AB 1244,
as amended, Gray. Workers’begin delete compensation: providers: suspension: fees and expenses.end deletebegin insert compensation.end insert
Under existing law, the Director of Health Care Services is authorized, for purposes of administering the Medi-Cal program, to suspend a provider of service from further participation under the program for specified reasons, including conviction of any felony or any misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service. Existing law requires the director, upon receipt of written notification from the Secretary of the United States Department of Health and Human Services that a physician or other individual practitioner has been suspended from participation in the Medicare or Medicaid programs, to promptly suspend the practitioner from participation in the Medi-Cal program.
Existing law establishes a workers’ compensation system, administered by the Administrative Director of the Division of Workers’ Compensation, that generally requires employers to secure the payment of workers’ compensation for injuries incurred by their employees that arise out of, or in the course of, employment. Existing law requires an employer to provide all medical services reasonably required to cure or relieve the injured worker from the effects of the injury.
Existing law authorizes an insurer, employer, or entity that provides physician network services to establish or modify a medical provider network for the provision of medical treatment to injured employees and requires the administrative director to contract with individual physicians or an independent medical review organization to perform medical provider network independent medical reviews.begin delete Existing law also requires the administrative director to appoint qualified medical evaluators in each of the respective specialties as required for the
evaluation of medical-legal issues. Existing law requires the administrative director to terminate from the list of medical evaluators a physician who has been subject to disciplinary action by the relevant licensing board or who has been convicted of a misdemeanor or felony related to the conduct of his or her medical practice.end delete
This bill would require the administrative director to promptly suspend anybegin delete physician or practitionerend deletebegin insert physician, practitioner, or providerend insert from participating in the workers’ compensation systembegin delete in any capacity whenend deletebegin insert if as a physician, practitioner, or providerend insert
the individual or entity meets specified criteria, includingbegin delete whenend deletebegin insert ifend insert that individual has been convicted of any felony or misdemeanor involving fraud or abuse of the Medi-Cal program, Medicare program, or workers’ compensation system,begin delete whenend deletebegin insert ifend insert that individual’s license, certificate, or approval to provide health care has been surrendered or revoked, orbegin delete whenend deletebegin insert ifend insert that individual or entity has been suspended, due to fraud or abuse, from
participation in the Medicare or Medicaid programs. The bill would require the administrative director to adopt regulations for suspending abegin delete physician’s or practitioner’s participationend deletebegin insert physician, practitioner, or provider from participatingend insert in the workers’ compensation system pursuant to these provisions, as specified, and would require the administrative director to furnish to thebegin delete physician or practitionerend deletebegin insert physician, practitioner, or providerend insert written notice of the right to a hearing regarding the suspension and the procedure to follow to request that hearing.begin delete If a physician is a qualified medical examiner, and the division finds that the physician meets the criteria for suspension pursuant to these provisions, the bill would require the administrative director to terminate the physician from the list of medical evaluators.end delete
The bill would also require the administrative director to promptly notify the appropriate state licensing, certifying, or registering authority of abegin delete physician’s or practitioner’send deletebegin insert physician’s, practitioner’s, or provider’send insert suspension and to update the division’s databases of qualified medical evaluators and medical provider networks. The bill wouldbegin delete prohibit a
provider of services from submitting or pursuing claims for payment for services or supplies provided by a physician or practitioner whose participation in the workers’ compensation system has been suspended, unless that claim for payment has been reduced to final judgment or the services or supplies are unrelated to a violation of the laws governing workers’ compensation.end deletebegin insert require the administrative director to notify the chief judge of the division of a suspension under these provisions, as specified, and post a notice on the department’s Internet Web site. The bill would enact special lien proceedings for the adjudication of any liens of a physician, practitioner, or provider who has been suspended pursuant to these provisions because he or she has been convicted of a felony or misdemeanor that meets specified criteria.end insert
The bill would also require the
Director of Health Care Services to notify the administrative director of a suspension of a physician from participation in the Medi-Cal program imposed pursuant to the provisions described above authorizing the director to suspend a provider ofbegin delete servicesend deletebegin insert serviceend insert from participation.
Existing law establishes the Workers’ Compensation Appeals Board to exercise all judicial powers vested in it, as specified, including workers’ compensation proceedings for the recovery of compensation, or concerning any right or liability arising out of or incidental to the recovery of compensation. Existing law vests the appeals board with full power, authority, and jurisdiction to try and determine finally those matters, subject only to the review by the courts, as specified. Existing law
authorizes the appeals board to determine, and allow as liens against any sum to be paid as compensation, as specified, a reasonable attorney’s fee for legalbegin delete services and the reasonable expense incurred by or on behalf of the injured employee.end deletebegin insert
services and disbursements in connection with those legal services.end insert Existing law provides that a charge, claim, or agreement for those legal services orbegin delete disbursements, or that reasonable expense,end deletebegin insert disbursementsend insert is not enforceable, valid, or binding in excess of a reasonable amount.
Existing law also requires an attorney to furnish to the employee a written disclosure form describing the procedures available to the injured employee or his or her dependents and specified information regarding attorney’s fees. Existing law requires that a copy of the disclosure form be signed by the employee and the attorney and sent to the employer, or insurer or 3rd-party administrator, if either is known, by the attorney within 15 days of the employee’s and attorney’s execution of the form. Existing law also requires the employee, the insurer, the employer, and the attorneys for each party to sign and file with the board a statement, signed under penalty of perjury, attesting that the signatories have not violated specified laws prohibiting conflicts of interest.
