Additional Screening of Family PACT Provider Applicants in Certain Counties Update
October 12, 2020
Pursuant to Welfare and Institutions Code (W&I Code), Section 14132(aa)(2) and 24005(e), the Department of Health Care Services (DHCS) Office of Family Planning (OFP) has the authority to screen Family Planning, Access, Care and Treatment (Family PACT) Program provider applicants pursuant to requirements developed by DHCS to determine suitability for the Family PACT Program. Accordingly, OFP requires that any Family PACT provider applicant located in Los Angeles, Orange, Riverside or San Bernardino counties seeking enrollment in the Family PACT Program for the first time or submitting an application for a change in enrollment will be subject to certain screening requirements, with the exception of entities who are licensed and enrolled in Medi-Cal as clinics under Health and Safety Code (H&S Code), Section 1204, clinics exempt from licensure under H&S Code, Section 1206, student health centers and those operated by government entities. Entities who are licensed under H&S Code Section 1204 and are certified as a Federally Qualified Health Center (FQHC) are not exempt if the entities’ provider type in the Medi-Cal Provider Master File is noted as a FQHC.
DHCS has assessed the risk of fraud, waste and abuse from a program integrity perspective posed by the specific geographic locations described above. DHCS has determined that newly enrolling Family PACT provider applicants or existing Family PACT providers submitting an application for a change in enrollment in Los Angeles, Orange, Riverside or San Bernardino counties should be deemed to pose a risk of fraud, waste and abuse to the Family PACT Program, with the exception of entities who are licensed as clinics under H&S Code, Section 1204, clinics exempt from licensure under H&S Code, Section 1206, student health centers and those operated by government entities. This designation is based upon criteria including, but not limited to, the following:
- DHCS continues to find significant program integrity issues with certain Family PACT providers in Los Angeles, Orange, Riverside and San Bernardino counties
- DHCS’ reviews and investigations of Family PACT providers have led to numerous disenrollments from the Family PACT Program, Medi-Cal suspensions and referrals to the California Department of Justice
- DHCS’ experience with claims data that identify fraudulent billing practices
- DHCS’ expertise in investigating and identifying Medi-Cal fraud across a broad spectrum of providers
Due to the potential risk of fraud, waste and abuse, the Family PACT provider applicants described above are subject to the following additional enrollment screening:
DHCS will conduct onsite visits prior to any application approval, including newly enrolling Family PACT provider applicants or existing Family PACT providers submitting an application for a change in enrollment, as described above.