Molina Healthcare of California Partner Plan, Inc.are as follows: I. INTRODUCTION . Molina...

MEDICAL REVIEW – SOUTHERN SECTION II AUDITS AND INVESTIGATIONS

DEPARTMENT OF HEALTH CARE SERVICES

Molina Healthcare of

California Partner Plan, Inc.

Contract Numbers: 06-55498, 07-65851 and 09-86161

Audit Period: August 1, 2016 Through

July 31, 2017

Report Issued: June 11, 2018

TABLE OF CONTENTS

I. INTRODUCTION .............................................................................1

II. EXECUTIVE SUMMARY .................................................................2

III. SCOPE/AUDIT PROCEDURES ......................................................5

IV. COMPLIANCE AUDIT FINDINGS Category 1 – Utilization Management..............................................7 Category 2 – Case Management and Coordination of Care ..........16 Category 5 – Quality Management ................................................19

I. INTRODUCTION

Molina Healthcare of California Partner Plan, Inc. (MHC or the Plan) has been contracted by the State of California Department of Health Care Services since April 1996 under the provisions of Section 14087.3, Welfare and Institutions (W&I) Code. As of July 1, 2006, MHC is the Medi-Cal contracted Commercial Plan for Riverside and San Bernardino Counties and a Geographic Managed Care Plan for Sacramento and San Diego counties. In 2013, MHC acquired the Medicaid Expansion and the dual eligibility program.

MHC is a Long Beach based health maintenance organization that was founded in 1980 and is licensed in accordance with the provisions of the Knox-Keene Health Care Service Plan Act. MHC is a National Committee on the Quality Assurance (NCQA) accredited health plan.

MHC has been serving Medi-Cal members since January 1980. The Plan’s focus is on government-sponsored programs such as Medi-Cal, Medicare, Cal MediConnect (duals demo) and Marketplace (Covered California). As of July 1, 2017, there are 456,709 members across 4 counties.

The Plan’s enrollment totals for its Medi-Cal line of business in Riverside, San Bernardino, Sacramento, and San Diego Counties as of July 2017 are as follows:

• San Diego: 229,171 • San Bernardino: 77,617 • Riverside: 89,920 • Sacramento: 60,001

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II. EXECUTIVE SUMMARY

This report presents the audit findings of the Department of Health Care Services (DHCS) medical audit for the period of August 1, 2016 through July 31, 2017. The on-site review was conducted from August 7, 2017 through August 11, 2017. The audit consisted of a review of documents, verification studies, and interviews with Plan personnel.

An Exit Conference was held on April 13, 2018 with the Plan. The Plan was allowed 15 calendar days from the date of the Exit Conference to provide supplemental information addressing the draft audit report findings. On April 30, 2018 the Plan submitted additional information after the Exit Conference that is reflected in this report.

The audit evaluated six categories of performance: Utilization Management (UM), Continuity of Care, Access and Availability to Care, Member’s Rights, Quality Management (QI), and Administrative and Organizational Capacity. The summary of the findings by category follows:

Category 1 – Utilization Management

The Plan must ensure that all contracting providers are aware of the procedures and timeframes necessary to obtain prior authorization for medical services and the referral processes. The timeframes for retrospective authorizations conflict with notifications sent to all providers. Pharmacy timeframes for retrospective review are not evident in provider communications.

The Plan shall refer members identified as potential major organ transplant candidates to a Medi-Cal approved transplant center for evaluation. The Plan required that potential organ transplant candidates meet Medi-Cal criteria for transplants before approving referral to a transplant evaluation center

The Contract requires that the Plan shall notify members and/or providers of a decision to deny, defer, or modify requests for prior authorization in accordance with California Health and Safety Code 1367.01. The Plan did not send correct Utilization Management (UM) appeal information when it issued retrospective pharmacy denials to providers. Pharmacy provider letters were unclear in their reasons for denial. Notice of Action letters misstated medications’ Food and Drug Administration status.

The Plan may place utilization limits on services based on medical necessity if the services provided can reasonably achieve their purpose. Medi-Cal regulations allow off-label drug use when the use is reasonable and in-line with current prescribing practices evidenced by support in current medical literature and consultation with “provider organizations, and academic and professional specialists.” A verification study of 31 pharmacy authorizations revealed seven denials for off-label use of pharmaceuticals. The Plan applied criteria that was more restrictive than that required by Medi-Cal and denied requests for off label use of medications.