Existing law authorizes the appeals board, a workers’ compensation judge, or any party to the action or proceeding, as specified, to cause the deposition of witnesses in any investigation or hearing before the appeals board, and provides that the deponent is entitled to receive specified benefits, such as reasonable expenses of transportation, meals, and lodging, as specified.
This bill would prohibit payment forbegin insert legalend insert servicesbegin insert or disbursements in connection with those legal services,end insert or expensesbegin insert relating to the deposition of witnesses,end insert incurred under the provisions described above, as specified, prior to the filing of the disclosure form with the appeals board and the sending of that form to the employer, or to the insurer or 3rd-party administrator, if either is known, by the attorney. The bill would require the disclosure form described above to contain a paragraph setting forth the exact location of the district office of the appeals board at which the employee’s case will be filed and to include a specified statement. The bill would impose other requirements regarding the signing and content of the form, including that the form be signed under penalty of perjury by the attorney representing the employee, and would require the form to be filed with the appeals board.
The bill would also require an attorney who subsequently assumes the representation of the employee in the same action or proceeding to complete and sign under penalty of perjury a disclosure form that meets the above-described requirements and the statement attesting that the signatories have not violated specified laws prohibiting conflicts of interest. The bill would require the attorney to file the form and statement with the appeals board, and send them to the employer, or insurer or 3rd-party administrator, if either is known, within 15 days of the employee’s and attorney’s execution of the form and statement.
By expanding the scope of the crime of perjury under these provisions, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.
The people of the State of California do enact as follows:
Section 139.2 of the Labor Code is amended to
2read:
(a) The administrative director shall appoint qualified
4medical evaluators in each of the respective specialties as required
5for the evaluation of medical-legal issues. The appointments shall
6be for two-year terms.
7(b) The administrative director shall appoint or reappoint as a
8qualified medical evaluator a physician, as defined in Section
93209.3, who is licensed to practice in this state and who
10demonstrates that he or she meets the requirements in paragraphs
11(1), (2), (6), and (7), and, if the physician is a medical doctor,
12doctor of osteopathy, doctor of chiropractic, or a psychologist, that
13he or she also meets the applicable requirements in paragraph (3),
14(4), or (5).
15(1) Prior to his or her appointment as a qualified medical
16evaluator, passes an examination written and administered by the
17administrative director for the purpose of demonstrating
18competence in evaluating medical-legal issues in the workers’
19compensation system. Physicians shall not be required to pass an
20additional examination as a condition of reappointment. A
21physician seeking appointment as a qualified medical evaluator
22on or after January 1, 2001, shall also complete prior to
23appointment, a course on disability evaluation report writing
P6 1approved by the administrative director. The administrative director
2shall specify the curriculum to be covered by disability evaluation
3report writing courses, which shall include, but is not limited to,
412 or more hours of instruction.
5(2) Devotes at least one-third of total practice time to providing
6direct medical treatment, or has served as an agreed medical
7evaluator on eight or more occasions in the 12 months prior to
8
applying to be appointed as a qualified medical evaluator.
9(3) Is a medical doctor or doctor of osteopathy and meets one
10of the following requirements:
11(A) Is board certified in a specialty by a board recognized by
12the administrative director and either the Medical Board of
13California or the Osteopathic Medical Board of California.
14(B) Has successfully completed a residency training program
15accredited by the Accreditation Council for Graduate Medical
16Education or the osteopathic equivalent.
17(C) Was an active qualified medical evaluator on June 30, 2000.
18(D) Has qualifications that the
administrative director and either
19the Medical Board of California or the Osteopathic Medical Board
20of California, as appropriate, both deem to be equivalent to board
21certification in a specialty.
22(4) Is a doctor of chiropractic and has been certified in California
23workers’ compensation evaluation by a provider recognized by
24the administrative director. The certification program shall include
25instruction on disability evaluation report writing that meets the
26standards set forth in paragraph (1).
27(5) Is a psychologist and meets one of the following
28requirements:
29(A) Is board certified in clinical psychology by a board
30recognized by the administrative director.
31(B) Holds a doctoral degree in psychology, or a doctoral degree
32deemed equivalent for licensure by the Board of Psychology
33pursuant to Section 2914 of the Business and Professions Code,
34from a university or professional school recognized by the
35administrative director and has not less than five years’
36postdoctoral experience in the diagnosis and treatment of emotional
37and mental disorders.
38(C) Has not less than five years’ postdoctoral experience in the
39diagnosis and treatment of emotional and mental disorders, and
P7 1has served as an agreed medical evaluator on eight or more
2occasions prior to January 1, 1990.
3(6) Does not have a conflict of interest as determined under the
4regulations adopted by the administrative director pursuant to
5subdivision (o).
6(7) Meets any additional medical or professional standards
7adopted pursuant to paragraph (6) of subdivision (j).
8(c) The administrative director shall adopt standards for
9appointment of physicians who are retired or who hold teaching
10positions who are exceptionally well qualified to serve as a
11qualified medical evaluator even though they do not otherwise
12qualify under paragraph (2) of subdivision (b). A physician whose
13full-time practice is limited to the forensic evaluation of disability
14shall not be appointed as a qualified medical evaluator under this
15subdivision.
16(d) The qualified medical evaluator, upon request, shall be
17reappointed if he or she meets the qualifications of subdivision (b)
18and meets all of the
following criteria:
19(1) Is in compliance with all applicable regulations and
20evaluation guidelines adopted by the administrative director.
