Amended in Assembly April 14, 2015

California Legislature—2015–16 Regular Session

Assembly Bill No. 1223

Introduced by Assembly Member O'Donnell

February 27, 2015

An act to amend begin delete Section end delete begin insert Sections 1797.98a, 1797.98e, and end insert 1797.220 begin delete of end delete begin insert of, and to add Section 1797.120 to, end insert the Health and Safety Code, relating to emergency medical services.

LEGISLATIVE COUNSEL’S DIGEST

AB 1223, as amended, O'Donnell. Emergency medical services: noncritical cases.

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Existing law establishes the Maddy Emergency Medical Services (EMS) Fund, and authorizes each county to establish an emergency medical services fund for reimbursement of costs related to emergency medical services. Existing law limits payments made from the fund to claims for care rendered by physicians to patients who are initially medically screened, evaluated, treated, or stabilized in specified facilities, including a site that was approved by a county prior to January 1, 1990, as a paramedic receiving station for the treatment of emergency patients.

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This bill would expand those specified facilities to include any licensed clinic or mental health facility, and any site approved by a county as a paramedic receiving station for the treatment of emergency patients. This bill would make conforming changes.

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Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures begin insert to assure medical control of the emergency medical services system end insert that may require basic life support emergency medical transportation services to meet any medical control begin delete requirements end delete begin insert requirements, end insert including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would begin delete authorize the policies and procedures to allow for the transportation of a noncritical case that cannot be immediately admitted to a hospital emergency room to another appropriate medical treatment facility, including, but not limited to, a clinic, as defined, or a doctors’ office. end delete begin insert require a local EMS agency to include in those policies and procedures specified policies, including the establishment and enforcement of criteria relating to ambulance patient offload time, as defined, and for the transport of a patient to an alternate emergency department or facility under specified circumstances. The bill would require the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time. end insert

Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.

The people of the State of California do enact as follows:

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begin insert SECTION 1. end insert   

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begin insert Section 1797.98a of the end insert begin insert Health and Safety Code end insert
begin insert is amended to read: end insert

1797.98a.  

(a) The fund provided for in this chapter shall be
known as the Maddy Emergency Medical Services (EMS) Fund.

(b) (1) Each county may establish an emergency medical
services fund, upon the adoption of a resolution by the board of
supervisors. The moneys in the fund shall be available for the
reimbursements required by this chapter. The fund shall be
administered by each county, except that a county electing to have
the state administer its medically indigent services program may
also elect to have its emergency medical services fund administered
by the state.

(2) Costs of administering the fund shall be reimbursed by the
fund in an amount that does not exceed the actual administrative
costs or 10 percent of the amount of the fund, whichever amount
is lower.

(3) All interest earned on moneys in the fund shall be deposited
in the fund for disbursement as specified in this section.

(4) Each administering agency may maintain a reserve of up to
15 percent of the amount in the portions of the fund reimbursable
to physicians and surgeons, pursuant to subparagraph (A) of, and
to hospitals, pursuant to subparagraph (B) of, paragraph (5). Each
administering agency may maintain a reserve of any amount in
the portion of the fund that is distributed for other emergency
medical services purposes as determined by each county, pursuant
to subparagraph (C) of paragraph (5).

(5) The amount in the fund, reduced by the amount for
administration and the reserve, shall be utilized to reimburse
physicians and surgeons and hospitals for patients who do not
make payment for emergency medical services and for other
emergency medical services purposes as determined by each county
according to the following schedule:

(A) Fifty-eight percent of the balance of the fund shall be
distributed to physicians and surgeons for emergency services
provided by all physicians and surgeons, except those physicians
and surgeons employed by county hospitals, in general acute care
hospitals that provide basic, comprehensive, or standby emergency
services pursuant to paragraph begin delete (3) end delete begin insert (4) end insert or begin delete (5) end delete begin insert (6) end insert of subdivision (f)
of Section 1797.98e up to the time the patient is stabilized.

(B) Twenty-five percent of the fund shall be distributed only to
hospitals providing disproportionate trauma and emergency medical
care services.

(C) Seventeen percent of the fund shall be distributed for other
emergency medical services purposes as determined by each
county, including, but not limited to, the funding of regional poison
control centers. Funding may be used for purchasing equipment
and for capital projects only to the extent that these expenditures
support the provision of emergency services and are consistent
with the intent of this chapter.

