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California State Auditor releases report outlining flaws with Medi-Cal program



June 24, 2015
Area(s) of Interest: Payor Issues and Reimbursement Practice Management Public Payors 

The California State Auditor’s office released a report on Tuesday expressing a need for better monitoring of the health plans participating in California’s Medicaid program, Medi-Cal, in order to improve beneficiaries’ access to care.


Among the key findings of the audit was that the California Department of Health Care Services (DHCS), which administers Medi-Cal, “has not consistently monitored health plans to ensure that they meet beneficiaries’ medical needs—it did not perform any annual medical audits before 2012 and performed medical audits on less than half of the health plans in fiscal year 2013-14,” according to a summary.


The audit also found that DHCS “did not verify health plan data,” resulting in an inability to ensure that beneficiary health plans had sufficient networks of physician providers, and that the tool DHCS uses to evaluate the accuracy of doctor directories is “inadequate.”


“Furthermore, we noted that thousands of calls from Medi-Cal beneficiaries seeking assistance through Health Care Services’ Medi-Cal Managed Care Office of the Ombudsman have gone unanswered,” California’s independent State Auditor Elaine Howle wrote in the report. “Specifically, each month between February 2014 and January 2015 an average of 12,500 calls went unanswered.”


The state legislature ordered the State Auditor to conduct the review last August amid concerns of inaccuracies with provider directories.


Currently, about 12.2 million Californians — or about one-third of the state’s residents — receive health care coverage through Medi-Cal. That number has spiked since Medi-Cal eligibility was expanded under the Affordable Care Act last year.


For the full report, click here.

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