21(2) Has not had more than five of his or her evaluations that
22were considered by a workers’ compensation administrative law
23judge at a contested hearing rejected by the workers’ compensation
24administrative law judge or the appeals board pursuant to this
25section during the most recent two-year period during which the
26physician served as a qualified medical evaluator. If the workers’
27compensation administrative law judge or the appeals board rejects
28the qualified medical evaluator’s report on the basis that it fails to
29meet the minimum standards for those reports established by the
30administrative director or the appeals board, the workers’
31compensation
administrative law judge or the appeals board, as
32the case may be, shall make a specific finding to that effect, and
33shall give notice to the medical evaluator and to the administrative
34director. Any rejection shall not be counted as one of the five
35qualifying rejections until the specific finding has become final
36and time for appeal has expired.
37(3) Has completed within the previous 24 months at least 12
38hours of continuing education in impairment evaluation or workers’
39compensation-related medical dispute evaluation approved by the
40administrative director.
P8 1(4) Has not been terminated, suspended, placed on probation,
2or otherwise disciplined by the administrative director during his
3or her most recent term as a qualified medical evaluator.
4If
the evaluator does not meet any one of these criteria, the
5administrative director may in his or her discretion reappoint or
6deny reappointment according to regulations adopted by the
7administrative director. A physician who does not currently meet
8the requirements for initial appointment or who has been terminated
9under subdivision (e) because his or her license has been revoked
10or terminated by the licensing authority shall not be reappointed.
11(e) The administrative director may, in his or her discretion,
12suspend or terminate a qualified medical evaluator during his or
13her term of appointment without a hearing as provided under
14subdivision (k) or (l) whenever either of the following conditions
15occurs:
16(1) The evaluator’s license to practice in California has been
17suspended
by the relevant licensing authority so as to preclude
18practice, or has been revoked or terminated by the licensing
19authority.
20(2) The evaluator has failed to timely pay the fee required by
21the administrative director pursuant to subdivision (n).
22(f) The administrative director shall furnish a physician, upon
23request, with a written statement of its reasons for termination of,
24or for denying appointment or reappointment as, a qualified
25medical evaluator. Upon receipt of a specific response to the
26statement of reasons, the administrative director shall review his
27or her decision not to appoint or reappoint the physician or to
28terminate the physician and shall notify the physician of its final
29decision within 60 days after receipt of the physician’s response.
30(g) The administrative director shall establish agreements with
31qualified medical evaluators to ensure the expeditious evaluation
32of cases assigned to them for comprehensive medical evaluations.
33(h) (1) When requested by an employee or employer pursuant
34to Section 4062.1, the medical director appointed pursuant to
35Section 122 shall assign three-member panels of qualified medical
36evaluators within five working days after receiving a request for
37a panel. Preference in assigning panels shall be given to cases in
38which the employee is not represented. If a panel is not assigned
39within 20 working days, the employee shall have the right to obtain
40a medical evaluation from any qualified medical evaluator of his
P9 1or her choice within a reasonable geographic area. The
medical
2director shall use a random selection method for assigning panels
3of qualified medical evaluators. The medical director shall select
4evaluators who are specialists of the type requested by the
5employee. The medical director shall advise the employee that he
6or she should consult with his or her treating physician prior to
7deciding which type of specialist to request.
8(2) The administrative director shall promulgate a form that
9shall notify the employee of the physicians selected for his or her
10panel after a request has been made pursuant to Section 4062.1 or
114062.2. The form shall include, for each physician on the panel,
12the physician’s name, address, telephone number, specialty, number
13of years in practice, and a brief description of his or her education
14and training, and shall advise the employee that he or she is entitled
15to
receive transportation expenses and temporary disability for
16each day necessary for the examination. The form shall also state
17in a clear and conspicuous location and type: “You have the right
18to consult with an information and assistance officer at no cost to
19you prior to selecting the doctor to prepare your evaluation, or you
20may consult with an attorney. If your claim eventually goes to
21court, the workers’ compensation administrative law judge will
22consider the evaluation prepared by the doctor you select to decide
23your claim.”
24(3) When compiling the list of evaluators from which to select
25randomly, the medical director shall include all qualified medical
26evaluators who meet all of the following criteria:
27(A) He or she does not have a conflict of interest in the case, as
28defined
by regulations adopted pursuant to subdivision (o).
29(B) He or she is certified by the administrative director to
30evaluate in an appropriate specialty and at locations within the
31general geographic area of the employee’s residence. An evaluator
32shall not conduct qualified medical evaluations at more than 10
33locations.
34(C) He or she has not been suspended or terminated as a
35qualified medical evaluator for failure to pay the fee required by
36the administrative director pursuant to subdivision (n) or for any
37other reason.
38(4) When the medical director determines that an employee has
39requested an evaluation by a type of specialist that is appropriate
40for the employee’s injury, but there are not enough qualified
P10 1medical
evaluators of that type within the general geographic area
2of the employee’s residence to establish a three-member panel,
3the medical director shall include sufficient qualified medical
4evaluators from other geographic areas and the employer shall pay
5all necessary travel costs incurred in the event the employee selects
6an evaluator from another geographic area.
7(i) The medical director appointed pursuant to Section 122 shall
8continuously review the quality of comprehensive medical
9evaluations and reports prepared by agreed and qualified medical
10evaluators and the timeliness with which evaluation reports are
11prepared and submitted. The review shall include, but not be
12limited to, a review of a random sample of reports submitted to
13the division, and a review of all reports alleged to be inaccurate
14or incomplete by a party to a case for which the
evaluation was
15prepared. The medical director shall submit to the administrative
16director an annual report summarizing the results of the continuous
17review of medical evaluations and reports prepared by agreed and
18qualified medical evaluators and make recommendations for the
19improvement of the system of medical evaluations and
20determinations.
