Report 2022-112 Recommendation 6 Responses

Report 2022-112: CalOptima Health: It Has Accumulated Excessive Surplus Funds and Made Questionable Hiring Decisions (Release Date: May 2023)

Recommendation #6 To: CalOptima Health

To reduce the risk that it does not appropriately evaluate allegations of fraud, waste, and abuse and report them to DHCS, by June 2023 the FWA unit should revise its written procedures to clearly specify the types of cases that should be addressed through investigations and the types that should be addressed through monitoring activities. In addition, it should establish written procedures for conducting monitoring activities.

60-Day Agency Response

CalOptima Health updated policy HH.1107: Fraud, Waste, and Abuse Investigation and Reporting (Attachment A1). This policy has been updated to clearly specify that all allegations of suspected FWA shall be preliminarily researched, and all allegations received shall be documented in a FWA tracking log within one (1) business day. Allegations for which sufficient information is initially provided or garnered through preliminary investigation will undergo a full investigation. CalOptima Health's Board of Directors approved the implementation of this policy on June 1, 2023.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

The policy CalOptima references in its response and the procedures that correspond with the policy provide additional context and definitions for the phases of CalOptima's Fraud, Waste, and Abuse Investigation and Reporting process; and we assess this recommendation as fully implemented.

All Recommendations in 2022-112

Agency responses received are posted verbatim.