Orange County Medi-Cal Managed Care Program Extends Deadline for Pharmacies To Join Antifraud Program

CalOPTIMA, the managed care program that provides benefits to Orange County's Medi-Cal beneficiaries, on Tuesday announced that it will extend a deadline requiring pharmacies to comply with a new antifraud requirement, but 28 pharmacies in Little Saigon that "strongly oppose" the requirement said they will not participate in the program, the Orange County Register reports (Wolfson, Orange County Register, 2/2).

The requirement is a one-year pilot program that requires CalOPTIMA pharmacies to be certified by the not-for-profit Fraud Prevention Institute, which is run by a former antifraud officer for Medi-Cal and the Federal Bureau of Investigations. CalOPTIMA says the program, which requires pharmacies to fill out a short survey, can help reduce costs.

Some Vietnamese-American pharmacists say the pilot program is intended to force them out of the Medi-Cal network in favor of larger chain pharmacies. Pharmacists and Medi-Cal beneficiaries also say the FPI contracts violate patient privacy, and they note that the institute has a conflict of interest because it can require pharmacies to pay as much as $5,000 to continue to participate in Medi-Cal if evidence of fraud is discovered.

Alan Cates, FPI's director of fraud-prevention services, has said that the $5,000 fee is intended to help defray costs of further investigations.

Between 28 and 40 of the pharmacies have refused to sign a deal with FPI and have been dropped from the Medi-Cal network. The Vietnamese-American Independent Pharmacies Group has filed a lawsuit against CalOPTIMA seeking to nullify the requirement that stores sign the FPI deal.

Assembly member Van Tran (R-Costa Mesa) said he has proposed a compromise to CalOPTIMA that would temporarily suspend the fraud surveillance requirement while the two sides discuss possible alternatives. Tran also said he proposed allowing the pharmacies that closed in response to the requirement to continue filing electronic claims with CalOPTIMA for the time being. The agency has said it will only honor paper claims through Feb. 28, a policy pharmacies said would lead to difficulties collecting reimbursements and checking patient profiles (California Healthline, 1/28). The protesting pharmacies closed their doors two weeks ago in response to the policy.

At a CalOPTIMA board meeting on Tuesday, Chambers said he was extending the deadline for pharmacies to sign up with FPI from Jan. 14 to Feb. 28. Additionally, CalOptima CEO Richard Chambers said the agency will hold a series of meetings with individual pharmacists to address their concerns. According to the Register, Chambers "made clear that CalOPTIMA will not drop the [FPI] requirement altogether" and any "dissident pharmacists" that continue to refuse to sign up will be dropped from Medi-Cal.

Chambers also said that if a pharmacy signs a letter of intent to register with FPI by the new deadline, CalOPTIMA will allow the pharmacy to resume electronic filing.

Paul Hoang, manager of Orange Pharmacy in Westminster and steering committee chair of the Vietnamese-American Independent Pharmacies Group, said, "We will not sign. We've come this far, and we're not going to turn back."

Hoang added that CalOPTIMA's offer to permit participating stores to resume electronic filing was "just another tactic they are using to slowly force all the pharmacies in the FPI program."

Jack Silberstein, owner of the Grove Harbor Medical Center Pharmacy in Garden Grove, said he was pleased to have signed up with FPI, adding, "It's a kind of good housekeeping seal." Silberstein said, "I would urge my colleagues who are having worries about this program to put their fears aside and participate because it's an excellent program" (Orange County Register, 2/2).