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The Plan’s Utilization Management (UM) program shall use appropriate processes to review and approve medically necessary covered services. The Plan allowed reconsideration of adverse UM decisions and did not describe the process in its UM program or policies. In processing reconsiderations, the Plan did not adhere to established appeal requirements.

Category 2 – Case Management and Coordination of Care

The Contract requires that the Plan cover and ensure the provision of a complete Initial Health Assessment (IHA) that includes an Individual Health Education Behavioral Assessment (IHEBA) to all new members within stipulated timelines and make at least three documented attempts to contact a Member and schedule an IHA. The Plan did not monitor or track the attempted contacts to schedule the IHA to help bolster their IHA outreach program.

Category 3 – Access and Availability of Care

No findings.

Category 4 – Member’s Rights

In the prior year, the Plan did not process quality of care grievances as required by the contract requirements and regulations. As a result, the Plan developed a new process and revised Quality Management policies and procedures to ensure the Plan meets contractual requirements related to processing quality of care member grievances.

Category 5 – Quality Management

In the prior year, the Plan did not take effective action to ensure improvements in quality of care when grievance case files demonstrated quality problems. As a result, the Plan developed a tracking log for monitoring Corrective Action Plans (CAPs) issued to providers to ensure timely completion and documentation of outcomes. Potential Quality of Care (PQOC) cases which are pending due to non-responsive providers or Independent Physician Associations (IPAs), non-closed incomplete CAPs or incomplete peer reviews will be escalated first to the PQOC lead Medical Director and then to the Chief Medical Officer as outlined in the CAP policy.

All Plan Letter 02-03 and the Contract requires that the Plan must develop policies and procedures to verify the credentials of Non-physician Medical Practitioners (NMP), such as Nurse Practitioners, Certified Nurse Midwives, Clinical Nurse Specialists and Physician Assistants in accordance with State requirements applicable to the provider category. The Plan did not track or verify the credentials of Non-physician Medical Practitioners who are credentialed by site providers.

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Category 6 – Administrative and Organizational Capacity

No findings.

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III. SCOPE/AUDIT PROCEDURES

SCOPE

This audit was conducted by the Department of Health Care Services (DHCS) Medical Review Branch to ascertain that the medical services provided to Plan members comply with federal and state laws, Medi-Cal regulations and guidelines, and the State Contract.

PROCEDURE

The on-site review was conducted from August 7, 2017 through August 11, 2017. The audit included a review of the Plan’s policies for providing services, the procedures used to implement the policies, and verification studies of the implementation and effectiveness of the policies. Documents were reviewed and interviews were conducted with Plan administrators and staff. The following verification studies were conducted:

Category 1 – Utilization Management

Prior Authorization Requests: 23 medical and 31 pharmacy prior authorization requests were reviewed for timeliness, consistent application of criteria, and appropriate review by the Plan.

Appeal Procedures: 19 prior authorization appeals were reviewed for appropriate and timely adjudication.

Category 2 – Case Management and Coordination of Care

Individual Health Assessment (IHA): 20 medical records were reviewed for completeness and timely completion.

Behavioral Health Treatment (BHT): 10 samples listed as BHT were reviewed for completeness and timely completion.

Category 4 – Member’s Rights

Grievance Procedures: 29 grievances were reviewed for timely resolution, response to complaint, and submission to the appropriate level for review. 17 quality of care grievances were reviewed for response to complainant, and submission to the appropriate level for review and 12 quality of service grievances were reviewed for timely resolution.

Category 5 – Quality Management

Medical Records: 14 providers were interviewed to ensure that the providers are

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delegated the responsibility of securing and maintaining medical records at each site. Also, the Plan’s policies and procedures were reviewed for completeness.

New Provider Training: 20 new provider training records were reviewed for timely Medi-Cal Managed Care program training.

A description of the findings for each category is contained in the following report.

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COMPLIANCE AUDIT FINDINGS

PLAN:Molina Healthcare of California Partner Plan, Inc.

