Code Section Group

Welfare and Institutions Code - WIC

DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.8]

  ( Division 9 added by Stats. 1965, Ch. 1784. )

PART 4.7. HEALTH CARE FOR INDIGENTS [16900 - 16996.2]

  ( Heading for Part 4.7 added by Stats. 1990, Ch. 50, Sec. 10.5. )

CHAPTER 5. California Healthcare for Indigents Program [16940 - 16995.1]

  ( Chapter 5 added by Stats. 1989, Ch. 1331, Sec. 9. )

ARTICLE 3.5. Physician Services Account [16951 - 16959]
  ( Article 3.5 added by Stats. 1989, Ch. 1331, Sec. 9. )

16951.
  

As a condition of receiving funds pursuant to this chapter, each county shall establish an emergency medical services fund as authorized by subdivision (a) of Section 1797.98 of the Health and Safety Code. This section shall not be interpreted to require any county to impose the assessment authorized by Section 1465 of the Penal Code.

(Added by Stats. 1989, Ch. 1331, Sec. 9. Effective October 2, 1989.)

16952.
  

(a) (1) Each county shall establish within its emergency medical services fund a Physician Services Account. Each county shall deposit in the Physician Services Account those funds appropriated by the Legislature for the purposes of the Physician Services Account of the fund.

(2) (A) Each county may encumber sufficient funds to reimburse physician losses incurred during the fiscal year for which bills will not be received until after the fiscal year.

(B) Each county shall provide a reasonable basis for its estimate of the necessary amount encumbered.

(C) All funds that are encumbered for a fiscal year shall be expended or disencumbered prior to the submission of the report of actual expenditures required by Sections 16938 and 16980.

(b) (1) Funds deposited in the Physician Services Account in the county emergency medical services fund shall be exempt from the percentage allocations set forth in subdivision (a) of Section 1797.98. However, funds in the county Physician Services Account shall not be used to reimburse for physician services provided by physicians employed by county hospitals.

(2) No physician who provides physician services in a primary care clinic which receives funds from this act shall be eligible for reimbursement from the Physician Services Account for any losses incurred in the provision of those services.

(c) The county physician services account shall be administered by each county, except that a county that is eligible to participate in the CMSP pursuant to Section 16809, may elect to have its county physician services account administered by the state.

(d) Costs of administering the account, whether by the county or by the department through the emergency medical services contract-back program, shall be reimbursed by the account based on actual administrative costs, not to exceed 10 percent of the amount of the account.

(e) For purposes of this article “administering agency” means the agency designated by the board of supervisors to administer this article, or the department, in the case of those counties that are eligible to participate in the CMSP pursuant to Section 16809, and that elect to have the state administer this article on their behalf.

(f) The county Physician Services Account shall be used to reimburse physicians for losses incurred for services provided during the fiscal year of allocation due to patients who do not have health insurance coverage for emergency services and care, who cannot afford to pay for those services, and for whom payment will not be made through any private coverage or by any program funded in whole or in part by the federal government with the exception of claims submitted for reimbursement through Section 1011 of the federal Medicare Prescription Drug, Improvement and Modernization Act of 2003.

(g) Physicians shall be eligible to receive payment for patient care services provided by, or in conjunction with, a properly credentialed nurse practitioner or physician’s assistant for care rendered under the direct supervision of a physician and surgeon who is present in the facility where the patient is being treated and who is available for immediate consultation. Payment shall be limited to those claims that are substantiated by a medical record and that have been reviewed and countersigned by the supervising physician and surgeon in accordance with regulations established for the supervision of nurse practitioners and physician assistants in California.

(h) (1) Reimbursement for losses shall be limited to emergency services as defined in Section 16953, obstetric, and pediatric services as defined in Sections 16905.5 and 16907.5, respectively.

(2) It is the intent of this subdivision to allow reimbursement for all of the following:

(A) All inpatient and outpatient obstetric services which are medically necessary, as determined by the attending physician.

(B) All inpatient and outpatient pediatric services which are medically necessary, as determined by the attending physician.

