Amended IN Senate August 17, 2018 Amended IN Senate June 14, 2018 Amended IN Assembly May 25, 2018 Amended IN Assembly April 16, 2018 Amended IN Assembly April 02, 2018 Amended IN Assembly March 21, 2018 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Assembly Bill No. 2674Introduced by Assembly Member Aguiar-CurryFebruary 15, 2018 An act to amend Section 1371.39 of the Health and Safety Code, relating to health care service plans.LEGISLATIVE COUNSEL'S DIGESTAB 2674, as amended, Aguiar-Curry. Health care service plans: disciplinary actions.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law prohibits a health care service plan from engaging in an unfair payment pattern, as defined, and requires the department to adopt regulations that ensure that plans have adopted a dispute resolution mechanism, as specified. This bill would require the department to review complaints of unfair payment patterns on or before July 1, 2019, and at least annually thereafter. The bill would require authorize the department to conduct an audit and or an enforcement action, as specified, if the Director of the Department of Managed Health Care department determines the complaint review indicates a possible unfair payment pattern. Upon a final determination by the department that a health care service plans, or plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the bill would require the director to assess an administrative penalty in, and to require the plan to pay the provider, an amount not less than the amount owed plus interest.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1371.39 of the Health and Safety Code is amended to read:1371.39. (a) Providers may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.(b) Plans may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.(c) Unfair billing pattern means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.(e)If the department makes a final determination that a plans, or a plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.
Amended IN Senate August 17, 2018 Amended IN Senate June 14, 2018 Amended IN Assembly May 25, 2018 Amended IN Assembly April 16, 2018 Amended IN Assembly April 02, 2018 Amended IN Assembly March 21, 2018 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Assembly Bill No. 2674Introduced by Assembly Member Aguiar-CurryFebruary 15, 2018 An act to amend Section 1371.39 of the Health and Safety Code, relating to health care service plans.LEGISLATIVE COUNSEL'S DIGESTAB 2674, as amended, Aguiar-Curry. Health care service plans: disciplinary actions.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law prohibits a health care service plan from engaging in an unfair payment pattern, as defined, and requires the department to adopt regulations that ensure that plans have adopted a dispute resolution mechanism, as specified. This bill would require the department to review complaints of unfair payment patterns on or before July 1, 2019, and at least annually thereafter. The bill would require authorize the department to conduct an audit and or an enforcement action, as specified, if the Director of the Department of Managed Health Care department determines the complaint review indicates a possible unfair payment pattern. Upon a final determination by the department that a health care service plans, or plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the bill would require the director to assess an administrative penalty in, and to require the plan to pay the provider, an amount not less than the amount owed plus interest.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
Amended IN Senate August 17, 2018 Amended IN Senate June 14, 2018 Amended IN Assembly May 25, 2018 Amended IN Assembly April 16, 2018 Amended IN Assembly April 02, 2018 Amended IN Assembly March 21, 2018
Amended IN Senate August 17, 2018
Amended IN Senate June 14, 2018
Amended IN Assembly May 25, 2018
Amended IN Assembly April 16, 2018
Amended IN Assembly April 02, 2018
Amended IN Assembly March 21, 2018
CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION
Assembly Bill No. 2674
Introduced by Assembly Member Aguiar-CurryFebruary 15, 2018
Introduced by Assembly Member Aguiar-Curry
February 15, 2018
An act to amend Section 1371.39 of the Health and Safety Code, relating to health care service plans.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 2674, as amended, Aguiar-Curry. Health care service plans: disciplinary actions.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law prohibits a health care service plan from engaging in an unfair payment pattern, as defined, and requires the department to adopt regulations that ensure that plans have adopted a dispute resolution mechanism, as specified. This bill would require the department to review complaints of unfair payment patterns on or before July 1, 2019, and at least annually thereafter. The bill would require authorize the department to conduct an audit and or an enforcement action, as specified, if the Director of the Department of Managed Health Care department determines the complaint review indicates a possible unfair payment pattern. Upon a final determination by the department that a health care service plans, or plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the bill would require the director to assess an administrative penalty in, and to require the plan to pay the provider, an amount not less than the amount owed plus interest.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law prohibits a health care service plan from engaging in an unfair payment pattern, as defined, and requires the department to adopt regulations that ensure that plans have adopted a dispute resolution mechanism, as specified.
This bill would require the department to review complaints of unfair payment patterns on or before July 1, 2019, and at least annually thereafter. The bill would require authorize the department to conduct an audit and or an enforcement action, as specified, if the Director of the Department of Managed Health Care department determines the complaint review indicates a possible unfair payment pattern. Upon a final determination by the department that a health care service plans, or plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the bill would require the director to assess an administrative penalty in, and to require the plan to pay the provider, an amount not less than the amount owed plus interest.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 1371.39 of the Health and Safety Code is amended to read:1371.39. (a) Providers may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.(b) Plans may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.(c) Unfair billing pattern means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.(e)If the department makes a final determination that a plans, or a plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 1371.39 of the Health and Safety Code is amended to read:1371.39. (a) Providers may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.(b) Plans may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.(c) Unfair billing pattern means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.(e)If the department makes a final determination that a plans, or a plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.
SECTION 1. Section 1371.39 of the Health and Safety Code is amended to read:
### SECTION 1.
1371.39. (a) Providers may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.(b) Plans may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.(c) Unfair billing pattern means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.(e)If the department makes a final determination that a plans, or a plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.
1371.39. (a) Providers may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.(b) Plans may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.(c) Unfair billing pattern means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.(e)If the department makes a final determination that a plans, or a plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.
1371.39. (a) Providers may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.(b) Plans may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.(c) Unfair billing pattern means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.(e)If the department makes a final determination that a plans, or a plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.
1371.39. (a) Providers may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the provider believes a plan is engaging in an unfair payment pattern.
(b) Plans may report to the departments Office of Plan and Provider Relations department through the toll-free provider line (877-525-1295), e-mail address (plans-providers@dmhc.ca.gov), line, email address, or another method designated by the department, instances in which the plan believes a provider is engaging in an unfair billing pattern.
(c) Unfair billing pattern means engaging in a demonstrable and unjust pattern of unbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.
(d) On or before July 1, 2019, and at least annually thereafter, the department shall review complaints filed pursuant to subdivision (a). If the director determines the review of complaint data indicates a possible unfair payment pattern, the department shall may conduct an audit and or an enforcement action pursuant to subdivision (s) of Section 1300.71 of Title 28 of the California Code of Regulations.
(e)If the department makes a final determination that a plans, or a plans capitated providers, practice, policy, or procedure constitutes a demonstrable and unjust payment pattern or unfair payment pattern, the director shall do both of the following for each case used to substantiate a determination that a health care service plan has underpaid or failed to pay a provider in violation of this chapter:
(1)Assess an administrative penalty in an amount not less than the amount owed plus interest.
(2)Require the plan to pay the provider an amount not less than the amount owed plus interest.
(f)Subdivision (e) shall not apply to claims subject to Section 1371.30.