september 13, 2005 - board of supervisors agenda itemsep 13, 2005 · medical services (ems) fund...

THE BOARD OF SUPERVISORS OF THE COUNTY OF STANISLAUS ACTION AGEN

DEPT: BOARD AGENDA # *B-2

AGENDA DATE September 13 , 2005

CEO Concurs with Recommendation YES 415 Vote Required YES NO

SUBJECT:

Approval of the Standard Agreement for the State's Emergency Medical Services Appropriation for Fiscal Year 2005-2006 for Stanislaus County and Approval of the Agreement with the Stanislaus Foundation for Medical Care to Process the Emergency Services Physicians' Claims

STAFF RECOMMENDATIONS:

1. Approve the Standard Agreement for the State's Emergency Medical Services Appropriation for Fiscal Year 2005-2006 for Stanislaus County.

2. Approve the Agreement with the Stanislaus Foundation for Medical Care to process the emergency services physicians' claims.

3. Authorize the Health Services Agency Managing Director, or her designee, to sign the Standard Agreement. (Continued on Page 2)

FISCAL IMPACT:

The Agreement for the State's Emergency Medical Services Appropriation (EMSA) for Stanislaus County is $285,588 for Fiscal Year 2005-2006. From this amount, $21,420 will be paid to the Stanislaus Foundation for Medical Care to process claims from providers for emergency services. This funding and the claims processing expense were included in the Agency's Proposed Budget for Fiscal Year 2005-2006 (Indigent Health Care Program CHIP legal budget units 1426 and 1427).

................................................................................................................... BOARD ACTION AS FOLLOWS: NO. 2005-705

On motion of Supervisor ----- Sim_o_n - - - - - - - - - - - - - - - - - - - - _ n , Seconded by Supervisor ---Mayfield ----------------- and approved by the following vote, Ayes: Su pervisors:-O;B~i_e_n~ -M_ayf i_e!dLSimmQn,-D_e_M_artin_iZ and Gba_irma_n_ -Gr_o_v_ec - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Noes: Supervisors:_N_o_ng .................................................................................... Excused or Absent: Supervisors: N Q O ~ ....................................................................... - Abstaining: Supervisor:None ................................................................................. I) X Approved as recommended 2) Denied 3) Approved as amended 4) Other: MOTION:

TALLMAN, Clerk File No.


STAFF RECOMMENDATIONS (CONTINUED):

4. Authorize the Health Services Agency Managing Director, or her designee, to sign the Agreement with the Stanislaus Foundation for Medical Care.

DISCUSSION:

In September 2000, the State of California approved SB2132, referred to as the "Emergency Medical Services Appropriation (EMSA)", to fund the reimbursement of uncompensated physician provided emergency medical services. For example, a qualifying claim for payment from these funds would be to an emergency room physician who provided services to an uninsured patient who failed to pay the physician's bill. Payment to providers is limited to 50% of the claimed amount. This funding is for physician services only and does not allow for compensation to hospitals.

The Emergency Medical Services Appropriation is administered by the Health Services Agency Indigent Health Care Program (IHCP). IHCP will retain approximately 2.5% of the appropriation, which equals the cost of the administrative burden. An additional $21,420, or 7.5% of the appropriation, is to be paid to the Stanislaus Foundation for Medical Care to receive and process claims in accordance with the EMSA regulations and to issue payment to providers for services rendered during Fiscal Year 2005-2006. Due to the lag time associated with claims receipt and in accordance with the statute, the term of the proposed agreement with the Stanislaus Foundation for Medical Care is from July 1, 2005 through March 31, 2007.

In order to receive this funding, staff is requesting the Board approve an agreement authorizing Stanislaus County to participate in this program. Two original standard agreements are required, each bearing an original signature by the Board or the Board's designee. Additionally, staff is requesting the Board approve the agreement with the Stanislaus Foundation for Medical Care to provide claims processing and payment services to distribute the appropriation.

Stanislaus County has participated in this program since September 2000 and has entered an agreement each year with the Stanislaus Foundation for Medical Care to process and pay claims. Total revenues received to date for EMSA are $1,427,953. This amount includes $285,591 for Fiscal Year 2000-2001, $285,589 for Fiscal Year 2001-2002, $285,591 for Fiscal Year 2002-2003, $285,592 for Fiscal Year 2003-2004, and $285,590 for Fiscal Year 2004-2005.


