Health care service plans: vision care services: provider claims: fraud.

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, and makes a willful violation of the act a crime. Existing law requires a health care service plan doing business in this state to establish an antifraud plan to organize and implement an antifraud strategy to identify and reduce costs, and to protect consumers through the timely detection, investigation, and prosecution of suspected fraud. Existing law specifies required elements of an antifraud plan and requires a health care service plan to annually submit a written report to the department director describing the plan's efforts to deter, detect, and investigate fraud, and to report cases of fraud to a law enforcement agency. Existing law requires a health care service plan to reimburse a claim or portion of a claim no later than 30 working days after receipt of the claim, unless the plan contests or denies the claim, in which case the plan is required to notify the claimant within 30 working days that the claim is contested or denied. Existing law extends these timelines to 45 working days for a health maintenance organization. Existing law provides for the accrual of interest after these 30- and 45-day periods. Existing law requires a health care service plan or health maintenance organization to comply with additional timelines when a claim is reasonably contested. This bill would specify that a specialized health care service plan that undertakes solely to arrange for the provision of vision care services may use a statistically reliable method, as specified, to investigate suspected fraud and to recover overpayments made as a result of fraud, under designated circumstances. The bill would require the specialized health care service plan's statistically reliable method, and how the plan intends to utilize that method to determine recovery of overpayments made as a result of fraud, to be submitted to, and approved by, the department as elements of the specialized health care service plan's antifraud plan. The bill would specify procedures and timelines for a provider to contest a specialized health care service plan's notice of suspected fraud or to request a hearing, and the circumstances under which a specialized health care service plan may offset the amount the specialized health care service plan disclosed as overpaid to the provider in an uncontested notice of suspected fraud against a provider's current claim submissions. Because a violation of these provisions by a specialized health care service plan would be a crime, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.