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CMA - California Medical Association

California Physician's
Legal Handbook

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Everything about health care law. All in one place.

The California Physician’s Legal Handbook is the legal resource for health care law. CPLH offers more than 5,400 pages of comprehensive legal information including current laws, regulations and court decisions that affect health care in California.

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ADA/Discrimination

  • 6075Disability Parking Certification (2013)
  • 6002Disabled Patients: Health Care Services
  • 6001Disabled Physicians and Employees
  • 6006Discrimination: HIV-Infected Patients (ADA) (2017)
  • 6003Language Interpreters
  • 6004Patient Access to Physician Offices/Facilities: Barrier Removal and New Construction
  • 6005Sign Language Interpreters
  • 6000The Americans with Disabilities, Rehabilitation & Genetic Information Nondiscrimination Acts, Affordable Care Act: General Requirements and Defenses
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Adverse Events

  • 3602Medical Error and Adverse Events: Mandatory Systems and Reporting
  • 3601Medical Error and Adverse Events: Transformation Through A Fair and Just Culture
  • 3600Medical Error and Adverse Events: Voluntary Systems and Reporting
  • 3603Vaccines, Drugs, and Devices: Reporting Adverse Events
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Advertising

  • 0100Accessing Patients: Marketing and Other Steps Physicians Can Take
  • 0101Advertising By Allied Health Professionals
  • 0102Advertising by Physicians
  • 0175False & Misleading Advertising: How to Report Fraud (2013)
  • 0103Medical Referral Services
  • 0104Practice Promotion through Third-Party Coupons
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Allied Health Professionals

  • 3000Allied Health Professional Relationships: Business Issues
  • 3001Allied Health Professional Relationships: Liability Issues
  • 3002Alternative and Complementary Health Care Practitioners
  • 3003Medical Assistants
  • 3004Naturopathic Doctors
  • 3005Nurses
  • 3006Optometrists
  • 3009Pharmacists
  • 3007Physician Assistants
  • 3008Speech-Language Pathologists and Audiologists
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Ancillary Services

  • 3700Clinical Trials
  • 3701Cosmetic Procedures
  • 3702Liposuction
  • 3703Physicians Selling Vitamins, Dietary Supplements, and Other Items Not Requiring a Prescription
  • 3704Tissue Banks
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Antitrust

  • 1002Physicians and Unions
  • 1001The Antitrust Laws: Physician Group Mergers
  • 1000The Antitrust Laws: What Physicians Can Do
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Business Prohibitions/Disclosure

  • 0200Corporate Practice of Medicine Bar
  • 0202Corporate Practice of Medicine Bar: Decision-Making Authority for Integrated Entities Criteria
  • 0201Disclosure Requirements-State and Federal
  • 0203Physician Ownership, Employment, and Business Prohibitions
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Clinical Laboratories

  • 5301Clinical Laboratories: Certification, Licensure, and Registration
  • 5300Clinical Laboratories: Disclosure, Payment, Billing, Record Retention, and Storage
  • 5302Clinical Laboratories: Self-Referral and Fee-Splitting Prohibitions
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Consent

  • 3112Cancer Information Requirements
  • 3107Consent by Minors
  • 3111Consent for Blood Transfusions
  • 3116Consent for HIV Test
  • 3113Dimethyl Sulfoxide (DMSO) (2016)
  • 3110Exposed Health Care Workers: Testing Patients' Blood
  • 3106Format for Informed Consent Forms
  • 3102Incompetent Patients: Determining Capacity to Give Consent and Who Consents if the Patient Lacks Capacity
  • 3100Informed Consent
  • 3101Informed Consent Exceptions: Emergencies, SNF Residents Who Lack Decision-Making Capacity, Therapeutic Privilege and Patient Requests Not to Be Informed
  • 3104Informed Consent: Choosing Surrogates
  • 3103Informed Consent: Inpatient Procedures
  • 3105Informed Consent: Long-Term Care Facilities
  • 3109Mental Health 5150 Holds 72-Hour Detention
  • 3108Use of Restraints and Seclusion
  • 3114Vaccine Administration: Mandated Information
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Death/Organ Donation

  • 3400Autopsies
  • 3402Determination and Pronouncement of Death and Death Certificates
  • 3403Diagnosis of Death by Neurologic Criteria: Model Policy and Procedure
  • 3401Organ and Tissue Donations
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Digital Health