POLICY ISSUES:

Approval of the Standard Agreement for EMSA funds supports the Board of Supervisors' priorities for a healthy community and effective partnerships.

STAFFING IMPACT:

There is no staffing impact associated with the approval of this agreement.

The State of California, by and through the California Department of Health Services (hereinafter called the "Department"), and the County of Stanislaus (hereinafter called the "County"), do hereby agree as follows:

This Standard Agreement is entered into pursuant to the provisions set forth in Chapter 80, Statutes of 2005 (Assembly Bill 131). As a condition of receiving EMSA monies, the County agrees to all of the following:

I. Expenditure Requirements

A. Use the Hospital Services Account (HSA), Physician Services Account (PSA) and Unallocated Account (UA) monies only for reimbursement of uncompensated emergency services as defined in Welfare and Institutions (W&l) Code, Section 16953.

B. Transfer HSA, PSA, and UA monies to the PSA in the County's Emergency Medical Services (EMS) fund to reimburse physicians for uncompensated emergency services per W&l Code, Sections 16951 and 16952.

C. Reimburse physicians for emergency services rendered during FY 2005-06.

11. Reporting Requirements

A. Submit one progress report and one final report of expenditures and physicians data in accordance with the instructions provided by the Department. In addition, -- counties that submit a Report of Actual Financial Data (Actual) must report the:? ;:; EMSA monies as an expenditure and revenue in the Actual, and report indigent" i.:; . .. data in their Medically Indigent Care Reporting System (MICRS). ~ ..

.. .~. . ~. ,. ~. ~. . ,

:i; .. B. Maintain financial records of the expenditures and physicians data for at least - I<

.,~: , , three years after the end of FY 2005-06. These records will be subject to - r ~ i j possible review and audit by the State. .~ .. .

7.3 . -. . . .;, Ill. General Requirements "" i

-3 J J

A. These monies are only for emergency services to patients who cannot afford to pay for those services and for whom payment will not be made through any

ORIGINAL EMSA Standard Agreement - FY 2005-06 County of

private coverage or by any program funded in whole or in part by the Federal Government. No physician shall be reimbursed more than 50 percent of losses.

B. The monies shall not be used to reimburse physicians employed by county hospitals and physicians who provide services in a primary care clinic that receives funds from the Tobacco Tax and Health Protection Act of 1988.

C. The monies shall be paid only to physicians who directly provide emergency medical services to patients, based on claims submitted or a subsequent reconciliation of claims. Payments shall be made as provided in Sections 16951 to 16959, inclusive, of the W&l Code, and payments shall be made on an equitable basis, without preference to any particular physician or group of physicians.

IV. EMSA Contract Back Program (Rural Health Services Counties only)

RHS counties may ask the Department to administer their EMSA HSA andlor PSAJUA.

V. Administrative Cost

Cost of administering HSA and PSAJUA funds shall not exceed ten (10) percent of the total EMSA monies in each account.

VI. Recoupment

EMSA monies shall be returned to the Department if they are not encumbered or expended within the fiscal year according to this Standard Agreement and the requirements of Chapter 5 (commencing with Sections 16930 and 16940) of Part 4.7 of Division 9 of the W&l Code. (W&l Code, Sections 16930 and 16940.)

THIS AGREEMENT FOR FUNDING HAS BEEN APPROVED BY THE BOARD OF SUPERVISORS AND IS HEREBY EXECUTED.

County Signatur

Name: Greaorv ~ d n k l i n , M.H.A. N ~ ~ ~ : 'Margaret Szczepaniak

(Please print or type.) Title: Deputy Director, Health Information and Managing Director

Strategic Plannina Division Title: ~ - l l th S o n r i r o c A o o n r x r

Date: /o/& A&' Date: 5-// -0 y-' Page 2

AB 131 EMERGENCY MEDICAL SERVICES APPROPRIATION STANISLAUS COUNTY CLAIMS PROCESSING SERVICE AGREEMENT

(FOR FISCAL YEAR 2005-06)

This Agreement is made this first day of July 2005, by and between Stanislaus County

("County"), and the Stanislaus Foundation for Medical Care ("Foundation") a nonprofit

corporation organized under the laws of the State of California.

A. RECITALS

1. WHEREAS, Assembly Bill (AB) 13 1 (Chapter 80, Statutes of 2005) provides

that County shall establish two Emergency Medical Services Funds, as authorized by Sections

1695 1 and 16952 of the W&I; (1) A Hospital Services Account Emergency Medical Services

Appropriation and (2) A Physicians Services Account Emergency Medical Services Appropriation.