AUDIT PERIOD: August 1, 2016 – July 31, 2017

DATE OF AUDIT: August 7, 2017 – August 11, 2017

CATEGORY 1 - UTILIZATION MANAGEMENT

1.1 UTILIZATION MANAGEMENT PROGRAM

Utilization Management (UM) Program Requirements:Contractor shall develop, implement, and continuously update and improve, a Utilization Management (UM) program that ensures appropriate processes are used to review and approve the provision of Medically Necessary Covered Services. GMC/2-Plan Contract A.5.1

There is a set of written criteria or guidelines for utilization review that is based on sound medical evidence, is consistently applied, regularly reviewed, and updated. GMC/2-Plan Contract A.5.2.C

Review of Utilization Data: Contractor shall include within the UM Program mechanisms to detect both under- and over-utilization of health care services. Contractor’s internal reporting mechanisms used to detect Member Utilization Patterns shall be reported to DHCS upon request. GMC/2-Plan Contract A.5.4

SUMMARY OF FINDINGS:

1.1 Retrospective Review

The Plan shall ensure that it employs appropriate processes to approve medically necessary services, and shall communicate to providers the procedures and timeframes for obtaining services requiring prior authorization. (Contract, Exhibit A, Attachment 5(1)(E))

The Plan shall ensure that its pre-authorization, concurrent review, and retrospective review procedures include that a qualified treating health care professional with appropriate clinical expertise will decide to deny or to modify service requests. (Contract, Exhibit A, Attachment 5(2)(A))

The Plan did not have consistent polices or communications regarding post-service authorization requests.

Policy CA-HCS-CAM-384 defined retrospective or post-service review as “Any request for authorization of non-urgent service after the service(s) has been rendered.”

Molina Policy UM-25, signed April 5, 2017, allowed providers 60 days to submit retrospective

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authorization requests. After 60 days, the claim should be submitted electronically to Molina via a claims processing clearinghouse. The Plan did not specify the time limit for submitting a provider retrospective review in the Provider Manual or the Member Handbook. A “Just the Fax” provider notification on July 1, 2016 indicated 30 days as the timeframe for submitting a retrospective review after hospital discharge. A spring 2017 “Partners in Care” provider newsletter did not update deadlines for medical or pharmacy retrospective review. Concurrent review notices to hospital providers on May 1, 2017 reflected the more lenient time frame for medical retrospective review, though they did not describe the procedure for retrospective review submissions after 60 days.

A Plan memo dated September 6, 2017 about the retrospective review process clarified that although a 60-day time limit applied for submission of medical service retrospective requests, the Plan did not deny the cases automatically for lateness and stated that only a medical director issued service denials.

Molina pharmacy Policy P-07 dated February 21, 2017 stated the Plan would not grant retrospective requests older than 30 days from the date of medication delivery, that the Plan would only approve one retrospective request per member per drug, and that it would not provide retrospective authorizations for specialty medications. A verification study showed that a Plan pharmacist reviewed all retrospective denials in the sample, with consideration for clinical details in the case.

In summary,

• There were different submission time frames for medical and pharmacy retrospective reviews.

• Though pharmacy policy stated the Plan would not grant retrospective requests past a certain date, a verification study showed that a pharmacist issued retrospective case denials after consideration for clinical review. The Plan documented that only a medical director made denials and only a medical director directed the issuing of administrative denials.

• Plan documentation did not show that the Plan updated providers about current submission timeframes for medical or pharmacy retrospective reviews.

Inconsistent policies and processes may lead to resolution of retrospective reviews in a manner that varies from contractual and regulatory requirements, including denial without a medical necessity review by a medical director or a pharmacist. This may negatively affect providers’ payments and their future willingness to provide services to Plan beneficiaries.

RECOMMENDATION

1.1 Revise Plan policies and processes so that provider information regarding submission timeframes for retrospective authorizations for medical and pharmacy services is current,

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consistent, and compliant with regulatory requirements for processing post-service authorization requests.

1.2 PRIOR AUTHORIZATION REVIEW REQUIREMENTS

Prior Authorization and Review Procedures: Contractor shall ensure that its pre-authorization, concurrent review and retrospective review procedures meet the following minimum requirements… GMC/2-Plan Contract A.5.2.A, B, D, F, H, and I.