  • 0405Electronic Communication with Patients: Patient Portals, E-mail and Online Advice
  • 0401Online Consumer Review and Rating Sites
  • 0402Physician Practice Websites
  • 3301Physician Use of Mobile Devices and Cloud Computing
  • 0403Physicians and the Use of Social Media
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Drug Prescribing/Dispensing

  • 3212California's Prescription Drug Monitoring Program: The Controlled Substance Utilization Review and Evaluation System (CURES)
  • 3200Controlled Substances: Dispensing
  • 3201Controlled Substances: Prescribing
  • 3208Drug Compounding
  • 3203Drug Dispensing (Not Schedule II-V Drugs)
  • 3204Drug Formularies, Prescription Drug Benefit Plans, and Pharmacy Benefit Managers
  • 3205Drug Prescribing (Not Schedule II-V Drugs)
  • 3206Drug Prescribing: Drugs from Other Countries
  • 3202Drug Prescribing: Unauthorized
  • 3207e-Prescribing (2015)
  • 3209Medical Cannabis
  • 3210Pain Management
  • 3211Vaccine Administration
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Drug Testing

  • 6100Employer Obligations Regarding Drug and Alcohol Use in the Workplace
  • 6101Medical Staff Drug and Alcohol Testing Programs
  • 6102Physician Obligations Regarding Drug or Alcohol Testing
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eMedicine

  • 0404Electronic Funds Transfer (EFT)
  • 4300Electronic Health Records
  • 4303Electronic Health Records (EHRs): Selecting the Right EHR System for Your Practice
  • 4301Electronic Health Records: Federal Incentive Programs
  • 0400Electronic Signatures
  • 4304Federal Electronic Health Record (EHR) Incentives: Reassignment of Incentive Payments
  • 4302Meaningful Use of Electronic Health Records (EHRs): 2015-2018 Modifications to State 1 & 2
  • 4305 Meaningful Use of Electronic Health Records (EHRs): Stage 3
  • 3300Telehealth
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Emergency Transfer

  • 5000Emergency Transfer Laws
  • 5001Emergency Transfer Laws Medical Staff and On-Call Requirements
  • 5003Reducing/Restructuring On-Call Coverage Requirements
  • 5002Structuring On-Call Coverage Requirements
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End of Life Issues

  • 3458CMA Model Policy: Responding to Requests for Non-Beneficial Treatment
  • 3450Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST
  • 3451Decisions Regarding Life-Sustaining Treatment- Advance Directives and POLST
  • 3454Decisions Regarding Life-Sustaining Treatment: The Patient Self-Determination Act and Joint Commission Accreditation Standards
  • 3453Decisions Regarding Resuscitative Measures DNR Requests and Orders and Cardiopulmonary Resuscitation
  • 3452Documenting Decisions Regarding Life-Sustaining Treatment and End-of-Life Options
  • 3455Physician-Assisted Suicide/Physician Aid in Dying
  • 3456Responding to Requests for Non-Beneficial Treatment
  • 3459The California End of Life Option Act
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Expert Witness Issues

  • 0500Expert Witness Guidelines
  • 0501Expert Witness Issues
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Fraud and Abuse

  • 1100Advice of Counsel Defense
  • 1101Criminal Convictions - Collateral Consequences
  • 1102Federal Criminal Investigations/ Prosecutions
  • 1103Fraud and Abuse: Overview of Federal and California Law
  • 1104How Physicians Become The Victims
  • 1105Medicare OIG Investigations
  • 1106The Medicare Recovery Audit Contractor Program
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Fraud and Abuse: Referral Issues

