BILL ANALYSIS
------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 839|
|Office of Senate Floor Analyses | |
|1020 N Street, Suite 524 | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
------------------------------------------------------------
THIRD READING
Bill No: AB 839
Author: Emmerson (R)
Amended: 8/18/09 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 6-0, 6/17/09
AYES: Alquist, DeSaulnier, Leno, Maldonado, Pavley, Wolk
NO VOTE RECORDED: Strickland, Aanestad, Cedillo, Cox,
Negrete McLeod
SENATE JUDICIARY COMMITTEE : 5-0, 7/7/09
AYES: Corbett, Harman, Florez, Leno, Walters
SENATE APPROPRIATIONS COMMITTEE : Senate Rule 28.8
ASSEMBLY FLOOR : 77-0, 5/21/09 - See last page for vote
SUBJECT : Medi-Cal: providers: remedies
SOURCE : Deaprtment of Health Care Services
DIGEST : This bill changes Medi-Cal provider remedies,
including specifying the judicial remedy when there is a
dispute over processing or payment of money and modifies
the date for the beginning of a period when a health care
provider is barred from enrollment in Medi-Cal as specified
in law.
Senate Floor Amendments of 8/18/09 are to avoid chaptering
out problems with AB 1540 (Committee on Health).
CONTINUED
AB 839
Page
2
ANALYSIS :
Existing Law
1.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health care coverage for low-income
individuals and their families; pregnant women; elderly,
blind, or disabled persons; nursing home residents; and
refugees who meet specified eligibility criteria.
2.Requires the Director of DHCS, by regulation, to adopt
procedures for the review of a grievance or complaint
concerning the process 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 preceding two provisions to be the exclusive
remedy available to the health care provider for monies
alleged to be payable by the Medi-Cal program.
5.Requires that health care providers apply to, and be
certified to, 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 based
from the date the application package is denied or the
provisional provider status is terminated, unless there
is an appeal from that denial or termination, then the
three-year period begins from the date of the final
decision following an appeal.
7.Provides for a ten-year ban on reapplying, if the denial
or termination is based on the applicant's conviction of
specified offenses.
AB 839
Page
3
This bill:
1.Clarifies that a health care provider who files a
grievance or complaint regarding the processing or
payment of money by the Medi-Cal program, and who filed a
complaint with DHCS may appeal the DHCS decision by
filing a petition for writ of mandate in superior court.
2.Modifies the three-year and ten-year prohibition on
enrollment as a health care provider in any DHCS program
to begin from the date the provider's application package
is denied or provisional provider status is terminated.
This bill is double-jointed to AB 1540 (Assembly Health
Committee).
Comments
To address provider fraud in the Medi-Cal program, SB 857
(Speier), Chapter 601, Statutes of 2005, established new
requirements for health care providers seeking to bill the
Medi-Cal program. Health care providers must apply to, and
be certified by, DHCS's Medi-Cal Provider Enrollment Branch
prior to their participation in the Medi-Cal program.
Existing law allows DHCS, if specified conditions are met,
to grant provisional provider status or preferred
provisional provider status to an applicant or provider,
and requires DHCS to terminate that status if any of the
specified grounds exist. If an application for provisional
provider status or preferred provisional provider status is
denied, or that status is terminated, the applicant or
provider is prohibited from reapplying for enrollment, or
continued enrollment, in the Medi-Cal program or for
participation in any health care program administered by
DHCS.
Existing law allows DHCS, if specified conditions are met,
to grant provisional provider status or preferred
provisional provider status to an applicant or provider,
and requires DHCS to terminate that status if any of the
specified grounds exist. If an application for provisional
provider status or preferred provisional provider status is
AB 839
Page
4
denied, or that status is terminated, the applicant or
provider is prohibited from reapplying for enrollment, or
continued enrollment, in the Medi-Cal program or for
participation in any health care program administered by
DHCS.
This prohibition from reapplication to the Medi-Cal program
is for a period of three years from the date the
application package is denied or the provisional provider
status is terminated, or from the date of the final
decision following an appeal from that denial or
termination, except as specified. If a 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 cared program administered by DHCS. This
prohibition is for a period of ten y ears 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 : Appropriation: No Fiscal Com.: Yes
Local: No
SUPPORT : (Verified 8/19/09)
Department of Health Care Services (source)
California Association of Health Facilities
California Medical Association
Judicial Council of California
ARGUMENTS IN SUPPORT : According to DHCS, the bill's
sponsor, this bill will benefit the state and Medi-Cal
providers who sue the state by creating a speedy and
equitable remedy for claims. The sponsor also points out
that the bill will also benefit Medi-Cal providers who
choose to appeal their denied application for enrollment
because current law allowing for appropriate judicial
remedies is vague, and fails to outline a specific legal
remedy for Medi-Cal providers seeking to appeal the denial
of a claim for reimbursement. The result is that providers
AB 839
Page
5
file a variety of actions for reimbursement, including
money damages or breach of contract actions where it is
unclear what contract or statute they are suing to enforce.
The sponsor notes that this confusing situation contrasts
with the traditional remedy for individuals seeking relief
from a denial by a state agency, which is pursuing a writ
of mandate under Code of Civil Procedure Section 1085 to
overturn the denial.
ASSEMBLY FLOOR :
AYES: Adams, Ammiano, Anderson, Arambula, Beall, Bill
Berryhill, Tom Berryhill, Blakeslee, Block, Blumenfield,
Brownley, Buchanan, Caballero, Charles Calderon, Carter,
Chesbro, Conway, Cook, Coto, Davis, De La Torre, De Leon,
DeVore, Duvall, Emmerson, Eng, Evans, Feuer, Fletcher,
Fong, Fuller, Furutani, Gaines, Galgiani, Garrick,
Gilmore, Hagman, Hall, Harkey, Hayashi, Hernandez, Hill,
Huber, Huffman, Jeffries, Jones, Knight, Krekorian, Lieu,
Logue, Bonnie Lowenthal, Ma, Mendoza, Miller, Monning,
Nestande, Niello, Nielsen, John A. Perez, V. Manuel
Perez, Portantino, Price, Ruskin, Salas, Silva, Skinner,
Smyth, Solorio, Audra Strickland, Swanson, Torlakson,
Torres, Torrico, Tran, Villines, Yamada, Bass
NO VOTE RECORDED: Fuentes, Nava, Saldana
CTW:cm 8/19/09 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****