56-32-115 - Regulation by commissioner Examination of books and records. - Tennessee Statutes

56-32-115. Regulation by commissioner Examination of books and records.

(a)  The commissioner of commerce and insurance, in cooperation with the commissioner of health, shall coordinate the regulation of any HMO holding a certificate of authority to ensure the financial viability of the HMO and that the HMO is currently providing and shall in the future provide health care services efficiently, effectively and economically. The commissioner of commerce and insurance and the commissioner of health shall develop an interdepartmental agreement to coordinate the functions necessary for the proper administration of this section.

(b)  The commissioner of commerce and insurance may make an examination of the affairs of any HMO and any providers with whom the HMO has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state. The examinations of HMOs shall occur not less frequently than once every four (4) years. The commissioner of commerce and insurance may also contract, at reasonable fees for work performed, with qualified, impartial outside sources to perform audits or examinations, or portions of audits or examinations, pertaining to the qualification of an entity for issuance for a certificate of authority to operate as an HMO or to determine the continued compliance of any operating HMO. Any contracted assistance shall be under the direct supervision of the commissioner of commerce and insurance. The results of any contracted assistance shall be subject to the review of, and approval, disapproval, or modification by, the commissioner of commerce and insurance.

(c)  The commissioner of health or the commissioner's designee may make an examination concerning an HMO's capability to provide health care services efficiently, effectively and economically, and any providers with whom the HMO has contracts, agreements, or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state. The examinations of HMOs shall occur not less frequently than once every three (3) years. The commissioner of health shall report findings to the commissioner of commerce and insurance, who may then suspend or revoke a certificate of authority issued to the HMO as provided in § 56-32-116.

(d)  Every HMO shall submit its books and records for the examinations and in every way facilitate the completion of the examinations. For the purpose of examinations, the commissioner of commerce and insurance and the commissioner of health may administer oaths to, and examine, officers and agents of the HMO.

(e)  The expenses of examinations of HMOs under this section shall be assessed against the HMO being examined and remitted to the commissioner for whom the examination is being conducted.

(f)  In lieu of the examinations, the commissioner of commerce and insurance or the commissioner of health may accept the report of an examination made by the commissioner of insurance or the commissioner of health of another state.

[Acts 1986, ch. 713, § 15; 1997, ch. 60, § 2; T.C.A. § 56-32-215.]