(i) Any physician may be reimbursed for up to 50 percent of the amount claimed pursuant to Section 16955 for the initial cycle of reimbursements made by the administering agency in a given year. All funds remaining at the end of the fiscal year shall be distributed proportionally, based on the dollar amount of claims submitted and paid to all physicians who submitted qualifying claims during that year. The administering agency shall not disburse funds in excess of the total amount of a qualified claim.

(Amended by Stats. 2007, Ch. 577, Sec. 26. Effective October 13, 2007.)

16952.1.
  

(a) Each county that elects to establish a Physicians Services Account in the county emergency medical services fund shall annually, on April 15, report to the Legislature on the implementation and status of the Physicians Services Account. The report shall cover the preceding fiscal year, and shall include, but not be limited to, all of the following:

(1) The total amount of moneys deposited in the Physicians Services Account.

(2) The account balance and the amount of moneys disbursed to physicians and surgeons.

(3) The number of claims paid to physicians, and the percentage of claims paid, based on the uniform fee schedule, as adopted by the county.

(4) The amount of moneys available to be disbursed to physicians, descriptions of the physician claims payment methodologies, the dollar amount of the total allowable claims submitted, and the percentage at which those claims are reimbursed.

(5) A statement of the policies, procedures, and regulatory action taken to implement and run the program under this chapter.

(6) The name of the physician and hospital administrator organization, or names of specified physicians and hospital administrators, contracted to review claims payment methodologies.

(b) Each county shall make available to any member of the public, upon request, the report required under subdivision (a).

(Added by Stats. 2005, Ch. 671, Sec. 7. Effective January 1, 2006.)

16952.5.
  

(a) Notwithstanding subdivision (g) of Section 16952, expenses incurred by Solano County for the development of managed care systems to increase access for indigents to physician emergency services shall be reimbursed subject to the availability of unexpended 1990–91 and 1991–92 fiscal year funds, up to a maximum of four hundred thousand dollars ($400,000).

(b)  The county shall consult with the local medical society before seeking reimbursement pursuant to this subdivision.

(Added by Stats. 1993, Ch. 105, Sec. 1. Effective July 13, 1993.)

16953.
  

(a) For purposes of this chapter “emergency services” means physician services in one of the following:

(1) A general acute care hospital which provides basic or comprehensive emergency services for emergency medical conditions.

(2) A site which was approved by a county prior to January 1, 1990, as a paramedic receiving station for the treatment of emergency patients, for emergency medical conditions.

(3) Beginning in the 1991–92 fiscal year and each fiscal year thereafter, in a facility which contracted prior to January 1, 1990, with the National Park Service to provide emergency medical services, for emergency medical conditions.

(4) A standby emergency room in a hospital specified in Section 124840 of the Health and Safety Code, for emergency medical conditions.

(5) A standby emergency room in a hospital in existence on January 1, 2007, located in Los Angeles County that meets all of the following requirements:

(A) The requirements of subdivision (m) of Section 70413 and Sections 70415 and 70417 of Title 22 of the California Code of Regulations.

(B) Reported at least 18,000 emergency department patient encounters to the Office of Statewide Health Planning and Development in 2007 and continues to report at least 18,000 emergency department patient encounters to the Office of Statewide Health Planning and Development in each year thereafter.

(C) A hospital with a standby emergency department meeting the requirements of this paragraph shall do both of the following:

(i) Annually provide the State Department of Public Health and the local emergency medical services agency with certification that it meets the requirements of subparagraph (A). The department shall confirm the hospital’s compliance with subparagraph (A).

(ii) Annually provide to the State Department of Public Health and the local emergency medical services agency the emergency department patient encounters it reports to the Office of Statewide Health Planning and Development to establish that it meets the requirement of subparagraph (B).

(b) For purposes of this chapter, “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, which in the absence of immediate medical attention could reasonably be expected to result in any of the following:

(1) Placing the patient’s health in serious jeopardy.

(2) Serious impairment to bodily functions.

(3) Serious dysfunction to any bodily organ or part.

