County of Ventura - Health Care Agency
EMSF/CHIP UNCOMPENSATED CARE PROGRAM

EMSF/CHIP POLICIES AND PROCEDURES

SECTION I: INTRODUCTION

Pursuant to provisions of the State of California Welfare and Institutions Code ("WIC") sections16950, et seq., and Health and Safety Code ("HSC"), sections 1797.98a, et seq., an Uncompensated Care Program ("UCP") has been established by the County of Ventura ("County") to provide reimbursement to private physicians ("Physicians") for certain professional services that have been rendered in Ventura County to eligible indigents patients. Professional physician services herein referred to are limited to emergency services as defined in WIC, section 16953; obstetric services as defined in WIC, section 16905.5; and pediatric services as defined in WIC, section 16907.5.

Professional physician services which can be reimbursed under this claiming process are restricted by applicable provisions of law (including, but not limited to WIC sections 16950 et seq. and HSC sections 1797.98a et seq.) and are additionally restricted as prescribed by the County, in these "Policies and Procedures". The applicable legal provisions are subject to amendment or revision from time to time. The County also has discretion to amend or revise these "Policies and Procedures" from time to time as deemed necessary or appropriate. In the event of any inconsistency between these "Policies and Procedures" and any applicable provision of law, the later shall prevail.

This document defines the procedures which must be followed by Physician in seeking reimbursement under this Program. Reimbursement is permitted only for covered services and only to the extent that monies are made available therefor. Submission of a request or claim for the reimbursement constitutes an agreement by Physician to abide by the terms and conditions in these "Policies and Procedures" and makes applicable all provisions of law relating to the specific program under which the request or claim is submitted.

This claiming process may not be used by a Physician if he or she is an employee of the hospital. Further, this claiming process may not be used by a physician if his/her services are included in whole or in part in hospital or physician services claimed by a hospital or by Physician under a separate formal contract with County. Nor may this claiming process be used if Physician has previously billed County for the emergency, obstetrics, or pediatric services under any other claiming process established by County.

SECTION II: PHYSICIAN ELIGIBILITY

A. Physicians who provide emergency services to eligible patients in a basic or comprehensive emergency department of a licensed general acute care hospital in Ventura County may submit claims hereunder if all of the following conditions are met:

1. Emergency services are provided in person, on site, and in an eligible service setting.
2. Emergency services are provided on the calendar day on which emergency services are first provided, and on the immediately following two calendar days, not to exceed a 48-hour period of continuous service.

Physician employees of the hospital are not, however, eligible for reimbursement under this claiming process.

B. As to CHIP Funds, there are additional limitations as per Welfare and Institutions Code, Section 16950(b).

C. An emergency physician and surgeon or an emergency physician group with a gross billings arrangement with a hospital located in Ventura County shall be entitled to receive reimbursement for services provided in that hospital, if all of the following conditions are met:

1. The services are provided in a basic or comprehensive general acute care hospital emergency department.
2. The physician and surgeon is not an employee of the hospital.
3. All provisions of section III of these Policies and Procedures 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.
4. Reimbursement 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.

For the purposes of this section, a "gross billings arrangement" is 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 a percentage of the emergency physician and surgeon's or group's billings for all patients.

D. In no event may this claiming process be used by a Physician if his/her services are included in whole or in part in hospital or physician services claimed by a hospital or by Physician under a separate formal contract with the County of Ventura. Nor may this claiming process be used if physician has previously billed the County for his/her emergency, obstetric or pediatric services under any other claiming process established by the County.

SECTION III: PATIENT ELIGIBILITY/BILLING EFFORTS

A. Reimbursement under this claiming process shall be limited to services for which the physician, following reasonable billing efforts (as discussed herein below), has not received any payment from a patient, a responsible relative, a third party payer, or any other source.

B. Only patients who cannot afford to pay for services rendered 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, including Medi-Cal and Medicare, are covered by this claiming process.