Exceptions to Prior Authorization:Prior Authorization requirements shall not be applied to Emergency Services, Minor Consent Services, family planning services, preventive services, basic prenatal care, sexually transmitted disease services, and HIV testing. GMC Contract A.5.2.G

Prior Authorization requirements shall not be applied to emergency services, family planning services, preventive services, basic prenatal care, sexually transmitted disease services, and HIV testing. 2-Plan Contract A.5.2.G

Timeframes for Medical Authorization Pharmaceuticals: 24 hours or one (1) business day on all drugs that require prior authorization in accordance with Welfare and Institutions Code Section 14185(a)(1) or any future amendments thereto. GMC Contract A.5.3.F

Pharmaceuticals: 24 hours or one (1) business day on all drugs that require prior authorization in accordance with Welfare and Institutions Code, Section 14185 or any future amendments thereto. 2-Plan Contract A.5.3.F

Routine authorizations: five (5) working days from receipt of the information reasonably necessary to render a decision (these are requests for specialty service, cost control purposes, out-of-network not otherwise exempt from prior authorization) in accordance with Health and Safety Code Section 1367.01(h)(1), or any future amendments thereto, but, no longer than 14 calendar days from the receipt of the request. GMC Contract A.5.3.H

Routine authorizations: Five (5) working days from receipt of the information reasonably necessary to render a decision (these are requests for specialty service, cost control purposes, out-of-network not otherwise exempt from prior authorization) in accordance with

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Health and Safety Code, Section 1367.01, or any future amendments thereto, but, no longer than 14 calendar days from the receipt of the request. 2-Plan Contract A.5.2.H

Denial, Deferral, or Modification of Prior Authorization Requests:Contractor shall notify Members of a decision to deny, defer, or modify requests for Prior Authorization by providing written notification to Members and/or their authorized representative…This notification must be provided as specified in 22 CCR in accordance with CCR, Title 22, Sections 51014.1, 51014.2, and 53894, and Health and Safety Code Section 1367.01. GMC Contract A.13.8.A Contractor shall notify Members of a decision to deny, defer, or modify requests for prior authorization, in accordance with Title 22 CCR Sections 51014.1 and 53894 by providing written notification to Members and/or their authorized representative...This notification must be provided as specified in 22 CCR Sections 51014.1, 51014.2, and 53894, and Health and Safety Code Section 1367.01. 2-Plan Contract A.13.8.A


1.2.1 Transplant Evaluations

The Plan shall refer members identified as potential major organ, except kidneys, transplant candidates to a Medi-Cal approved transplant center. If the member qualifies for a transplant as determined by the transplant center physician, the Plan shall submit a treatment request to the San Francisco Medi-Cal Field Office for approval of the procedure, which is covered by Medi-Cal Fee for Service (FFS). (Contract, Exhibit A, Attachment 11(18)(B))

The Plan required that enrollees identified as potential major organ transplant candidates meet Medi-Cal criteria for organ transplants before referring them to a Medi-Cal approved center for transplant evaluation.

Plan Policy UM-60: Major Organ Transplant described the transplant approval process.

• The enrollee’s Primary Care Physician (PCP) and specialist identify potential transplant candidates.

• The PCP must use Medi-Cal criteria for specific organ transplants to identify potential candidates.

• The corporate transplant unit and the Plan’s Medical Director process the evaluation request. • The Plan’s Medical Director should approve the evaluation request when either the PCP or specialist determines the member meets or may meet the Medi-Cal criteria.

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In an interview, the Plan confirmed that the final approval for referral to a transplant center for evaluation depended on meeting clinical and administrative criteria.

The Contract states that the Plan shall refer a potential transplant candidate to a transplant center for evaluation. Transplant center expert physicians and Medi-Cal Fee for Service are responsible for the evaluation of a potential transplant candidate and the final determination for transplant appropriateness, not the Plan.

In requiring PCPs or specialists to identify potential transplant candidates by fulfilling lengthy clinical criteria, the Plan risks inappropriate service delay or denial of consultation with experts and potentially curative treatment.

