2009 California Welfare and Institutions Code - Section 16951-16959 :: Article 3.5. Physician Services Account

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.