2. WHEREAS, the County desires to enter into an agreement with Foundation

for the purpose of obtaining the claim processing services necessary to reimburse physicians who are

eligible for payment fiom the Hospital Services Account Emergency Medical Services Appropriation

and Physicians Services Account Emergency Medical Services Appropriation Funds, hereinafter

referred to as "AB 131 Emergency Medical Services Appropriation" pursuant to W&I Sections

1695 1 and 16952.

3. WHEREAS, Foundation desires to provide claim processing services with

respect to the physician's portion of the AB 13 1 Emergency Medical Services Appropriation in

accordance with W&I Sections 16950, 1695 1, and 16952 et seq., and pursuant to the terms and

conditions of this agreement;

4. NOW, THEREFORE, in consideration of the mutual promises stated herein

and with the intent of being legally bound hereby, it is agreed by and between the parties hereto as

follows:

B. TERMS OF AGREEMENT

1. Claims Processing Services AB 13 1 Emergency Medical Services

Appropriation. Foundation shall provide claims processing services in accordance with this

agreement and Exhibit "A" attached hereto, including Attachment A-1 to said exhibit, for claims

submitted by physicians for reimbursement from the AB 131 Emergency Medical Services

Appropriation for services rendered during the period commencing July I, 2005 and ending June 30,

2006. The Foundation shall provide trained claims and clerical staff, professional peer reviews to

assist in the determination of when a patient is stabilized, and periodic random claims file audits.

The services required herein, shall be performed in a manner consistent with sound and efficient

business practices.

2. compensation Services AB 13 1 Emergency Medical Services Appropriation.

In exchange for the services provided pursuant to this contract, County shall pay to Foundation

seven and one-half percent (7 112%) of the AB 13 1 Emergency Medical Services Appropriation

received by the County. (For Fiscal Year 2005-06, said AB 13 1 Emergency Medical Services

Appropriation consists of funds in the amount of $285,588) County shall transfer the sum of

$21,420 as and for the compensation called for in this Agreement, by way of a payment to

Foundation in said amount upon execution of this Agreement. Foundation shall set aside said

funds to be used solely for the purpose of administrative compensation during the term of this

Agreement.

3. AE3 13 1 Emergency Medical Services Appropriation Fund Transfer from

Countv to Foundation. Transfer of funds from the AB 131 Emergency Medical Services

Appropriation for the purpose of paying approved physicians' claims shall be accomplished by

Foundation providing to the Auditor of the County of Stanislaus a check register to which is

attached a cover sheet setting forth the Al3 13 1 Emergency Medical Services Appropriation Tmst

Fund Reporting Requirements as set forth fully on Attachment "A-2" to Exhibit "A" of this

Agreement. The Auditor of Stanislaus County will then transfer the appropriate amount of the Al3

13 1 Emergency Medical Services Appropriation into a separate account established by Foundation

fi-om which checks shall be made payable to physicians who claims have been approved pursuant to

the terms of this Agreement.

4. Term of Agreement. This agreement shall commence on July 1,2005, and

shall remain in effect until March 3 1, 2007 unless terminated earlier by either party as provided

herein or extended upon agreement by the parties hereto.

A. Either party shall have the right to terminate this Agreement without

cause at any time by mailing to the other party a notice of intent to terminate the Agreement ninety

(90) days in advance of the desired date of termination.

B. County shall have the right to terminate this Agreement for cause and

without notice in the event that Foundation materially breaches this Agreement.

C . Foundation shall have the right to terminate this Agreement for cause

and without notice in the event that the County materially breaches this Agreement.

D. In the event of termination of this Agreement by either party, whether

with or without cause, Foundation, at the option of County, shall continue to provide claims

processing services for a period of ninety (90) days after the date of termination. Foundation shall

be entitled to administrative compensation during said period, if and to the extent period extends

beyond March 31, 2007. Should termination occur prior to March 31, 2007, Foundation shall

refund the prorated balance of the administrative fees to County within thirty (30) calendar days of

the effective date of termination. The amount that Foundation shall refund shall be determined by

dividing the total administrative fees paid in advance by the 2 1 -month period of the Agreement, then

multiplying the number of months remaining from the date of termination to March 3 1,2007. This

would work as follows:

m e r e X = dollars paid in advance by County to Foundation and Y = number of months remaining from the effective date of termination to 3/31/07. then Xx Y = $2

21 $2 = the amount Foundation shall refund to County

4.1. Indemnity and Insurance. Foundation shall defend, indemnify and save

harmless the County, its officers, employees, agents, and representatives from any all liability,

losses, damages, costs or expenses, including attorneys' fees, arising out of any and every claim,

demand, lawsuit, or cause of action asserted against the County which results from or arises in

connections with any negligent, wronghl act or omission of Foundation or the Foundation's

officers or employees in connection with the performance of this agreement.