1.2.2 Pharmacy Notice of Action (NOA) Letters

“(The Plan) shall ensure that its pre-authorization, concurrent review and retrospective review procedures meet the following minimum requirements...Notification to members regarding denied, deferred or modified referrals is made as specified in Exhibit A, Attachment 13…(The Plan) must notify the requesting provider or member of any decision to deny, approve, modify, or delay a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the provider may be orally or in writing.” (Contract, Exhibit A, Attachment 5(2) (E) and (I))

The Health and Safety Code states that written notices to members and providers shall include a clear and concise explanation of the reasons for the plan's decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity. Notices shall include information as to how the enrollee may file a grievance with the plan (CA HSC 1367.01)

The Plan sent unclear letters to providers, and did not send UM appeal information when it issued retrospective pharmacy denials. Pharmacy letters contained misinformation about medication FDA approval status.

A verification study of 31 pharmacy cases showed:

• Five of 10 retrospective denials revealed deficiencies.

• Three of the five provider letters contained the title “Administrative Denial” and stated that the Plan denied due to no prior authorization requested, yet documented that the criteria used to deny was non-formulary or off label use of the drugs without further explanation.

• Five of the five letters gave providers information on how to submit a provider appeal within 365 days but did not contain member grievance information.

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• Nine pharmacy letters stated that denied medications were not Federal Drug Administration (FDA) approved. The medications in question were FDA-approved, though not as treatment for the conditions in the requests.

Molina pharmacy Policy P-07 dated 2/21/17 stated that the Plan would not grant retrospective requests older than 30 days from the date of medication delivery. However, review showed that the five cases above, three of which providers submitted past the 30-day limit, received a pharmacist’s review with consideration for clinical details. The cases had not met administrative and medical necessity criteria pursuant to the pharmacist’s assessment.

Regarding post-service (retrospective) NOA letters, the Plan reported that discussion regarding how to approach the matter is ongoing. The Plan reported that a letter stating it could not approve a medication that the member had already received might be confusing.

The Contract requires clarity in member communications to so that enrollees can make informed health care decisions. Though the Plan has made efforts to correct this problem, deficiencies remain. This is an ongoing finding.

1.2.3 Off-Label Medication Requests

The Plan shall provide covered services in an amount no less than that offered to beneficiaries under Fee for Service (FFS). The Plan may place utilization limits based on criteria such as medical necessity if the services provided can reasonably achieve their purpose. (Contract, Exhibit A, Attachment 10(1)(A and B))

Medi-Cal regulations allow off-label drug use when the use is reasonable and in-line with current prescribing practices evidenced by support in current medical literature and consultation with “provider organizations, and academic and professional specialists.” (22 CCR Section 51313 -Pharmaceutical Services and Prescribed Drugs)

Pursuant to the FDA, off-label drug use is the prescribing of FDA approved medications for other that their officially authorized indications. https://www.fda.gov/forpatients/other/offlabel/default.htm

The Plan applied criteria that was more restrictive than that required by Medi-Cal when reviewing requests for off-label medication use.

A verification study of 31 pharmacy authorizations revealed seven denials for off-label use of pharmaceuticals. In spite of evidence of a plan for reasonable use, providers did not consistently supply two peer-reviewed articles supporting their medication choice. A pharmacist decided all of

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https://www.fda.gov/forpatients/other/offlabel/default.htm





the cases without discussion with content area experts or with the requesting providers who were all specialists, and without medical director input.

Cases include:

• The provider documented that the patient had taken the requested medication since 2012 after participation a clinical trial with improvement and no adverse side effects.

• One denial for medication to increase severely depleted white blood cells (WBCs) in a patient who required immunosuppression after a heart transplant. Medi-Cal allowed use of this drug in patients with severely low WBCs, though the Food Drug Administration (FDA) had not approved the medication for this condition in transplant patients.

• Five denials for off label use of anti-cancer medications. In one case, a provider requested off label use of a medication for a young patient with brain metastases at the time of diagnosis. Other providers requested off label drug use for metastatic uterine, anal, breast and possible gastrointestinal cancer (primary unknown) for patients who tried and failed other therapies. Literature shows that the FDA approved the denied medications for treatment of specific cancers other than those in the above cases.

Plan pharmacy Policy P-07: Prior Authorization (PA) Request Procedures required that providers supply evidence of drug safety and efficacy in off-label medication requests. Pharmacy policies for off-label use of drugs (MCP 162: Off-Label Use of Drugs and Biologic Agents and MHC P-25 Non-Formulary Exceptions Process) required two peer reviewed scientific articles supporting the use of the requested medicine. MCP 162 stated that the Plan might make exceptions to the policy based on the features of a unique case.

