By Supervisor Todd Spitzer
On Friday, the federal government’s Centers for Medicare & Medicaid Services (CMS) released a comprehensive audit finding 57 deficiencies in CalOptima, the government agency that serves as the health plan for the poor and elder in Orange County. The federal government ordered a halt to new enrollments in CalOptima’s OneCare Program, which is the health plan for 16,000 Orange County residents who are enrolled in both Medi-Cal and Medicare Parts A and B.
“Chairman Shawn Nelson and I have summoned CalOptima CEO Michael Schrader and CalOptima Board Chairman Mark Refowitz to Tuesday’s meeting of the Board of Supervisors,” Supervisor Todd Spitzer said. “Orange County residents demand and deserve government services that work, and the Board of Supervisors needs answers as to what is going on at CalOptima.”
This week, Board of Supervisors Chairman Shawn Nelson and Supervisor Todd Spitzer placed an item on the agenda for the Tuesday, February 4 meeting of the Board of Supervisors to discuss the federal audit with the Chairman and the CEO of CalOptima.
Among the 57 findings in the audit were:
- Failure to pay for emergency medical services.
- Failure to include the specific reason(s) for an adverse decision in payment denial letters to non-contracted providers.
- Failure to notify non-contracted providers of their applicable appeal rights when denying requests for payment.
- Failure to include the specific reason(s) for an adverse decision in denial letters to beneficiaries.
- Failure to adequately consider clinical information when rendering a decision.
- Failure to appropriately process grievances within the required timeframes.
- Routinely forward timely appeal requests to the IRE [Independent Review Entity] for dismissal instead of processing the reconsideration within CMS required timeframes.
- Failure to process reimbursement requests as coverage determinations and issue payments to beneficiaries within the required timeframes.
- Failure to appropriately consider clinical information from prescribers when rendering a decision.
- Failure to conduct appropriate prescriber outreach before denying coverage requests which contain incomplete clinical information.
- Failure to ensure that the initiation of the coverage determination, redetermination, or grievance was by an authorized representative of the beneficiary.
- Failure to establish an adequate process for tracking and maintaining records about the receipt and disposition of grievances.
- Failure to property administer its CMS-approved formulary [for prescription drugs] by applying unapproved quantity limits.
- Failure to provide coverage for protected class drugs.
- Failure to verify the beneficiary’s dual eligibility prior to enrollment in the D-SNP [Dual-Eligible Special Needs Plan].
- Failure to administer the initial health risk assessment to beneficiaries within 90 days of their enrollment.
- Failure to provide documented evidence and maintain records of an individualized care plan (ICP) for beneficiaries.
- Failure to establish and implement an effective system to ensure appropriate corrective actions are taken when instances of noncompliance or potential FWA [fraud, waste, and abuse] are identified.
- Failure to demonstrate the establishment and implementation of a system for monitoring and auditing compliance program effectiveness.
- Failure to establish and implement effective fraud, waste, and abuse training for its first tier, downstream, and related entities (FDRs) upon contracting and annually thereafter.
CalOptima is carrying out its contracts with CMS in a manner that is inconsistent with the effective and efficient implementation of the program.
“In just a few years, CalOptima OneCare went from being a nationally-recognized, award-winning health plan to being halted by the federal government,” Supervisor Spitzer also said. “There are serious questions and findings about processes in the past several years, as the plan now may be placing our most vulnerable residents at risk.”
While the federal government has halted new enrollment in CalOptima’s OneCare Program, CalOptima’s Medi-Cal and PACE programs, which serve 500,000 Orange County residents, are unaffected.