2016 Maryland Code
Health - General
Title 19 - Health Care Facilities
Subtitle 7 - Health Maintenance Organizations
§ 19-712.4. Prohibited referrals

(a) Definitions. -- In this section the terms "health care practitioner", "health care entity", and "health care service" have the same meanings as provided in § 1-301 of the Health Occupations Article.

(b) Repayments. -- A health maintenance organization may seek repayment from a health care practitioner of any money paid for any claim, bill, or other demand or request for payment for the health care services that were determined by the appropriate regulatory licensing board to be furnished as a result of a referral prohibited by § 1-302 of the Health Occupations Article.

(c) Contract provision excluding payment authorized. -- Every contract between a health maintenance organization and its subscribers or a group of subscribers for the provision of health care services shall include a provision excluding payment of any claim, bill, or other demand or request for payment for health care services determined to be furnished as a result of a referral prohibited by § 1-302 of the Health Occupations Article.

(d) Report of pattern of claims. -- A health maintenance organization subject to the provisions of this section shall report to the Commissioner and the appropriate regulatory board any pattern of claims, bills or other demands or requests for payment submitted for a health care service provided as a result of a referral prohibited by § 1-302 of the Health Occupations Article within 30 days after that health maintenance organization has knowledge of that pattern.

(e) Audit or investigation not required. --

(1) Notwithstanding the provisions of this section, a health maintenance organization reimbursing for health care services is not required to audit or investigate any claim, bill, or other demand or request for payment for the purpose of determining whether those services were the result of a prohibited referral.

(2) Any audit or investigation of any claim, bill, or other demand or request for payment for the purpose of determining whether those services were the result of the prohibited referral are not grounds to delay payment or waive the provisions of § 15-1005 of the Insurance Article.

(f) Refunds. -- For any claim, bill, or request for payment that is paid and is subsequently determined to be the result of a prohibited referral, a health maintenance organization may seek a refund of that payment in accordance with the provisions of § 1-305 of the Health Occupations Article.