It's January. That means the start of many new laws, enacted by the Legislature. One of those, SB 941, affects the Emergency Medical Services Fund (EMSF) program, which is implemented by the County of Orange and administered by the Orange County Medical Association. Because some of the changes are significant, EMSF-enrolled physicians and their billing agents should learn about the changes and submit claims accordingly.

The biggest change is the provision prohibiting the use of Maddy funds to pay for claims when the patient has insurance. (Maddy funds represent about 25 percent to 30 percent of EMSF program monies.)

Previously, the program would pay these claims as long as they were submitted with denial letters from the insurer. However, legislators became concerned that insurance companies were purposely denying claims that would qualify for payment with EMSF monies.

While the new provision does not apply to the Tobacco Settlement Revenue (TSR) funds (about 70 percent of EMSF monies), there are questions about whether it is in conflict with Measure H, which covers TSR funding. Orange County Health Care Agency staff members have requested an opinion from county counsel on this matter to determine if the laws are in conflict and how they should be applied.

Unfortunately, that decision was not available at press time.

However, it is clear that many claims previously paid under the EMSF program will no longer be eligible. The bad news is that claims denied by insurance companies will not be paid. However, the good news is that there will be more money available to pay other qualified claims.

In addition, SB 941 will allow, for the first time, a physician or surgeon to be reimbursed for patient care provided by, or in conjunction with, a nurse practitioner or physician's assistant. However, the care must be rendered onsite and under the direct supervision of the doctor. While it is uncertain what impact these additional claims will have on program funding overall, providers have long sought reimbursement for services provided by PAs and nurse practitioners.

The new law also makes changes to Children's Health Insurance Program (CHIP) funds. While CHIP funding has been very limited or nonexistent in recent years, the state did recently agree to send approximately $481,000 in one-time CHIP funds to Orange County for the EMSF program. The primary changes are the same as those described above for Maddy funds. CHIP funds cannot be used to pay claims denied by an insurance carrier, as long as emergency services are covered. Likewise, services by a nurse practitioner and/or a PA are covered.

Finally, the new law requires each county to provide the Legislature an annual report on the status of the EMSF program account, including the account balance, claims paid, and the names of the physicians or hospitals receiving payment. This requirement should be fairly easy for Orange County to meet since that information is currently compiled on an annual basis.

SB 941 allows each county to do the following:

* The county can establish an EMSF Advisory Committee, but it must include emergency physicians and emergency department on-call physicians.

* If the county elects to establish the committee, then this group may, upon a unanimous vote, recommend adoption of a special fee schedule and claims submission process for reimbursement on services to uninsured trauma patients.

* The county may adopt this schedule. This may include authorizing reimbursement beyond the initial day and two calendar days following.

Currently, Orange County has an EMSF committee that meets on a regular basis to handle administrative issues. The committee refines program rules and regulations as necessary to comply with state law; raises or lowers the reimbursement rate as appropriate; contracts for an outside audit; handles physicians' and/or billers' concerns; and conducts educational efforts.

For more information on the EMSF program or to enroll, visit the OCMA home page at www.ocma.org and click on the EMSF button.

Perry Cain is program administrator for the Orange County Emergency Medical Services Fund program. He can be reached at 714/978-1160 or pcain@ocma.org.