C. During the time prior to submission of the bill to the Fund, Physician must have made reasonable efforts to obtain reimbursement and not received payment for any portion of the amount billed. For purposes of this claiming process, reimbursement for unpaid physician billings shall be limited to the following:

1. patients for whom Physician has conducted reasonable inquiry to determine if there is a responsible private or public third-party source of payment ; and
2. patients for whom Physician has billed all possible payment sources, but has not received reimbursement for any portion of the amount billed; and
3. either of the following has occurred:

   (a) A period of not less than three (3) months has passed from the date Physician billed the patient or responsible third party, during which time Physician has made reasonable efforts to obtain reimbursement and has not received payment for any portion of the amount billed.

   (b) Physician has received actual notification from the patient or responsible third party that no payment will be made for the services.

D. Upon receipt of payment from the Fund under this claiming process, Physician must cease any current, and waive any future, collection efforts to obtain reimbursement from the patient or responsible third party. During the period after a claim has been submitted and prior to receipt of payment, the Physician can continue attempts to collect from a patient. However, once the Physician receives payment from the Fund, further collection efforts shall cease.

E. If, after payment from the Fund, a physician is reimbursed by a patient or a responsible party, the physician shall reimburse the Fund in an amount equal to the amount of reimbursement received from the Fund for the patient's care or an amount equal to the reimbursement received from the patient or responsible party, whichever is less. Refunds are to be made to the Ventura County Health Care Agency, Attn Fiscal - EMSF/CHIP Refund, 2323 Knoll Dr, Ventura, CA 93003.

SECTION IV: BILLING AND PAYMENT PROCEDURES AND POLICIES

A. Claims must be submitted no earlier than 3 months, nor later than 120 days, from the date (1) the Physician billed the patient or responsible third party, during which time the Physician made reasonable billing efforts as specified in Section III above, or (2) the Physician received actual notification that no payment will be made. The 120 day limitation will not apply to claims related to services provided during the period July 1, 2000 through June 30, 2001 due to the transitional stage of the program.

B. Billings shall be submitted on HFC1500 (1-84) claim forms. Each form must be legible and accurately completed, to be considered. Physicians shall submit with the claim form (1) a fully executed Acknowledgment Form certifying that the physician has complied with the required claiming process set forth above in Sections I, II, & III and (2) Patient Data Requirement Form.

C. Claims and executed acknowledgement forms and Patient Data Requirement forms shall be submitted to the County's contracted Claims Adjudicator - American Insurance Administrators (AIA):

AIA/Ventura County EMSF/CHIP Claims
P.O. Box 641635
Los Angeles, CA 90064-1635.

D. Payment will be made as follows:

1. Effective July 1, 2000, Maximum reimbursement will be up to 50% of the allowable charges based on RBRVS Unit Values and 200% of Medicare Allowable conversion rates; not to exceed billed amounts.
2. The full amount of the maximum allowable fee reimbursement will be paid if there are sufficient funds available to pay for all claims submitted during that quarter. If the fund is not sufficient to pay all claims, the percentage of payment will be determined at the end of each fiscal quarter based on funding levels and eligible claims received during that quarter.
3. Checks will be issued quarterly.
4. AIA will, on a monthly basis, review claims received for Medi-Cal Eligibility. If Medi-Cal coverage is determined effective for the date of service, the claim will be rejected and returned to submitting physician with information for submission to Medi-Cal.
5. Electronic Billing: As an option, the County's Claims Adjudicator AIA can receive claims electronically. The record layout necessary for electronic submission shall be obtained directly from AIA at (310) 390-7900, Extension 301.

A. Revised claims previously rejected for incomplete information must be received by the contracted Claims Adjudicator (AIA) within 20 calendar days from the date of the rejection letter.

B. The Physician must submit an appeal of any denied claim within thirty (30) calendar days from the date of the denied Remittance Advice. A denied claim can be appealed once. Request for appeal may be submitted to the Physician Reimbursement Advisory Committee, a committee of physicians selected by the Ventura County Medical Association. Appeals shall include the CHIP Data Collection Form, HCFA 1500 Claim Form, and if applicable operative reports and other supporting documents as needed. Appeals shall be mailed to:

American Insurance Administrators (AIA)
Ventura EMSF/CHIP
Attn: Appeals Unit
P.O. Box 641635
Los Angeles, CA 90064

SECTION VI: PHYSICIANS REFUNDS

A. If, after payment from the Fund, a physician is reimbursed by a patient or a responsible party, the physician shall reimburse the Fund in an amount equal to the amount of reimbursement received from the Fund for the patient's care or an amount equal to the reimbursement received from the patient or responsible party, whichever is less. Refunds are to be made to the Ventura County Health Care Agency, Attn Fiscal - EMSF/CHIP Refund, 2323 Knoll Dr, Ventura, CA 93003.

