Report 2018-115 Recommendation 3 Responses
Report 2018-115: Department of Health Care Services: Although Its Oversight of Managed Care Health Plans Is Generally Sufficient, It Needs to Ensure That Their Administrative Expenses Are Reasonable and Necessary (Release Date: April 2019)
Recommendation #3 To: Health Care Services, Department of
To ensure that DHCS consistently identifies health plans that do not have required processes to detect and prevent fraud, it should immediately reevaluate its audit program for medical audits and revise it as necessary to ensure that staff follow the audit procedures regarding fraud and abuse programs.
6-Month Agency Response
The DHCS Medical Review Branch revisited the audit review protocols with audit managers to reaffirm the expectation that audit documentation reviews be performed thoroughly to ensure all planned audit program steps are executed as expected. With this update we are including requested substantiation.
- Completion Date: May 2019
- Response Date: September 2019
California State Auditor's Assessment of 6-Month Status: Fully Implemented
DHCS provided evidence in its 60-Day response demonstrating that it had a meeting with all Medical Review Branch staff responsible for audits to discuss our audit findings and Yellow Book requirements for supervision. In addition, in its 6-Month response, DHCS provided evidence demonstrating that it reevaluated and revised its audit program for medical audits to ensure that staff follow the audit procedures regarding fraud and abuse programs. Thus, we agree that this recommendation is fully implemented.
60-Day Agency Response
DHCS' Medical Review Branch management revisited the audit review protocols with audit managers to reaffirm the expectation that audit documentation reviews be performed thoroughly to ensure all planned audit program steps are executed as expected.
- Completion Date: May 2019
- Response Date: May 2019
California State Auditor's Assessment of 60-Day Status: Pending
DHCS did not provide evidence that it reevaluated its audit program for medical audits and revised it as necessary to ensure that staff follow the audit procedures regarding fraud and abuse programs. Until it does so, we will assess this recommendation as pending.
- Auditee did not substantiate its claim of full implementation
All Recommendations in 2018-115
Agency responses received are posted verbatim.