(c) The source of the moneys in the fund shall be the penalty
assessment made for this purpose, as provided in Section 76000
of the Government Code.

(d) Any physician and surgeon may be reimbursed for up to 50
percent of the amount claimed pursuant to subdivision (a) of
Section 1797.98c for the initial cycle of reimbursements made by
the administering agency in a given year, pursuant to Section
1797.98e. All funds remaining at the end of the fiscal year in excess
of any reserve held and rolled over to the next year pursuant to
paragraph (4) of subdivision (b) shall be distributed proportionally,
based on the dollar amount of claims submitted and paid to all
physicians and surgeons who submitted qualifying claims during
that year.

(e) Of the money deposited into the fund pursuant to Section
76000.5 of the Government Code, 15 percent shall be utilized to
provide funding for all pediatric trauma centers throughout the
county, both publicly and privately owned and operated. The
expenditure of money shall be limited to reimbursement to
physicians and surgeons, and to hospitals for patients who do not
make payment for emergency care services in hospitals up to the
point of stabilization, or to hospitals for expanding the services
provided to pediatric trauma patients at trauma centers and other
hospitals providing care to pediatric trauma patients, or at pediatric
trauma centers, including the purchase of equipment. Local
emergency medical services (EMS) agencies may conduct a needs
assessment of pediatric trauma services in the county to allocate
these expenditures. Counties that do not maintain a pediatric trauma
center shall utilize the money deposited into the fund pursuant to
Section 76000.5 of the Government Code to improve access to,
and coordination of, pediatric trauma and emergency services in
the county, with preference for funding given to hospitals that
specialize in services to children, and physicians and surgeons
who provide emergency care for children. Funds spent for the
purposes of this section, shall be known as Richie’s Fund. This
subdivision shall remain in effect until January 1, 2017, and shall
have no force or effect on or after that date, unless a later enacted
statute, that is chaptered before January 1, 2017, deletes or extends
that date.

(f) Costs of administering money deposited into the fund
pursuant to Section 76000.5 of the Government Code shall be
reimbursed from the money collected in an amount that does not
exceed the actual administrative costs or 10 percent of the money
collected, whichever amount is lower. This subdivision shall remain
in effect until January 1, 2017, and shall have no force or effect
on or after that date, unless a later enacted statute, that is chaptered
before January 1, 2017, deletes or extends that date.

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begin insert SEC. 2. end insert   

end insert

begin insert Section 1797.98e of the end insert begin insert Health and Safety Code end insert begin insert is
amended to read: end insert

1797.98e.  

(a) It is the intent of the Legislature that a simplified,
cost-efficient system of administration of this chapter be developed
so that the maximum amount of funds may be utilized to reimburse
physicians and surgeons and for other emergency medical services
purposes. The administering agency shall select an administering
officer and shall establish procedures and time schedules for the
submission and processing of proposed reimbursement requests
submitted by physicians and surgeons. The schedule shall provide
for disbursements of moneys in the Emergency Medical Services
Fund on at least a quarterly basis to applicants who have submitted
accurate and complete data for payment. When the administering
agency determines that claims for payment for physician and
surgeon services are of sufficient numbers and amounts that, if
paid, the claims would exceed the total amount of funds available
for payment, the administering agency shall fairly prorate, without
preference, payments to each claimant at a level less than the
maximum payment level. Each administering agency may
encumber sufficient funds during one fiscal year to reimburse
claimants for losses incurred during that fiscal year for which
claims will not be received until after the fiscal year. The
administering agency may, as necessary, request records and
documentation to support the amounts of reimbursement requested
by physicians and surgeons and the administering agency may
review and audit the records for accuracy. Reimbursements
requested and reimbursements made that are not supported by
records may be denied to, and recouped from, physicians and
surgeons. Physicians and surgeons found to submit requests for
reimbursement that are inaccurate or unsupported by records may
be excluded from submitting future requests for reimbursement.
The administering officer shall not give preferential treatment to
any facility, physician and surgeon, or category of physician and
surgeon and shall not engage in practices that constitute a conflict
of interest by favoring a facility or physician and surgeon with
which the administering officer has an operational or financial
relationship. A hospital administrator of a hospital owned or
operated by a county of a population of 250,000 or more as of
January 1, 1991, or a person under the direct supervision of that
person, shall not be the administering officer. The board of
supervisors of a county or any other county agency may serve as
the administering officer. The administering officer shall solicit
input from physicians and surgeons and hospitals to review
payment distribution methodologies to ensure fair and timely
payments. This requirement may be fulfilled through the
establishment of an advisory committee with representatives
comprised of local physicians and surgeons and hospital
administrators. In order to reduce the county’s administrative
burden, the administering officer may instead request an existing
board, commission, or local medical society, or physicians and
surgeons and hospital administrators, representative of the local
community, to provide input and make recommendations on
payment distribution methodologies.

