| January 31, 2014 |
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Volume 2 Issue 4 |
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| Supervisors Nelson and Spitzer Demand Answers from CalOptima |
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 On Friday, the federal government’s Centers for Medicare & Medicaid Services (CMS) released a comprehensive audit finding 57 deficiencies in CalOptima, the government agency that serves as the health plan for the poor and elder in Orange County. The federal government ordered a halt to new enrollments in CalOptima’s OneCare Program, which is the health plan for 16,000 Orange County residents who are enrolled in both Medi-Cal and Medicare Parts A and B.
“Chairman Shawn Nelson and I have summoned CalOptima CEO Michael Schrader and CalOptima Board Chairman Mark Refowitz to Tuesday’s meeting of the Board of Supervisors,” Supervisor Todd Spitzer said. “Orange County residents demand and deserve government services that work, and the Board of Supervisors needs answers as to what is going on at CalOptima.”
This week, Board of Supervisors Chairman Shawn Nelson and Supervisor Todd Spitzer placed an item on the agenda for the Tuesday, February 4 meeting of the Board of Supervisors to discuss the federal audit with the Chairman and the CEO of CalOptima.
Among the 57 findings in the audit were:
- Failure to pay for emergency medical services.
- Failure to include the specific reason(s) for an adverse decision in payment denial letters to non-contracted providers.
- Failure to notify non-contracted providers of their applicable appeal rights when denying requests for payment.
- Failure to include the specific reason(s) for an adverse decision in denial letters to beneficiaries.
- Failure to adequately consider clinical information when rendering a decision.
- Failure to appropriately process grievances within the required timeframes.
- Routinely forward timely appeal requests to the IRE [Independent Review Entity] for dismissal instead of processing the reconsideration within CMS required timeframes.
- Failure to process reimbursement requests as coverage determinations and issue payments to beneficiaries within the required timeframes.
- Failure to appropriately consider clinical information from prescribers when rendering a decision.
- Failure to conduct appropriate prescriber outreach before denying coverage requests which contain incomplete clinical information.
- Failure to ensure that the initiation of the coverage determination, redetermination, or grievance was by an authorized representative of the beneficiary.
- Failure to establish an adequate process for tracking and maintaining records about the receipt and disposition of grievances.
- Failure to property administer its CMS-approved formulary [for prescription drugs] by applying unapproved quantity limits.
- Failure to provide coverage for protected class drugs.
- Failure to verify the beneficiary’s dual eligibility prior to enrollment in the D-SNP [Dual-Eligible Special Needs Plan].
- Failure to administer the initial health risk assessment to beneficiaries within 90 days of their enrollment.
- Failure to provide documented evidence and maintain records of an individualized care plan (ICP) for beneficiaries.
- Failure to establish and implement an effective system to ensure appropriate corrective actions are taken when instances of noncompliance or potential FWA [fraud, waste, and abuse] are identified.
- Failure to demonstrate the establishment and implementation of a system for monitoring and auditing compliance program effectiveness.
- Failure to establish and implement effective fraud, waste, and abuse training for its first tier, downstream, and related entities (FDRs) upon contracting and annually thereafter.
- CalOptima is carrying out its contracts with CMS in a manner that is inconsistent with the effective and efficient implementation of the program.
“In just a few years, CalOptima OneCare went from being a nationally-recognized, award-winning health plan to being halted by the federal government,” Supervisor Spitzer also said. “There are serious questions and findings about processes in the past several years, as the plan now may be placing our most vulnerable residents at risk.”
While the federal government has halted new enrollment in CalOptima’s OneCare Program, CalOptima’s Medi-Cal and PACE programs, which serve 500,000 Orange County residents, are unaffected.
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| Supervisors Approve Agreement with Lowe Enterprises to Develop 100 Acres at El Toro Adjacent to Great Park |
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Conceptual depiction of the 100-acre site.
