Bill Text: CA AB613 | 2009-2010 | Regular Session | Amended
Bill Title: Medi-Cal: treatment authorization requests.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Introduced - Dead) 2010-02-02 - From committee: Filed with the Chief Clerk pursuant to Joint Rule 56. [AB613 Detail]
Download: California-2009-AB613-Amended.html
BILL NUMBER: AB 613 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MAY 5, 2009
AMENDED IN ASSEMBLY APRIL 14, 2009
INTRODUCED BY Assembly Member Beall
FEBRUARY 25, 2009
An act to amend Sections 14133.01 and 14133.9 of the Welfare and
Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 613, as amended, Beall. Medi-Cal: treatment authorization
requests.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, and
pursuant to which, health care services are provided to qualified
low-income persons.
Under existing law, one of the utilization controls to which
services are subject under the Medi-Cal program is the treatment
authorization request (TAR) process, which is approval by a
department consultant of a specified service in advance of the
rendering of that service based upon a determination of medical
necessity. Existing law requires the department to pursue means to
improve and streamline the TAR process.
This bill would require the department, in pursuing means to
improve and streamline the TAR process, to do so in specified ways,
including performing a cost-benefit analysis for each procedure
requiring a TAR and reducing the number of TARs required.
Existing law specifies the number of days within which certain
TARs are required to be authorized.
This bill would reduce the number of days within which these TARs
shall be authorized.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 14133.01 of the Welfare and Institutions Code
is amended to read:
14133.01. (a) Notwithstanding any other provision of law, the
director or his or her designee may apply prior authorization by
designing a sampling methodology that will result in a generally
acceptable audit standard for approval of a treatment authorization
request (TAR), or a class of TARs. The director or his or her
designee shall determine the applicable sampling methodology based
upon health care industry standards and discussions with applicable
Medi-Cal providers or their representatives. This sampling
methodology shall be implemented by no later than July 1, 2005, and
an outline of it shall be provided to the fiscal and policy
committees of both houses of the Legislature. It is the intent of the
Legislature for the department to review the sampling methodology on
an ongoing basis and update it as applicable on a periodic basis in
order to keep abreast of health care industry trends and the need to
manage an efficient and effective Medi-Cal program.
(b) The department shall pursue additional means to improve and
streamline the treatment authorization request process including,
where applicable, those identified by independent analyses such as
the July 2003 report by the California Healthcare Foundation entitled
Medi-Cal Treatment Authorizations and Claims Processing: Improving
Efficiency and Access to Care, and those identified by Medi-Cal
providers. It is the intent of the Legislature that any
identified improvements be cost-beneficial to the state and to the
Medi-Cal program as a whole, including, but not limited to, only
requiring TARs for services with documented overutilization
or fraudulent activity so that the number of state staff
needed to process TARs is reduced. The department shall
pursue additional means to improve and streamline the treatment
authorization request process in all of the following ways:
(1) Perform a cost-benefit analysis for each procedure requiring a
TAR and reduce the number of TARs required so that a TAR shall only
be required for services with documented overutilization or
a high level of fraudulent activity.
(2) Develop alternative approaches for fraud and abuse detection,
through targeted analysis of utilization baselines for each drug or
service, that identify potential anomalies.
(3) Develop an alternative to the requirement that a patient
obtain a TAR for each individual day of his or her stay in the
hospital and consider adopting a single TAR for the entire length of
a patient's hospital stay.
(4) Make publicly available the rules and criteria for determining
medical necessity.
(5) Work with licensed health care providers that are affected by
the TAR process in developing processes to improve efficiency and
access to care through a more streamlined and relevant TAR process.
(c) 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, interpret, or make specific, this section
by means of all-county letters, provider bulletins, or similar
instructions. Thereafter, the department may adopt regulations in
accordance with the requirements of Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code.
SEC. 2. Section 14133.9 of the Welfare and Institutions Code is
amended to read:
14133.9. The implementation of prior authorization permitted by
subdivision (a) of Section 14133 shall be subject to all of the
following provisions:
(a) The department shall secure a toll-free telephone number for
the use of providers of Medi-Cal services listed in Section 14132.
For providers, the department shall provide access to an individual
knowledgeable in the program to provide Medi-Cal providers with
information regarding available services. Access shall include a
toll-free telephone number that provides reasonable access to that
person. The toll-free telephone number shall be operated 24 hours a
day, seven days a week.
(b) For major categories of treatment subject to prior
authorization, the department shall publicize and continue to develop
its list of objective medical criteria that indicate when
authorization should be granted. Any request meeting these criteria,
as determined by the department, shall be approved, or deferred as
authorized in subdivision (e) by specific medical information.
(c) The objective medical criteria required by subdivision (d)
shall be adopted and published in accordance with the Administrative
Procedure Act, and shall be made available at appropriate cost.
(d) When a proposed treatment meets objective medical criteria,
and is not contraindicated, authorization for the treatment shall be
provided within an average of two working days. When a treatment
authorization request is not subject to objective medical criteria, a
decision on medical necessity shall be made by a professional
medical employee or contractor of the department within an average of
two working days.
(e) Notwithstanding the provisions of subdivisions (c) and (d),
the department shall adopt, by emergency regulations as provided by
this subdivision, a list of elective services that the director
determines may be nonurgent. In determining these services, the
department shall be guided by commonly accepted medical practice
parameters. Authorization for these services may be deferred for a
period of up to 15 days. In making determinations regarding these
referrals, the department may use criteria separate from, or in
addition to, those specified in subdivision (c). These deferrals
shall be determined through the treatment authorization request
process. When a proposed service is on the list of elective services
that the director determines may be considered nonurgent,
authorization for the service shall be granted or deferred within an
average of five working days. The State Department of Health Care
Services may adopt emergency regulations to implement this
subdivision in accordance with the Administrative Procedure Act
(Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code). The initial adoption of emergency
regulations and one readoption of the initial regulations shall be
deemed to be an emergency and necessary for the immediate
preservation of the public peace, health and safety or general
welfare. Initial emergency regulations and the first readoption of
those regulations shall be exempt from review by the Office of
Administrative Law. The emergency regulations authorized by this
subdivision shall be submitted to the Office of Administrative Law
for filing with the Secretary of State and publication in the
California Code of Regulations and shall remain in effect for no more
than 120 days.
(f) The department shall submit to the Legislature, every three
months, its treatment authorization request status report.
(g) Final decisions of the department on denial of requests for
prior authorization for inpatient acute hospital care shall be
reviewable upon request of a provider by a Professional Standards
Review Organization established pursuant to Public Law 92-603, or a
successor organization if either of the following applies:
(1) The original decision on the request was not performed by a
Professional Standards Review Organization, or its successor
organization.
(2) The original decision on the request was performed by a
Professional Standards Review Organization, or its successor
organization, and the original decision was reversed by the
department. The department shall contract with one or more of these
organizations to, among other things, perform the review function
required by this subdivision. The review performed by the contracting
organization shall result in a finding that the department's
decision is either appropriate or unjustified, in accordance with
existing law, regulation, and medical criteria. The cost of each
review shall be borne by the party that does not prevail.
The decision of this body shall be reviewable by civil action.
(h) This section, and any amendments made to Section 14103.6 by
Assembly Bill 2254 of the 1985-86 Regular Legislative Session, shall
not apply to treatment or services provided under contracts awarded
by the department under which the contractor agrees to assume the
risk of utilization or costs of services.
