Program Monitoring and Medical Policy Branch
The Program Monitoring and Medical Policy Branch (PMMPB) monitors contracted health plans for compliance with federal, state and contractual requirements in multiple areas, including quality of care provided to members, plan and provider performance measurement, quality improvement activities, plan informing materials for members and providers, safeguards for member rights, and prevention and detection of fraud and abuse. In addition to PMMPB’s monitoring activities, the Branch also develops policy and addresses critical issues in these areas and provides data support for the entire Medi-Cal Managed Care Program.
Program Monitoring and Medical Policy Branch is composed of the following sections:
Plan Monitoring/Program Integrity Section
Medical Policy Section
Program Data and Performance Measurement Section
Plan Monitoring/program integrity Section
This section is made up of the Medical Monitoring Unit and the Member Rights/Program Integrity Unit.
Medical Monitoring Unit
The Medical Monitoring Unit (MMU) ensures that Medi-Cal managed care plans have developed and implemented quality of care monitoring programs and systems so that they provide quality health care services and communicate appropriate plan information to member and providers. The MMU reviews and evaluates medical and quality improvement policies and procedures, provider network composition, Evidence of Coverage (EOCs), Memorandum of Understanding (MOUs) with other health care agencies, Medical Exemption Requests (MERs), and Expedited Disenrollment Requests (EDERs). The MMU reviews, comments and makes recommendations on the Audit and Investigations (A&I) medical audits and, in conjunction with Department of Managed Health Care (DMHC), reviews and approves corrective action plans (CAPs).
The MMU monitors the Facility Site Review (FSR) process used by the health plans by conducting on-site reviews of randomly chosen Medi-Cal provider sites to provide validation reviews. Critical analysis of FSR data submitted from the health plans (every six months) is performed by the MMU.
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Member Rights/Program Integrity Unit
The Member Rights/Program Integrity Unit (MR/PIU) is responsible for monitoring health plans’ compliance with contract requirements and all applicable State and federal statutes and regulations related to member rights. Staff reviews plan compliance with requirements in such areas as member grievances, prior authorization request notifications, marketing and enrollment programs, and cultural and linguistics services. Additionally, MR/PIU coordinates and addresses fraud and abuse issues within the Medi-Cal managed care program and contracted health plans. Unit staff research complaints related to fraud and abuse by members and providers and forward them to Audits and Investigation for further investigation. The MR/PIU also provides technical assistance and training on fraud prevention to health plans and facilitates sharing of information and best practices.
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Medical Policy section
The Medical Policy Section works collaboratively with program staff and contracted managed care plans to develop and clarify medical policies and contract requirements related to the quality of care provided to plan members. The section also runs the statewide collaborative Quality Improvement Project (QIP) in which all full-scope plans are required to participate. Each statewide collaborative QIP generally runs for at least three years and focuses on a clinical or service issue which affects members within all plans and presents an opportunity for quality improvement throughout the Medi-Cal Managed Care Program. (The current statewide collaborative QIP is focused on reducing avoidable emergency room visits through a combination of interventions focused on hospital ERs, primary care providers, and members.) Section staff meet with the health plan medical directors every quarter to address clinical and other policy issues of concern to the plans and their members.
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Program Data and Performance Measurement Section
Research staff reporting directly to the Section Chief conduct data analysis and research related to member demographics, enrollment trends, utilization of services by plan members, and the quality of care provided to members. For these projects, section staff works with member eligibility and enrollment data from the Medi-Cal Eligibility Determination System (MEDS), as well as health plans’ encounter data and fee-for-service program data pulled from the DHCS data warehouse. Research staff also coordinate special data projects with other areas of DHCS and the data warehouse vendor, administer the Auto Assignment Incentive Program, serve on the DHCS Data and Research Committee, and respond to ad hoc data requests related to the Medi-Cal Managed Care Program.
Performance Measurement Unit
The Performance Measurement Unit (PMU) administers the federally required External Quality Review Organization (EQRO) contract and monitors the quality and timeliness of health plan encounter data. PMU ensures that the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures reported annually by the plans and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) member satisfaction survey results are audited and validated by the EQRO contractor and are made publicly available in summary reports on the MMCD webpage. PMU also monitors health plans’ required quality improvement projects, provides health plan ratings for various consumer resources, reviews health plan policies and procedures, organizes the Medi-Cal Managed Care Division's annual Quality Conference and Quality Awards, and responds to ad hoc internal and external requests for information regarding performance measurement and quality improvement within the Medi-Cal Managed Care Program.
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