In an interview, the Plan revealed that it required peer reviewed support of off label medications for patient safety. The Plan revealed that it was more flexible in approving oncology medication requests from a specialty group in its network because of the providers’ expertise. There was no policy describing this exception.

Using criteria more limiting than Medi-Cal’s for off label medication use may lead to denial of appropriate treatment for enrollees with no further medication options.

1.2.4 Reconsideration of Denials

The Plan’s Utilization Management (UM) program shall use appropriate processes to review and approve medically necessary covered services. (Contract, Exhibit A, Attachment 5(1))

Section 1300.68 (a)(1) of Title 28, of the California Code of Regulations (28 CCR 1300.68(a)(1)) defines an appeal as a request for reconsideration made by a member or their representative. A

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professional other than the one who made the initial adverse decision shall resolve appeals (reconsiderations). (Contract, Exhibit A, Attachment 14 (2)(G))

The Plan did not use appropriate processes to review and approve medically necessary covered services; the Plan instituted an optional post-denial process that bypassed contractual requirements for IP and some outpatient (OP) reviews. A verification study revealed seven of eight inpatient cases with reconsideration notices.

• Provider requested reconsideration in four of seven cases. • The Plan reconsidered and reversed its denial in one case. • The same physician who made the initial denial performed the reconsideration review in all

cases. • Three of the four cases contained provider notification faxes after reconsideration. • One case file contained no provider notification after reconsideration.

The Provider Manual and a “Just the Fax” document dated July 1, 2016 described the reconsideration process: after an IP denial, providers had five days to submit additional case information for possible overturn of an adverse determination.

CRC UMK2: Annotations for Inpatient Decisions dated July 11, 2017 contained reconsideration notice templates. Providers had up to 60 days after a denial to send more information to the Plan, which then had 28 days for reconsideration.

A memo dated 9/6/17 stated that the Plan does not have a policy, only Quick Reference Guides (QRGs) and workflows for the process because reconsideration is not a regulatory mandate. The Plan updated guides and workflows according to changes in practices and processes.

In an interview, the Plan reported that the reconsideration process was an effort to ensure timely processing of requests for inpatient hospitalizations. By not deferring cases and allowing the submission of additional information after adverse decisions, the Plan could make timely (within National Committee for Quality Assurance (NCQA) timeframes) UM decisions. Providers could submit additional information even after a denial without having to engage in the deferral or appeal processes. The Plan reported that it performed outpatient reconsiderations on a limited basis.

In a written communication dated April 30, 2018, the Plan reported that it followed deferral and appeal processes in its UM program and did not have any cases that fit criteria for deferment in the audit period. The Plan provided documentation of provider appeals submitted after three of the reconsiderations noted in the verification study.

The reconsideration process eliminates steps that may appear cumbersome, but which serve as protections for the delivery of health care services to members with transparency and oversight.

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RECOMMENDATIONS:

1.2.1 Revise authorization criteria for pre-transplant evaluations so that potential major organ transplant candidates are not required to meet clinical Medi-Cal transplant criteria before referral for evaluation.

1.2.2 Send NOA letters that clearly reflect the Plan’s reasons for denial, avoid misstatements, and include member appeal information. Ensure policies and processes for these letters complies with requirements as stipulated in the Contract and All Plan Letter 17-006 Grievance and Appeal Requirements and Revised Notice Templates and “Your Rights” Attachments, which took effect July 1, 2017.

1.2.3 Revise Plan policy so that criteria for approving off label medications are only as restrictive as Medi-Cal’s. Implement processes noted in Plan policies that state the Plan considers other information (e.g., peer to peer discussion with providers and experts) when deciding an authorization for off label drug use.

1.2.4 If a request for services results in an adverse Utilization Management decision, apply the appeal process as the next step.

