2006 Kansas Code - 44-510j
44-510j. Medical benefits; fee disputes; utilization and peer review. When an employer's insurance carrier or a self-insured employer disputes all or a portion of a bill for services rendered for the care and treatment of an employee under this act, the following procedures apply:
(a) (1) The employer or carrier shall notify the service provider within 30 days of receipt of the bill of the specific reason for refusing payment or adjusting the bill. Such notice shall inform the service provider that additional information may be submitted with the bill and reconsideration of the bill may be requested. The provider shall send any request for reconsideration within 30 days of receiving written notice of the bill dispute. If the employer or carrier continues to dispute all or a portion of the bill after receiving additional information from the provider, the employer, carrier or provider may apply for an informal hearing before the director.
(2) If a provider sends a bill to such employer or carrier and receives no response within 30 days as allowed in subsection (a) and if a provider sends a second bill and receives no response within 60 days of the date the provider sent the first bill, the provider may apply for an informal hearing before the director.
(3) Payments shall not be delayed beyond 60 days for any amounts not in dispute. Acceptance by any provider of a payment amount which is less than the full amount charged for the services shall not affect the right to have a review of the claim for the outstanding or remaining amounts.
(b) The application for informal hearing shall include copies of the disputed bills, all correspondence concerning the bills and any additional written information the party deems appropriate. When anyone applies for an informal hearing before the director, copies of the application shall be sent to all parties to the dispute and the employee. Within 20 days of receiving the application for informal hearing, the other parties to the dispute shall send any additional written information deemed relevant to the dispute to the director.
(c) The director or the director's designee shall hold the informal hearing to hear and determine all disputes as to such bills and interest due thereon. Evidence in the informal hearing shall be limited to the written submissions of the parties. The informal hearing may be held by electronic means. Any employer, carrier or provider may personally appear in or be represented at the hearing. If the parties are unable to reach a settlement regarding the dispute, the officer hearing the dispute shall enter an order so stating.
(d) After the entry of the order indicating that the parties have not settled the dispute after the informal hearing, the director shall schedule a formal hearing.
(1) Prior to the date of the formal hearing, the director may conduct a utilization review concerning the disputed bill. The director shall develop and implement, or contract with a qualified entity to develop and implement, utilization review procedures relating to the services rendered by providers and facilities, which services are paid for in whole or in part pursuant to the workers compensation act. The director may contract with one or more private foundations or organizations to provide utilization review of service providers pursuant to the workers compensation act. Such utilization review shall result in a report to the director indicating whether a provider improperly utilized or otherwise rendered or ordered unjustified treatment or services or that the fees for such treatment or services were excessive and a statement of the basis for the report's conclusions. After receiving the utilization review report, the director also may order a peer review. A copy of such reports shall be provided to all parties to the dispute at least 20 days prior to the formal hearing. No person shall be subject to civil liability for libel, slander or any other relevant tort cause of action by virtue of performing a peer or utilization review under contract with the director.
(2) The formal hearing shall be conducted by hearing officers, the medical administrator or both as appointed by the director. During the formal hearing parties to the dispute shall have the right to appear or be represented and may produce witnesses, including expert witnesses, and such other relevant evidence as may be otherwise allowed under the workers compensation act. If the director finds that a provider or facility has made excessive charges or provided or ordered unjustified treatment, services, hospitalization or visits, the provider or facility may, subject to the director's order, receive payment pursuant to this section from the carrier, employer or employee for the excessive fees or unjustified treatment, services, hospitalization or visits and such provider may be ordered to repay any fees or charges collected therefor. If it is determined after the formal hearing that a provider improperly utilized or otherwise rendered or ordered unjustified treatment or services or that the fees for such treatment or services were excessive, the director may provide a report to the licensing board of the service provider with full documentation of any such determination, except that no such report shall be provided until after judicial review if the order is appealed. Any decision rendered under this section may be reviewed by the workers compensation board. A party must file a notice of appeal within 10 days of the issuance of any decision under this section. The record on appeal shall be limited only to the evidence presented to the hearing officer. The decision of the director shall be affirmed unless the board determines that the decision was not supported by substantial competent evidence.
