The provisions of this chapter are enacted pursuant to the provisions of Health and Safety Code Sections 1797.98a through 1797.98g; Welfare and Institutions Code Sections 16952 and 16956; and California Constitution Article XI, Section 7.
This chapter regulates disbursements of the money in the Maddy EMS Fund pursuant to Health and Safety Code Sections 1797.98a through 1797.98g and Welfare and Institutions Code Section 16951 et seq.
(SCC 0824 § 2, 1991; SCC 1614 § 1, 2017)
The term "Physician Group"
means an organization, including, but not limited to, corporations, partnerships, and joint ventures, comprised of member physicians and surgeons formed for, among other reasons, the purpose of providing patient billing and collection services to its members.
(SCC 0824 § 2, 1991; SCC 1614 § 9, 2017)
The Director, or designee, shall establish policies and procedures in accordance with Health and Safety Code sections 1797.98a through 1797.98g to include:
Definitions: Emergency services, emergency medical condition, medical screening exam and stabilized;
Claiming Procedure: Eligible services, patients, physicians and surgeons;
Claim Submission Guidelines: Payments, reimbursements, appeals, records and right of review.
(SCC 1614 § 7, 2017)
Excess funds, if any, remaining in the Maddy EMS Fund, after maximum disbursement for the relevant period to physicians, surgeons, or hospitals, as allowed by law, shall be carried forward, in the same account, and utilized for reimbursement of future Claims.
(SCC 0824 § 2, 1991; SCC 1614 § 17, 2017)
In making a Claim, the claimant certifies that they have not discriminated in the provision of services for which claim is made because of race, color, religion, national origin, ancestry, sex, age, or condition of physical or mental handicap, in accordance with all applicable requirements of Federal and State law.
(SCC 0824 § 2, 1991; SCC 1614 § 25, 2017)
In determining the validity and qualification for payment of Claims filed under this chapter, the Director may rely upon and presume to be true, correct and appropriate any and all factual representations and legal conclusions certified in Claims, and shall have no duty to independently audit the records of claimants, investigate or make other inquiry concerning the factual representations or legal conclusions unless an appeal is filed placing in issue the truthfulness, accuracy or validity of the facts or legal results certified. The types of factual representations and legal conclusions to which the provisions of this section apply include, but are not limited to, the following: (i) that if the claimant is an individual, he (she) is a physician or surgeon licensed to practice under the laws of this State; (ii) that if the claimant is an individual, he (she) delivered the services indicated, to the patients named, on the dates indicated, billed for the services and failed to receive payment in the manner specified; (iii) that the types of services identified in Claims are the types for which reimbursement is authorized this chapter; (iv) that if the claimant is an individual, he (she) is not an employee of a County hospital; (v) that if the Claim is for obstetric or pediatric services, the services were not performed at a clinic which receives cigarette and tobacco surtax funds; and (vi) that if the claimant is a hospital, the physician or physicians and surgeons to which the Claim relates are not employees of this hospital.
(SCC 0824 § 2, 1991; SCC 1614 § 26, 2017)
The physician, surgeon, Physician Group or hospital seeking reimbursement from the Maddy EMS Fund bears the burden of proof in establishing the validity of their Claim.
(SCC 0824 § 2, 1991; SCC 1614 § 27, 2017)
The County or its authorized representative shall have the right of access to and audit of all the claimants' records, including original documents, that pertain to the Claim submitted. If the claimant is a Physician Group or hospital claiming on behalf of a physician, surgeon, or emergency physicians group it shall be the duty of the hospital to provide access to the records of the physicians, surgeons, and, if any, the physician emergency group, that pertain to the Claim. This section is permissive and does not impose an affirmative duty upon the County to conduct an audit of any Claim.
(SCC 0824 § 2, 1991; SCC 1614 § 29, 2017)
The sole remedy of a party who has exhausted their administrative appeals as established in the policy and procedures, shall be a petition for writ of mandate directing payment filed in a court of competent jurisdiction. Notwithstanding any other provision in this chapter to the contrary, any payment ordered by a court of competent jurisdiction pursuant to such a mandate proceeding shall be made solely from the balance of revenues, if any, within the Maddy EMS Fund or, whichever Fund or Account the disbursement should have been made from, on hand on the date the judgment becomes final.
The sole remedy of a party who asserts that as a result of pro rata disbursements, that party has received lower disbursements than the party should otherwise be entitled to receive as a result of overpayments to other claimants, shall be the commencement of a mandate proceeding in a court of competent jurisdiction, to restrain, in advance of payment, disbursements to other claimants alleged to be improper.
(SCC 0824 § 2, 1991; SCC 1614 § 35, 2017)
Physicians, physicians and surgeons, and hospital claimants may, to the extent the total volume of Claims exceeds revenues available for disbursement from the Maddy EMS Fund, receive, as a result of payment on false Claims, otherwise, invalid Claims or negligent overpayment error by the Department, lower reimbursements on pro rata distributions than might have otherwise been received. Notwithstanding the foregoing, neither the Maddy EMS Fund, the County, or its officers, employees or agents shall be liable for any such deficiency in reimbursements.
Revenues within the Maddy EMS Fund constitute public funds, the legal, equitable and beneficial title to which is vested solely in the County as a governmental agency. No equitable, beneficial or other interest therein shall be deemed by virtue of this chapter, or otherwise to accrue to actual or potential claimants. Nor shall the provisions of this chapter be deemed to create any relationship of debtor and creditor between the County and any actual or potential claimant, or be deemed to create any expectancy of any kind or nature in actual or potential claimants.
It is hereby declared that the provisions of this chapter relating to administration of the Maddy EMS Fund is and has been enacted for the purpose of protecting such funds from illegal expenditure for the benefit of the public at large, and not for the benefit of actual or potential claimants upon such funds, in particular. No duty of care to actual or potential claimants in connection with administration of the funds is owed by the County, its officers, employees or agents to any actual or potential claimant.
(SCC 0824 § 2, 1991; SCC 1614 § 36, 2017)