Performance Improvement Initiative

Departments - Accomplishments

Department of Managed Health Care (DMHC)

Highlights

• Completed business process analysis to reduce licensing documents received by Health Plans by 50%.
• Acted aggressively to protect consumers from fraudulent discount health card companies.
• Improved HMO Help Center telephone service to cut waits.
• Established system to ensure claims payment to doctors and hospitals.
• Collaborating with Health and Human Services Agency on access to health insurance solutions.

Accomplishments

• Aggressively acted on behalf of consumers to stop the operation of fraudulent discount health card companies. Since 2004, the DMHC Enforcement Division has opened nearly 40 investigations into discount health card entities, issuing six cease and desist orders and taking other action where necessary.
• Fined health plans (Plans) more than $986,000 for violations of the Knox-Keene Act in 2005 and $723,000 in 2004. Two of the more significant cases were a $200,000 fine to Kaiser for exposing patient information via its website and $250,000 to HealthNet for the underpayment of provider claims.
• Established a Provider Complaint Unit (PCU) at the Health Maintenance Organization (HMO) Help Center to help resolve payment disputes between Plans and providers. Since it began in late 2004, the PCU has received more than 1,500 complaints and recovered nearly $300,000 in additional payments to providers.
• Implemented improvements within the Licensing Division that will reduce from one year to six months the average time it takes to license a new health plan applicant. Ultimately, DMHC is aiming to reduce the average licensing period to as low as 90 days, with some new product approvals achieved within 30 days.
• Revamped, and revised the automation for, the Risk-bearing Organizations financial data collection and corrective action processes to monitor provider group solvency. In 2005, ten training sessions throughout the State were given to providers on the new Web-based financial filing application process.
• Implemented a new telephone feature to ensure that staff can handle the majority of calls during normal working hours. The system automatically redirects overflow calls initially sent to the External Call Center, back to Help Center Agents, as they subsequently become available.
• Began redesign of the public website to make it easier for the public to navigate and find the important consumer information needed; the new website is due out in early 2006. Collaborated with UC Berkeley on the DMHC health literacy initiative to ensure that information provided to consumers is readily understood, consumer-friendly, factually correct, and legally accurate
• Worked with seven health plans and the California Association of Health Plans to secure a $30 million, three-year commitment to implement obesity prevention strategies for HMO enrollees. Commitment was presented at the Governor’s Summit on Health, Nutrition and Obesity.
• Established with the Department of Health Services (DHS) a Joint Work Group that meets quarterly. Accomplishments to date include:
  • Formed a sub-group that meets monthly to improve the licensure and financial filings from Medi-Cal Managed Care.
  • Identified gaps, overlaps and opportunities for integration through a review and analysis of licensing, financial and medical survey data and processes.
  • Developed a work plan to manage process changes and enhance integration.
• Established Joint Medical Surveys that are ongoing between DMHC and DHS (Medi-Cal Managed Care and Audit and Investigation Units). The survey activity is supported by regular quarterly meetings between the two departments; the meetings are centered on information sharing regarding regulation changes, report templates and survey schedules.
• Organized the Licensing Division counsels into functional teams so that all health plans now have specific staff assigned. Distributed to plans a listing of assigned counsels to provide a knowledgeable single point of contact for inquiries and issues.
• Revised the training program for e-filing submission of licensing documents by plans, and conducted training programs for existing and potential licensees. The DMHC is planning to conduct a new training program for plans to increase their knowledge and understanding of the Knox-Keene Act.
• Processing a new Memorandum of Understanding (MOU) that will support sharing financial information between DMHC and DHS. This MOU will allow better coordination of functions of both departments. Also established a Joint Filing Work Group and will continue to ensure new Medi-Cal/KKA license candidates filings are handled in a consistent manner between the two departments.
• Researched and in the process of developing a proposal to eliminate duplicative surveys of health plans by State and national agencies.