(e) By accepting payment pursuant to this section for treatment or services rendered to an injured employee, the provider shall be deemed to consent to submitting all necessary records to substantiate the nature and necessity of the service or charge and other information concerning such treatment to utilization review under this section. Such health care provider shall comply with any decision of the director pursuant to this section.
(f) Except as provided in K.S.A. 60-437 and amendments thereto and this
section,
findings and records which relate to utilization and peer review conducted
pursuant to
this section
shall be privileged
and shall not be
subject to discovery, subpoena or other means of legal compulsion for release
to any person or
entity and shall not be admissible in evidence in any judicial or
administrative proceeding, except
those proceedings authorized pursuant to this section. In any proceedings where
there is an
application by an employee, employer, insurance carrier or the workers
compensation
fund for a
hearing pursuant to K.S.A. 44-534a, and amendments thereto, for a change of
medical benefits
which has been filed after a health care provider, employer, insurance carrier
or the workers
compensation fund has made application to the medical services section of the
division for the
resolution of a dispute or matter pursuant to the provisions of this section,
all reports, information, statements, memoranda, proceedings, findings
and records
which relate to utilization and peer review including the records of contract
reviewers
and findings and records of the medical services
section of the
division shall be admissible at the hearing before the administrative law judge
on the issue of the
medical benefits to which an employee is entitled.
(g) A provider may not improperly overcharge or charge for services which
were not provided for the purpose of obtaining additional payment. Any dispute
regarding such actions
shall be resolved in the same manner as other bill disputes as provided by
this section. Any
violation of the provisions of this section or K.S.A. 44-510i, and
amendments thereto, which is willful or which demonstrates a pattern of
improperly charging or overcharging for services rendered pursuant to this act
constitutes
grounds for the director to impose a civil fine not to exceed $5,000. Any civil
fine imposed under
this section shall be subject to review
by the board. All
moneys received for
civil fines imposed under this section shall be deposited in the state treasury
to the credit of the
workers compensation fund.
(h) Any health care provider, nurse, physical therapist, any entity providing
medical,
physical or vocational rehabilitation services or providing reeducation or
training pursuant to
K.S.A. 44-510g and amendments thereto, medical supply establishment, surgical
supply
establishment, ambulance service or hospital which accept the terms of the
workers compensation
act by providing services or material thereunder shall be bound by the fees
approved by the
director and no injured employee or dependent of a deceased employee shall be
liable for any
charges above the amounts approved by the director. If the employer has
knowledge of the injury
and refuses or neglects to reasonably provide the services of a health care
provider required by
this act, the employee may provide the same for such employee, and the employer
shall be liable
for such expenses subject to the regulations adopted by the director. No action
shall be filed in
any court by a health care provider or other provider of services under this
act for the payment of
an amount for medical services or materials provided under the workers
compensation act and no
other action to obtain or attempt to obtain or collect such payment shall be
taken by a health care
provider or other provider of services under this act, including employing any
collection service,
until after final adjudication of any claim for compensation for which an
application for hearing
is filed with the director under K.S.A. 44-534 and amendments thereto. In the
case of any such
action filed in a court prior to the date an application is filed under K.S.A.
44-534 and
amendments thereto, no judgment may be entered in any such cause and the action
shall be
stayed until after the final adjudication of the claim. In the case of an
action stayed hereunder,
any award of compensation shall require any amounts payable for medical
services or materials
to be paid directly to the provider thereof plus an amount of interest at the
rate provided by
statute for judgments. No period of time under any statute of limitation, which
applies to a cause
of action barred under this subsection, shall commence or continue to run until
final adjudication
of the claim under the workers compensation act.
(i) As used in this section, unless the context or the specific provisions
clearly require
otherwise, "carrier" means a self-insured employer, an insurance company or a
qualified group-funded workers compensation pool and "provider" means any
health care provider, vocational rehabilitation
service provider
or any facility providing health care services or vocational rehabilitation
services, or both,
including any hospital.
History: L. 2000, ch. 160, § 3; July 1.
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