21(j) After public hearing pursuant to Section 5307.3, the
22administrative director shall adopt regulations concerning the
23following issues:
24(1) (A) Standards governing the timeframes within which
25medical evaluations shall be prepared and submitted by agreed
26and qualified medical evaluators. Except as provided in this
27subdivision, the timeframe for initial medical evaluations to be
28prepared and submitted shall be
no more than 30 days after the
29evaluator has seen the employee or otherwise commenced the
30medical evaluation procedure. The administrative director shall
31develop regulations governing the provision of extensions of the
3230-day period in both of the following cases:
33(i) When the evaluator has not received test results or consulting
34physician’s evaluations in time to meet the 30-day deadline.
35(ii) To extend the 30-day period by not more than 15 days when
36the failure to meet the 30-day deadline was for good cause.
37(B) For purposes of subparagraph (A), “good cause” means any
38of the following:
39(i) Medical emergencies of the evaluator or evaluator’s family.
40(ii) Death in the evaluator’s family.
P11 1(iii) Natural disasters or other community catastrophes that
2interrupt the operation of the evaluator’s business.
3(C) The administrative director shall develop timeframes
4governing availability of qualified medical evaluators for
5unrepresented employees under Section 4062.1. These timeframes
6shall give the employee the right to the addition of a new evaluator
7to his or her panel, selected at random, for each evaluator not
8available to see the employee within a specified period of time,
9but shall also permit the employee to waive this right for a specified
10period of time thereafter.
11(2) Procedures to be followed by all physicians
in evaluating
12the existence and extent of permanent impairment and limitations
13resulting from an injury in a manner consistent with Sections 4660
14and 4660.1.
15(3) Procedures governing the determination of any disputed
16medical treatment issues in a manner consistent with Section
175307.27.
18(4) Procedures to be used in determining the compensability of
19psychiatric injury. The procedures shall be in accordance with
20Section 3208.3 and shall require that the diagnosis of a mental
21disorder be expressed using the terminology and criteria of the
22American Psychiatric Association’s Diagnostic and Statistical
23Manual of Mental Disorders, Third Edition-Revised, or the
24terminology and diagnostic criteria of other psychiatric diagnostic
25manuals generally approved and accepted nationally
by
26practitioners in the field of psychiatric medicine.
27(5) Guidelines for the range of time normally required to perform
28the following:
29(A) A medical-legal evaluation that has not been defined and
30valued pursuant to Section 5307.6. The guidelines shall establish
31minimum times for patient contact in the conduct of the
32evaluations, and shall be consistent with regulations adopted
33pursuant to Section 5307.6.
34(B) Any treatment procedures that have not been defined and
35valued pursuant to Section 5307.1.
36(C) Any other evaluation procedure requested by the Insurance
37Commissioner, or deemed appropriate by the administrative
38director.
P12 1(6) Any additional medical or professional standards that a
2medical evaluator shall meet as a condition of appointment,
3reappointment, or maintenance in the status of a medical evaluator.
4(k) Except as provided in this subdivision, the administrative
5director may, in his or her discretion, suspend or terminate the
6privilege of a physician to serve as a qualified medical evaluator
7if the administrative director, after hearing pursuant to subdivision
8(l), determines, based on substantial evidence, that a qualified
9medical evaluator:
10(1) Has violated any material statutory or administrative duty.
11(2) Has failed to follow the medical procedures or qualifications
12established
pursuant to paragraph (2), (3), (4), or (5) of subdivision
13(j).
14(3) Has failed to comply with the timeframe standards
15established pursuant to subdivision (j).
16(4) Has failed to meet the requirements of subdivision (b) or
17(c).
18(5) Has prepared medical-legal evaluations that fail to meet the
19minimum standards for those reports established by the
20administrative director or the appeals board.
21(6) Has made material misrepresentations or false statements
22in an application for appointment or reappointment as a qualified
23medical evaluator.
24A hearing shall not be required prior to the suspension or
25termination of a
physician’s privilege to serve as a qualified
26medical evaluator when the physician has done either of the
27following:
28(A) Failed to timely pay the fee required pursuant to subdivision
29(n).
30(B) Had his or her license to practice in California suspended
31by the relevant licensing authority so as to preclude practice, or
32had the license revoked or terminated by the licensing authority.
33(l) The administrative director shall cite the qualified medical
34evaluator for a violation listed in subdivision (k) and shall set a
35hearing on the alleged violation within 30 days of service of the
36citation on the qualified medical evaluator. In addition to the
37authority to terminate or suspend the qualified medical evaluator
38upon
finding a violation listed in subdivision (k), the administrative
39
director may, in his or her discretion, place a qualified medical
40evaluator on probation subject to appropriate conditions, including
P13 1ordering continuing education or training. The administrative
2director shall report to the appropriate licensing board the name
3of any qualified medical evaluator who is disciplined pursuant to
4this subdivision.
