Bill Text: OR HB2093 | 2011 | Regular Session | Enrolled
Bill Title: Relating to managed care in workers' compensation system.
Sponsorship: Unknown
Status: (Passed) 2011-05-19 - Chapter 98, (2011 Laws): Effective date January 1, 2012. [HB2093 Detail]
Download: Oregon-2011-HB2093-Enrolled.html
76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
Enrolled
House Bill 2093
Introduced and printed pursuant to House Rule 12.00. Presession
filed (at the request of Governor John A. Kitzhaber for
Department of Consumer and Business Services)
CHAPTER ................
AN ACT
Relating to managed care in workers' compensation system;
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
required by this chapter in a manner that:
(A) Meets quality, continuity and other treatment standards
adopted by the health care provider or group of medical service
providers in accordance with processes approved by the director;
and
Enrolled House Bill 2093 (HB 2093-A) Page 1
(B) 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 Oregon Medical
Board. 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
Enrolled House Bill 2093 (HB 2093-A) Page 2
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
Enrolled House Bill 2093 (HB 2093-A) Page 3
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 United States.
(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.
Enrolled House Bill 2093 (HB 2093-A) Page 4
(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.
{ + (20)(a) Except as otherwise provided in this chapter,
only a managed care organization certified by the director may:
(A) Restrict the choice of a health care provider or medical
service provider by a worker;
(B) Restrict the access of a worker to any category of medical
service providers;
(C) Restrict the ability of a medical service provider to refer
a worker to another provider;
(D) Require preauthorization or precertification to determine
the necessity of medical services or treatment; or
(E) Restrict treatment provided to a worker by a medical
service provider to specific treatment guidelines, protocols or
standards.
(b) The provisions of paragraph (a) of this subsection do not
apply to:
(A) A medical service provider who refers a worker to another
medical service provider;
(B) Use of an on-site medical service facility by the employer
to assess the nature or extent of a worker's injury; or
(C) Treatment provided by a medical service provider or
transportation of a worker in an emergency or trauma situation.
(c) Except as provided in paragraph (b) of this subsection, if
the director finds that a person has violated a provision of
paragraph (a) of this subsection, the director may impose a
sanction that may include a civil penalty not to exceed $2,000
for each violation.
(d) If violation of paragraph (a) of this subsection is
repeated or willful, the director may order the person committing
the violation to cease and desist from making any future
communications with injured workers or medical service providers
or from taking any other actions that directly or indirectly
affect the delivery of medical services provided under this
chapter.
(e)(A) Penalties imposed under this subsection are subject to
ORS 656.735 (4) to (6) and 656.740.
(B) Cease and desist orders issued under this subsection are
subject to ORS 656.740. + }
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Enrolled House Bill 2093 (HB 2093-A) Page 5
Passed by House March 15, 2011
.............................................................
Ramona Kenady Line, Chief Clerk of House
.............................................................
Bruce Hanna, Speaker of House
.............................................................
Arnie Roblan, Speaker of House
Passed by Senate May 9, 2011
.............................................................
Peter Courtney, President of Senate
Enrolled House Bill 2093 (HB 2093-A) Page 6
Received by Governor:
......M.,............., 2011
Approved:
......M.,............., 2011
.............................................................
John Kitzhaber, Governor
Filed in Office of Secretary of State:
......M.,............., 2011
.............................................................
Kate Brown, Secretary of State
Enrolled House Bill 2093 (HB 2093-A) Page 7
