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HomeMy WebLinkAboutsb12-guidelines-summarized-for-providers-11162017 ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY Public Health Department – Administrative Services MADDY EMERGENCY MEDICAL SERVICES FUND (SB 12) PHYSICIAN REIMBURSEMENT GUIDLEINES FOR UNCOMPENSATED EMERGENCY MEDICAL SERVICES Revised November 16, 2017 Authority: California Health and Safety Code Chapter 2.5 – Emergency Medical Services Fund Added by SB 12 (CH 1240) 1987 Amended by SB 612 (CH 945) 1988; SB 2098 (CH 1171) 1990; SB 946 (CH 1169) 1991. Amended by SB 1683 (CH 1143) 1994 Amended by SB 623 (CH 679) 1999 Amended by SB 941 (CH 671) 2005 Source of Fund: Penalty Assessments made for this purpose as provided in Section 1465 of the Penal Code. Fund Disbursement: Fund shall be utilized to reimburse physicians and surgeons and hospitals for patients who do not make payment for emergency medical services and for other emergency medical services purposes as determined by the County. Maddy Emergency Medical Services (SB12) is a funded program. The SB12 Program is not an insurance company and does not insure patients nor guarantees payment to providers. Disbursement from the SB12 fund is governed by existing legislation and is allocated as follows: 58% - Physician Reimbursements 25% - Hospital(s) providing disproportionate trauma and emergency medical care 17% - County discretionary emergency medical services (A)Fifty-eight percent of the balance of the fund shall be distributed to physicians and surgeons for emergency services provided by all physicians and surgeons, except those physicians and surgeons employed by county hospitals, in general acute care hospitals that provide basic, comprehensive, or standby emergency services pursuant to paragraph (3) or (5) of subdivision (f) of Section 1797.98e up to the time the patient is stabilized. (B)Twenty-five percent of the fund shall be distributed only to hospitals providing disproportionate trauma and emergency medical care services. (C)Seventeen percent of the fund shall be distributed for other emergency medical services purposes as determined by each county, including, but not limited to, the funding of regional poison control centers. Funding may be used for purchasing equipment and for capital projects only to the extent that these expenditures support the provision of emergency services and are consistent with the intent of this chapter. 10% of each portion of the fund is allocated for administrative costs. Administration of Fund: The Alameda County Public Health Department Administrative Services Division will administer the SB 12 Fund. • Process claims monthly. • Use the CPT procedural terminology reference for payment of claims. • Reconcile and maintain monthly fund balance. • Determine fund amount available for physician reimbursement – monthly. • Prepare and submit required reports as required by legislation. • Establish equitable mechanism for resolving disputes relating to claims reimbursements. • Provide enrollment information to physicians interested in participating in the program. • Screen claims for Medi-Cal eligibility. • Maintain roster of program participants. • Publish program guidelines. • Establish mechanism for appropriate medical review of claims. Reimbursement Guidelines Payment of claims under the SB 12 Program is limited to the availability of funds in the SB 12 fund. Valid claims submitted to the Public Health Department with appropriate medical documentation will be reviewed by our consulting physician before processing payment to you. In addition, we will be reviewing your past and present claims per our guidelines and may adjust claims accordingly. All payments from the fund shall be limited to claims for care rendered by physicians or surgeons to patients who are initially medically screened, evaluated, treated, or stabilized in a:basic or comprehensive emergency department of a licensed general acute care hospital in Alameda County; Claims are not accepted for services performed outside of Alameda County. Payments shall be made only for emergency medical services provided on the calendar day on which emergency medical services are first provided and the following two calendar days. If it is necessary to transfer a patient to a second facility that provides for a higher level of care for the treatment of the emergency conditions, reimbursement shall be available for services provided on the calendar day of transfer and on the immediately following two calendar days. Reimbursement for losses incurred by any physician or surgeon shall be limited to services provided to a patient who does not have health insurance coverage for emergency services and care, 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, and where all the following conditions have been met: 1. The physician/surgeon has inquired if there is a responsible third party source of payment. 2. The physician/surgeon has billed the responsible third party, if any, or patient for payment of services. 