BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K Alquist, Chair
BILL NO: AB 839
A
AUTHOR: Emmerson
B
AMENDED: March 26, 2009
HEARING DATE: June 17, 2009
8
REFERRAL: Judiciary
3
CONSULTANT:
9
Dunstan/cjt
SUBJECT
Medi-Cal: providers: remedies
SUMMARY
Changes Medi-Cal provider remedies, including specifying
the judicial remedy when there is a dispute over processing
or payment of money and modifies the date for the beginning
of a period when a health care provider is barred from
enrollment in Medi-Cal as specified in law.
CHANGES TO EXISTING LAW
Existing law:
Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health care coverage for low-income
individuals and their families; pregnant women; elderly,
blind, or disabled persons; nursing home residents; and
refugees who meet specified eligibility criteria.
Requires the director of DHCS, by regulation, to adopt
procedures for the review of a grievance or complaint
concerning the processing or payment of money alleged by a
provider of services to be payable under the Medi-Cal
Continued---
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program.
Permits a provider who complies with these procedures and
is not satisfied with the director's decision regarding
that claim to seek appropriate judicial remedies within a
specified time period.
Requires the preceding two provisions to be the exclusive
remedy available to the health care provider for moneys
alleged to be payable by the Medi-Cal program.
Requires that health care providers apply to, and be
certified by, DHCS prior to their participation in the
Medi-Cal program.
Prohibits an applicant or provider from reapplying for
enrollment or continued enrollment in the Medi-Cal program
or for participation in any health care program
administered by DHCS for a period of three years based from
the date the application package is denied or the
provisional provider status is terminated, unless there is
an appeal from that denial or termination, then the
three-year period begins from the date of the final
decision following an appeal. Provides for a ten-year ban
on reapplying, if the denial or termination is based on the
applicant's conviction of specified offenses.
This bill:
Clarifies that a health care provider who files a grievance
or complaint regarding the processing or payment of money
by the Medi-Cal program, and who filed a complaint with
DHCS may appeal the DHCS decision by filing a petition for
writ of mandate in superior court.
Modifies the three-year and ten-year prohibition on
enrollment as a health care provider in any Department of
Health Care Services (DHCS) program to begin from the date
the provider's application package is denied or provisional
provider status is terminated.
FISCAL IMPACT
According to the Assembly Appropriations Committee
Analysis, there would be no direct fiscal impact to DHCS in
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their oversight of provider appeals in the Medi-Cal
program.
BACKGROUND AND DISCUSSION
The author argues that AB 839 will also address the current
situation where current Medi-Cal claims cases proceed
through assignments to general civil courts on a
first-come-first-served basis. Because they lack priority,
some claims cases linger on as judges resolve other higher
priority cases thus delaying the resolution of providers'
claims. According to the author, the expanded time frame
in resolving these cases results in an increased number of
claims that are over one year old, which limits the state's
ability to claim federal financial participation.
According to DHCS, the bill's sponsor, AB 839 will benefit
the state and Medi-Cal providers who sue the state by
creating a speedy and equitable remedy for claims. The
sponsor also points out that the bill will also benefit
Medi-Cal providers who choose to appeal their denied
application for enrollment because current law allowing for
appropriate judicial remedies is vague, and fails to
outline a specific legal remedy for Medi-Cal providers
seeking to appeal the denial of a claim for reimbursement.
The result is that providers file a variety of actions for
reimbursement, including money damages or breach of
contract actions where it is unclear what contract or
statute they are suing to enforce. The sponsor notes that
this confusing situation contrasts with the traditional
remedy for individuals seeking relief from a denial by a
state agency, which is pursuing a writ of mandate under
Code of Civil Procedure Section 1085 to overturn the
denial.
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Provider enrollment in Medi-Cal
To address provider fraud in the Medi-Cal program,
legislation introduced in 2002 (SB 857 (Speier), Chapter
601, Statutes of 2003) established new requirements for
health care providers seeking to bill the Medi-Cal program.
Health care providers must apply to, and be certified by,
DHCS's Medi-Cal Provider Enrollment Branch prior to their
participation in the Medi-Cal program.
Existing law allows DHCS, if specified conditions are met,
to grant provisional provider status or preferred
provisional provider status to an applicant or provider,
and requires DHCS to terminate that status if any of the
specified grounds exist. If an application for provisional
provider status or preferred provisional provider status is
denied, or that status is terminated, the applicant or
provider is prohibited from reapplying for enrollment, or
continued enrollment, in the Medi-Cal program or for
participation in any health care program administered by
DHCS.
This prohibition from reapplication to the Medi-cal program
is for a period of three years from the date the
application package is denied or the provisional provider
status is terminated, or from the date of the final
decision following an appeal from that denial or
termination, except as specified. If an application for
provisional provider status or preferred provisional
provider status is denied based upon a criminal conviction
for specified offenses or acts, the applicant or provider
is prohibited from reapplying for enrollment or continued
enrollment in the Medi-Cal program or for participation in
any health care program administered by DHCS. This
prohibition is for a period of ten years from the date the
application package is denied or the provisional provider
status or preferred provisional provider status is
terminated, or from the date of the final decision
following an appeal from that denial or termination.
Prior legislation
AB 1226 (Hayashi), Chapter 693 of 2008, makes specified
physicians eligible for expedited enrollment as Medi-Cal
physicians.
PRIOR ACTIONS
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Assembly Floor: 77-0
Assembly Appropriations: 16-0
Assembly Health: 19-0
Assembly Judiciary: 10-0
POSITIONS
Support: Department of Health Care Services (sponsor)
California Medical Association
Judicial Council of California
Oppose: None received
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