Chapter 423
AN ACT
SB 563
Relating to managed care plans for injured workers; amending ORS
656.260.
Be It Enacted by the People of
the State of Oregon:
SECTION 1.
ORS 656.260 is amended to read:
656.260. (1) Any health
care provider or group of medical service providers may make written
application to the Director of the Department of Consumer and Business Services
to become certified to provide managed care to injured workers for injuries and
diseases compensable under this chapter. However, nothing in this section
authorizes an organization that is formed, owned or operated by an insurer or
employer other than a health care provider to become certified to provide
managed care.
(2) Each application for
certification shall be accompanied by a reasonable fee prescribed by the
director. A certificate is valid for such period as the director may prescribe
unless sooner revoked or suspended.
(3) Application for
certification shall be made in such form and manner and shall set forth such information
regarding the proposed plan for providing services as the director may
prescribe. The information shall include, but not be limited to:
(a) A list of the names
of all individuals who will provide services under the managed care plan,
together with appropriate evidence of compliance with any licensing or
certification requirements for that individual to practice in this state.
(b) A description of the
times, places and manner of providing services under the plan.
(c) A description of the
times, places and manner of providing other related optional services the
applicants wish to provide.
(d) Satisfactory
evidence of ability to comply with any financial requirements to insure
delivery of service in accordance with the plan which the director may
prescribe.
(4) The director shall
certify a health care provider or group of medical service providers to provide
managed care under a plan if the director finds that the plan:
(a) Proposes to provide medical
and health care services [that meet]
required by this chapter in a manner that:
(A) Meets quality, continuity and other treatment
standards [reviewed and] adopted
by the health care provider or group of medical service providers in accordance
with processes approved by the director; and
(B) [Will provide all medical and health care
services that may be required by this chapter in a manner that] Is timely,
effective and convenient for the worker.
(b) Subject to any other
provision of law, does not discriminate against or exclude from participation
in the plan any category of medical service providers and includes an adequate
number of each category of medical service providers to give workers adequate
flexibility to choose medical service providers from among those individuals
who provide services under the plan. However, nothing in the requirements of
this paragraph shall affect the provisions of ORS 441.055 relating to the
granting of medical staff privileges.
(c) Provides appropriate
financial incentives to reduce service costs and utilization without
sacrificing the quality of service.
(d) Provides adequate
methods of peer review, service utilization review, quality assurance, contract
review and dispute resolution to ensure appropriate treatment or to prevent
inappropriate or excessive treatment, to exclude from participation in the plan
those individuals who violate these treatment standards and to provide for the
resolution of such medical disputes as the director considers appropriate. A
majority of the members of each peer review, quality assurance, service
utilization and contract review committee shall be physicians licensed to
practice medicine by the Board of Medical Examiners. As used in this paragraph:
(A) “Peer review” means
evaluation or review of the performance of colleagues by a panel with similar
types and degrees of expertise. Peer review requires participation of at least
three physicians prior to final determination.
(B) “Service utilization
review” means evaluation and determination of the reasonableness, necessity and
appropriateness of a worker’s use of medical care resources and the provision
of any needed assistance to clinician or member, or both, to ensure appropriate
use of resources. “Service utilization review” includes prior authorization,
concurrent review, retrospective review, discharge planning and case management
activities.
(C) “Quality assurance”
means activities to safeguard or improve the quality of medical care by
assessing the quality of care or service and taking action to improve it.
(D) “Dispute resolution”
includes the resolution of disputes arising under peer review, service
utilization review and quality assurance activities between insurers,
self-insured employers, workers and medical and health care service providers,
as required under the certified plan.
(E) “Contract review”
means the methods and processes whereby the managed care organization monitors
and enforces its contracts with participating providers for matters other than
matters enumerated in subparagraphs (A), (B) and (C) of this paragraph.
(e) Provides a program
involving cooperative efforts by the workers, the employer and the managed care
organizations to promote workplace health and safety consultative and other
services and early return to work for injured workers.
(f) Provides a timely
and accurate method of reporting to the director necessary information
regarding medical and health care service cost and utilization to enable the
director to determine the effectiveness of the plan.
(g) Authorizes workers
to receive compensable medical treatment from a primary care physician who is
not a member of the managed care organization, but who maintains the worker’s
medical records and with whom the worker has a documented history of treatment,
if that primary care physician agrees to refer the worker to the managed care
organization for any specialized treatment, including physical therapy, to be
furnished by another provider that the worker may require and if that primary
care physician agrees to comply with all the rules, terms and conditions
regarding services performed by the managed care organization. Nothing in this
paragraph is intended to limit the worker’s right to change primary care
physicians prior to the filing of a workers’ compensation claim. As used in
this paragraph, “primary care physician” means a physician who is qualified to
be an attending physician referred to in ORS 656.005 (12)(b)(A) and who is a
family practitioner, a general practitioner or an internal medicine
practitioner.