3. Either of the following: • The physician/surgeon has received actual notification from the patient or responsible third party that no payment will be made for the services rendered by the physician and surgeon. • A period of not less than three months has passed from the date the physician/surgeon billed the patient or responsible third party, during which time the physician/surgeon made reasonable efforts to obtain reimbursement and has not received reimbursement for any portion of the amount billed. 4. The physician/surgeon has stopped any current, and waives any future, collection efforts to obtain reimbursement from the patient, upon receipt of moneys from the fund. Claims are to be submitted on an HCFA-1500 claim form (copies are not accepted) with medical documentation. If no documentation supporting the services provided is included, your claim will not be processed. The Public Health Department has the ability to process claims electronically for some providers with large volumes of claims. The guidelines and procedure for electronic claiming can be found elsewhere in documents entitled “EDI TRADING PARTNER GUIDELINES” and “EDI COMPANION GUIDE,” which may be available online or from the SB 12 Manager in the Public Health Department. Each physician or surgeon shall submit regular certifications of compliance with the Alameda County Public Health Department established claiming process upon request by the SB12 Program. The SB12 Physician Certification for Reimbursement of Uncompensated Emergency Medical Services will be sent to providers on a biannual basis, or as determined by the SB12 Program. Paper claims shall be sent to: Alameda County Public Health Department, Administrative Services Division SB 12 Program – Claims Processing, QIC 21953 1000 Broadway, Suite 500 Oakland, CA 94607 Time limit for submission of valid claims shall be eighteen 18 months following the date of service. If you wish to resubmit claims that were denied, you must provide the original claim number and preferably a copy of the entire claim along with a copy of the EOB if possible. You must note “RESUBMISSION” and reference the original claim number. You have 60 days from receipt of the original remittance advice/EOB to resubmit a claim. Maximum reimbursement shall be 50% of the Medicare Limiting Charge fee schedule utilizing current procedural terminology (CPT) for procedure codes. Reimbursement to Fund If, after payment from the SB12 fund, the patient or responsible party reimburses a physician, then the physician shall reimburse the Fund in an amount equal to the amount collected from the patient or responsible payer but not more than the amount of reimbursement previously received from the Fund. Failure to do so is grounds for termination from the SB12 Program. Please make every effort to bill insurance during the three month waiting period after the service date before submitting claims to the SB12 Program. If you are required to refund the SB12 Program for subsequent collection from the patient, please make your check payable to the “County of Alameda.” If you are frequently refunding the County of Alameda, you need to be more rigorous in your initial collection efforts during the three month waiting period prior to submitting claims to the program. However, per our guidelines, if you do subsequently collect from patients, you must refund our program. We reserve the right to audit claims at any time. Records/Audit Adjustments Physician/surgeon shall keep and maintain records sufficient to fully and accurately reflect the services and costs related to the claim. Such records shall include, but are not limited to: Patient name and address Other patient identifying information, as needed Services provided Date(s) of service(s) and charges Proof of billing and collection efforts as necessary Physician shall retain all records for a minimum of three years following the date the service was provided. Such records shall be made available to representatives of the Public Health Department or to authorized representatives of the State, upon request, during normal working hours during such three-year period for the purpose of inspection, audit and copying. If County or State representatives conduct an audit of physician or hospital records related to services for which a claim was made and paid and find that: Records do not support the emergency medical nature for all or part of the services provided, No records exist to evidence the provision of all or a portion of the services, Physician failed to report or remit payments from other sources as required, Physician shall remit to the fund the difference between the claim amount paid by the Fund and the amount of the adjusted billing as determined by the audit. Physicians found to submit requests for reimbursement that are inaccurate or unsupported by records may be excluded from submitting future requests for reimbursement and subject to legal recourse.