Facility Site Review

Health Net and all other Medi-Cal and Cal MediConnect managed care health plans are required to collaborate in conducting facility site reviews (FSRs). On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a primary care physician (PCP) site. Copies of the FSR and related regulatory requirements are available online at the DHCS website and the All Plan Letter (APL) 22-017 (PDF).

Representatives from the responsible plan contact the provider office prior to the FSR to discuss audit policies and procedures. A packet containing documentation materials is sent prior to the office site review to enable the provider office to prepare for the site visit. Preliminary office site review findings are communicated at the time of the review. In addition, written results are sent to the provider by the responsible health plan. The Health Net Medi-Cal Facility Site Review Compliance Department (Cal MediConnect, Medi-Cal) is responsible for conducting collaborative review process for Health Net.

An FSR is conducted as part of the contracting process for new providers. New providers must receive a passing score of at least 80 percent prior to being admitted into the plan's provider network. Facility site review audit results are shared among Medi-Cal and Cal MediConnect managed care plans. Sites receiving a non-passing score on any audit from one plan are considered to have a non-passing score by all other Medi-Cal and Cal MediConnect managed care plans. A medical record review (MRR) is also conducted on new provider offices three to six months following inclusion in the network and assignment of members. The minimum passing score for the MRR is also 80 percent. Like the FSR results, MRR results are also shared and handled uniformly among participating plans.

Cap Submission and Implementation

Providers must correct deficiencies in critical elements within 10 business days following the date of the review. Providers scoring 90 percent or greater on the facility site review are not required to submit a corrective action plan (CAP) unless deficiencies are found in critical elements, including pharmaceutical services or infection control. Providers scoring 89 percent or less are required to submit a CAP (refer to CAP Submission and Implementation topic above for more information). CAPs must be submitted to the plan administering the review within 30 calendar days from the date of the review.

Providers may be re-reviewed in 12 months or sooner, if deemed appropriate to assess compliance with the CAP. New members are not assigned to a PCP who receives a non-passing score until corrections are verified and the CAP is closed.

After the initial audit, participating providers are re-audited at least every three years. A full-scope site audit, which includes both the FSR and MRR, is conducted at this time. Providers must receive a passing score of at least 80 percent on both reviews. Sites receiving a non-passing score from one plan are considered to have a non-passing score by all other Medi-Cal and Cal MediConnect managed care plans. New members are not assigned to a PCP who receives a non-passing score until corrections are verified and the CAP is closed. Providers who do not comply with the CAP within the established time frames are removed from the network.

Practitioners who do not comply with a CAP or fail to meet threshold scores on a FSR or MRR are forwarded to Health Net's Credentialing Committee for administrative termination. The termination is applicable to the Medi-Cal and Cal MediConnect contracting lines of business and practice locations and remains in effect for three years from the date of the committee's final decision. The provider must undergo an initial site review at the time of reapplication.

The affected practitioner is afforded rights to an informal appeal (reconsideration) of the committee's decision to administratively terminate. The reconsideration must be administered in accordance with Health Net's Medi-Cal Termination Appeals Process Policy & Procedure.

Provider sites that score below 80 percent in either the FSR or MRR for two consecutive reviews must score a minimum of 80 percent during the next site review in both the FSR and MRR, including sites with open CAPs in place. Sites that do not score a minimum of 80 percent in the FSR and MRR, despite ongoing monitoring, are removed from the network and members are appropriately reassigned to other providers. Health Net must notify affected members in writing 30 calendar days in advance of any provider terminations. 

Health Net re-audits the provider within 12 months if the provider scores below 80 percent on FSR or MRR on a full scope audit.