  • 1155Federal Antikickback Safe Harbors
  • 1150Gifts and Free Services (Including Promotional Items)
  • 1152Kickbacks and Fee-Splitting: Other Laws Used to Deter Payments for Referrals
  • 1157Physician–Hospital Compensation Arrangements and the Potential for Improper Referrals
  • 1153Professional Courtesy
  • 1151Prohibitions Against Kickbacks and Fee-Splitting
  • 1154Referring Patients: If the Practice Is Not Prohibited Altogether, Is It Safe From Antikickback Prosecution?
  • 1156Self-Referral Prohibitions: California Overview
  • 1162Self-Referral Prohibitions: Federal Exceptions Related to Both Ownership and Investment Interests
  • 1160Self-Referral Prohibitions: Federal Exceptions Related to Electronic Information
  • 1163Self-Referral Prohibitions: Federal Exceptions Related to Managed Care Arrangements
  • 1164Self-Referral Prohibitions: Federal Exceptions Related to Other Compensation Arrangements
  • 1161Self-Referral Prohibitions: Federal Exceptions Related to Rural or Underserved Areas
  • 1158Self-Referral Prohibitions: Federal Overview
  • 1159Self-Referral Prohibitions: Federal Physician and In-Office Ancillary Services, Academic Medical Centers, and Group Practice Exceptions
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Managed Care: Contracting

  • 7050All Products/Affiliates Clauses
  • 7051Contract Termination by Physicians and Continuity of Care Provisions
  • 7054Contract Termination/Exclusion: Legal Challenges (Non-Antitrust)
  • 7055Exclusivity Provisions and Membership Requirements in Contracts, Including Most-Favored-Nation Clauses
  • 7056Failure to Receive Plan Referrals
  • 7057Managed Care Contractual Protections
  • 7052Termination/Exclusion of Physicians: Antitrust Challenges
  • 7053Termination/Exclusion: Action Plan for Physicians
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Managed Care: Overview

  • 7075Adding New Doctors to Panel* (2013)
  • 7000Coverage Requirements and Related Health Insurance Market Reforms
  • 7001Disclosure by Managed Care Plans (and Their Contracting Medical Groups/IPAs)
  • 7010Essential Health Benefits Under the ACA
  • 7002Managed Care Glossary
  • 7008Managed Care: Health Plan Liability
  • 7009Managed Care: Physician Malpractice Liability
  • 7003Office Audits: Managed Care
  • 7004Patient Complaints About Managed Care Plans
  • 7005Physician Complaints About Managed Care Plans
  • 7006Point-of-Service Plans (2017)
  • 7007Retaliation by Managed Care Plans or Others
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Managed Care: Risk Arrangements

  • 7100Capitation, Including Risk Adjustment
  • 7104Pay-for-Performance
  • 7102Risk-Bearing Medical Groups, Including IPAs: Regulation of Solvency
  • 7101State and Federal Laws on Financial Incentive Arrangements
  • 7103Value-Based Purchasing
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Managed Care: Utilization Review & Management

  • 7150Access to Physicians
  • 7151Clinical Guidelines
  • 7152Denials of Necessary Medical Services
  • 7153Disease Management Organizations (2017)
  • 7161Formation and Use of Utilization Profiles
  • 7154Hospital Stay and Discharge Requirements
  • 7155Independent External Medical Review
  • 7156Medical Directors: Utilization Review and the Practice of Medicine
  • 7162Penalties for Failure to Follow Utilization Review Procedures
  • 7157Physician Specific Outcome Reporting
  • 7158Primary Care Physicians & Direct Access to OB/GYNs
  • 7163Provider Directories
  • 7159Second Opinions (2017)
  • 7160Telephone Medical Advice
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Medical Board: Discipline & Licensing

  • 2000Grounds for Medical Board Discipline
  • 2001MBC Enforcement Authority
  • 2003MBC Public Disclosure Program
  • 2002Medical Board Investigations
  • 2004Sexual Relations with Patients: Sexual Misconduct
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Medical Board: Reports

  • 2052Federal NPDB Reporting
  • 2054MBC & NPDB Reports: Self-Query, Disputing and Correcting Information
  • 2051MBC & NPDB: Reporting Disciplinary Actions
  • 2050MBC & NPDB: Reporting Malpractice Payments
  • 2053MBC: Other Reporting Requirements (Not Malpractice or Discipline)
  • 2055Reporting Incompetent, Impaired or Unethical Colleagues
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Medical Practice: Workforce Issues

  • 6205Covering Physicians (Locum Tenens)
  • 6201Employer Poster Requirements
  • 6200Employment Contract Model
  • 6202Ethical Guidelines for Employer and Employee Physicians
  • 6203Family and Medical Leave
  • 6204Independent Contractors
  • 6206New-Hire Reporting Requirement
  • 6210Overview of Select Physician Practice Employment Issues
  • 6207Pre-Employment Inquiries
  • 6208Retirement Notice
  • 6211Wage and Hour Laws
  • 6209Whistleblower Protections for Employees
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Medical Practice: Physician Practice Models

