should obtain Social Security's Death Master File and update monthly its beneficiary eligibility system with death information.

Annual Follow-Up Agency Response From October 2021

DHCS is still in negotiations with SSA to gain access to SSA's DMF with no estimated date to secure an agreement. Therefore, the dental Administrative Services Organization contractor will continue to utilize the date of death information from a monthly FAME file. FAME is an extract of DHCS' MEDS, which is updated monthly and in real-time batch transactions. MEDS is the central repository for Medi-Cal eligibility data. MEDS records are created and updated in partnership with the statewide county eligibility offices. FAME is used to create a report to check against beneficiaries' date of death, which is a temporary solution. The report lists beneficiaries with a date of service past the date of death and the Administrative Services Organization contractor performs claim reversals to prevent inappropriate payments. Once DHCS secures access to the SSA's DMF, DHCS will update its monthly beneficiary eligibility system used by the DHCS contractors and fully implement the recommendation.

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

Annual Follow-Up Agency Response From November 2020

We experienced delays in securing an agreement to gain access to the SSA's DMF; therefore, the dental Administrative Services Organization contractor has utilized the date of death information from a monthly Fiscal Intermediary Access to Medi-Cal Eligibility (FAME) file. FAME is an extract of DHCS' Medi-Cal Eligibility Data Systems (MEDS), which is updated monthly and in real-time batch transactions. MEDS is the central repository for Medi-Cal eligibility data. MEDS records are created and updated in partnership with the statewide county eligibility offices. FAME is used to create a report (See attached CP-0-292) to check against beneficiaries' date of death, which is a temporary solution. The report lists beneficiaries with a date of service past the date of death and the Administrative Services Organization contractor performs claim reversals as needed. DHCS expects to secure access to the SSA's DMF as a permanent solution by February 2021, and share the access with DHCS' contractors via contractual agreements.

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

Annual Follow-Up Agency Response From October 2019

DHCS received the Social Security Administration's (SSA) approval for the DMF on August 21, 2019. DHCS is working with SSA to enter into a new agreement to obtain the actual file. DHCS requested to receive the file from SSA on a weekly basis and intends to match it to DHCS' eligibility system using the same frequency. Once DHCS has the file, it will take approximately 90 days to implement the file match with DHCS' eligibility system. Estimated implementation date is unknown as this process is reliant upon SSA. In the interim, DHCS has been collaborating with a data vendor who has access to the DMF and a third party data source to model a quarterly death matching sweep. DHCS received the first matching outputs in June 2019 and is working on the death detection sweep. A second quarterly sweep is expected to commence in October 2019 and ongoing quarterly until SSA can directly share the DMF file with DHCS on a weekly basis.

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

Annual Follow-Up Agency Response From November 2018

DHCS continues to receive monthly updates of the DMF, but has not finalized a process to match its eligibility system against these updates. DHCS was recently informed that the DMF is available from the Centers for Medicare and Medicaid Services, and approval is expected by the end of 2018. DHCS anticipates it will begin receiving the DMF file in mid-2019. Once the DMF file is received, DHCS will complete the necessary system changes to utilize the DMF file to match against the Medi-Cal Enrollment Data System (MEDS) and CD-MMIS.

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

Annual Follow-Up Agency Response From September 2017

DHCS issued a letter on January 12, 2017 to all counties reaffirming the instruction to check MEDS alerts for SSN verifications that failed to match. The county must take appropriate steps to verify the accuracy of the SSN should it fail an electronic verification.

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

Health Care Services' response does not address obtaining Social Security's Death Master File. When we followed up with Health Care Services' staff, they asserted that Health Care Services now obtains a monthly update of the Death Master File, but it has not yet implemented a process to match its eligibility system against these updates.

Annual Follow-Up Agency Response From November 2016

DHCS-Eligibility Division is actively working towards the implementation of a monthly update from the SSA Death Master File. We believe the audit finding was caused by applicants using fraudulent or erroneous SSNs not the frequency of the death file from SSA. DHCS will issue a policy letter to counties reminding them to follow-up on MEDS alerts when SSNs fail verification. The anticipated completion date of this letter is December 19, 2016.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

DHCS maintains its forecast that the improvements will be in place on or before April 30, 2016.

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

6-Month Agency Response

The Department of Health Care Services (DHCS) is continuing to work on improving the ability to detect unreported beneficiary deaths. Over the last 60 days, DHCS has identified and evaluated numerous federal, state, private, and direct reporting sources. Based on this evaluation, DHCS maintains its forecast that the improvements will be in place on or before April 30, 2016. These improvements include the acquisition, testing, and roll out of new sources and the improvement of existing sources.

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

60-Day Agency Response

DHCS intends to increase the frequency of updates to the Medi-Cal Eligibility Data System (MEDS) with the Social Security Administration's Death Master File from quarterly to monthly. The request to increase the frequency to monthly was already in progress and will most likely require an amendment to the existing DHCS/SSA information sharing agreement. The implementation date of April 30, 2016 accounts for the development and testing needed to complete this request.

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

All Recommendations in 2013-125

Agency responses received are posted verbatim.