4.2 County shall defend, indemnify and save harmless Foundation, its officers

and employees, from any and all liability, losses, damages, costs or expenses, including attorneys'

fee, arising out of any and every claim, demand, lawsuit, or cause of action asserted against the

Foundation which results from or arises in connection with any negligent, wrongful act or omission

of the County or the County's officers or employees in connection with the performance of this

Agreement.

4.3. Foundation shall maintain throughout the term of this Agreement policies of

insurance listed below. It is understood that any insurance required herein shall be primary to any

other insurance carried by the County. A copy of each certificate of insurance or bond shall be made

available for inspection by the County upon request.

A. Workers' Compensation Insurance for all employees of the

Foundation in accordance with statutory requirements.

B. Employer's Liability Insurance with minimum limits of $1,000,000.

C. Comprehensive Personal Injury Liability Insurance with minimum

limits of $1,000,000.

D. Comprehensive Property Damage Liability Insurance with minimum

limits of $1,000,000.

E. Blanket Insurance Fidelity Bond and Forgery coverage with minimum

limits of $500,000.

5 . Assinnment. This Agreement may not be assigned by either party without the

prior written consent of the other party. Neither party may subcontract or otherwise delegate its

duties under this Agreement without the prior written consent of the other party.

6 . Relationship of Parties. The provisions of this Agreement do not create, nor

shall they be construed to create, any relationship between the County and the Foundation other

than that of independent contractor. Neither of the parties hereto, or any of their respective

representatives, shall be construed to be the agent, employee, employer or representative of the other.

7. Confidentialitv. Except for reporting and auditing requirements contained in

this Agreement, all medical records shall be treated as confidential so as to comply with all state and

federal laws regarding the confidentiality of patient records.

8. Access to Information. Foundation agrees to provide County with access

upon demand and at reasonable times to the books, records and papers of the Foundation relating to

Foundation's performance of this Agreement or any physicians' claims submitted for reimbursement

from the AB 13 1 Emergency Medical Services Appropriation.

9. Financial Report AB 13 1 Emerpencv - Medical Services Appropriation. On

March 31, 2007, the Foundation shall report to the County on the implementation and

status of the physicians' portion of the AB 131 Emergency Medical Services Appropriation.

The report shall include all of the following for each account:

A. The amount of monies disbursed under the program to physicians;

B. The total dollar amount of all allowable claims submitted, and the total

dollar amount paid on all allowable claims.

C. The number of claims received by Foundation; and the number of

claims paid.

D. An account of the expenditures for compensation to Foundation; and

E. A statement of the policies, procedures and regulatory action taken to

implement the Agreement.

10. Waiver. No waiver of any of the provisions of this Agreement shall be

deemed to constitute a continuing waiver thereof unless otherwise expressly provided in writing.

1 1. Notice. Any notice required to be given pursuant to the terms and provisions

hereof shall be in writing and sent by first class mail, postage prepaid to the County

in care of:

With copies to: Stanislaus County Health Services Agency IHCP Administrator Attention: Managing Director Health Services Agency P.O. Box 3271 P.O. Box 3007 Modesto, CA 95353 Modesto, CA 95353-3007

Stanislaus County County Counsel 1010 1 0 ~ street Modesto, CA 95354

and to the Foundation in care of

Joanne Chipponeri, Chief Executive Officer P.O. Box 576007 Modesto, CA 95357-6007

12. Amendments. This Agreement may be amended at any time by mutual written

agreement of the parties.

13. Entire Aweement. This Agreement contains all the terms and conditions

agreed upon by the parties hereto, and supersedes all other agreements, oral and otherwise, between

the parties regarding the subject matter of this agreement.