  • 0302ADR in Physician Contracts
  • 0319Applicability of Sales and Use Tax on Physicians
  • 0301CMA Principles and Guidance Regarding ACOs
  • 0307Governance Issues for Physician Organizations
  • 0300Legal and Practical Considerations Concerning Accountable Care Organizations (ACOs)
  • 0305Legal and Practical Considerations Concerning Medical Foundations
  • 0306Medical Foundation: CMA Principles and Guidance
  • 0308Medical Group: How to Form
  • 0309Medical Partnerships and Corporations
  • 0310Medical Practice Options Overview
  • 0312Physician Alignment Models
  • 0314Physician Rights Medical Groups and IPAs
  • 0315Practice Consultant How to Hire
  • 0316Practice Consultant Sample Agreement and RFP
  • 0317Providing and Collecting for Care through Concierge (Boutique) Arrangements or Other Private Retainer Agreements
  • 0318Selling Your Practice to an Integrated Delivery System
  • 0304Specialty IPA: How to Form
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Medical Records: HIPAA

  • 4103Business Associate Agreements
  • 4104HIPAA Electronic Transaction Rule
  • 4100HIPAA Overview & Enforcement
  • 4101HIPAA Privacy Rule
  • 4102HIPAA Security Rule
  • 4105National Provider Identification Numbers
  • 4175Spanish Notice of Privacy Practices (2013)
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Medical Records: Management

  • 4001Accounting of Disclosures
  • 4003Contents of Medical Records
  • 4004Fax Machines and the Medical Office
  • 4176HIPAA Breach Notification Policies and Procedures
  • 4002Medical Records: Allowable Copying Charges
  • 4000Medical Records: Most Commonly Asked Questions
  • 4005Retention of Medical Records
  • 4006Security Breach of Health Information
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Medical Records: Requests for Access

  • 4200Attorney Pre-Litigation Request for Medical Information
  • 4201Employer Access to Medical Records Employment Physicals
  • 4202Health Plan Access to Medical Records
  • 4204Medi-Cal and Medicare Investigators' Access to Medical Records
  • 4205Patient Access to Medical Records
  • 4206QIO Access to Physician Office Charts
  • 4203Requests by Law Enforcement Search Warrants
  • 4207Requests by Other Third Parties: CMIA, IIPPA and the HIPAA Privacy Rule
  • 4208Subpoenas Guide for Responding
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Medical Records: Special Confidentiality Requirements

  • 4253Confidentiality of HIV/AIDS Information
  • 4250Confidentiality of Sensitive Medical Information
  • 4252Disclosure of Immunization Information
  • 6007Goals and Recommendations of State and Federal HIV/AIDS Programs
  • 4251Special Confidentiality Requests
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Medical Staffs

  • 1201Allied Health Practitioners (AHPs) in the Hospital (1994)
  • 5101Disruptive Behavior Involving Members of the Medical Staff
  • 5103Economic Credentialing and Exclusive Contracts
  • 5102Exclusive Contracts
  • 5112HIV-Infected Physicians (2017)
  • 5108Hospital Accreditation Organization Standards Concerning Medical Staff Self-Governance
  • 1219Hospital Medical Staff Incorporation (2009)
  • 5105Legal Counsel for the Medical Staff Consistent or Conflicting Interests
  • 1703Medical Staff Bylaws Analysis Service (2010)
  • 5110Medical Staff Bylaws: A Binding Agreement to Protect Patient Care
  • 5100Medical Staff Membership for Physician Excluded from any Federally Funded Health Care Program (2017)
  • 5107Medical Staff Relationship with Hospital Board (Governing Body)
  • 5106Medical Staff Self-Governance Policy and Law
  • 5177Physician Well-Being Committees: Guidelines
  • 5111Sexual Harassment in the Medical Staff Context
  • 5109Ten Strategies to Protect Quality Through Medical Staff Self-Governance
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Medicare and Medi-Cal

