(a)
(1)The administrative director shall promptly suspend, pursuant to subdivision (b), any physician, practitioner, or provider from participating in the workers’ compensation system as a physician, practitioner, or provider if the individual or entity meets any of the following criteria:
(A)The individual or entity has been convicted of any felony or misdemeanor and that crime comes within any of the following descriptions:
(i)It involves fraud or abuse of the federal Medicare or Medicaid programs, the Medi-Cal program, or the workers’ compensation system, or fraud or abuse of any patient.
(ii)It relates to
the conduct of the individual’s medical practice as it pertains to patient care.
(iii)It is a financial crime that relates to the federal Medicare or Medicaid programs, the
Free access — add to your briefcase to read the full text and ask questions with AI
(a)
(1)
The administrative director shall promptly suspend, pursuant to subdivision (b), any physician, practitioner, or provider from participating in the workers’ compensation system as a physician, practitioner, or provider if the individual or entity meets any of the following criteria:
(A)
The individual or entity has been convicted of any felony or misdemeanor and that crime comes within any of the following descriptions:
(i)
It involves fraud or abuse of the federal Medicare or Medicaid programs, the Medi-Cal program, or the workers’ compensation system, or fraud or abuse of any patient.
(ii)
It relates to
the conduct of the individual’s medical practice as it pertains to patient care.
(iii)
It is a financial crime that relates to the federal Medicare or Medicaid programs, the Medi-Cal program, or the workers’ compensation system.
(iv)
It is otherwise substantially related to the qualifications, functions, or duties of a provider of services.
(B)
The individual or entity has been suspended, due to fraud or abuse, from the federal Medicare or Medicaid programs or the Medi-Cal program.
(C)
The individual’s license, certificate, or approval to provide health care has been surrendered or revoked.
(D)
The entity is controlled by an individual who has been convicted of a felony or misdemeanor
described in subparagraph (A).
(E)
The changes made to clauses (i) and (iii) of subparagraph (A) and subparagraph (B) during the 2017–18 Regular Session of the Legislature do not constitute a change in, but are declaratory of, the existing law.
(2)
The administrative director shall exercise due diligence to identify physicians, practitioners, or providers who have been suspended pursuant to subparagraph (B) of paragraph (1) by accessing the quarterly updates to the list of suspended and ineligible providers maintained by the State Department of Health Care Services for the Medi-Cal program at https://files.medi-cal.ca.gov/pubsdoco/SandILanding.asp.
(3)
For purposes of this section and Section 4615, an entity is controlled by an individual if the individual is an officer or a director of the entity, or a shareholder
with a 10 percent or greater interest in the entity.
(4)
For purposes of this section and Section 4615, an individual or entity is considered to have been convicted of a crime if any of the following applies:
(A)
A judgment of conviction has been entered by a federal, state, or local court, regardless of whether there is an appeal pending or whether the judgment of conviction or other record relating to criminal conduct has been expunged.
(B)
There has been a verdict or finding of guilt by a federal, state, or local court.
(C)
A plea of guilty has been accepted by a federal, state, or local court.
(5)
Notwithstanding the initiation or completion of a prior suspension pursuant to this
section, the administrative director may amend an existing notice of suspension or commence a subsequent suspension proceeding based upon new or additional grounds for suspending the physician, practitioner, or provider pursuant to paragraph (1).
(6)
The administrative director may adopt regulations specifying any exemptions that shall not serve as the basis for exclusion under paragraph (1).
(b)
(1)
The administrative director shall adopt regulations for suspending a physician, practitioner, or provider from participating in the workers’ compensation system, subject to the notice and hearing requirements in paragraph (2).
(2)
The administrative director shall furnish to the physician, practitioner, or provider written notice of the right to a hearing regarding the suspension and the procedure
to follow to request a hearing. The notice shall state that the administrative director is required to suspend the physician, practitioner, or provider pursuant to subdivision (a) after 30 days from the date the notice is mailed unless the physician, practitioner, or provider requests a hearing and, in that hearing, the physician, practitioner, or provider provides proof that paragraph (1) of subdivision (a) is not applicable. The physician, practitioner, or provider may request a hearing within 10 days from the date the notice is sent by the administrative director. The request for the hearing shall stay the suspension. The hearing shall be held within 30 days of the receipt of the request. Upon the completion of the hearing, if the administrative director finds that paragraph (1) of subdivision (a) is applicable, the administrative director shall immediately suspend the physician, practitioner, or provider.
