July 06, 2018
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
In January 2018, the California Department of Health Care Services (DHCS) began requiring that all Medi-Cal managed care providers be enrolled through the Medi-Cal program. Medi-Cal managed care plans have the option to develop and implement a managed care physician screening and enrollment process that meets federal requirements, or they may direct their network physicians to enroll through the DHCS fee-for-service (FFS) enrollment portal. (Enrolling through DHCS does not obligate managed care network providers to also see FFS patients.)
Some physicians have already reported receiving notices from Medi-Cal managed care plans regarding the change, which is in response to a new federal rule that took effect on January 1, 2018, that requires states to screen and enroll, and periodically revalidate, all network physicians of managed care organizations. These requirements apply to both existing contracting network physicians as well as prospective network physicians.
All contracted physicians in a Medi-Cal managed care plan network prior to January 1, 2018, are required to enroll as soon as feasibly possible and no later than December 31, 2018.
For plans that choose to develop their own credentialing process, the plan must complete the enrollment process and provide the applicant with an official determination within 120 days of receipt of a physician application. Plans may allow physicians to participate in their networks for up to 120 days, pending the outcome of the screening process.
For plans that choose to have their network physicians enroll through DHCS, DHCS will have up to 180 days to complete the enrollment process. If a case is returned to a physician for correction, the 180 days may be extended. Physicians should note that because plans may only allow physicians to participate in their networks for 120 days pending completion of the screening/enrollment process, there could be instances where they would have to stop seeing Medi-Cal managed care patients if DHCS takes more than 120 days to process their application. Medi-Cal managed care physician applicants will not receive expedited processing.
Plans are not required to conduct additional screening and enrollment activities for physicians who are enrolled in the Medi-Cal FFS program. Plans and physicians may confirm Medi-Cal FFS enrollment by accessing the Open Data Portal, which is updated monthly.
DHCS has confirmed that network physicians who enroll through the DHCS FFS enrollment process do not need to render services to FFS beneficiaries. There is nothing on the Medi-Cal application that would indicate whether a physician is participating in FFS, managed care or both. DHCS has indicated that at some point it intends to modify the application to allow physicians to provide this information.