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AB-2674 Health care service plans: disciplinary actions.(2017-2018)



Current Version: 08/17/18 - Amended Senate        


AB2674:v93#DOCUMENT

Amended  IN  Senate  August 17, 2018
Amended  IN  Senate  June 14, 2018
Amended  IN  Assembly  May 25, 2018
Amended  IN  Assembly  April 16, 2018
Amended  IN  Assembly  April 02, 2018
Amended  IN  Assembly  March 21, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Assembly Bill No. 2674


Introduced by Assembly Member Aguiar-Curry

February 15, 2018


An act to amend Section 1371.39 of the Health and Safety Code, relating to health care service plans.


LEGISLATIVE COUNSEL'S DIGEST


AB 2674, as amended, Aguiar-Curry. Health care service plans: disciplinary actions.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law prohibits a health care service plan from engaging in an unfair payment pattern, as defined, and requires the department to adopt regulations that ensure that plans have adopted a dispute resolution mechanism, as specified.
This bill would require the department to review complaints of unfair payment patterns on or before July 1, 2019, and at least annually thereafter. The bill would require authorize the department to conduct an audit and or an enforcement action, as specified, if the Director of the Department of Managed Health Care department determines the complaint review indicates a possible unfair payment pattern. Upon a final determination by the department that a health care service plan’s, or plan’s capitated provider’s, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the bill would require the director to assess an administrative penalty in, and to require the plan to pay the provider, an amount not less than the amount owed plus interest.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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


SECTION 1.

 Section 1371.39 of the Health and Safety Code is amended to read:

1371.39.
 (a) Providers may report to the department’s Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.
(b) Plans may report to the department’s Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.
(c) “Unfair billing pattern” means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.
(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.

(e)If the department makes a final determination that a plan’s, or a plan’s capitated provider’s, practice, policy, or procedure constitutes a “demonstrable and unjust payment pattern” or “unfair payment pattern,” the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:

(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.

(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.

(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.