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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

Los Angeles County Grand Jury • 2013-2014

2. A Timely and Clean “Bill” of Health May Save $285 Million

51 pages
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Findings 17 findings

F1 Page 67
Medi-Cal accounts represent the majority of write-offs for the Untimely Billing write-off sub-classification.
F2 Page 67
The Department does not use Affinity Adjustment Codes or
F3 Page 67
The sample of Untimely Billing write-offs analyzed demonstrates key trends that align with reported problems in interviews. A TIMELY AND CLEAN “BILL” OF HEALTH MAY SAVE $285 MILLION 48 2013-2014 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT
F4 Page 68
Vendors are not following-up on some denials and information provided by the vendor does not enable DHS to determine causes for the denial.
F5 Page 68
Facility Patient Financial Services is not processing some accounts in a timely fashion
F6 Page 68
The Department’s Consolidated Business Office is not processing some claims in a timely fashion.
F7 Page 39
Facility Utilization Review divisions maintain a substantial backlog on patient medical records in need of review for medical necessity
F8 Page 79
Overall, Medicare gross charges of the Incomplete or No Medical Documentation write-offs are the highest among all payers, accounting for $101.6 million in DHS gross charge write-offs between Fiscal Years 2008-09 and 2012-13.
F9 Page 79
The audit sample of Incomplete or No Medical Records write-offs demonstrated key trends that aligned with problems reported by DHS staff involved in managing and executing the patient billing processes.
F10 Page 79
Approximately $24.5 million in gross charge write-offs between FY 2009-10 and 2012-13 was attributed to physicians without
F11 Page 40
Barriers or complications in coding accounts by Health
F12 Page 79
Coding backlogs in Health Information Divisions.
F13 Page 91
Physicians reportedly scheduling follow-up outpatient services, after basic needs are met through emergency room/urgent care or after a patient has been discharged from the hospital, when the patient does not have prior authorization.
F14 Page 91
The Department of Health Services is not obtaining timely authorization for high dollar value inpatient services due to the inability of Patient Financial Services staff to obtain prior authorization or redirect patient’s to facilities in the patient’s health plan’s network prior to all schedule outpatient appointments.
F15 Page 41
Insufficient or inadequate allocation of resources and tools for Utilization Review nurses to obtain timely authorization from other health care plans for inpatient.
F16 Page 91
Write-offs for Medi-Cal Managed Care patient accounts due to no authorization for services have increased over time. As Medi- Cal Managed Care enrollment is expected to increase over time, it is imperative that DHS improve its business processes to ensure timely authorization and billing for Medi-Cal Managed Care patients.
F17 Page 91
Because the Board of Supervisors is able to decrease subsequent fiscal year General Fund contributions to offset increased DHS revenues from prior fiscal years, such Board actions could potentially serve as a disincentive for DHS staff to increase revenue collections.

Recommendations 18