  • 7204Billing Limitations and Private Pay Agreements with Medi-Cal Patients
  • 7203Denials Under Medicare Managed Care
  • 7210MACRA Overview
  • 7201Medi-Cal Audits
  • 7205Medicare Audits
  • 7202Medicare Drug Benefit (Part D) (2017)
  • 7206Medicare Managed Care/Medicare Advantage
  • 7209Medicare Participation (and Non-Participation) Options
  • 7208Medicare Reassignment Rules
  • 7211Providing Care to Medi-Cal Enrollees
  • 7207Reasonable and Necessary Services Under the Medicare Program
  • 7200Resource Guide on Medicare/Medi-Cal
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Miscellaneous Issues

  • 1701Asking for CMA legal assistance*
  • 7076CMA Contract Analysis Service
  • 0602Driving Laws: Emergency Exemptions
  • 0601IMQ Continuing Medical Education-Certification Program for Physicians
  • 2090U.S. Medical Licensing Agencies (2014)
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Office Safety

  • 6301Accidents Investigating and Documenting
  • 6302Aerosol Transmissible Diseases
  • 6303Bloodborne Pathogens
  • 6300Cal-OSHA Compliance and Inspections
  • 6304Ergonomics
  • 6305Hazardous Substances: Communication in the Workplace
  • 6306Hazardous Waste
  • 6307Injury and Illness Prevention Programs
  • 6309Medical Waste
  • 6308Occupational Injury and Illness Records: Log Form 300
  • 6310Sharps and Safety Needles
  • 6311Tuberculosis Transmission
  • 6312Workplace Violence
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Outpatient Facilities

  • 5400Ambulatory Care Accreditation Program
  • 5401Hospital Outpatient 1206(d) Clinics-- Legal Considerations Impacting Physicians
  • 5403Mammography Facilities and X-rays
  • 5402Surgicenters and Other Outpatient Facilities
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Peer Review

  • 5207A Guide to Physician Peer Review Hearings
  • 5200Administrator and Board Access to Peer Review Files
  • 2092Assisting Physicians with Substance Abuse or Mental Health Problems (2014)
  • 5201Board Certification as a Requirement for Medical Staff Privileges
  • 5202Credentialing - Liability Releases, Indemnification
  • 5203Credentialing - Malpractice Claims and History
  • 5204Documentation of Peer Review Activities
  • 5205External Peer Review
  • 5208Ongoing Professional Practice Evaluation
  • 5206Peer Review - Fair Hearing Requirements
  • 5211Peer Review Protections - Executive Summary
  • 5209Privileging Low Volume Practitioners
  • 1422Proctoring (2011)
  • 5212Sharing of Peer Review Information
  • 5213State Agency Requests for Peer Review Information
  • 5214Summary Suspensions
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Physician-Patient Relationship

  • 3500Establishment of the Physician–Patient Relationship
  • 3501Patient Retention/Restrictive Covenants
  • 3502Physician–Patient Communication
  • 3504Promoting Quality of Life for Older Patients
  • 3503Termination of the Physician–Patient Relationship
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Professional Liability

  • 8002Arbitration of Medical Injury Claims
  • 8000Commonly Asked Questions About Professional Liability
  • 8003Countersuits (Malicious Prosecution) (2017)
  • 8005Elder and Dependent Adult Abuse Liability
  • 8006Good Samaritan and Other Immunities
  • 8007Malpractice Insurance Issues
  • 8004Malpractice, Manslaughter or Murder
  • 8011Managing the Risks of an Unanticipated Outcome
  • 8008MICRA Information
  • 8009Punitive Damages (2016)
  • 8010Resolution of Claims with Medicare-Eligible Claimants
  • 8012Sexual Harassment of Patients or Employees
  • 8001What Happens When You're Sued
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Reimbursement: From Patients

  • 7600Billing Patients
  • 7602 Collecting from Deceased Patient's Estate
  • 7601Collecting from Patients/Extending Credit
  • 7603Health Savings Accounts
  • 7604Red Flags Rule (2014)
  • 7605Waiver of Copayment
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Reimbursement: From Private & Public Payors

