287.135. Managed care services, department to establish program to certify organizations, procedures--effect on fees and services. - Missouri Statutes

Managed care services, department to establish program to certifyorganizations, procedures--effect on fees and services.

287.135. 1. The department of insurance, financial institutions andprofessional registration shall establish a program whereby managed careorganizations in this state shall be certified by the department for theprovision of managed care services to employers who voluntarily choose to usesuch organizations. The department shall report to the division of workers'compensation all managed care organizations certified pursuant to theprovisions of this section. The division shall maintain a registry ofcertified managed care organizations that can be readily accessed by employersfor the provision of managed care services. For the purposes of this section,the term "managed care organizations" shall mean organizations such aspreferred provider organizations, health maintenance organizations and otherdirect employer/provider arrangements which have been certified by thedepartment designed to provide incentives to medical care providers to managethe cost and use of care associated with claims covered by workers'compensation insurance.

2. The director of the department of insurance, financial institutionsand professional registration shall promulgate rules which set out theapproval criteria for certification of a managed care organization. Approvalcriteria shall take into consideration the adequacy of services that theorganization will be able to offer the employer, the geographic area to beserved, staff size and makeup of the organization in relation to both servicesoffered and geographic location, access to health care providers, the adequacyof internal management and oversight, the adequacy of procedures for peerreview, utilization review, and internal dispute resolution, including amethod to resolve complaints by injured employees, medical providers, andinsurers over the cost, necessity and appropriateness of medical services, theavailability of case management services, and any other criteria as determinedby the director. Thirty days prior to the annual anniversary of any currentcertification granted by the director, any managed care organization seekingcontinued certification shall file an application for recertification with thedirector, on a form approved by the director, accompanied by a filing feeestablished by the director by rule and any other materials specified by thedirector.

3. The director of the department of insurance, financial institutionsand professional registration shall promulgate rules which set out thecriteria under which the fees charged by a managed care organization shall bereimbursed by an employer's workers' compensation insurer and which establishcriteria providing for the coordination and integration between the managedcare organization and the insurer of their respective internal operationalsystems relating to such matters as claim reporting and handling, medical casemanagement procedures and billing. Such criteria shall require any suchreimbursable fees to be reasonable in relation both to the managed careservices provided and to the savings which result from those services. Suchcriteria shall discourage the use of fee arrangements which result inunjustified costs being billed for either medical services or managed careservices. Insurers and managed care organizations shall be permitted tovoluntarily negotiate and utilize alternative fee arrangements.Notwithstanding any provision of this subsection to the contrary, if aninsurer and a managed care organization enter into a voluntary agreement thataccomplishes the same purposes as this subsection, that insurer and thatmanaged care organization with respect to that agreement shall not be requiredto meet the requirements of this subsection or regulations promulgated by thedepartment pursuant to this subsection.

4. Any managed care organization, including any managed careorganization that has been established or selected by or has contracted with aworkers' compensation insurance carrier to provide managed care services toinsured employers, that has previously been certified prior to August 28,1993, by the director of the department of insurance, financial institutionsand professional registration shall be deemed to have met the criteria setforth in this section.

5. The necessity and appropriateness of medical care servicesrecommended or provided by providers shall be subject to review by thedivision of workers' compensation, upon application, following a decision bythe managed care organization's utilization review and dispute resolutionreview and appeal procedure. The decision of the managed care organizationrelating to payment for such medical care services shall be subject tomodification by the division of workers' compensation, after mediationconference or hearing, only upon showing that it was unreasonable, arbitraryor capricious.

(L. 1993 S.B. 251)