DMC Provider Resource Tool-Kit Monitoring
DRUG MEDI-CAL MONITORING
The Interagency Agreement (IA) between the Department of Health Services and the Department of Alcohol and Drug Programs (ADP) requires that all Drug Medi-Cal (DMC) programs be 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. ADP developed regulations in C.C. R., Title 22 detailing the minimum requirements that must be met in order for DMC services to be reimbursed to providers. The Title 22 regulations define the roles and Responsibilities of the State, County, and Treatment Provider. Title 22 regulations require that ADP conduct post service, post payment (PSPP) utilization reviews onsite to determine compliance with standards of care and other requirements of the regulations. The PSPP review process is intended to provide statewide quality assurance and accountability for DMC services.
ADP 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 on-site visits to DMC providers by ADP staff. The purpose of these visits is to ensure that DMC compliance measures are in place for each provider participating in DMC programs, to provide technical assistance and training to provider staff, and to initiate the recovery of payments when DMC requirements have not been met. A written report is issued at the conclusion of each on-site visit, detailing the deficiencies found. Title 22 also requires recovery of payment(s) for units of service provided that are out of compliance with the regulations. The county and/or provider are also required to develop and implement a written corrective action plan for every deficiency identified in the report.
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.
All DMC providers must be certified to participate in the DMC treatment service system and must comply with all DMC requirements. This includes, at a minimum:
- Identifying the DSM diagnostic code;
- Establishing the medical necessity for treatment;
- Following DMC admission criteria and procedures;
- Developing and updating treatment plans;
- Preparing progress notes;
- Providing group, and when it meets certain criteria, individual counseling;
- Justifying the need to continue services; and
- Completing a discharge summary.
ADP monitoring and auditing 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 on-site utilization review provides an opportunity for the provider to receive technical assistance in how to reach compliance with the regulations through an exit conference with on-site staff.