SECTION VII: INFORMATION CONTACTS

A. For Claims Status call: AIA Physician Hotline 800/303-5242

B. For Program/Policy Issues call: Ventura County Medical Association, EMSF Education Director 805/484-6822

Section VIII: COUNTY LIABILITY/PAYMENT/SUBROGATION

A. Payment of any claim under this claiming process is expressly contingent upon the availability of monies allocated therefor by the State and by the County of Ventura Board of Supervisors. To the extent such monies are available for expenditure under the Physician Services for Indigents Program, and until such available monies are exhausted, valid claims may be paid. Valid claims will be paid in the order of receipt; that is, if a complete and correct claim is received by County, it will have priority over claims subsequently received.

B. After the Fund pays Physician for services billed hereunder, it is understood that County is subrogated to all rights which the Physician may have against the patient and any third-party payer, and that the County may pursue any such source to recover its expenditures hereunder, using all appropriate means. The Physician shall cooperate with the County in these collection efforts.

Section IX: GENERAL OBLIGATION OF PHYSICIANS SUBMITTING CLAIMS

In addition to any Physician duties specified previously herein, Physicians using this claiming process are obligated as follows:

A. Records/Audit Adjustment:

1. Physician shall immediately prepare, and thereafter maintain, complete and accurate records sufficient to fully and accurately reflect the services provided, the costs thereof, all collection attempts from the patient and third-party payers, and revenue collected, if any, for which claim has been made under this claiming process.
2. All such records shall be retained by Physician at a location in Ventura County for a minimum of three (3) years following the last date the Physician provided services to the patient.
3. Such records shall be made available during normal working hours to representatives of the County and/or State, upon request, at all reasonable times during such three year period for the purposes of inspection, audit, and copying. Photocopying capability must be made available to County representatives during an on-site audit.
4. County may periodically conduct an audit of the Physician's records. Audits shall be performed in accordance with generally accepted auditing standards. The audit may be conducted on a single claim, a group of claims, or a statistically random sample of claims from the adjudicated universe for a fiscal year. The scope of the audit shall include an examination of patient medical and financial records, patient/insurance billing records, and collections agency reports associated with the sampled claims.
5. Audited claims that do not comply with program requirements shall result in a refund to the County. If the audit was conducted on a statistically random sample of claims, the dollar amount disallowed shall become a percentage of the total paid on the sample, referred to as the exception rate. The audit exception rate found in the sampled claims reflects, from a statistical standpoint, the overall exception rate potentially possible within the universe of adjudicated claims for that fiscal year. This exception rate shall be applied to the total universe of paid claims which will determine the final reimbursement due to the County.
6. If an audit of Physician or hospital records conducted by County and/or State representatives relating to the services for which claim was made and paid hereunder finds that (1) the records are incomplete or do not support the medical necessity for all or a portion of the services provided, or (2) no records exist to evidence the provision of all or a portion of the claimed services, or (3) Physician failed either to report or remit payments received from patients or third parties as required herein, or (4) the patient was ineligible for services hereunder
7. County also reserves the right to exclude Physician from reimbursement of future claims for any failure to satisfy conditions of this claiming process.

B. Indemnification/Insurance:

1. By utilizing this claiming process, the Physician certifies that the services rendered by him/her, and for which claim is made, are covered under a program of professional liability insurance with a combined single-limits of not less than one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) aggregate.
2. By utilizing this claiming process, the Physician further certifies that his/her workers' compensation coverage is in an amount and form to meet all applicable requirements of the California Labor Code and that it specially covers all persons providing services on behalf of the Physician and all risks to such persons.