Recurring Findings

Health Care: Recurring Material Internal Control Deficiencies
Federal Program Issue First Year Reported
Department's Assertion Page Number
Medical Assistance Program Findings cited in the 2007 annual Medi-Cal Payment Error Study revealed that 6.56 percent of the total dollars paid for claims had some indication that they contained a provider payment error, 2.53 percent of paid claims were submitted by providers that disclose characteristics of potential fraud, and 46 percent of the payments for claims with errors did not have sufficient documentation to support the services claimed. 2005-06
Health Care Services concurs with the recommendation and will continue to implement the corrective action steps outlined in the MPES 2007. 125
Medical Assistance Program Health Care Services and Public Health did not retain the federally required provider agreements for four of 50 sampled. 2006-07
Health Care Services agrees with the recommendation to strengthen its controls to retain all provider agreements and necessary documentation to continue efforts to ensure that appropriate certifications and agreements are obtained. One provider did not have documentation of an active license, application, provider agreement, or disclosure statement; most likely, the documents were inadvertently missed when PED implemented its tracking database in 1999. Three facility providers did not have a provider agreement on file; since June 2010, provider agreements have been obtained from these three facility providers. 153
Medical Assistance Program Health Care Services lacks sufficient internal controls to ensure only medically necessary claims are paid, and to detect providers in violation of record retention rules. Of the 50 expenditure claims reviewed, 10 did not appear to be for allowable services. 2006-07
Health Care Services has developed pre- and post-payment reviews (Random Claims Review, Self-audits, Desk Audits, Field Audit Reviews, and Audits for Recovery) to ensure only medically necessary claims and eligible providers are paid and providers adhere to record retention rules. Health Care Services also conducts an annual Medi-Cal Payment Error Rate Study (MPES) to identify any potential problem trends. Through MPES, Health Care Services identified documentation issues with pharmacies, adult day health centers (ADHC), local educational agencies (LEA) and non-emergency medical transportation (NEMT) providers. 127
Medical Assistance Program Health Care Services lacks adequate internal controls over its redetermination requirements for Medi-Cal beneficiaries to ensure benefits are discontinued when redeterminations are not received within 12 months of the most recent redetermination date. 2008-09
Health Care Services staff will discuss each of the audit findings with affected counties. These discussions will include a review of the specific findings with each affected county, indicated remedial actions, possible best practices referrals, and if warranted, appropriate focused reviews to address specific eligibility performance issues. 141