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CATEGORY 2 – CASE MANAGEMENT AND COORDINATION OF CARE

2.4 INITIAL HEALTH ASSESSMENT

Provision of Initial Health Assessment: Contractor shall cover and ensure the provision of an IHA (comprehensive history and physical examination) in conformance with 22 CCR 53910.5(a)(1) to each new Member within timelines stipulated in Provision 5 and Provision 6 below. GMC Contract A.10.3.A

Contractor shall cover and ensure the provision of an IHA (complete history and physical examination) in conformance with Title 22, CCR, Sections 53851(b)(1) to each new Member within timelines stipulated in Provision 5 and Provision 6 below. 2-Plan Contract A.10.3.A

Provision of IHA for Members under Age 21 For Members under the age of 18 months, Contractor shall ensure the provision of an IHA within 120 calendar days following the date of enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) for ages two and younger, whichever is less. GMC Contract A.10.5

For Members under the age of 18 months, Contractor is responsible to cover and ensure the provision of an IHA within 120 calendar days following the date of enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) for ages two and younger whichever is less. 2-Plan Contract A.10.5

For Members 18 months of age and older upon enrollment, Contractor is responsible to ensure an IHA is performed within 120 calendar days of enrollment. GMC/2-Plan Contract A.10.5

IHAs for Adults, Age 21 and older Contractor shall cover and ensure that an IHA for adult Members is performed within 120 calendar days of enrollment. Contractor shall ensure that the performance of the initial comprehensive history and physical exam for adults includes…(as required by Contract) GMC Contract A.10.6

Contractor shall cover and ensure that an IHA for adult Members is performed within 120 calendar days of enrollment. Contractor shall ensure that the performance of the initial complete history and physical exam for adults includes…(as required by Contract)

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2.4 INITIAL HEALTH ASSESSMENT 2-Plan Contract A.10.6 Contractor shall make repeated attempts, if necessary, to contact a Member and schedule an IHA. Contractor shall make at least three documented attempts that demonstrate Contractor’s unsuccessful efforts to contact a Member and schedule an IHA. Contact methods must include at least one telephone and one mail notification. Contractor must document all attempts to perform an IHA at subsequent office visit(s) until all components of the IHA are completed. GMC Contract A.10.3.E

Contractor shall make reasonable attempts to contact a Member and schedule an IHA. All attempts shall be documented. Documented attempts that demonstrate Contractor’s unsuccessful efforts to contact a Member and schedule an IHA shall be considered evidence in meeting this requirement. 2-Plan Contract A.10.3.D

Individual Health Education Behavioral Assessment: Contractor shall ensure that the IHA includes the IHEBA as described in Exhibit A, Attachment 10, Provision 8, Subprovision A. GMC Contract A.10.3.B

Contractor shall ensure that the IHA includes an IHEBA [Individual Health Education Behavioral Assessment] as described in Exhibit A, Attachment 10, Provision 8, paragraph A.10 using an age appropriate DHS approved assessment tool. 2-Plan Contract A.10.3.B


2.4 Initial Health Assessment (IHA)

The Plan shall cover and ensure the provision of a complete Initial Health Assessment (IHA) that includes an Individual Health Education Behavioral Assessment (IHEBA) to all new members within stipulated timelines and make at least three documented attempts to contact a member and schedule an IHA. (Contract, Exhibit A, Attachment 10(3))

Procedure No. QM-SP-028: The IHA Member Outreach Process aims to increase the number of calls to new members and link them to a primary care provider for an IHA. The process includes three attempts to contact members, twice by phone and once by mail. In the previous Corrective Action Plan (CAP) for the review period 8/1/14-7/31/15, a deficiency about monitoring and tracking access of newly enrolled members with their Primary Care Providers noted. To correct this deficiency, the Plan will have QI Member Outreach unit receive a new data report within 30 days of

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enrollment from the Finance Department. Expected completion date for the implementation of the new system was 10/6/15. During the previous audit, some medical records requested were not available and did not have an IHA. However, since the Plan’s Initial Health Assessment Member Outreach Process through Procedure No. QM SP-028 was issued on January 22, 2016, monitoring of compliance rates and addressing the barriers are still to be enhanced at that time. This Procedure was created but not implemented.

The Plan does not monitor the attempted contacts to schedule the IHA.

The 2016 Focused Medical Record Review Annual Report demonstrated a large number of members were not contacted for their IHA. The report had insufficient data to substantiate that all three contacts were attempted.

A verification study revealed the Plan was not able to provide medical records or outreach logs for 10 of 20 samples requested. In an interview, the Plan stated the 10 primary care provider/clinics did not have the documented attempts to schedule an IHA. The Plan identified they lacked staff to properly support and implement an efficient IHA outreach process.

