Drug Medi-Cal Treatment Program - Monitoring
DMC Monitoring
All Drug Medi-Cal (DMC) programs are subject to utilization review and control. Authority governing utilization controls is provided in the Federal Medicaid Law [(42 USC 1396(a)(30-33)] and Federal Medicaid Regulations, Title 42, Code of Federal Regulations, Sections 456.2 through 456.6. Utilization review provides safeguards against DMC paying for unnecessary services provided by substance abuse programs. The Department of Alcohol and Drug Programs (ADP) developed regulations in CCR, Title 22 detailing the minimum requirements that must be met in order for DMC services to be reimbursed to providers. Title 22 regulations define the roles and responsibilities of the State, County, and treatment providers. Title 22 regulations require that ADP conduct onsite post service, post-payment (PSPP) utilization reviews to determine compliance with standards of care and other requirements of the regulations. Assembly Bill (AB) 106, which Governor Brown signed into law on June 28, 2011, required the transfer of the administration of the DMC treatment program from the Department of Alcohol and Drug Programs to the Department of Health Care Services (DHCS) on July 1, 2012. DHCS is now responsible for conducting all onsite PSPP utilization reviews. The PSPP review process is intended to provide statewide quality assurance and accountability for DMC services.
State Role
DHCS is responsible for administrative and fiscal oversight, monitoring, and auditing to safeguard California’s investment in DMC alcohol and drug treatment services. This is accomplished through the promulgation of the Title 22 DMC regulations and onsite reviews of DMC providers by DHCS staff. The purpose of the review is to ensure that DMC compliance measures are in place for each provider participating in DMC programs, to provide technical assistance and training to providers and their staff, and to initiate the recovery of payments when DMC requirements have not been met in accordance with all of the requirements outlined in the CCR, Title 22, Section 51341.1(k). A written report is issued at the conclusion of each onsite visit, detailing the deficiencies found. The county and/or provider are required to develop and implement a written corrective action plan (CAP) for every deficiency identified in the PSPP report.
County Role
The county is responsible for contracting with the providers, if applicable (programs may be county entities);implementing and maintaining a system of fiscal disbursements and controls; monitoring the billings to ensure that reimbursement is within the rates established for services; and processing claims for reimbursement. Beginning in fiscal year 2014-15, counties are required to certify that their DMC providers have implemented all corrective actions. Counties should complete form DHCS 8049 (instructions) and submit it to SUD County Reports.
Provider Role
All DMC providers must be certified by DHCS Provider Enrolment Division to participate in the DMC treatment service system and must comply with all DMC requirements.
Outcome
Monitoring of DMC services results in quality control in publicly funded treatment, assists counties and providers in identifying and resolving compliance issues, and provides training and technical assistance to counties and providers. Where appropriate, the onsite utilization review provides an opportunity for the provider to receive technical assistance in how to reach compliance with the regulations.