14. Applicable Law. This contract shall be governed and construed in accordance

with the Senate Bill No. 2132 (Chapter 826, Statutes of 2000), Assembly Bill No. 430 (Chapter 171,

Statutes of 2001), Assembly Bill No. 442 (Chapter 1 161, Statutes of 2002), Assembly Bill No. 1762

(Chapter 230, Statutes of 2003), Senate Bill No. 29 (Chapter 4, Statutes of2005), and Assembly Bill

No. 13 1 (Chapter 80, Statutes of 2005 - regarding Emergency Medical Services Fund) as in their

current form or as they may be amended hereinafter.

15. Governing Law. The validity, enforceability and interpretation of any of the

clauses of this Agreement shall be determined and governed by the laws of the State of California.

IN WITNESS WHEREOF, the parties hereto have made and executed this Agreement

as of the day and year first written above.

COUNTY CONTRACTOR NAME

APPROVED AS TO CONTENT: Stanislaus County Health Services Agency By:

By: Joanne Chipponeri Date Chief Executive Officer

Margaret Szczepaniak Date Managing Director

APPROVED AS TO FORM: Michael H. Krausnick County Counsel

~ . L i q -1 - 2 ~ 5 By: %eq

Dean Wright Date Deputy County Counsel

Board Order # Dated

EXHIBIT "A"

AB 131 EMERGENCY MEDICAL SERVICES APPROPRIATION

CLAIM REIMBURSEMENT PROCEDURES

The purpose of Assembly Bill 13 1 (Chapter 80, Statutes of 2005) is to reimburse

physicians for uncompensated emergency services, as defined in W&I Section 16953, as provided in

W&I Section 16951 and 16952, referred to hereinafter as "reimbursable medical services", will be

made according to the following policies and procedures:

1. Payments can be made to reimburse emergency physicians only for losses

incurred in providing reimbursable medical services due to 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.

2. Reimbursement for losses shall be limited to emergency services as defined in

W&I Section 16953. Said services are referred to herein as "reimbursable medical services."

3. Emergency medical services must have been provided by the physician, on an

inpatient or outpatient basis, in a general acute care hospital in Stanislaus Countywhich has a license

to provide basic or comprehensive emergency medical services, and which is not a County hospital.

4. A physician who is an independent contractor, who is providing emergency

medical coverage for a basic or comprehensive general acute hospital emergency department, and

who is not compensated for nonpaying patients by the hospital as part of the physician's contractual

agreement shall not be disqualified from seeking reimbursement from the AB 131 Emergency

Medical Services Appropriation for the sole reason that the hospital provides billing and collection

services and makes payments to the emergency physician based on a percentage of the physician's

gross billings. Any claim submitted by the hospital on behalf of a physician shall contain the

following:

A. A statement that the physician is an independent contractor who

routinely provides emergency medical coverage for the hospital emergency department;

B. That the physician is not compensated for nonpaying patients by the

hospital as part of the physician's contractual agreement with the hospital;

C. The amount that the hospital would have paid the physician for the

care by the physician, if the services had been compensated, (i.e. not the amount charged to the

patient).

1. If the physician is paid a percentage of the physician's gross

billings, the claim for the physician's services shall be reduced to reflect same percentage paid to the

physician pursuant to the physician's contractual agreement with the hospital.

ii. The claim shall not include hospital or emergency charges for

overhead or supplies, billing or collection service charges, or administrative costs or charges

imposed by the hospital or other third party.

5 . The time limits for submitting a claim are as follows:

A. Only reimbursable emergency medical services provided on or after

July 1,2005 and prior to July 1,2006, will be eligible under this program.

B. Pursuant to W&I Section 16955, claims must be submitted within six

(6) months after the end of the fiscal year in which the services was provided in order to be eligible

for reimbursement under the program and pursuant to this Agreement. (This will allow for

compliance with the provisions of item 9., C. (1) of this exhibit regarding the three (3) month waiting

period for billings.) All the conditions set forth in W&I Section 16955, as amended must be

complied with in addition to any other requirements set forth herein. That is, for example, for any

services rendered within fiscal year 2005-2006, from July 1,2005, through June 30,2006, a claim

must be submitted not later than December 3 1,2006.

6. The following services will be reimbursable:

A. Emergency services as defined in W&I Section 16953, which provides

as follows:

(a) For purposes of this chapter "emergency services" means

physicians services in general acute care hospitals which provide basic or comprehensive emergency

services for emergency medical conditions.

(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 reasonable be expected to

result in any of the following: (1) placing the patient's health in serious jeopardy; (2) serious

impairment to bodily functions; or (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.

