(a) The department may limit, for 18 months or less, the American Medical Association’s Current Procedural Terminology Fourth Edition (CPT-4) codes, the National Drug Codes (NDC), the Healthcare Common Procedure Coding System (HCPCS) codes, or codes established under Title II of the Health Insurance Portability & Accountability Act of 1996 (42 U.S.C. Sec. 1320d et seq.) for which any provider may bill, or for which reimbursement to any person or entity may be made by, the Medi-Cal program or other health care programs administered by the department if either of the following conditions exist:
(1) The department determines, by audit or other investigation, that excessive services or billings, or abuse, has occurred, which may include the department’s discovery or determination that a claim was submitted for reimbursement under the Medi-Cal program for a nerve conduction test, electromyography, or procedures, tests, examinations, or other medical services that the department has specified requires a certain residency or board certification, but the records did not contain, or the person or entity submitting the claim for reimbursement did not have, the certificate or diploma required by Section 14170.11.
(2) The Medical Board of California or other licensing authority or a court of competent jurisdiction limits a licensee’s practice of medicine or the rendering of health care, and the limitation precludes the licensee from performing services that could otherwise be reimbursed by the Medi-Cal program or other health care programs administered by the department.
(b) The department may impose a limitation pursuant to subdivision (a) for one or more codes or any combination of codes after giving the provider notice of the proposed limitation and, if applicable, the opportunity to appeal pursuant to subdivision (c).
(c) (1) A provider who receives notice of a proposed limitation based on paragraph (1) of subdivision (a) shall have 45 days from the date of notice to appeal the limitation by providing to the department reliable evidence that excessive services or billings, or abuse, did not occur.
(2) The department shall review the evidence and issue a decision within 45 days of receipt of the evidence.
(d) If a limitation is imposed pursuant to paragraph (1) of subdivision (a), it shall take effect on the 46th day after notice of the proposed limitation was given or, if the limitation is timely appealed, 15 days after the department gives the provider notice of its decision to impose the limitation. If a limitation is imposed pursuant to paragraph (2) of subdivision (a), it shall take effect 15 days after notice of the proposed limitation was given.
(e) If the department’s limitation could interfere with the provider’s or other prescriber’s ability to provide health care services to a beneficiary, the burden to transfer a patient’s care to another qualified person shall remain the responsibility of the licensee.
(f) For purposes of this section, the following definitions apply:
(1) “Abuse” has the same meaning as defined in Section 14043.1.
(2) “Administered by the department” means administered by the department or its agents or contractors.
(3) “Excessive services or billings” means an amount that is substantially in excess of what the department reasonably expects from the provider, based on data regarding the provider or other providers in the health care community who provide substantially similar services to a substantially similar patient population, that is available to the department from any source, including the department.
(4) “Licensee” means a person licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.
(5) “Other prescriber” means that person who is not the primary or attending physician for a patient who is a beneficiary of the Medi-Cal program or other health care program administered by the department, and that person causes the department, or its agents or contractors, to provide reimbursement for a drug, device, medical service, or supply to the beneficiary.
(6) “Provider” has the same meaning as defined in Section 14043.1.
(Amended by Stats. 2004, Ch. 228, Sec. 10.7. Effective August 16, 2004.)
Last modified: October 25, 2018