(3)
The administrative director
shall have power and jurisdiction to do all things necessary or convenient to conduct the hearings provided for in paragraph (2). The hearings and investigations may be conducted by any designated hearing officer appointed by the administrative director. Any authorized person conducting that hearing or investigation may administer oaths, subpoena and require the attendance of witnesses and the production of books or papers, and cause the depositions of witnesses residing within or without the state to be taken in the manner prescribed by law for like depositions in civil cases in the superior court of this state under Title 4 (commencing with Section 2016.010) of Part 4 of the Code of Civil Procedure.
(c)
The administrative director shall promptly notify the physician’s, practitioner’s, or provider’s state licensing, certifying, or registering authority of a suspension imposed pursuant to this section and shall update the division’s qualified
medical evaluator and medical provider network databases, as appropriate.
(d)
Upon suspension of a physician, practitioner, or provider pursuant to this section, the administrative director shall give notice of the suspension to the chief judge of the division, and the chief judge or his or her designee shall promptly thereafter provide written notification of the suspension to district offices and all workers’ compensation judges. The method of notification to all district offices and to all workers’ compensation judges shall be in a manner determined by the chief judge in his or her discretion. The administrative director shall also post notification of the suspension on the department’s Internet Web site.
(e)
The following procedures apply for the adjudication of any liens of a physician, practitioner, or provider suspended pursuant to subparagraph (A) or (D) of paragraph (1)
of subdivision (a), including any liens filed by or on behalf of the physician, practitioner, or provider or any entity controlled by the suspended physician, practitioner, or provider:
(1)
If the disposition of the criminal proceeding provides for or requires, whether by plea agreement or by judgment, dismissal of liens and forfeiture of sums claimed therein, as specified in the criminal disposition, all of those liens shall be deemed dismissed with prejudice by operation of law as of the effective date of the final disposition in the criminal proceeding, and orders notifying of those dismissals shall be entered by workers’ compensation judges.
(2)
All liens that have not been dismissed in accordance with paragraph (1) and remain pending in any workers’ compensation case in any district office within the state shall be consolidated and adjudicated in a special lien proceeding as
described in subdivisions (f) to (i), inclusive.
(f)
After notice of suspension, pursuant to subdivision (d), and if subdivision (e) applies, the administrative director shall appoint a special lien proceeding attorney, who shall be an attorney employed by the division or by the department. The special lien proceeding attorney shall, based on the information that is available, identify liens subject to disposition pursuant to subdivision (e), and workers’ compensation cases in which those liens are pending, and shall notify the chief judge regarding those liens. Based on this information, the chief judge or his or her designee shall identify a district office for a consolidated special lien proceeding to adjudicate those liens, and shall appoint a workers’ compensation judge to preside over that proceeding.
(g)
It shall be a presumption affecting the burden of proof that all liens
to be adjudicated in the special lien proceeding, and all underlying bills for service and claims for compensation asserted therein, arise from the conduct subjecting the physician, practitioner, or provider to suspension, and that payment is not due and should not be made on those liens because they arise from, or are connected to, criminal, fraudulent, or abusive conduct or activity. A lien claimant shall not have the right to payment unless he or she rebuts that presumption by a preponderance of the evidence.
(h)
The special lien proceedings shall be governed by the same laws, regulations, and procedures that govern all other matters before the appeals board. The administrative director may adopt regulations for the implementation of this section.
(i)
If it is determined in a special lien proceeding that a lien does not arise from the conduct subjecting a physician,
practitioner, or provider to suspension, the workers’ compensation judge shall have the discretion to adjudicate the lien or transfer the lien back to the district office having venue over the case in which the lien was filed.
(j)
At any time following suspension, a physician, practitioner, or provider lien claimant may elect to withdraw or to dismiss his or her lien with prejudice, which shall constitute a final disposition of the claim for compensation asserted therein.
(k)
The provisions of this section do not affect, amend, alter, or in any way apply to the provisions of Section 139.2.