The IHA is an important tool for physicians to review risk factors and behaviors with members, specific to the appropriate age group, gender or similar classifications. The IHA may prevent acute and chronic diseases through health education and follow up clinic visits.

RECOMMENDATION:

2.4 Develop a system to monitor and track IHA outreach calls among new members in order to comply with IHA contractual obligations.

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CATEGORY 5 – QUALITY MANAGEMENT

5.2 PROVIDER QUALIFICATIONS

Credentialing and Re-credentialing:Contractor shall develop and maintain written policies and procedures that include initial credentialing, recredentialing, recertification, and reappointment of Physicians including Primary Care Physicians and specialists in accordance with the MMCD Policy Letter 02-03, Credentialing and Re-credentialing. Contractor shall ensure those policies and procedures are reviewed and approved by the governing body, or designee. Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body. GMC/2-Plan Contract A.4.12

Standards: All providers of Covered Services must be qualified in accordance with current applicable legal, professional, and technical standards and appropriately licensed, certified or registered….Providers that have been terminated from either Medicare or Medicaid/Medi-Cal cannot participate in Contractor’s provider network. GMC/2-Plan Contract A.4.12.A

Medi-Cal Managed Care Provider Training:Contractor shall ensure that all providers receive training regarding the Medi-Cal Managed Care program in order to operate in full compliance with the Contract and all applicable Federal and State statutes and regulations. Contractor shall ensure that provider training relates to Medi- Cal Managed Care services, policies, procedures and any modifications to existing services, policies or procedures. Training shall include methods for sharing information between Contractor, provider, Member and/or other healthcare professionals. Contractor shall conduct training for all providers within ten (10) working days after the Contractor places a newly contracted provider on active status…. GMC/2-Plan Contract A.7.5

Delegated Credentialing:Contractor may delegate credentialing and recredentialing activities. If Contractor delegates these activities, Contractor shall comply with Provision 6, Delegation of Quality Improvement Activities… GMC/2-Plan Contract A.4.12.B

Disciplinary Actions:Contractor shall implement and maintain a system for the reporting of serious quality deficiencies that result in suspension or termination of a practitioner to the appropriate authorities. Contractor shall implement and maintain policies and procedures for disciplinary actions including reducing, suspending, or terminating a practitioner’s privileges. Contractor shall implement and maintain a

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provider appeal process. GMC/2-Plan Contract A.4.12.D

Medi-Cal and Medicare Provider Status: The Contractor will verify that their subcontracted providers have not been terminated as Medi-Cal or Medicare providers or have not been placed on the Suspended and Ineligible Provider List. Terminated providers in either Medicare or Medi-Cal or on the Suspended and Ineligible Provider List, cannot participate in the Contractor’s provider network. GMC/2-Plan Contract A.4.12.E


5.2 Provider Qualifications

The Plan shall ensure appropriate credentialing of non-physician medical practitioners. (Contract, Exhibit A, Attachment 4(12)(G))

The Plan must develop policies and procedures to verify the credentials of non-physician medical practitioners such as Nurse Practitioners, Certified Nurse Midwives, Clinical Nurse Specialists and Physician Assistants in accordance with State requirements applicable to the provider category (All Plan Letter 02-03).

Policy CR-01: Credentialing Program Policy established criteria and the sources used to verify these criteria for the evaluation and selection of practitioners for participation in the plan network. Policy CR-01 does not require credentialing for Non-physician Medical Practitioners (NMPs) who are credentialed by site providers/clinics that employ or contract with NMPs. The Plan does not assign its members directly to those NMPs, but NMPs are able to see the Plan members as long as their supervising/collaborating physician is contracted and credentialed with the Plan.

In interviews with the Plan and provider sites personnel, the Plan does not credential NMPs who contract or employ with site providers.

The Plan did not maintain and implement policies and procedures to verify the credentials of non-physician medical practitioners (NMPs) who are credentialed by the organization(s) that employ or contract with NMPs. Not confirming the credentials of providers may result in adverse member health related events. This may place a risk on quality of care provided to the member.

RECOMMENDATION:

5.2 Develop a system to verify the credentials of non-physician medical practitioners, who contract or employ with site providers as required by Contract and APL 02-03.

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