  • 7500Assignment of Benefits
  • 7504Authorization and Payment for Emergency Services
  • 7501Bankruptcy of IPAs or Health Plans
  • 7502Coordination of Benefits
  • 7503Coordination of Benefits: Payment Below Medicare Allowable
  • 7450Covered California: California's Health Benefits Exchange
  • 7505ERISA Plans
  • 7507Fee Schedules
  • 7514Health Plan Special Claims Review
  • 7509Insolvency of Health Plan, IPA or Other Entities that Contract with Health Plans (Pre-Bankruptcy or
  • 7506Late Payment
  • 7508Non-Contracting Physicians
  • 7510Payment Denial after Treatment Authorization or Verification of Eligibility
  • 7511Payment Denials by Managed Care Plans and IPAs
  • 7512Plan Requests for Refunds from Physicians
  • 0185Reimbursement for Immunizations and Other Injections (2005)
  • 7576RICO Settlements (2014)
  • 7513Silent PPO (Unfair Discounting) Action Guide
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Reimbursement: Other Issues

  • 7656Charging for Form Completion
  • 7651Hiring a Billing Company
  • 7652Medical Liens
  • 7653Physician Access to Hospital, Laboratory and Pharmacy Charges (2017)
  • 7654Small Claims Action to Recover Payment
  • 7650The Emergency Medical Services Fund and Federal Funds for Medically Indigent Emergency Care (2017)
  • 7655Treatment of Relatives (or Oneself)
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Reporting Abuse

  • 3650Child Abuse or Neglect
  • 3651Reporting Dependent Adult and Elder Abuse
  • 3652Reporting Domestic Violence
  • 3653Reporting Injuries by a Deadly Weapon, Criminal Act, Health Facility Neglect, or Emergency Departmen
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Reporting Diseases, Conditions, & Events

  • 3664DMV Reports: Epilepsy, Lapses of Consciousness
  • 3666Occupational Illness and Injury
  • 3660Pandemic and Emergency Health Preparedness Act (2017)
  • 3667Psychiatric Inpatients Reporting Firearms Prohibition (2017)
  • 3663Reporting Communicable Diseases, Including Tuberculosis and Diseases Related to Bioterrorism
  • 3665Reporting Neonatal and Pediatric Disorders
  • 3662Requirements for Reporting Cancer and Parkinson's Disease Cases
  • 3661Vital Statistic Reporting Birth and Marriage
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Reproductive Issues

  • 3750Abortion Issues
  • 3115Infertility Treatment Consent Requirements
  • 3752Infertility Treatment Licensing and Disease Screening Requirements (2017)
  • 3753Informed Consent for Sterilization (and Hysterectomies)
  • 3751Tests of Pregnant Women, Newborns and Young Children
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Warning Obligations

  • 3675Physician's Duty to Protect
  • 3676Proposition 65 Warnings (2017)
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Workers' Compensation

  • 7300Basics of the Workers' Compensation System
  • 7301Health Care Organizations (HCOs) (2017)
  • 7304Medical Provider Networks
  • 7303Medical-Legal: Evaluations, Reports, and Payment
  • 7311MPN Independent Medical Review (2017)
  • 7305Qualified Medical Evaluators (QMEs) Requirements and Responsibilities
  • 7306Spinal Surgery Second Opinion Process (2014)
  • 7308Treating Physicians Obligations and Reports
  • 7309Treating Physicians Payment for Treatment (OMFS)
  • 7310Utilization Review
  • 0105Workers' Compensation Advertising (2016)
  • 7302Workers' Compensation Fraud Identifying, Reporting and Responding to Suspected Fraud
  • 7307Workers' Compensation Subpoenas

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        Emergency Transfer
        Reducing/Restructuring On-Call Coverage Requirements

        The following discusses issues which arise when medical staffs or departments attempt to reduce orotherwise restructure their emergency department on-call coverage requirements. For information onthe ...

        Item Details
        Medicare and Medi-Cal  |  14 pages
        Providing Care to Medi-Cal Enrollees

        In California, more than one third of state’s population receives health care through the Medi-Cal program. The Department of Health Care Services (DHCS), which administers Medi-Cal, both contra...

        Item Details
        End of Life Issues  |  17 pages
        The California End of Life Option Act

        On October 5, 2015, California became the fifth state in the nation to allow physicians to prescribeterminally ill patients medication to end their lives. ABX2-15, the ...

        Item Details
        Ancillary Services  |  17 pages
        Clinical Trials

        Advances in medicine depend on clinical trials conducted by public and private institutions. Physicians considering referring patients or participating in such clinical research studies should take st...