• Developed collaborative strategies with health plans to efficiently license health plans to provide services to Medi-Cal enrollees or commercial enrollees in connection with the quality improvement fee (QIF) program implemented by the Department of Health Services. Issued eleven (11) licenses to date. Several additional license applications in connection with the QIF program are under review or expected to be received soon.
• Developed and executed a Focused Survey Project evaluating the impact and compliance of the Mental Health Parity Law (AB 88), which included on-site surveys of seven large health plans. It also developed and executed a Focused Survey evaluating continuity of care concerns raised as a result of Blue Shield's limited network with CalPERS.
• Revised HMO Help Center consumer letter templates to meet suggested "health literacy guidelines” so that enrollees are able to easily understand them.
• Developed a new strategy to make the DMHC regulations-development process more transparent and accessible to health plans, providers, consumers and other stakeholders, and applied the new processes to the development of five major regulations:
  • Data Collection, Grading/Reviewing and Corrective Action for Risk-Bearing Organizations (final reg. effective in 2005)
  • Provider Claims Payment (SB 260 - final reg. effective in 2005)
  • Language Assistance Services (SB 853 - final reg. will be effective in 2006)
  • Pharmacy Standards Regulation (SB 842 - final reg. will be effective in 2006)
  • Timely Access Regulation (AB 2179 - final reg. will likely be effective in 2006)
• Ensured that significant product changes made by Medicare supplement issuers to implement the new Medicare prescription drug program were in compliance with the law.
• Provided Help Center staff with extensive training on Medicare Supplement issues through a collaborative relationship with the Center for Medicare and Medicaid Services.
• Assisted by an outside contractor, completed a business process analysis in 2005 to work with staff to develop best practices in the review of licensing filings. The goals for this process were to reduce the number of documents received from plans by 50% while significantly improving the quality and timeliness of the review process.
• In conjunction with the implementation of the business process analysis for Licensing, established an ad-hoc work group with CAHP (California Association of Health Plans) to streamline and simplify the filing process for plan applications, amendments and material modifications.
• Developed an Evidence of Coverage (EOC) Technical Assistance Guide (TAG) for the review of EOC Filings. This guide will be used internally to ensure consistency in filing review and will be shared with the plans to assist them in understanding the Act and preparing documents for submission.
• Developed and gave presentations regarding specialized plans. Developed presentations for Dental, Vision, Chiropractic/Acupuncture and Mental Health with the goal of both educating staff and identifying policy issues unique to these service plans and market segments.
• Sponsored educational efforts to develop staff into “health policy experts” and to promote leadership and policy expertise throughout DMHC. Efforts included:
  • Nine-week series of classes on the Knox-Keene Act.
  • Master Policy Analysis seminar.
  • Presentation on “diabesity” by Dr. Francine Kaufman.
  • Presentation on California's individual market by Susan Marquis, Ph.D., Senior Economist at RAND.
• Developed a new Web-based, block-transfer database to provide DMHC with enhanced reporting capability on block-transfer filings. When contracts end between plans and provider groups, this database is important to help ease the transition of enrollees to a new primary care physician or health care facility.
• Developed a new licensing-tracking database internally to assist with the management and tracking of licensing filings. Staff also revised the Web portal to automate the creation of the execution page for the plans and provide a Web-based pre-checking mechanism to prevent rejected e-filings.
• Updated and made available to the Plans Technical Assistance Guides on the expectations and requirements of medical and financial examinations. Providing this information allows the Plans to prepare for the “transparent requirements” of the examination process.
• Developed a work plan to publicly identify policy issues and intended regulations for early vetting and public input to ensure all parties have the opportunity to review, comment and dialogue with DMHC on changes in policy. Whenever feasible, committee meetings will be scheduled to coincide with the public comment period of proposed regulations within the special focus of a committee.
• Initiated an effort with the California Association of Dental Plans to draft a model continuity of care plan for specialized dental plans as required by AB 1286/SB 244. Staff are also working with association representatives to develop the model plan, which allows dental plans to opt-in to adopt the form document. Of the 31 licensed dental plans, 29 used the model, lessening time needed for review and acceptance by DMHC.