Administrative Advocacy through CPCA’s DHCS PPS Workgroup 

Earlier this year, the Department of Health Care Services (DHCS) responded to requests from California Primary Care Association (CPCA) staff to communicate that it is ready to resume our conversations around administrative efforts to reform and improve the Medi-Cal prospective payment system (PPS) policy.

DHCS has transitioned the responsibility for PPS policy analysis and recommendations from the Audits and Investigations Division (A&I) to the Fee-For Service Rate Development Division (FFSRDD). Long term, DHCS is also considering transitioning the rate-setting responsibility out of A&I and to the FFSRDD. CPCA staff have already begun meeting with the FFSRDD team to discuss the Federally Qualified Health Center model of care and our historical challenges with Medi-Cal PPS policy.

Concurrently, CPCA staff invited interested members to apply to join the 10-member DHCS PPS Workgroup focusing on prioritizing and advocating to DHCS our most pressing PPS issues. These include concerns raised in CPCA’s PPS modernization legislation this year, AB 1549; PPS-specific issues affecting the Alternative Payment Methodology; and longstanding issues health centers have faced related to rate-setting change in scope of services requests (CSOSRs) and reconciliations.

With the member participants of the DHCS PPS Workgroup now approved, CPCA staff are working to regularly convene the workgroup with a focus on surfacing and prioritizing the issues to bring to the FFSRDD. While we coordinate the initial meetings of this workgroup, CPCA staff are continuing our efforts to orient DHCS’s FFSRDD staff to health centers by coordinating FFSRDD participation in health center site visits, as well as meeting regularly to familiarize FFSRDD with health centers’ challenges specific to Medi-Cal’s PPS policies. Our initial conversations have focused heavily on challenges related to the department’s historically narrow interpretation of triggering events for CSOSRs, opaque and often nonexistent cost accounting guidance that leads to questionable audit adjustments, including the need for DHCS to publish clear and publicly available guidelines for both health center and A&I reference. Our upcoming meetings will be focused on challenging the 20 percent reduction applied to PPS rates when undergoing and finalizing a CSOSR, with the goal of clarifying and establishing CSOSR policies that ensure health center costs are fully accounted for within PPS rates, as is required under Federal Statute.

We are hopeful that the changes within DHCS related to PPS policy oversight and recommendations represent an opportunity for CPCA to address many of our Medi-Cal PPS challenges administratively; though if unsuccessful via the DHCS PPS Workgroup, CPCA will continue to pursue other avenues to establish PPS policy that is fair and clear for health centers, including legislative action.

Staff will provide regular updates and opportunities for all members to weigh in on this work via the PPS Modernization Workgroup and the Chief Financial Officers Peer Network, with discussion and action items presented to the CPCA Legislative & Regulatory Affairs Committee as appropriate. For more information, please contact CPCA’s Deputy Director of Health Center Operations, Emily Shipman, eshipman@cpca.org.