(b) Each provider of health services that receives payment under
this chapter shall keep and maintain records of the services
rendered, the person to whom rendered, the date, and any additional
information the administering agency may, by regulation, require,
for a period of three years from the date the service was provided.
The administering agency shall not require any additional
information from a physician and surgeon providing emergency
medical services that is not available in the patient record
maintained by the entity listed in subdivision (f) where the
emergency medical services are provided, nor shall the
administering agency require a physician and surgeon to make
eligibility determinations.

(c) During normal working hours, the administering agency
may make any inspection and examination of a hospital’s or
physician and surgeon’s books and records needed to carry out
this chapter. A provider who has knowingly submitted a false
request for reimbursement shall be guilty of civil fraud.

(d) Nothing in this chapter shall prevent a physician and surgeon
from utilizing an agent who furnishes billing and collection services
to the physician and surgeon to submit claims or receive payment
for claims.

(e) All payments from the fund pursuant to Section 1797.98c
to physicians and surgeons shall be limited to physicians and
surgeons who, in person, provide onsite services in a clinical
setting, including, but not limited to, radiology and pathology
settings.

(f) All payments from the fund shall be limited to claims for
care rendered by physicians and surgeons to patients who are
initially medically screened, evaluated, treated, or stabilized in
any of the following:

(1) A basic or comprehensive emergency department of a
licensed general acute care hospital.

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(2) A licensed clinic or mental health facility.

end insert begin delete

(2)

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begin insert (3) end insert  A site that begin delete was end delete begin insert is end insert approved by a county begin delete prior to January 1,
1990, end delete as a paramedic receiving station for the treatment of
emergency patients.

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(3)

end delete

begin insert (4) end insert  A standby emergency department that was in existence on
January 1, 1989, in a hospital specified in Section 124840.

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(4)

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begin insert (5) end insert  For the 1991-92 fiscal year and each fiscal year thereafter,
a facility which contracted prior to January 1, 1990, with the
National Park Service to provide emergency medical services.

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(5)

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begin insert (6) end insert  A standby emergency room in existence on January 1, 2007,
in a hospital located in Los Angeles County that meets all of the
following requirements:

(A) The requirements of subdivision (m) of Section 70413 and
Sections 70415 and 70417 of Title 22 of the California Code of
Regulations.

(B) Reported at least 18,000 emergency department patient
encounters to the Office of Statewide Health Planning and
Development in 2007 and continues to report at least 18,000
emergency department patient encounters to the Office of Statewide
Health Planning and Development in each year thereafter.

(C) A hospital with a standby emergency department meeting
the requirements of this paragraph shall do both of the following:

(i) Annually provide the State Department of Public Health and
the local emergency medical services agency with certification
that it meets the requirements of subparagraph (A). The department
shall confirm the hospital’s compliance with subparagraph (A).

(ii) Annually provide to the State Department of Public Health
and the local emergency medical services agency the emergency
department patient encounters it reports to the Office of Statewide
Health Planning and Development to establish that it meets the
requirement of subparagraph (B).

(g) Payments shall be made only for emergency medical services
provided on the calendar day on which emergency medical services
are first provided and on the immediately following two calendar
days.

(h) Notwithstanding subdivision (g), if it is necessary to transfer
the patient to a second facility providing a higher level of care for
the treatment of the emergency condition, reimbursement shall be
available for services provided at the facility to which the patient
was transferred on the calendar day of transfer and on the
immediately following two calendar days.

