BILL ANALYSIS
AB 839
Page 1
Date of Hearing: April 14, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 839 (Emmerson) - As Amended: March 26, 2009
SUBJECT : Medi-Cal: providers: remedies.
SUMMARY : Makes changes to Medi-Cal provider appeal remedies
relating to filing an appeal of a grievance or complaint in
court, and requires the date on which a health care provider is
barred from enrollment in Medi-Cal to be the date of the denial
or termination of the providers' application package.
Specifically, this bill:
1)Requires a 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. Under current law, the prohibition begins
either on the date the application is denied or provisional
provider status is terminated, or from the date of the final
decision following an appeal from that denial or termination.
2)Allows a health care provider who has filed a grievance or
complaint regarding the processing or payment of money by the
Medi-Cal program, and who has filed a complaint with DHCS but
who is not satisfied with the DHCS decision, to file a
petition for writ of mandate in superior court, rather than
being authorized to seek "appropriate judicial remedies" under
existing law.
EXISTING LAW :
1)Establishes the Medi-Cal program, administered by DHCS, under
which basic health care services are provided to qualified
low-income persons.
2)Requires the director of DHCS, by regulation, to adopt such
procedures as are necessary 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 program.
3)Permits a provider who complies with these procedures and is
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not satisfied with the director's decision regarding that
claim to seek appropriate judicial remedies within a specified
time period.
4)Requires the above two provisions to be the exclusive remedy
available to the health care provider for moneys alleged to be
payable by the Medi-Cal program.
5)Requires that health care providers apply to, and be certified
by, DHCS prior to their participation in the Medi-Cal program.
6)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 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.
7)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
the DHCS, 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.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE . This bill is sponsored by DHCS to make two changes
related to provider appeals in Medi-Cal. Specifically, this
bill would require that the judicial remedy for Medi-Cal
providers seeking to appeal the denial of a grievance or
complaint related to Medi-Cal reimbursement is to file a
petition for a write of mandate in superior court.
Additionally, this bill would require the prohibition on
enrollment as a Medi-Cal provider to begin on the date of the
providers' denial or termination of enrollment, rather than
the date when the provider appeals. DHCS argues the current
process penalizes providers when they exercise their right to
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appeal their denial and/or termination of enrollment in
Medi-Cal.
2)MEDI-CAL PROVIDER ENROLLMENT BRANCH . 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 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 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.
This bill would delete the provisions that start the three-year
and ten-year prohibitions from the date of the final decision
following an appeal from that denial or termination. DHCS'
rationale for the proposed change is to not penalize Medi-Cal
providers and applicants when they exercise their right to
appeal their denial and/or termination of enrollment in
Medi-Cal.
3)WRIT OF MANDATE . Existing law authorizes any court to issue a
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write of mandate to any inferior tribunal, corporation, board,
or person to compel the performance of an act which the law
specifically enjoins as a duty resulting from an office,
trust, or station.
Under current Medi-Cal law, a health care provider who has filed
a grievance or complaint regarding the processing or payment
of money by the Medi-Cal program and who has filed a complaint
with DHCS, but who is not satisfied with the DHCS decision is
authorized to seek "appropriate judicial remedies" under
existing law. This bill would instead require that the
provider file a writ of mandate in superior court.
DHCS indicates this change would conform the appeals process
currently used to review the denial of Treatment Authorization
Requests (TAR). DHCS further states current law is vague in
that it fails to specify a legal remedy for Medi-Cal providers
seeking to appeal the denial of a claim for reimbursement. As
a result, DHCS indicates, 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. DHCS indicates current Medi-Cal
claims cases proceed through assignments to general civil
courts on a first come basis, and because they lack priority,
claims cases linger on as judges resolve other higher priority
cases thus delaying the resolution of provider claims
grievances. DHCS indicates the expanded time frame in
resolving these cases results in an increased number of claims
that are over one year old for purposes of claiming for
federal financial participation. The traditional remedy for
individuals seeking relief from a denial by a state agency has
been by writ of mandate under Code of Civil Procedure section
1085 to overturn the denial. DHCS indicates the proposed
change will benefit the state and Medi-Cal providers suing the
state by creating a speedy equitable remedy for claims against
a government entity.
4)DOUBLE REFERRAL . This bill has been double-referred. Should
this bill pass out of this committee, it will be referred to
the Judiciary Committee.
5)PREVIOUS LEGISLATION . AB 1226 (Hayashi), Chapter 693,
Statutes of 2008 revises Medi-Cal provider enrollment to
simplify re-enrollment of Medi-Cal physicians relocating
within the same county and to expedite enrollment of specified
and established physicians into the Medi-Cal program.
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Additionally, AB 1226 also specifies, in response to a court
decision, that an applicant whose application for enrollment
as a provider has been denied can reapply for a period of
three years from the date the application is denied.
REGISTERED SUPPORT / OPPOSITION :
Support
Department of Health Care Services (sponsor)
California Medical Association
Judicial Council of California
Opposition
None on file.
Analysis Prepared by : Scott Bain / HEALTH / (916) 319-2097