Please click here to see a larger version of the image. |
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This week, the Orange County Board of Supervisors approved a development agreement with Lowe Enterprises to develop 100 acres of County land adjacent at the former Marine Corps Air Station El Toro.
“My colleagues and I are very excited about this partnership with Lowe and the prospect of developing this great taxpayer asset,” Supervisor Todd Spitzer said. “Creating a vision, value, and long-term revenue is our goal.”
The agreement provides three phases for developing the 100 acres. The first phase will determine what kind of development will be permitted on the site, complete reviews of environmental impacts required by law, and develop a master plan for development and revenue. The Board of Supervisors has approved funding for this phase and the business plan.
“It is important that we team with the City of Irvine to make this development a seamless window into the Great Park,” Spitzer said.
The 100 acres of County land is adjacent to the southwestern portion of the Great Park site near Technology Drive and Barranca Parkway where the 5 and the 133 meet. The City of Irvine recently approved a plan partnering with FivePoint Communities that will develop approximately 60% of the Great Park.
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| Magnolia Keeps Ethics Disclosure Requirement |
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 This week, the Magnolia School District withdrew its request for authorization from the Board of Supervisors to remove the requirement for the school district’s independent bond oversight committee to file the Form 700 Statement of Economic Interests disclosure.
“The Form 700 helps provide the transparency needed for the public to evaluate the independence of the oversight committee,” Supervisor Todd Spitzer said. “The voters were promised an independent committee, and anything that erodes the transparency of the committee erodes the promise made to the voters.”
In 2010, Magnolia School District voters approved Measure I, which was a $16.3 million bond for school improvements. As part of the effort to gain approval of Measure I, the Magnolia School District promised voters an independent bond oversight committee.
In December, the Magnolia School District requested that the Board of Supervisors remove the requirement that its bond oversight committee members file the Form 700. After questioning from Supervisor Spitzer and his colleagues, the request was delayed to mid-January. Under further scrutiny in mid-January from Supervisor Spitzer and the Board of Supervisors, who expressed serious concerns about the reduced transparency and broken promise to the voters, the request was delayed again until this week. With the public attention and press coverage generated by the Supervisors’ inquiries, the Magnolia School District withdrew its request “in the spirit of continued transparency” this week.
The Orange County Register covered the proposal in “Lawyers advise bond oversight committees to drop ethics rules,” “School district drops controversial plan to weaken bond oversight,” and “School bonds need more, not less, oversight”.
According to the Department of Education, half of school districts with bond oversight committees in Orange County require Form 700s. The California League of Bond Committees has cited the Form 700 as a best practice for bond oversight committees.
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| Pet of the Week |
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Click on the image above to view a PDF version.
Click on the image above to view a PDF version. |
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| Events Around the District |
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Anaheim
Pajama Storytime
Monday, February 3, 7:00 PM
Anaheim Public Library – Canyon Hills Branch, 400 Scout Trail
Irvine
The Art of Civilization: A Lecture
Saturday, February 1, 11:00 AM
Orange County Public Library – Irvine University Park Branch,
4512 Sandburg Way
Orange
Tech Talk
Saturday, February 1, 2:00 PM – 3:00 PM
Orange Public Library – Taft Branch, 740 E. Taft Ave.
Silverado
Wilderness Access Day – Limestone Canyon
Saturday, February 1, 8:00 AM – 1:00 PM
Augustine Staging Area, Limestone Canyon Rd. & Hicks Haul Rd.
Tustin
5 Secrets to Permanent Solutions to Weight Loss
Monday, February 3, 6:00 PM – 7:00 PM
Orange County Public Library – Tustin Branch, 345 E. Main St.
Villa Park
Spartan Pancake Breakfast
Saturday, February 1, 7:00 AM – 11:00 AM
Villa Park High School, 18042 Taft Ave.
Yorba Linda
Blind Date with a Book
Saturday, February 1, 9:00 AM
Yorba Linda Public Library, 18181 Imperial Hwy.
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