5(m) The administrative director shall terminate from the list of
6medical evaluators any physician whose licensure has been
7terminated by the relevant licensing board, or who has been
8convicted of a misdemeanor or felony related to the conduct of his
9or her medical practice, or of a crime of moral turpitude. The
10administrative director shall suspend or terminate as a medical
11evaluator any physician who has been suspended or placed on
12probation by the relevant licensing board. The
administrative
13director shall terminate as a medical evaluator any physician who
14is a person described in paragraph (3) of subdivision (b) of Section
15139.21. If a physician is suspended or terminated as a qualified
16medical evaluator under this subdivision, a report prepared by the
17physician that is not complete, signed, and furnished to one or
18more of the parties prior to the date of conviction or action of the
19licensing board, whichever is earlier, shall not be admissible in
20any proceeding before the appeals board nor shall there be any
21liability for payment for the report and any expense incurred by
22the physician in connection with the report.
23(n) A qualified medical evaluator shall pay a fee, as determined
24by the administrative director, for appointment or reappointment.
25These fees shall be based on a sliding scale as established by the
26
administrative director. All revenues from fees paid under this
27subdivision shall be deposited into the Workers’ Compensation
28Administration Revolving Fund and are available for expenditure
29upon appropriation by the Legislature, and shall not be used by
30any other department or agency or for any purpose other than
31administration of the programs of the Division of Workers’
32Compensation related to the provision of medical treatment to
33injured employees.
34(o) An evaluator shall not request or accept any compensation
35or other thing of value from any source that does or could create
36a conflict with his or her duties as an evaluator under this code.
37The administrative director, after consultation with the Commission
38on Health and Safety and Workers’ Compensation, shall adopt
39regulations to implement this
subdivision.
Section 139.21 is added to the Labor Code, 3immediately following Section 139.2, to read:
(a) (1) The administrative director shall promptly
5begin delete suspend any physician or practitionerend deletebegin insert suspend, pursuant to
6subdivision (b), any physician, practitioner, or providerend insert from
7participating in the workers’ compensation systembegin delete in any capacity begin insert as a physician, practitioner, or provider ifend insert the individual or
8whenend delete
9entity meets any of the following criteria:
10(A) The individual has been convicted of any felony or
11
begin delete misdemeanor involvingend deletebegin insert misdemeanor and that crime comes within
12any of the following descriptions:end insert
13begin insert(i)end insertbegin insert end insertbegin insertIt involvesend insert fraud or abuse of the Medi-Cal program, Medicare
14program, or workers’ compensation system, or fraud or abuse of
15anybegin delete patient, orend deletebegin insert
patient.end insert
16
(ii) It relates to the conduct of the individual’s medical practice
17as it pertains to patient care.
18
(iii) It is a financial crime that relates to the Medi-Cal program,
19Medicare program, or workers’ compensation system.
20begin insert(iv)end insertbegin insert end insertbegin insertIt isend insert otherwise substantially related to the qualifications,
21functions, or duties of a provider of services.
22(B) The individual or entity has been suspended, due to fraud
23or
abuse, from the federal Medicare or Medicaid programs.
24(C) The individual’s license, certificate, or approval to provide
25health care has been surrendered or revoked.
26(2) The administrative director shall exercise due diligence to
27identifybegin delete physicians and practitionersend deletebegin insert physicians, practitioners, or
28providersend insert
who have been suspended as described in subdivision
29(a) by accessing the quarterly updates to the list of suspended and
30ineligible providers maintained by the State Department of Health
31Care Services for the Medi-Cal program at
32https://files.medi-cal.ca.gov/pubsdoco/SandILanding.asp.
33(b) (1) The administrative director shall adopt regulations for
34suspending abegin delete physician’s or practitioner’s participationend deletebegin insert physician,
35practitioner, or provider from participatingend insert in the workers’
36compensation system, subject to the notice and hearing
37requirements in paragraph (2).
38(2) The
administrative director shall furnish to thebegin delete physician or begin insert physician, practitioner, or providerend insert written notice of
39practitionerend delete
40the right to a hearing regarding the suspension and the procedure
P15 1to follow to request a hearing. The notice shall state that the
2begin delete divisionend deletebegin insert
administrative directorend insert is required to suspend thebegin delete physician begin insert physician, practitioner, or providerend insert pursuant to
3or practitionerend delete
4subdivision (a) after 30 days from the date the notice is mailed
5unless thebegin delete physician or practitionerend deletebegin insert physician, practitioner, or
6providerend insert
requests a hearing and, in that hearing, thebegin delete physician or begin insert physician, practitioner, or providerend insert provides proof
7practitionerend delete
8that paragraph (1) of subdivision (a) is not applicable. The
9begin delete physician or practitionerend deletebegin insert physician, practitioner, or providerend insert may
10request a hearing within 10 days from the date the notice is sent
11by the administrative director. The request for the hearing shall
12stay the suspension. The hearing shall be held within 30 days of
13the receipt of the request. Upon the completion of the hearing, if
14thebegin delete divisionend deletebegin insert
administrative directorend insert finds that paragraph (1) of
15subdivision (a) is applicable, the administrative director shall
16immediately suspend thebegin delete physician or practitioner.end deletebegin insert
physician,
17practitioner, or provider.end insert
18(3) If a physician is a qualified medical examiner, and the
19division finds, in accordance with the notice and hearing
20requirements of this section, that paragraph (1) of subdivision (a)
21is applicable to that physician, the physician shall be terminated
22from the list of medical evaluators pursuant to subdivision (m) of
23Section 139.2.