(i) Payment shall be made for medical screening examinations
required by law to determine whether an emergency condition
exists, notwithstanding the determination after the examination
that a medical emergency does not exist. Payment shall not be
denied solely because a patient was not admitted to an acute care
facility. Payment shall be made for services to an inpatient only
when the inpatient has been admitted to a hospital from an entity
specified in subdivision (f).

(j) The administering agency shall compile a quarterly and
yearend summary of reimbursements paid to facilities and
physicians and surgeons. The summary shall include, but shall not
be limited to, the total number of claims submitted by physicians
and surgeons in aggregate from each facility and the amount paid
to each physician and surgeon. The administering agency shall
provide copies of the summary and forms and instructions relating
to making claims for reimbursement to the public, and may charge
a fee not to exceed the reasonable costs of duplication.

(k) Each county shall establish an equitable and efficient
mechanism for resolving disputes relating to claims for
reimbursements from the fund. The mechanism shall include a
requirement that disputes be submitted either to binding arbitration
conducted pursuant to arbitration procedures set forth in Chapter
3 (commencing with Section 1282) and Chapter 4 (commencing
with Section 1285) of Part 3 of Title 9 of the Code of Civil
Procedure, or to a local medical society for resolution by neutral
parties.

(l) Physicians and surgeons shall be eligible to receive payment
for patient care services provided by, or in conjunction with, a
properly credentialed nurse practitioner or physician’s assistant
for care rendered under the direct supervision of a physician and
surgeon who is present in the facility where the patient is being
treated and who is available for immediate consultation. Payment
shall be limited to those claims that are substantiated by a medical
record and that have been reviewed and countersigned by the
supervising physician and surgeon in accordance with regulations
established for the supervision of nurse practitioners and physician
assistants in California.

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begin insert SEC. 3. end insert   

end insert

begin insert Section 1797.120 is added to the end insert begin insert Health and Safety
Code end insert begin insert , to read: end insert

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begin insert 1797.120. end insert   

The authority shall develop a statewide standard
methodology for the calculation and reporting by a local EMS
agency of ambulance patient offload time.

end insert

begin delete SECTION 1. end delete
begin insert SEC. 4. end insert   

Section 1797.220 of the Health and Safety Code is
amended to read:

1797.220.  

(a) The local EMS agency, using state minimum
standards, shall establish policies and procedures approved by the
medical director of the local EMS agency to assure medical control
of the EMS system. The policies and procedures approved by the
medical director may require basic life support emergency medical
transportation services to meet any medical control begin delete requirements end delete
begin insert requirements, end insert including dispatch, patient destination policies,
patient care guidelines, and quality assurance requirements.

(b) The policies and procedures adopted pursuant to subdivision
(a) begin delete may allow for the transportation of a noncritical case that cannot
be immediately admitted to a hospital emergency room to another
appropriate medical treatment facility, including, but not limited
to, a clinic as defined in Section 1200 or an establishment owned
or leased and operated as a clinic or office by one or more licensed
health care practitioners and used as an office for the practice of
their profession. end delete begin insert shall include the following: end insert

begin insert

(1) A policy that uses the authority’s standard methodology for
calculating ambulance patient offload time to establish and enforce
compliance with criteria for the offloading of a patient transported
by ambulance.

end insert begin insert

(2) Criteria for the reporting of and quality assurance followup
for a “never event,” as defined in subdivision (c).

end insert begin insert

(3) A policy that allows a patient the right to request transport
to another emergency department if the patient is subject to
extended ambulance patient offload time.

end insert begin insert

(4) A policy that allows a patient with a minor medical injury
or illness to be transported, as approved by a licensed physician
under direct medical control of the patient, to a county-approved
or state-approved receiving facility, including a clinic, stand-alone
emergency department, mental health facility, or sobering center.

end insert begin insert

(c) For the purposes of this section, a “never event” occurs
when the ambulance patient offload time for a patient exceeds one
hour.

end insert begin insert

(d) For the purposes of this section, “ambulance patient offload
time” is defined as the interval between the arrival of an
ambulance patient transported by the local EMS agency at an
emergency department and the time that the emergency department
assumes responsibility for care of the patient following the transfer
of the patient to a stretcher utilized by the emergency department.

end insert