7. To be reimbursed physicians shall submit their losses incurred due to patients

who do not make any payment for services and for whom no responsible third party makes any

payment subject to the terms and conditions provided for herein and pursuant to applicable laws.

No physician shall be reimbursed for more than fifty percent (50%) of the losses submitted for

payment.

8. Pursuant to W&I Section 16955, reimbursement for losses incurred due to

patients for whom no payment is received shall be limited to services provided to an eligible patient

as defined in subdivision (f) 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 (3) 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; or

(2) The physician has received actual notification from the patient

13

or responsible third-party that no payment will be made for the services rendered by the physician;

and

D. The physician has stopped any current, and waives any future,

collection efforts to obtain reimbursement from the patient, upon receipt of funds from; Hospital

Services Account Emergency Medical Appropriation and Physicians' Services Account Emergency

Medical Services Appropriation Fund Accounts.

This article shall not be applied or interpreted so as to prevent a physician from

seeking payment fi-om a patient or responsible third-party payor, or arranging a repayment schedule

for the cost of services rendered prior to receiving payment under this article pursuant to Section

16955.1 of the W&I.

9. All claims shall be submitted to the Foundation, Post Office Box 567007,

Modesto, CA 95357-6007. All claims shall include the name of the patient, the date, time, place and

description of the services performed, and the cost of the services rendered by the physician. The

names shall be given full confidentiality protection by the Foundation, except for reporting and

audit requirements. Claims shall be submitted on HCFA-1500 (1-84) claim forms. Each form must

be complete, legible and accurate. The physician shall submit with the claim form a fully executed

acknowledgement form certifying that the physician has complied with the required claim process.

10. Pursuant to W&I Section 1691 8, as amended by AB 1 154, (Chapter 5 1,

Statutes of 1990), one hundred percent (100%) of claims submitted by each provider shall be

accompanied by a form which meets the data requirements set forth under the MICRS Data

Requirements attached hereto as Attachment. "A-1" to this Exhibit "A". (See standardized form as

Attachment "A-3" for use by providers especially for disposition of Emergency Room visits.)

11. The Foundation may, as necessary, request records and documentation to

support the amounts of reimbursement requested by physicians and the Foundation may review and

audit such records for accuracy. Reimbursements requested and reimbursements made that are not

supported by records may be denied. Physicians found to submit requests for reimbursements that

are inaccurate or unsupported by records may be excluded from submitting future requests for

reimbursement.

12. Payment of any claim submitted by the physician is expressly contingent upon

the availability of monies in the; Hospital Services Account Emergency Medical Appropriation and

Physicians' Services Account Emergency Medical Services Appropriation Fund Accounts. To the

extent such monies are available, claims approved by the Foundation will be paid.

13. Payment will be determined as follows:

A. No physician shall be reimbursed for more than fifty percent (50%) of

the losses submitted to the Foundation as the administering agency pursuant to W&I Section 16952

at subdivision (h).

B. The total amount for the claim will be adjusted in accordance with the

Foundation's conversion factors. The maximum allowable reimbursement will be fifty (50%) of the

adjusted claim.

C. The full amount of the adjusted claim will be paid if there are

sufficient funds available. Claims will be paid on a "first come, first serve" basis.

14. Pursuant to W&I Section 16958, as amended by Chapter 5 1, Statutes of 1990,

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 Foundation and the Foundation shall reduce the

physician's future payment of claims fiom 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 fiom the patient or third-party payor; but not more than

the amount of the reimbursement received from the account; or

(b) NotifL the Foundation 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.

15. Any physician refbnds shall be collected by the Foundation and appropriately

credited on the next invoice to the County.

16. Pursuant to W&I Section 16957, any physician who submits any claim in

accordance with the provisions of this Agreement shall keep and maintain records of services

rendered, the person to whom services were rendered, and any additional information required

pursuant to the terms of applicable law, this Agreement, this Exhibit, and any Attachments hereto,

and as they may be amended from time to time. Said records shall be maintained for a period of not

less than three (3) years after the services were provided. Additionally, such records shall include

proof of billing efforts required by claiming process set forth herein.

17. Each physician who receives payment from the Hospital Services Account

Emergency Medical Appropriation and Physicians' Services Account Emergency Medical Services

Appropriation Fund Accounts shall keep and maintain records of the services rendered, the person to

whom rendered, the dates of service, and charges. Additionally such records shall include proof of

all billing efforts required by this claiming process. All such records shall be maintained at a

location in Stanislaus County for a period of three years from the date the service was provided.

