40-22a07. Same; unlawful acts; penalties; prior notification requirements, limitations on. - Kansas Statutes

40-22a07

Chapter 40.--INSURANCE Article 22a.--UTILIZATION REVIEW

      40-22a07.   Same; unlawful acts; penalties; priornotification requirements, limitations on.(a) (1) It is unlawful for any person or utilization revieworganization to perform utilization review activities in this state except inaccordance with this act.

      (2)   No utilization review organization nor any individual performingutilization review activities may agree to be compensated or receivecompensation which is contingent in any way upon frequency of certificationdenials, costs avoided by denial or reduction in payment of claims or otherresults which may be adverse to the needs of the patient as determined by theattending health care provider.

      (3) (A)   A utilization review organizationmay establishprior notification requirements for inpatient and outpatienthospital admissions. A utilization review organizationshall not require notificationsooner than the next business day afterany inpatient admission occurring on aweekend or holiday or any urgent or emergent inpatient or outpatient admissionregardless of whenthe patient presents forservices.

      (B)   For the purposes of this paragraph, a patient that is unstable oruncommunicative shall not be deemed to have presented to a health care facilityuntil the patient is able to provide insurance information and the health carefacility is permitted under state and federal law to inquire about insurancecoverage.

      (b)   A utilization revieworganization may not reduce or deny payment to a provider for such provider'sfailure to comply with any utilization review organization's policy thatconflicts with this act or any rules and regulations adopted pursuant to K.S.A.40-22a11 and amendments thereto.

      (c)   When the commissioner has reason to believe a utilization revieworganization subject to this act has been or is engaged in any conduct whichviolates this act or any rules and regulations adopted pursuant to K.S.A.40-22a11,the commissioner, after a hearing conducted in accordance with the Kansasadministrative procedure act, may:

      (1)   Issue and cause to be served upon the utilization review organization anorder requiring such organization to cease and desist from engaging in suchviolations;

      (2)   suspend or revoke the utilization review organization's certificate toperform utilization review affecting residents of this state;

      (3)   assess a monetary penalty of not less than $500 and not more than $1,000for each violation; or

      (4)   apply any combination of the above provisions as the commissioner, bywritten order, deems appropriate.

      History:   L. 1994, ch. 238, § 7;L. 2008, ch. 134, § 7; July 1.