CMA asks CMS to make the Medi-Cal eligibility verification process more accurate and complete

January 22, 2015
Area(s) of Interest: Advocacy Payor Issues and Reimbursement Practice Management Public Payors 

On January 15, the California Medical Association (CMA) sent a letter to the Centers for Medicare and Medicaid Services (CMS) asking that the California Department of Health Care Services (DHCS) be directed to provide physicians with access to complete and accurate eligibility information for Medi-Cal patients. Currently, physicians checking eligibility through California's Automated Eligibility Verification System (AEVS) are unable to access information on delegated and/or sub-contracted relationships. Additionally, information that is available through AEVS is not always accurate. These issues make it difficult to provide timely access to care for Medi-Cal patients in the managed care program.

CMA has raised these issues with DHCS on multiple occasions, but the department has yet to take any action to address the deficiencies in eligibility information provided by AEVS, the letter said.

“Physicians that willingly participate in the Medi-Cal program are finding it more difficult to remain active Medi-Cal providers,” the letter said. “Not only have reimbursement rates continued to fall, administrative obstacles are making it more difficult for physicians to provide health care to their Medi-Cal patients.”

Physicians who check a recipient’s eligibility through Medi-Cal’s AEVS are in danger of providing services without reimbursement unless they take additional, independent steps to double check and, in some cases, triple check a recipient’s eligibility. With over 12 million Medi-Cal beneficiaries, DHCS should be looking for ways to retain and attract more physicians to the program, the letter said.

Medi-Cal provides eligibility information to providers through AEVS, a program that is intended to allow practices to verify patient eligibility and cost-sharing through either an interactive voice response system or a point of service electronic system. However, the system does not provide information on delegated and/or sub-contracted relationships and oftentimes the managed care plan listed is not accurate. Currently, California physicians must independently investigate whether the plan listed is correct and whether there might be a non-disclosed delegated and/or sub-contracted relationship that impacts the patient’s eligibility. ­

Due to the fact that most plans delegate their Medi-Cal managed care business to other plans or groups, physicians need to further check eligibility with another entity, possibly two if the plan has sub-contracted with another plan that then delegates to a group. Once eligibility is finally confirmed with a particular plan or delegated group, the physician must then ensure he/she is participating in that network. That is, even though the physician may be contracted with the patient’s plan, he or she may not be contracted with the group or plan that is delegated downstream.

Because the task of confirming eligibility has become so time-consuming, CMA fears that if physicians are not efficiently given accurate and complete eligibility information, patients will not receive timely access to care or, worse, physicians will be forced to terminate their contracts with Medi-Cal managed care plans/groups.

The letter urges CMS to direct DHCS to provide physicians with accurate and complete information to enable California physicians continue to provide care to Medi-Cal recipients.

Read the full letter here.

Contact: CMA Legal Information Line, (800) 786-4262 or legalinfo@cmadocs.org.


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