18. Physician's records shall be made available to representatives of the

Foundations, or authorized representatives of the County, upon request, at all reasonable times

within such three year period for the purpose of inspection, audit and copying.

19. If the Foundation, County or State conducts an audit ofphysician or hospital

records relating to the services for which a claim was made and paid hereunder, and finds that (1) the

records do not support the reimbursable medical services of all or a portion of the services provided,

or (2) no record exists to evidence the provision of all or a portion of the service, or (3) the physician

failed either to report or remit payments from other sources as required herein, the physician shall,

upon receipt of a billing from the County therefore, remit such amount forthwith to the County

which shall place said funds, in any, into the Hospital Services Account Emergency Medical

Appropriation and Physicians' Services Account Emergency Medical Services Appropriation Fund

Accounts. The total billed shall be paid forthwith, and in no event later than sixty (60) days after the

date of the billing and shall include interest at the rate of ten percent (10%) on the principal amount

of the billing plus an additional six percent (6%) penalty on said principal amount.

ATTACHMENT "A-1"

MICRS Data Requirements

for AB 131 Emergency Medical Services Appropriation Funds

PATIENT DEMOGRAPHIC DATA:

-Patient Name

-Birth date

-Sex

-Ethnicity

-Zip Code or patient residence

CLAIMS DATA

-Specific physician who provided service

-Physician Specialty

-Facility where services performed

-Type of Service (IP, OP, ER)

-Service Setting (IP, ER, OP, CL, OF, OT)

-Diagnosis

-Procedure Code(s) (RVS or CPT-4)

-Other potential 3rd party liability

-Date of Service

-Amount Billed

-Amount Paid

-County Fund # out of which claim paid

ATTACHMENT "A-2"

AB 131 Emergency Medical Services Appropriation

Trust Fund Reporting Requirements

For the Hospital Services Account Emergency Medical Services Appropriation and

Physicians' Services Account Emergency Medical Services Appropriation Fund Accounts, the data

shall include the following for each County Fund number:

Hospital Services Account Emergency Services (Fund # 1426)

a. The number of claims received.

b. The amount billed.

c. The number of claims paid.

d. The amount paid.

Physicians' Services Account Emergency Medical Services (Fund #1427)

a. The number of claims received.

b. The amount billed.

c. The number of claims paid.

d. The amount paid.

Claims must be separately processed for each of the two accounts using the separate

County fund numbers and reported separately against the fimd numbers in any electronic

submission to the County for Trust Fund Reporting.

. e ATTACHMENT "A-3" MEDICALLY INDIGENT CARE REPORTING SYSTEM (MICRS)

PATIENT DATA SHEET

The following information should be captured at the time of patient registration and must be submitted with your claim.

1. Patient Name

2. Patient residence Zip Code

3. Date of Birth (rnrnlddlyy)

4. Sex tl Male Cl Female

5. Patient's Social Security Number

6. Ethnicity: tl 1 = White tl 2 = Black tl 3 = Hispanic t14 = Native AmericadEskimo/Aleutian Cl 5 = Asiaflacific Islander 0 6 = Other

7. Family Size (Use number 1-99)

8. Family Gross Monthly Income: $

9. Family Principal Income Source: Cl 1 =None C12 = EmployedISelf Employed t13 = Disability C14 = Retirement 0 5 = GeneralPublic Assistance CJ 6 = Other

10. Type of Employment: tl 1 = Professional/Technician t12 = ProductiodLabor tl 3 = SalesIService d 4 = Farming CJ 5 = Unemployed

11. Other Potential Payor * ATTACH COPY OF EOB CJ 1 = Private Insurance * CJ 2 = Medi-Cal * CJ 3 = Medicare * CJ 4 = Other CJ 5 = None

................................................................................. IF THIS IS AN EMERGENCY ROOM VISIT - DISPOSITION OF VISIT

tl 1 = Non Emerg b Release 0 6 = Emerg b Release 0 2 = Non Emerg b HSA Admit CJ 7 = Emerg b HSA Admit 0 3 = Non Emerg b County Hosp Cl8 = Emerg b County Hosp a 4 = Non Emerg F Univ Hosp 0 9 = Emerg Univ Hosp a 5 = Non Emerg b Other Hosp tl 10 = Emerg b Other Hosp

september 13, 2005 - board of supervisors agenda itemsep 13, 2005 · medical services (ems) fund...

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