(c) It is the intent of this section to allow reimbursement for all inpatient and outpatient services which are necessary for the treatment of an emergency medical condition as certified by the attending physician or other appropriate provider.

(Amended by Stats. 2008, Ch. 288, Sec. 3. Effective January 1, 2009.)

16953.1.
  

Notwithstanding any other provision of this chapter, an emergency physician and surgeon, or an emergency physician group, with a gross billings arrangement with a hospital shall be entitled to receive reimbursement from the physician services account in the county’s emergency medical services fund for services provided in that hospital, if all of the following conditions are met:

(a) The services are provided in a basic or comprehensive general acute care hospital emergency department.

(b) The physician and surgeon is not an employee of the hospital.

(c) All provisions of Section 16955 are satisfied, except that payment to the emergency physician and surgeon, or an emergency physician group, by a hospital pursuant to a gross billings arrangement shall not be interpreted to mean that payment for a patient is made by a responsible third party.

(d) Reimbursement from the physician services account in the county’s emergency medical services fund is sought by the hospital or the hospital’s designee, as the billing and collection agent for the emergency physician and surgeon, or an emergency physician group.

(e) For purposes of this section, “gross billings arrangement” means an arrangement whereby a hospital serves as the billing and collection agent for the emergency physician and surgeon, or an emergency physician group, and pays the emergency physician and surgeon, or an emergency physician group, a percentage of the emergency physician and surgeon’s or group’s gross billings for all patients.

(Amended by Stats. 1991, Ch. 278, Sec. 20. Effective July 30, 1991.)

16953.2.
  

Nothing in this article shall prevent a physician from utilizing an agent who furnishes billing and collection services to the physician to submit claims or receive payment for claims.

(Added by Stats. 1991, Ch. 278, Sec. 21. Effective July 30, 1991.)

16953.3.
  

(a) Notwithstanding any other restrictions on reimbursement, a county shall adopt a fee schedule to establish a uniform, reasonable level of reimbursement from the Physician Services Account for reimbursable services.

(b) (1) Notwithstanding any other restrictions on reimbursement, the State Department of Public Health shall adopt a single fee schedule to establish a uniform, reasonable level of reimbursement for use in the physician services reimbursement programs operated by the department pursuant to contract, as provided for in subdivision (c) of Section 16952.

(2) The State Department of Public Health may develop, contract for the development of, or adopt by reference, the fee schedule required by paragraph (1).

(3) Pursuant to subdivision (d) of Section 16952, the State Department of Public Health may be reimbursed by the Physician Services Account and the Hospital Services Account based on actual administrative costs to develop or adopt the fee schedule required by paragraph (1), not to exceed 10 percent of the amount of the account.

(4) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this subdivision by means of provider bulletins, or similar instruction, without taking formal regulatory action.

(Amended by Stats. 2007, Ch. 483, Sec. 53. Effective January 1, 2008.)

16955.
  

Reimbursement for losses incurred by any physician shall be limited to services provided to a patient as established by subdivisions (f) and (g) of Section 16952, and where all of the following conditions have been met:

(a) The physician has inquired if there is a responsible third-party source of payment.

(b) The physician has billed for payment of services.

(c) Either of the following:

(1) A period of not less than three months has passed from the date the physician billed the patient or responsible third party, during which time the physician has made reasonable efforts to obtain reimbursement and has not received reimbursement for any portion of the amount billed.

(2) The physician has received actual notification from the patient or responsible third party that no payment will be made for the services rendered by the physician.

(d) The physician has stopped any current, and waives any future, collection efforts to obtain reimbursement from the patient, upon receipt of funds from the county physician services account in the county emergency medical services fund.

(Amended by Stats. 2005, Ch. 671, Sec. 9. Effective January 1, 2006.)

16955.1.
  

This article shall not be applied or interpreted so as to prevent a physician from seeking payment from a patient or responsible third-party payor, or arranging a repayment schedule for the costs of services rendered prior to receiving payment under this article.

(Added by Stats. 1990, Ch. 51, Sec. 42. Effective April 18, 1990.)

16956.
  

