354.609. Termination of a contract, procedure. - Missouri Statutes

Termination of a contract, procedure.

354.609. 1. A health carrier and a participating provider shall provideat least sixty days written notice to each other before terminating thecontract without cause. The written notice shall include an explanation ofwhy the contract is being terminated. The health carrier shall providewritten notice within thirty working days of receipt or issuance of a noticeof termination to all enrollees who are patients seen on a regular basis bythe provider whose contract is terminating, irrespective of whether thetermination was for or without cause. Where a contract termination involves aprimary care professional, all enrollees who are patients of such professionalshall be notified. Within fifteen working days of the date that the providereither gives or receives notice of termination, the provider shall supply thehealth carrier with a list of those patients of the provider that are coveredby a plan of the health carrier.

2. (1) A health carrier shall not terminate a contract with a healthcare professional unless the health carrier provides to the health careprofessional a written explanation of the reasons for the proposed contracttermination and an opportunity for a review or hearing as hereinafterprovided. This subsection shall not apply in cases involving imminent harm topatients, a determination of fraud, or a final disciplinary action by a statelicensing board or other governmental agency.

(2) The notice of the proposed contract termination provided by thehealth carrier to the health care professional shall include:

(a) The reasons for the proposed action;

(b) Notice that the health care professional has the right to request ahearing or review, at the professional's discretion, before a panel appointedby the health carrier;

(c) A time limit of not less than thirty days within which a health careprofessional may request a hearing; and

(d) A time limit for a hearing date which shall be held within thirtydays after the date of receipt of a request for a hearing.

(3) The hearing panel shall be comprised of at least three personsappointed by the health carrier. At least one person on such panel shall be aclinical peer in the same discipline and the same or similar specialty as thehealth care professional under review. The hearing panel may consist of morethan three persons, provided however that the number of clinical peers on suchpanel shall constitute one-third or more of the total membership of the panel.

(4) The hearing panel shall render a decision on the proposed actionwithin fifteen days after a hearing. Such decision shall includereinstatement of the health care professional by the health carrier,provisional reinstatement subject to conditions set forth by the healthcarrier or termination of the health care professional. Such decision shallbe provided in writing to the health care professional.

(5) A decision by the hearing panel to terminate a health careprofessional shall be effective not less than thirty days after the receipt bythe health care professional of the hearing panel's decision.

(6) In no event shall termination be effective earlier than sixty daysfrom the receipt of the notice of termination.

3. Either party to a contract may exercise a right of nonrenewal at theexpiration of the contract period set forth therein or upon sixty days' noticeto the other party; provided, however, that any nonrenewal shall notconstitute a termination for purposes of this section.

4. A health carrier shall develop and implement policies and proceduresto ensure that a health care professional is regularly informed of informationmaintained by the health carrier to evaluate the performance or practice ofthe health care professional. The health carrier shall consult with healthcare professionals in developing methodologies to collect and analyze healthcare professional profiling data. The health carrier shall provide any suchinformation and profiling data and analysis to the health care professionals.Such information, data or analysis shall be provided on a periodic basisappropriate to the nature and amount of data and the volume and scope ofservices provided. Any profiling data used to evaluate the performance orpractice of a health care professional shall be measured against statedcriteria and an appropriate group of health care professionals using similartreatment modalities serving a comparable patient population. Uponpresentation of such information or data, each health care professional shallbe given the opportunity to discuss the unique nature of the health careprofessional's patient population which may have a bearing on the health careprofessional's profile and to work cooperatively with the health carrier toimprove performance.

5. No health carrier shall terminate a contract or employment solely orin part because a health care provider in good faith:

(1) Advocates on behalf of an enrollee;

(2) Files a complaint against the health carrier;

(3) Appeals a decision of the health carrier;

(4) Provides information or files a report with the department ofinsurance, financial institutions and professional registration; or

(5) Requests a hearing or review pursuant to this section.

6. A health carrier shall give a provider at least thirty days to reviewa managed care contract.

(L. 1997 H.B. 335)