A searing review of Medi-Cal managed care provider directories released Tuesday by the California State Auditor found numerous inaccuracies ranging from incorrect phone numbers of doctors to listings of providers who no longer were participating in the health plans.
Telephone calls from thousands of frustrated consumers also have gone unanswered by the state Ombudsman Office, the audit said.
The review comes as California has enrolled more than 1.1 million new Medi-Cal beneficiaries in 2014 under an expanded Medi-Cal program offered through Obamacare, as the Affordable Care Act is called. According to the audit, more than 12.2 million Californians now rely on the state-federal insurance for people with low incomes. In the central San Joaquin Valley, more than 850,000 people — nearly 43% of children and adults —have Medi-Cal coverage
The audit included the provider directory for Anthem Blue Cross of Fresno County, which it found to have the highest rate of inaccurate provider information of three plans that were studied.
Anthem and the two other plans, Health Net in Los Angeles County and Partnership HealthPlan of California in Solano County, all had inaccurate provider information, the audit found, but Anthem had the highest rate at 23.4%. Health Net had an 11.8% inaccuracy rate and Partnership HealthPlan had a 3.1% inaccuracy rate.
Anthem spokesman Darrel Ng said the audit was flawed. Of 18 Anthem providers out of 77 that the audit found to have inaccurate information, only one was an error on the health plan’s part, Ng said. “In other cases, doctors had moved and changed their provider status, and despite what is required in their contracts, they did not contact Anthem.”
Updating provider directories is a shared responsibility between the health plan and providers, he said.
The audit said Partnership HealthPlan in Solano County, which visits each of its providers eight to 10 times a year, had fewer errors in provider directories than Anthem Blue Cross, which only recently began to actively reach out to its providers to update information.
Ng said Anthem wants to “provide better service to our members, and we started going to medical groups multiple times a year to get updated rosters of their doctors.”
The audit faulted the California Department of Health Care Services, which has oversight of Medi-Cal managed care plans, for not verifying health plans’ information and said the department could not ensure that the health plans had adequate numbers of providers to serve Medi-Cal beneficiaries. The audit was ordered by the Joint Legislative Audit Committee in August 2014 to examine the Department of Health Services’ oversight of the health plans.
The Department of Health Services also did not perform annual medical audits of health plans and has not always ensured that the state’s Managed Health Care office had performed required quarterly adequacy assessments, the audit said.
Consumers’ complaints also went unheard. The audit said thousands of telephone calls from Medi-Cal beneficiaries to the Medi-Cal Managed Care Office of the Ombudsman went unanswered.
The ombudsman office was established to investigate and resolve complaints, but the office’s telephone system rejected about 7,000 to 45,000 calls per month between February 2014 and January 2015, the audit said. The ombudsman office said it could answer just about 30% to 50% of the calls that the telephone system accepted.
Department of Health Services Director Jennifer Kent issued a statement Tuesday. “DHCS agrees with many of the state auditor’s recommendations, and we have already begun to work to implement new processes that enhance our monitoring and certification processes,” she said.
Kent said, however, that the audit targeted only a portion of the department’s efforts, which include network monitoring through secret shopping, she said.
Advocates for health consumers said the audit shows the strain on state agencies as the state has moved more people into Medi-Cal managed care plans. According to the audit, statewide about 76% of the beneficiaries are in health plans. The remainder are in the fee-for-service system, which provides services and then pays claims. Under the managed care system, health plans provide the care and the Department of Health Care services pays the plans a fixed amount per month for each enrolled beneficiary.
“As we shifted more people into managed care, we didn’t update the oversight,” said Anthony Wright, executive director of Health Access California, a statewide consumer advocacy coalition. The audit confirms the need for pending reforms, including the implementation of annual surveys of network adequacy through Senate Bill 964, Wright said.
The state auditor made eight recommendations, including:
â–ª By September, the Department of Health Services should have a process to verify the accuracy of provider network information the health plan uses to demonstrate that it meets network adequacy standards.
â–ª By September, develop more detailed policies and procedures for verifying the accuracy of provider directories, including procedures for staff to select a sample size of providers, ensure the sample size is randomly selected and retain the documents with the review for at least three years.
The audit also said Health Care Services should implement “an effective plan to upgrade or replace the ombudsman office’s telephone system and database.”
Health plans said they work to keep online provider directories current.
Medi-Cal beneficiaries in Fresno County have two managed care plans from which to choose, Anthem Blue Cross and CalViva Health. The audit did not review CalViva, but on Tuesday, CalViva CEO Gregory Hund said the plan had established a “data integrity team” that is responsible for accuracy of both the Medi-Cal provider directories and the demographic data the plan receives from providers. The plan’s provider relation team also physically visits the office of each provider that has not returned requested demographic information, he said.
Advocates for health consumers said the stinging rebuke of the Department of Health Services by the state shows a need for action.
The audit is “eye-opening and should be something the state Senate uses to have an oversight hearing of the state Department of Health Services,” said Jamie Court, president of Consumer Watchdog, a national nonprofit consumer group.
Court said the audit also shows that “what has happened to too many patients in the private market is also happening in Medi-Cal.” Consumer Watchdog has a “narrow network” class action lawsuit against Anthem Blue Cross and Blue Shield of California on behalf of people who purchased individual coverage.
The California Academy of Family Physicians used the audit to push for a 5% increase in Medi-Cal payments to doctors that was approved by the state Legislature this week.
“The combination of inaccurate provider directories demonstrated by this audit and Medi-Cal’s bottom-of-the barrel payment rates are leading to a crisis in access,” said Dr. Jay W. Lee, president of the 9,000-member academy. “Primary care alone saw a more than 50% payment cut in Medi-Cal rates this year between state action and the expiration of Affordable Care Act funding provisions.”
Wright said while many patients in Medi-Cal get access to the care they need, problems persist and oversight is needed to find them so they can be resolved. ”At the end of the day, what’s at stake is the care of millions of Californians.”