(a) The administering agency shall establish procedures and time schedules for submission and processing of reimbursement claims submitted by physicians in accordance with this chapter.

(b) Schedules for payment established in accordance with this section shall provide for disbursement of the funds available in the account periodically and at least quarterly, if funds remain available for disbursement, to all physicians who have submitted claims containing accurate and complete data for payment by the dates established by the administering agency.

(c) Claims which are not supported by records may be denied by the administering agency, and any reimbursement paid in accordance with this chapter to any physician which is not supported by records shall be repaid to the administering agency, and shall be a claim against the physician.

(d) Any physician who submits any claim for reimbursement under this chapter which is inaccurate or which is not supported by records may be excluded from reimbursement of future claims under this chapter.

(e) A listing of patient names shall accompany a physician’s claim, and those names shall be given full confidentiality protections by the administering agency.

(f) The administering agency shall not give preferential treatment to any facility, physician, or category of physician and shall not engage in practices that constitute a conflict of interest by favoring a facility or physician with which the administering officer has an operational or financial relationship.

(g) Payments shall be made only for emergency medical services provided on the calendar day on which emergency medical services are first provided and on the immediately following two calendar days.

(h) Notwithstanding subdivision (g), if it is necessary to transfer the patient to a second facility that provides for a higher level of care for the treatment of the emergency condition, reimbursement shall be available for services provided to the facility to which the patient was transferred on the calendar day of transfer and on the immediately following two calendar days.

(Amended by Stats. 2005, Ch. 671, Sec. 10. Effective January 1, 2006.)

16956.5.
  

(a) The administering agency may establish an EMS Fund advisory committee. The committee shall include emergency physicians and emergency department oncall backup panel physicians. The committee shall advise the administering agency regarding distribution of funds pursuant to this section.

(b) If the administering agency establishes a committee pursuant to subdivision (a) and the committee, upon an affirmative vote by every member of the committee, recommends that the administering agency adopt a special fee schedule and claims submission criteria for reimbursement for services rendered to uninsured trauma patients, the administering agency may adopt the special fee schedule and claims submission criteria.

(c) Notwithstanding any provision of law to the contrary, in addition to reimbursement for trauma service rendered in the initial day and the following two calendar days, the administering agency may reimburse pursuant to this section for services rendered to uninsured trauma patients beyond the calendar day on which emergency medical services are first provided and the immediately following two calendar days.

(d) Only up to 15 percent of the tobacco tax revenues allocated to the county’s EMS Fund may be distributed through this special fee schedule.

(e) All providers who render services to uninsured trauma patients may submit claims for reimbursement under this section. No provider’s claim shall be initially reimbursed pursuant to this section at greater than 50 percent of losses.

(Added by Stats. 2005, Ch. 671, Sec. 11. Effective January 1, 2006.)

16957.
  

Any physician who submits any claim in accordance with this chapter shall keep and maintain records of the services rendered, the person to whom services were rendered, and any additional information the administering agency may require, for a period of three years after the services were provided.

(Added by Stats. 1989, Ch. 1331, Sec. 9. Effective October 2, 1989.)

16958.
  

If, after receiving payment from the account, a physician is reimbursed by a patient or a responsible third-party, the physician shall do one of the following:

(a) Notify the administering agency and the administering agency shall reduce the physician’s future payment of claims from the account . In the event there is not a subsequent submission of a claim for reimbursement within one year, the physician shall reimburse the account in an amount equal to the amount collected from the patient or third-party payor, but not more than the amount of reimbursement received from the account.

(b) Notify the administering agency of the payment and reimburse the account in an amount equal to the amount collected from the patient or third-party payor, but not more than the amount of the reimbursement received from the account for that patient’s care.

(Amended by Stats. 1990, Ch. 51, Sec. 43. Effective April 18, 1990.)

16959.
  

The moneys contained in a Physician Services Account within an Emergency Medical Services Fund shall not be subject to Chapter 2.5 (commencing with Section 1797.98a) of Division 2.5 of the Health and Safety Code.

(Added by Stats. 1991, Ch. 1169, Sec. 5.)

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