BILL ANALYSIS
AB 839
Page 1
Date of Hearing: April 27, 2009
ASSEMBLY COMMITTEE ON JUDICIARY
Mike Feuer, Chair
AB 839 (Emmerson) - As Amended: March 26, 2009
PROPOSED CONSENT
SUBJECT : MEDI-CAL SERVICE PROVIDERS: JUDICIAL REMEDIES
KEY ISSUES :
1)SHOULD A HEALTH CARE PROVIDER WHO HAS FILED AN APPEAL OF A
GRIEVANCE OR COMPLAINT BE ALLOWED TO FILE A PETITION FOR WRIT
OF MANDATE IN SUPERIOR COURT?
2)SHOULD THE DATE ON WHICH A HEALTH CARE PROVIDER IS BARRED FROM
ENROLLMENT IN MEDI-CAL BE THE DATE OF THE DENIAL OR
TERMINATION OF THE PROVIDERS' APPLICATION PACKAGE?
FISCAL EFFECT : As currently in print this bill is keyed fiscal.
SYNOPSIS
This non-controversial bill recently passed the Assembly Health
Committee by a vote of 19-0 on consent. It merely makes some
needed clarifications regarding judicial review in the Medi-Cal
domain. It is sponsored by the Department of Health Care
Services and supported by the California Medical Association and
Judicial Council and there is no known opposition.
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
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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
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
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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.
COMMENTS : 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 writ 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 appeal their denial
and/or termination of enrollment in Medi-Cal.
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.
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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.
WRIT OF MANDATE . Existing law authorizes any court to issue a
writ 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
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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.
Prior Related 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. 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 : Drew Liebert and Edward Ahn / JUD. /
(916) 319-2334