(h) Provides a written
explanation for denial of participation in the managed care organization plan
to any licensed health care provider that has been denied participation in the
managed care organization plan.
(i) Does not prohibit
the injured worker’s attending physician from advocating for medical services
and temporary disability benefits for the injured worker that are supported by
the medical record.
(j) Complies with any
other requirement the director determines is necessary to provide quality
medical services and health care to injured workers.
(5) The director shall
refuse to certify or may revoke or suspend the certification of any health care
provider or group of medical service providers to provide managed care if the
director finds that:
(a) The plan for
providing medical or health care services fails to meet the requirements of
this section.
(b) Service under the
plan is not being provided in accordance with the terms of a certified plan.
(6) Any issue concerning
the provision of medical services to injured workers subject to a managed care
contract and service utilization review, quality assurance, dispute resolution,
contract review and peer review activities as well as authorization of medical
services to be provided by other than an attending physician pursuant to ORS 656.245
(2)(b) shall be subject to review by the director or the director’s designated
representatives. The decision of the director is subject to review under ORS
656.704. Data generated by or received in connection with these activities,
including written reports, notes or records of any such activities, or of any
review thereof, shall be confidential, and shall not be disclosed except as
considered necessary by the director in the administration of this chapter. The
director may report professional misconduct to an appropriate licensing board.
(7) No data generated by
service utilization review, quality assurance, dispute resolution or peer
review activities and no physician profiles or data used to create physician
profiles pursuant to this section or a review thereof shall be used in any
action, suit or proceeding except to the extent considered necessary by the
director in the administration of this chapter. The confidentiality provisions
of this section shall not apply in any action, suit or proceeding arising out
of or related to a contract between a managed care organization and a health
care provider whose confidentiality is protected by this section.
(8) A person
participating in service utilization review, quality assurance, dispute
resolution or peer review activities pursuant to this section shall not be
examined as to any communication made in the course of such activities or the
findings thereof, nor shall any person be subject to an action for civil
damages for affirmative actions taken or statements made in good faith.
(9) No person who
participates in forming consortiums, collectively negotiating fees or otherwise
solicits or enters into contracts in a good faith effort to provide medical or
health care services according to the provisions of this section shall be
examined or subject to administrative or civil liability regarding any such
participation except pursuant to the director’s active supervision of such
activities and the managed care organization. Before engaging in such
activities, the person shall provide notice of intent to the director in a form
prescribed by the director.
(10) The provisions of
this section shall not affect the confidentiality or admission in evidence of a
claimant’s medical treatment records.
(11) In consultation
with the committees referred to in ORS 656.790 and 656.794, the director shall
adopt such rules as may be necessary to carry out the provisions of this
section.
(12) As used in this
section, ORS 656.245, 656.248 and 656.327, “medical service provider” means a
person duly licensed to practice one or more of the healing arts in any country
or in any state or territory or possession of the
(13) Notwithstanding ORS
656.005 (12) or subsection (4)(b) of this section, a managed care organization
contract may designate any medical service provider or category of providers as
attending physicians.
(14) If a worker,
insurer, self-insured employer or the attending physician is dissatisfied with
an action of the managed care organization regarding the provision of medical
services pursuant to this chapter, peer review, service utilization review or
quality assurance activities, that person or entity must first apply to the
director for administrative review of the matter before requesting a hearing. Such
application must be made not later than the 60th day after the date the managed
care organization has completed and issued its final decision.
(15) Upon a request for
administrative review, the director shall create a documentary record
sufficient for judicial review. The director shall complete administrative
review and issue a proposed order within a reasonable time. The proposed order
of the director issued pursuant to this section shall become final and not
subject to further review unless a written request for a hearing is filed with
the director within 30 days of the mailing of the order to all parties.
(16) At the contested
case hearing, the order may be modified only if it is not supported by
substantial evidence in the record or reflects an error of law. No new medical
evidence or issues shall be admitted. The dispute may also be remanded to the
managed care organization for further evidence taking, correction or other
necessary action if the Administrative Law Judge or director determines the
record has been improperly, incompletely or otherwise insufficiently developed.
Decisions by the director regarding medical disputes are subject to review
under ORS 656.704.
(17) Any person who is
dissatisfied with an action of a managed care organization other than regarding
the provision of medical services pursuant to this chapter, peer review,
service utilization review or quality assurance activities may request review
under ORS 656.704.
(18) Notwithstanding any
other provision of law, original jurisdiction over contract review disputes is
with the director. The director may resolve the matter by issuing an order
subject to review under ORS 656.704, or the director may determine that the
matter in dispute would be best addressed in another forum and so inform the
parties.
(19) The director shall
conduct such investigations, audits and other administrative oversight in
regard to managed care as the director deems necessary to carry out the
purposes of this chapter.
Approved by the Governor June 13, 2007
Filed in the office of Secretary of State June 13, 2007
Effective date January 1, 2008
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