24
(3) The administrative director shall have power and jurisdiction
25to do all things necessary or convenient to conduct the hearings
26provided for in paragraph (2). The
hearings and investigations
27may be conducted by any designated hearing officer appointed by
28the administrative director. Any authorized person conducting that
29hearing or investigation may administer oaths, subpoena and
30require the attendance of witnesses and the production of books
31or papers, and cause the depositions of witnesses residing within
32or without the state to be taken in the manner prescribed by law
33for like depositions in civil cases in the superior court of this state
34under Title 4 (commencing with Section 2016.010) of Part 4 of the
35Code of Civil Procedure.
36(c) The administrative director shall promptly notify the
37begin delete physician’s or practitioner’send deletebegin insert physician’s, practitioner’s, or
38provider’send insert state
licensing, certifying, or registering authority of a
39suspension imposed pursuant to this section and shall update the
P16 1division’s qualified medical evaluator and medical provider
2network databases, as appropriate.
3(d) A provider of services, whether an individual, clinic, group,
4corporation, or other association, may not submit a claim for
5payment to, or pursue a claim for payment from, a payor for any
6services or supplies provided by a physician or practitioner whose
7participation in the workers’ compensation system has been
8suspended pursuant to this section, unless that claim for payment
9has been reduced to final judgment or the services or supplies are
10unrelated to a violation of the laws governing workers’
11compensation.
12
(d) Upon suspension of a physician, practitioner, or provider
13pursuant to this section, the administrative director shall give
14notice of the suspension to the chief judge of the division, and the
15chief judge shall promptly thereafter provide written notification
16of the suspension to district offices and all workers’ compensation
17judges. The method of notification to all district offices and to all
18workers’ compensation judges shall be in a manner determined
19by the chief judge in his or her discretion. The administrative
20director shall also post notification of the suspension on the
21department’s Internet Web site.
22
(e) The following procedures shall apply for the adjudication
23of any liens of a physician, practitioner, or provider suspended
24pursuant to subparagraph (A) of
paragraph (1) of subdivision (a),
25including any liens filed by or on behalf of the physician,
26practitioner, or provider or any clinic, group or corporation in
27which the suspended physician, practitioner, or provider has an
28ownership interest.
29
(1) If the disposition of the criminal proceeding provides for or
30requires, whether by plea agreement or by judgment, dismissal of
31liens and forfeiture of sums claimed therein, as specified in the
32criminal disposition, all of those liens shall be deemed dismissed
33with prejudice by operation of law as of the effective date of the
34final disposition in the criminal proceeding, and orders notifying
35of those dismissals may and shall be entered by workers’
36compensation judges.
37
(2) If the disposition of the criminal proceeding fails to specify
38the disposition to be made of lien filings in the workers’
39compensation system as set forth in paragraph
(1), all liens
40pending in any workers’ compensation case in any district office
P17 1within the state shall be consolidated and adjudicated in a special
2lien proceeding as described in subdivisions (f) to (i), inclusive.
3
(f) After notice of suspension, pursuant to subdivision (d), and
4if subdivision (e) applies, the administrative director shall appoint
5a special lien proceeding attorney, who shall be an attorney
6employed by the division or by the department. The special lien
7proceeding attorney shall, based on the information that is
8available, identify liens subject to disposition pursuant to
9subdivision (e), and workers’ compensation cases in which those
10liens are pending, and shall notify the chief judge regarding those
11liens. Based on this information, the chief judge shall identify a
12district office for a consolidated special lien proceeding to
13adjudicate those liens, and shall appoint a workers’ compensation
14judge to preside over that
proceeding.
15
(g) It shall be a presumption affecting the burden of proof that
16all liens to be adjudicated in the special lien proceeding, and all
17underlying bills for service and claims for compensation asserted
18therein, arise from the conduct subjecting the physician,
19practitioner, or provider to suspension, and that payment is not
20due and should not be made on those liens because they arise from,
21or are connected to, criminal, fraudulent, or abusive conduct or
22activity. A lien claimant shall not have the right to payment unless
23he or she rebuts that presumption by a preponderance of the
24evidence.
25
(h) The special lien proceedings shall be governed by the same
26laws, regulations, and procedures that govern all other matters
27before the appeals board. The administrative director shall
28promulgate regulations for the implementation of this section.
29
(i) If it is determined in a special lien proceeding that a lien
30does not arise from the conduct subjecting a physician,
31practitioner, or provider to suspension, the workers’ compensation
32judge shall have the discretion to adjudicate the lien or transfer
33the lien back to the district office having venue over the case in
34which the lien was filed.
35
(j) At any time following suspension, a physician, practitioner,
36or provider lien claimant may elect to withdraw or to dismiss his
37or her lien with prejudice, which shall constitute a final disposition
38of the claim for compensation asserted therein.
39
(k) The provisions of this section shall not affect, amend, alter,
40or in any way apply to the provisions of Section 139.2.
Section 4906 of the Labor Code is amended to read:
(a) A charge, claim, or agreement for the legal services
4or disbursements mentioned in subdivision (a) of Section 4903,
5or for the expense mentioned in subdivision (b) of Section 4903,
6is not enforceable, valid, or binding in excess of a reasonable
7amount. The appeals board may determine what constitutes a
8reasonable amount, but payment pursuant to subdivision (a)begin delete or (b)end delete
9 of Section 4903 or Section 5710 shall not be allowed for any
10services or expenses incurred prior to the filing of the disclosure
11form described in subdivision (e) with the appeals board and the
12sending of that form to the employer, or to the insurer or third-party
13administrator,
if either is known, by the attorney.
14(b) An attorney or agent shall not demand or accept any fee
15from an employee or dependent of an employee for the purpose
16of representing the employee or dependent of an employee in any
17proceeding of the division, appeals board, or any appellate
18procedure related thereto until the amount of the fee has been
19approved or set by the appeals board.
