Report 2013-119 Recommendations

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately coordinate with the appropriate counties to recover inappropriate payments to ineligible providers and for services purportedly rendered to deceased beneficiaries.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately develop and implement new procedures for routinely identifying and initiating recovery efforts for payments that it authorizes between the effective date of a provider's decertification and the date it became aware of the decertification, in addition to the payments it authorizes between a beneficiary's death date and its receipt of the death record.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately direct its investigations division to determine whether it authorized any improper payments to program providers for deceased beneficiaries outside of our audit period. It should also determine whether it authorized such payments through its other Medi-Cal programs. Health Care Services should initiate efforts to recover such payments as appropriate.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately direct its investigations division to determine whether it should recover any overpayments for the high-risk payments we identified in Table 7 on page 28 and Appendix A beginning on page 63. It should also take the appropriate disciplinary action against the affected providers, such as suspension or termination.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately direct its investigations division to further enhance its analysis of program claims data to identify the type of high-risk payments we identified on a monthly basis.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately direct its fiscal management and accountability branch to work with Fresno, Los Angeles, and Sacramento counties to recover the specific overpayments we identified during our visits.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately instruct the counties to remind their providers to adhere to the record retention policies stated in their contracts.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately ensure that each county has a process in place to follow up on their providers' implementation of corrective action plans aimed at resolving program deficiencies.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately ensure that Fresno County strengthens its provider contract monitoring process, including revising its report format and conducting follow-up visits to providers.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately ensure that Los Angeles County strengthens its provider contract monitoring process, including fully implementing its RATE system to track and respond to provider deficiencies, and that it imposes appropriate responses when warranted, such as withholding payment or suspending or terminating a contract.

To ensure that the providers receive reimbursement for only valid services, Health Care Services should immediately ensure that Sacramento County strengthens its provider contract monitoring process, including tracking provider deficiencies and conducting follow-up visits to providers.

To prevent the certification of ineligible providers, Health Care Services should immediately instruct its staff to compare the names of the managing employees whom applicant providers identify in their program applications to those whom they identify in their disclosure statements.

To prevent the certification of ineligible providers, Health Care Services should immediately train its staff regularly on the program requirements, including the certification standards and the federal Medicaid provider enrollment requirements.

To prevent the certification of ineligible providers, Health Care Services should immediately develop a provider agreement for program providers.

To prevent the certification of ineligible providers, Health Care Services should immediately update its procedures to include searches of the Social Security Death Master File.

To prevent the certification of ineligible providers, Health Care Services should immediately develop procedures on how to evaluate provider applicant license database searches.

To prevent the certification of ineligible providers, Health Care Services should immediately instruct its enrollment division to conduct all required database searches of individuals that provider applicants identify as their owners or managing employees.

To prevent the certification of ineligible providers, Health Care Services should immediately ensure that its enrollment division conducts LEIE and EPLS database searches of program providers at least monthly.

To prevent the certification of ineligible providers, Health Care Services should immediately designate provider applicants as moderate or high risk in accordance with federal regulations.

To prevent the certification of ineligible providers, Health Care Services should immediately establish a mechanism to identify the number of program sites the provider applicants' medical directors work at, and ensure that the physician ratio does not exceed 1-to-3 in accordance with state law and the certification standards.

To prevent the certification of ineligible providers, Health Care Services should immediately identify and perform an immediate recertification of providers that signed the Compliance Agreement to ensure that these providers are currently meeting all program requirements.

To prevent the certification of ineligible providers, Health Care Services should immediately use a risk-based approach for recertifying program providers.

To prevent the certification of ineligible providers, Health Care Services should immediately develop policies and procedures for its program recertification process.

To prevent the certification of ineligible providers, Health Care Services should immediately develop a schedule for recertifying all program providers every five years.

To prevent the certification of ineligible providers, Health Care Services should immediately continue its implementation of an automated provider enrollment system.

To prevent the certification of ineligible providers, Health Care Services should immediately complete its program recertification on or before March 24, 2016, as federal regulations require.

To prevent the certification of ineligible providers, Health Care Services should immediately establish a plan for eliminating its backlog of applications for new sites and services and changes to existing certifications.

To ensure that it appropriately and consistently reviews provider applications and conducts site visits, Health Care Services should update its program checklists to reflect the current federal and state laws and regulations.

To ensure that it appropriately and consistently reviews provider applications and conducts site visits, Health Care Services should retain the documentation, such as checklists, that it uses to support its certification decisions in accordance with its retention policy.

To ensure that it appropriately and consistently reviews provider applications and conducts site visits, Health Care Services should ensure that supervisors perform detailed reviews of all provider applicants' files, including the application, disclosure statement, and checklists, and that they evidence their reviews by signing off on the appropriate forms.

To improve the coordination between its divisions, branches, and units and ensure that it addresses allegations of fraud in a timely manner, Health Care Services should continue its efforts to develop its provider risk assessment model for the PSPP unit.

To improve the coordination between its divisions, branches, and units and ensure that it addresses allegations of fraud in a timely manner, Health Care Services should continue its efforts to establish a mechanism for its PSPP unit to report the status of fraud referrals to SUD management and its investigations division.

To improve the coordination between its divisions, branches, and units and ensure that it addresses allegations of fraud in a timely manner, Health Care Services should fully implement the investigations division's recommendations shown in Appendix B. If it chooses not to implement a recommendation, it should document sufficiently the reasons for its decision.

To strengthen the coordination between the State and the counties, Health Care Services should amend the State-county contract to address any gaps in their collective monitoring efforts.

To ensure that beneficiaries have safe and reliable access to program services, Health Care Services should amend the State-county contract to allow a process for counties to notify their key partners of the providers that it has suspended.