Home Services Medical Audits and Corrective Action Plans

Medical Audits and Corrective Action Plans

The Department of Health Care Services (DHCS) works with the Department of Managed Health Care (DMHC) to conduct routine medical surveys of Medi-Cal Managed Care Health Plans (MCPs) on selected populations on an annual basis. The medical survey is a comprehensive evaluation of the MCP’s compliance with managed health care law Period(Knox-Keene Health Care Service Plan Act).

DHCS’ Managed Care Quality and Monitoring Division (MCQMD) is responsible for ensuring overall monitoring and oversight of MCPs. MCQMD designates the Contract & Enrollment Review Division (CERD) of DHCS’ Audits and Investigations (A&I) to perform the mandated audits.

MCQMD and A&I have partnered together to create Technical Assistance Guides (TAG) for each of the following six audit categories of review. The TAGs are designed to identify key elements that will be commonly evaluated to inform MCPs of the audit process and increase transparency.

Utilization Management
Case Management and Coordination of Care
Access and Availability
Member Rights
Quality Improvement
Administrative and Organizational Capacity
State Supported Services

DHCS makes a finding of fact with respect to the ability of the MCPs to provide quality health care services, the effectiveness of peer review, and utilization control mechanisms, and the overall performance in providing health care benefits to its enrollees. These audits assist DHCS with its overall monitoring effort, and identify areas of non-compliance, which form the basis for corrective actions.

MCPs are required to provide a Corrective Action Plan (CAP) upon the completion of a DHCS Medical Audit or any other monitoring activity where findings are identified. DHCS conducts CAP submission evaluations and provides technical assistance to ensure compliance.

Medical Audit Reports and Corrective Action Plans:

See below for the most recent Audit Reports and Corrective Action Plans

Medical Audits and Corrective Action Plans

Medical Audit Reports and Corrective Action Plans:

Reports

Aetna Better Health of California

AIDS Healthcare Foundation

Alameda Alliance for Health

Anthem Blue Cross Partnership Plan

Blue Shield of CA Promise Health Plan

California Health and Wellness

CalOptima

CalViva Health

CenCal Health

Central California Alliance for Health

Community Health Group Partnership Plan

Community Health Plan of Imperial Valley

Contra Costa Health Plan

Gold Coast Health Plan

Health Net Community Solutions, Inc.

Health Plan of San Joaquin

Health Plan of San Mateo

Inland Empire Health Plan

Kern Health Systems

Kaiser

L.A. Care Health Plan

Molina Healthcare of California Partner Plan, Inc.

Partnership Health Plan of California

Rady Children’s Hospital-San Diego

San Francisco Health Plan

Santa Clara Family Health Plan

Senior Care Action Network Health Plan

United Healthcare Community Plan of California, Inc.

Corrective Action Plans