20(c) Any fee agreement shall be submitted to the appeals board
21for approval within 10 days after the agreement is made.
22(d) In establishing a reasonable attorney’s fee, consideration
23shall be given to the responsibility assumed by the attorney, the
24care exercised in representing the applicant, the time involved,
25and the results obtained.
26(e) At the initial consultation, an attorney shall furnish the
27employee a written disclosure form promulgated by the
28administrative director which shall clearly and prominently
29describe the procedures available to the injured employee or his
30or her dependents. The disclosure form shall describe this section,
31the range of attorney’s fees customarily approved by the appeals
32
board, and the attorney’s fees provisions of Section 4064 and the
33extent to which an employee may receive compensation without
34incurring attorney’s fees. The disclosure form shall include the
35telephone number of the administrative director together with the
36statement that the employee may receive answers at that number
37to questions concerning entitlement to compensation or the
38procedures to follow to receive compensation. A copy of the
39disclosure form shall be signed by the employee and the attorney
40and filed with the appeals board and sent to the employer, or insurer
P19 1or third-party administrator, if either is known, by the attorney
2within 15 days of the employee’s and attorney’s execution thereof.
3(f) The disclosure form set forth in subdivision (e) shall contain,
4prominently stated, the following statement:
6“Any person who makes or causes to be made any knowingly
7false or fraudulent material statement or representation for the
8purpose of obtaining or denying workers’ compensation benefits
9or payments is guilty of a felony.”
11(g) (1) The disclosure form described in subdivision (e) shall
12also contain a paragraph setting forth the exact location of the
13district office of the appeals board at which the employee’s case
14will be filed. This paragraph shall also contain, prominently
15displayed, the following statement:
17“The employee has been advised of the district office at which
18his or her case will be filed and that he or she may be required to
19
attend conferences or hearings at this location at his or her own
20expense.”
22(2) The disclosure form may not be signed by the employee
23until he or she has been advised of the location at which his or her
24case will be filed, has met with or personally spoken with an
25attorney licensed by the State Bar of California who is regularly
26employed by the firm by which the employee will be represented,
27and has been advised of his or her rights as set forth in subdivision
28(e) and the provisions of paragraph (1). The name of this individual
29shall be clearly and legibly set forth on the disclosure form.
30(3) The disclosure form shall include the actual date the
31disclosure form was signed by both the employee and the attorney
32and shall be signed under
penalty of perjury by the attorney
33representing the employee, or an attorney licensed by the State
34Bar of California who is regularly employed by his or her firm. A
35copy of the disclosure form containing all of the required
36information shall be given to the employee when he or she signs
37the disclosure form.
38(h) In addition to the disclosure form, the employee, the insurer,
39the employer, and the attorneys for each party shall sign under
40penalty of perjury and file with the board a statement, with the
P20 1begin insert completeend insert application or answer, and in addition to the disclosure
2required pursuant to subdivision (g), that they have not violated
3Section 139.3 and that they have not offered, delivered, received,
4or accepted any rebate, refund, commission,
preference, patronage
5dividend, discount, or other consideration, whether in the form of
6money or otherwise, as compensation or inducement for any
7referred examination or evaluation.
8(i) An attorney who subsequently assumes the representation
9of the employee in the same action or proceeding shall complete
10a disclosure form that meets all of the requirements of this section
11and the statement required by subdivision (h). Both the form and
12the statement shall be signed under penalty of perjury by the
13attorney or an attorney licensed by the State Bar of California who
14is regularly employed by his or her firm. Both the disclosure form
15and the statement shall be filed with the appeals board and sent to
16the employer, or insurer or third-party administrator, if either is
17known, by the attorney within 15 days of the employee’s and
18attorney’s
execution of the form and statement. Payment pursuant
19to subdivision (a)begin delete or (b)end delete of Section 4903 or Section 5710 shall not
20be allowed for any services or expenses incurred prior to the filing
21of the disclosure form described in subdivision (e) with the appeals
22board and the sending of that form to the employer, or to the insurer
23or third-party administrator, if either is known, by the attorney.
Section 14123 of the Welfare and Institutions Code is
26amended to read:
Participation in the Medi-Cal program by a provider
28of service is subject to suspension in order to protect the health of
29the recipients and the funds appropriated to carry out this chapter.
30(a) (1) The director may suspend a provider of service from
31further participation under the Medi-Cal program for violation of
32any provision of this chapter or Chapter 8 (commencing with
33Section 14200) or any rule or regulation promulgated by the
34director pursuant to those chapters. The suspension may be for an
35indefinite or specified period of time and with or without
36conditions, or may be imposed with the operation of the suspension
37stayed or probation granted. The
director shall suspend a provider
38of service for conviction of any felony or any misdemeanor
39involving fraud, abuse of the Medi-Cal program or any patient, or
P21 1otherwise substantially related to the qualifications, functions, or
2duties of a provider of service.
3(2) If the provider of service is a clinic, group, corporation, or
4other association, conviction of any officer, director, or shareholder
5with a 10 percent or greater interest in that organization, of a crime
6described in paragraph (1) shall result in the suspension of that
7organization and the individual convicted if the director believes
8that suspension would be in the best interest of the Medi-Cal
9program. If the provider of service is a political subdivision of the
10state or other government agency, the conviction of the person in
11charge of the facility of a crime described in
paragraph (1) may
12result in the suspension of that facility. The record of conviction
13or a certified copy thereof, certified by the clerk of the court or by
14the judge in whose court the conviction is had, shall be conclusive
15evidence of the fact that the conviction occurred. A plea or verdict
16of guilty, or a conviction following a plea of nolo contendere is
17deemed to be a conviction within the meaning of this section.
