Auditor Slams Medi-Cal Provider Access

The California Auditor has released a scathing report on patient access to the Medi-Cal system, raising concerns that those enrolled through commercial health plans may not be able to adequately access providers.

According to the 60-page report, both the Department of Health Care Services (DHCS), which administers the Medi-Cal program, and the Department of Managed Health Care (DMHC), which ensures the integrity of the provider networks of health plans, both stumbled on the job. As a result, Medi-Cal managed care enrollees not only have had issues reliably accessing a provider network, but often cannot lodge a concern of complaint with the Medi-Cal program's Office of the Ombudsman.

About 12.2 million Californians – more than 30% of the state's population – is enrolled in Medi-Cal, and about 9.2 million are in managed care plans operated by commercial insurers. 

The Medi-Cal program has experienced remarkable growth since the Great Recession began in late 2007 and Affordable Care Act was signed into law five years ago. Med-Cal enrollment is 60% higher than it was in 2012, and nearly double the total it was a decade ago.

But that dramatic growth was apparently not matched by program oversight. Enrollee complaints prompted the Auditor to launch an investigation into how the Medi-Cal program was managing access to providers. Its findings were blunt:

• DHCS failed to independently verify provider network data sent in by health plans

• DHCS' methodology for confirming the accuracy of health plan directories was inaccurate, and it did not keep any documentation of its process

• This faulty data was sent to the DMHC to ensure provider network integrity, causing issues of its own

• DHCS failed to ensure that DMHC conducted quarterly assessments of health plan provider networks, with the agency failing to do so in 28 of 58 counties as of last year

• DHCS' Medi-Cal Managed Care Office Of The Ombudsman is not equipped to handle the volume of phone calls that it is receiving from enrollees. According to the report, the office can handle only 25,000 phone calls per month. But monthly volumes reached more than 50,000.

The Auditor also sampled provider network directories of three Medi-Cal managed care health plans: Anthem Blue Cross in Fresno County; Health Net in Los Angeles County; and Partnership HealthPlan of California in Solano County.

According to the sampling, 23.4% of the Anthem Blue Cross providers vetted by the Auditor contained errors, including incorrect telephone numbers, incorrect addresses, and incorrect data as to whether the provider was open to Medi-Cal managed care enrollees or taking in new patients. Health Net had an 11.8% error rate, while PartnerShip Health Plan had a 3.1% error rate.

Such complaints from health plan enrollees – whether in Medi-Cal or not – about being furnished with inaccurate provider information have been fairly widespread in recent years, particularly as some payers began relying more heavily on so-called narrow networks. But the Auditor's survey is one of the first to actually quantify the issue.

Anthem Blue Cross spokesperson Darrel Ng said in an email that the health plan has asked its participating providers to submite updated medical rosters twice a year as opposed to annually. However, he noted that there is an onus on the providers to keep their information up-to-date.

“Anthem’s contracts with providers require that they notify Anthem of changes in their contact information (and) network status,” he said in an email. “When they fail to do so, despite proactive steps taken by Anthem to keep it current, the provider listing may become dated. Even when the provider listing is correct, Anthem relies on front office staff at doctors’ offices to provide accurate information.”

In addition to identifying the various issues regarding ensuring access to providers, the Auditor made a variety of recommendations for improvement. They included:

• Establishing no later than this September “a process to verify the accuracy of the provider network data the health plan uses to demonstrate that it meets network adequacy standards.” It also recommended a similar process for verifying the data it forwards to the DMHC. 

• DHCS should identify best practices for how each plan should update and verify the accuracy of its directory, identify best practices, and require health plans to follow those practices

• Also by September, DHCS should develop procedures to sample providers in health plan provider directories under review, and keep all documents associated with the review for at least three years 

• DHCS should undertake a plan to upgrade or replace the Office of the Managed Care Ombudsman's telephone system

• DMHC should be September find ways to eliminate any overlap in their work and DHCS's

The DHCS only partly concurred with the Auditor's findings. It agreed to enhance its document retention and is in the process of upgrading the Ombudsman Office's phone system. But it rejected a recommendation that it boost its oversight of DMHC in order to ensure it complete its quarterly assessments of its health plans.

“For the past three years, DHCS and DMHC have worked together to coordinate medical audits and surveys. This coordination includes conducting bi-weekly audit conference calls, the creation of a coordinated audit schedule, a side-by-side analysis of audit and survey tools, and coordinated heath plan corrective action plans, when applicable.

Additionally, the audit teams are onsite concurrently, conduct joint interviews, and

sampling of procedures and data,” DHCS Director Jennifer Kent said in a letter to the Auditor's office.

The DMHC agreed with all of the Auditor's recommendations.