        Item Details
        eMedicine  |  9 pages
        Meaningful Use of Electronic Health Records (EHRs): Stage 3

        Under the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA or the ...

        Item Details
        Reimbursement: From Private & Public Payors  |  11 pages
        Insolvency of Health Plan, IPA or Other Entities that Contract with Health Plans (Pre-Bankruptcy or

        The following questions and answers apply to physicians faced with the insolvency of a health plan or IPA, PPM, or other entity that contracts with a health plan to pay physician claims. This document...

        Item Details
        Reimbursement: From Private & Public Payors  |  19 pages
        Payment Denials by Managed Care Plans and IPAs

        Following is a discussion of the laws relating to private payors’ (non–Medicare/Medi-Cal) denials ofpayment for physician claims, including retrospective payment denials based on lack of m...

        Item Details
        Reimbursement: From Private & Public Payors  |  28 pages
        Silent PPO (Unfair Discounting) Action Guide

        Some physicians’ bills are being discounted when the physicians believe they never agreed to a discount. This occurs because either: 1) the physician unknowingly authorized a PPO, IPA, health pl...

        Item Details
        Reimbursement: From Private & Public Payors  |  10 pages
        Payment Denial after Treatment Authorization or Verification of Eligibility

        When rendering non-emergency services, payors may require the physician first to obtain confirmation that the patient is covered by the payor and/or pre-authorization for the particular service. Payor...

        Item Details
        Reimbursement: From Private & Public Payors  |  3 pages
        Health Plan Special Claims Review

        The following is some general information concerning the ability of a health plan to place physicians special claims review and seek copies of the physician’s medical records for the purposes of...

        Item Details
        Reimbursement: From Private & Public Payors  |  10 pages
        Plan Requests for Refunds from Physicians

        Physicians often contact CMA because managed care plans ask them to return monies allegedly overpaid on their claims. We understand that thousands of physicians have been unfairly asked to return paym...

        Item Details
        Reimbursement: From Private & Public Payors  |  30 pages
        Non-Contracting Physicians

        This document addresses reimbursement issues that may arise when an out-of-network physician treats a patient with commercial health care coverage. The following also includes an analysis of Assembly ...

        Item Details
        Outpatient Facilities  |  6 pages
        Hospital Outpatient 1206(d) Clinics-- Legal Considerations Impacting Physicians

        California hospitals are increasingly creating and operating outpatient clinics as vehicles to recruit new physicians or to retain existing physicians. By charging and receiving higher facilities (in ...

        Item Details
        Reimbursement: From Private & Public Payors  |  12 pages
        Covered California: California's Health Benefits Exchange

        The California Health Benefit Exchange (hereafter ...

        Item Details
        Reimbursement: From Private & Public Payors  |  17 pages
        Bankruptcy of IPAs or Health Plans

        The following questions and answers apply to physicians faced with the bankruptcy of a health plan, independent practice association (IPA), physician practice management (PPM), or other entity that co...

        Item Details
        Reimbursement: From Private & Public Payors  |  4 pages
        Coordination of Benefits: Payment Below Medicare Allowable

        For years, CMA has received numerous complaints from physicians and patients that managed care organizations that pay secondary to Medicare (in applying coordination of benefits provisions) are failin...

        Item Details
        Reimbursement: From Private & Public Payors  |  18 pages
        Authorization and Payment for Emergency Services

        The discussion below sets forth answers to some frequently asked questions about obtaining authorization for emergency services and how physicians are to be paid for emergency services. Also included ...

        Item Details
        Reimbursement: From Private & Public Payors  |  11 pages
        Late Payment

        Depending on the type of payor, physicians may be entitled to certain protections when payors fail to pay claims on time. The following provides guidance to deal with late payments by payors. For info...

        Item Details
        Reimbursement: From Private & Public Payors  |  5 pages
        Coordination of Benefits

        The following discusses the general rules applicable to coordination of benefit (COB) provisions in private health plans between a physician and a payor. These provisions apply when the physician trea...

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        Reimbursement: From Private & Public Payors  |  7 pages
        Assignment of Benefits

        An “assignment of benefits” enables a physician who has provided services to an insured or managed care patient but has no contractual agreement with the payor to legally obligate the payo...

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