18(3) After conviction, but before the time for appeal has elapsed
19or the judgment of conviction has been affirmed on appeal, the
20director, if he or she believes that suspension would be in the best
21interests of the Medi-Cal program, may order the suspension of a
22provider of service. When the time for appeal has elapsed, or the
23judgment of conviction has been affirmed on appeal or when an
24order granting probation is made
suspending the imposition of
25sentence irrespective of any subsequent order under Section 1203.4
26of the Penal Code allowing a person to withdraw his or her plea
27of guilty and to enter a plea of not guilty, or setting aside the verdict
28of guilty, or dismissing the accusation, information, or indictment,
29the director shall order the suspension of a provider of service.
30The suspension shall not take effect earlier than the date of the
31director’s order. Suspension following a conviction is not subject
32to the proceedings required in subdivision (c). However, the
33director may grant an informal hearing at the request of the provider
34of service to determine in the director’s sole discretion if the
35circumstances surrounding the conviction justify rescinding or
36otherwise modifying the suspension provided for in this
37subdivision.
38(4) If the
provider of service appeals the conviction and the
39conviction is reversed, the provider may apply for reinstatement
40to the Medi-Cal program after the conviction is reversed.
P22 1Notwithstanding Section 14124.6, the application for reinstatement
2shall not be subject to the one-year waiting period for the filing of
3a reinstatement petition pursuant to Section 11522 of the
4Government Code.
5(b) Whenever the director receives written notification from the
6Secretary of the United States Department of Health and Human
7Services that a physician or other individual practitioner has been
8suspended from participation in the Medicare or Medicaid
9programs, the director shall promptly suspend the practitioner from
10participation in the Medi-Cal program and notify the
11Administrative Director of the Division of Workers’ Compensation
12of the suspension, in
accordance with paragraph (2) of subdivision
13(e). This automatic suspension is not subject to the proceedings
14required in subdivision (c). No payment from state or federal funds
15may be made for any item or service rendered by the practitioner
16during the period of suspension.
17(c) The proceedings for suspension shall be conducted pursuant
18to Section 100171 of the Health and Safety Code. The director
19may temporarily suspend any provider of service prior to any
20hearing when in his or her opinion that action is necessary to
21protect the public welfare or the interests of the Medi-Cal program.
22The director shall notify the provider of service of the temporary
23suspension and the effective date thereof and at the same time
24serve the provider with an accusation. The accusation and all
25proceedings thereafter shall be in accordance with Section
100171
26of the Health and Safety Code. Upon receipt of a notice of defense
27by the provider, the director shall set the matter for hearing within
2830 days after receipt of the notice. The temporary suspension shall
29remain in effect until such time as the hearing is completed and
30the director has made a final determination on the merits. The
31temporary suspension shall, however, be deemed vacated if the
32director fails to make a final determination on the merits within
3360 days after the original hearing has been completed. This
34subdivision does not apply where the suspension of a provider is
35based upon the conviction of any crime involving fraud, abuse of
36the Medi-Cal program, or suspension from the federal Medicare
37program. In those instances, suspension shall be automatic.
38(d) (1) The suspension by the director of any provider of
service
39shall preclude the provider from submitting claims for payment,
40either personally or through claims submitted by any clinic, group,
P23 1corporation, or other association to the Medi-Cal program for any
2services or supplies the provider has provided under the program,
3except for services or supplies provided prior to the suspension.
4No clinic, group, corporation, or other association which is a
5provider of service shall submit claims for payment to the Medi-Cal
6program for any services or supplies provided by a person within
7the organization who has been suspended or revoked by the
8director, except for services or supplies provided prior to the
9suspension.
10
(2) If the provisions of this chapter, Chapter 8 (commencing
11with Section 14200), or the regulations promulgated by the director
12are violated by a provider of service that is a clinic, group,
13corporation, or other association, the director may suspend the
14organization and any individual person within the organization
15who is responsible for the violation.
16(e) (1) Notice of the suspension shall be sent by the director to
17the provider’s state licensing, certifying, or registering authority,
18along with the evidence upon which the suspension was based.
19(2) At the same time notice is provided pursuant to paragraph
20(1), the director shall provide written notification of the suspension
21to the Administrative Director of the Division of
Workers’
22Compensation, for purposes of Section 139.21 of the Labor Code.
23(f) In addition to the bases for suspension contained in
24subdivisions (a) and (b), the director may suspend a provider of
25service from further participation under the Medi-Cal dental
26program for the provision of services that are below or less than
27the standard of acceptable quality, as established by the California
28Dental Association Guidelines for the Assessment of Clinical
29Quality and Professional Performance, Copyright 1995, Third
30Edition, as periodically amended. The suspension shall be subject
31to the requirements contained in subdivisions (a) to (e), inclusive.
No reimbursement is required by this act pursuant to
34Section 6 of Article XIII B of the California Constitution because
35the only costs that may be incurred by a local agency or school
36district will be incurred because this act creates a new crime or
37infraction, eliminates a crime or infraction, or changes the penalty
38for a crime or infraction, within the meaning of Section 17556 of
39the Government Code, or changes the definition of a crime within
P24 1the meaning of Section 6 of Article XIII B of the California
2Constitution.
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92