12305.7. (Amended by Stats. 2020, Ch. 11, Sec. 72.)

(a) Beginning in the 2004–05 fiscal year, and in each subsequent fiscal year, the department in consultation with the State Department of Health Care Services and the county welfare departments shall design and conduct an error rate study to estimate the extent of payment and service authorization errors and fraud in the provision of supportive services. The error rate study findings shall be used to prioritize and direct state and county fraud detection and quality improvement efforts. The State Department of Health Care Services shall provide technical assistance and guidance for the error rate studies as requested by the department.

(b) (1) The department and the State Department of Health Care Services shall conduct automated data matches to compare Medi-Cal paid claims and third-party liability data with supportive services paid service hours data to identify potential overpayments, duplicate payments, alternative payment sources for supportive services, and other potential supportive services delivery discrepancies, including but not limited to, receipt of supportive services by a recipient on the same day that other potentially duplicative Medi-Cal services are received. Relevant data match findings shall be transmitted to the counties, or to the appropriate state entity, for action.

(2) The department, in consultation with the county welfare departments and the State Department of Health Care Services, shall determine, define, and issue instructions to the counties describing the roles and responsibilities of the department, the State Department of Health Care Services, and counties for resolving data match discrepancies requiring followup, defining the necessary actions that will be taken to resolve them, and the process for exchange of information pertaining to the findings and disposition of data match discrepancies.

(c) The department shall develop methods for verifying the receipt of supportive services by program recipients. In developing the specified methods the department shall obtain input from program stakeholders as provided in Section 12305.72. The department shall, in consultation with the county welfare departments, also determine, define, and issue instructions describing the roles and responsibilities of the department and the county welfare departments for evaluating and responding to identified problems and discrepancies.

(d) The department shall make available on its internet website the regulations, all-county letters, approved forms, and training curricula developed and officially issued by the department to implement the items described in Section 12305.72. The department shall inform supportive services providers, recipients, and the general public about the availability of these items and of the Medi-Cal toll-free fraud hotline and internet website for reporting suspected fraud or abuse in the provision or receipt of supportive services.

(e) (1) (A) The department, in consultation with counties and in accordance with Section 12305.72, shall develop a standardized curriculum, training materials, and work aids, and operate an ongoing, statewide training program on the supportive services uniformity system. The training shall address, at a minimum, statutes, regulations, and policies related to in-home supportive services and service assessment and authorization, including the functional index ranks and statewide hourly task guidelines.

(B) The department shall develop a one-day refresher training program on service assessment and authorization, including the functional index ranks and statewide hourly task guidelines.

(2) (A) In-Home Supportive Services program case workers, case worker supervisors, program managers, quality assurance staff, and program integrity staff hired after the effective date of the act that added this paragraph shall complete the training developed pursuant to subparagraph (A) of paragraph (1) within six months of being hired.

(B) In-Home Supportive Services program case workers, case worker supervisors, program managers, quality assurance staff, and program integrity staff hired prior to the effective date of the act that added this paragraph who have not taken the training developed pursuant to subparagraph (A) of paragraph (1), or who took the training prior to July 1, 2019, shall take the refresher training program developed pursuant to subparagraph (B) of paragraph (1) by December 31, 2021.

(C) State hearing officers and public authority or nonprofit consortium staff may, but are not required to, attend the training or refresher training developed pursuant to paragraph (1).

(3) Training shall be scheduled and provided at sites throughout the state. The department may obtain a qualified vendor to assist in the development of the training and to conduct the training program. The design of the training program shall provide reasonable flexibility to allow counties to use their preferred training modalities to educate their supportive services staff in this subject matter.

(f) The department shall, in conjunction with the counties, develop protocols and procedures for monitoring county quality assurance programs. The monitoring may include onsite reviews of county quality assurance activities. The focus of the established monitoring protocols and procedures shall include determining the extent to which counties are fulfilling their quality assurance responsibilities and county quality assurance staff are correctly applying the uniformity system in reviewing supportive services cases for consistent, appropriate, and accurate service need assessments. The department and the county welfare departments shall also develop the protocols and procedures under which the department will report its monitoring findings to a county, disagreements over the findings are resolved, to the extent possible, and the county, the State Department of Health Care Services, and the department will follow up on the findings.

(h) The department, in consultation with the county welfare departments and other stakeholders, as appropriate, shall develop protocols for the implementation of targeted mailings to providers, to convey program integrity concerns.