Current through Register 1531, September 27, 2024
(1)
General Rules for Compliance Enforcement. Pursuant to
452 CMR 6.00, the Office of Health Policy of the DIA monitors utilization
review agents and their programs to ensure full compliance with Massachusetts
General Laws and 452 CMR 6.00. Specific enforcement mechanisms include, but are
not limited to, the following:
(a) The
Commissioner may revoke or refuse to renew a license of a self-insurer for the
failure of any self-insurer to comply with all applicable laws, rules,
regulations, orders, and requirements of the Commonwealth.
(b) The Commissioner may revoke or refuse to
renew the approval of the utilization review agent for failure to comply with
all applicable laws, rules, regulations, orders, and requirements of the
Commonwealth.
(2) The
Department of Industrial Accidents will gather data on compliance with the
treatment guidelines through reports from insurers and utilization review
agents.
(3) If the Department finds
that the care provided to injured employees through an insurer is more
frequently deficient than that provided to other employees in receipt of
workers' compensation, the Department will address this issue with the insurer
by referring the matter to the Division of Insurance.
(4) The Department shall monitor the
utilization review techniques used, and determinations made, by utilization
review agents. If the Commissioner receives a complaint from a practitioner,
employer, or employee, or has reason to believe that a utilization review agent
has been or is engaged in conduct that violates 452 CMR 6.00, the Commissioner
shall notify the utilization review agent in writing of the alleged violation.
The utilization review agent shall have 14 days from the date the notice is
received to respond to the alleged violation. On or after the
14th day, the Commissioner shall render a finding
after reviewing all documents submitted by the parties. The Commissioner may
also schedule a hearing. If the Commissioner determines that the utilization
review agent has violated or is in violation of any law, rule, regulation,
order, or requirement, the Commissioner may issue an order requiring the
insurer and/or utilization review agent to cease and desist from engaging in
the violation(s). The Commissioner may also suspend or revoke the agent's
approval to conduct utilization review and may assess a fine.
If the utilization review agent requests a hearing regarding
the findings of the Commissioner, the request must be made in writing within 14
days from receipt of the findings. Upon receipt of the request, the
Commissioner shall schedule a hearing to be conducted pursuant to M.G.L. c.
30A.
If the Commissioner renders a finding that the utilization
agent has violated any law, rule, regulation, order, or requirement, the
utilization review agent must inform the adjuster handling the injured
employee's claim.
(5) A
Cease and Desist order may include:
(a) a
summary of the violation(s);
(b) a
summary of the facts giving rise to the violation(s);
(c) the penalty that the Commissioner intends
to apply; and
(d) information
pertaining to the rights and obligations of the utilization review agent; as
well as the procedure for the agent to file a written response or request a
hearing.
(6)
Non-compliance Categories Include but are not Limited to:
(a) Failure of an insurer/self-insurer to
conduct a proper utilization review in accordance with 452 CMR 6.00.
(b) Failure of the utilization review agent
to render a written determination to both the injured employee and the ordering
provider within the proper time constraints.
(c) Failure of the utilization review agent
to ensure an appeal level review is conducted by a same-school
practitioner.
(d) Failure of the
utilization review agent to issue a written introductory letter within the
required time period.
(e) Failure
of the utilization review agent to use the diagnosis and/or ICD code selected
by the ordering provider when determining medical necessity and appropriateness
of care.
(f) Failure of the
utilization review agent to cite the correct, research based treatment
guideline when rendering a determination.
(g) Failure of the utilization review agent
to document clinical rationale to support the determination.
(h) Failure of the utilization review agent
to utilize only licensed personnel to determine medical necessity and
appropriateness for all health care services under review.
(i) Failure of the utilization review agent
to maintain all required records in the form and manner prescribed by the OHP.
(j) Failure to inform the OHP of
any material change to the approved utilization review application within 30
days of said change.
(k) Failure
to adhere to the quality assurance and quality control measures set forth in
the utilization review application.
(l) Failure to maintain hours of operation
between 9:00 A.M. and 5:00 P.M. on each business day, and return after hour
calls within one business day.
(m)
Failure to inform the OHP of each site where utilization review is being
conducted for Massachusetts claims.
(n) Failure of the utilization review agent
to comply with audits.
(o) Failure
of the medical director and school to school reviewers to maintain an active
clinical practice of at least eight hours per week.
(p) Failure to conduct initial reviews at the
approved utilization review site.
(7)
Quality Assessment Audit
Review Procedures.
(a) The OHP
monitoring of the quality of care rendered to injured employees shall include,
but not be limited to: onsite audits; desk audits; and review of patient
satisfaction surveys, complaints, and statistical data provided by utilization
review agents, insurers, and self-insurers. Desk audits shall consist of review
of case records selected by the OHP. The OHP may also monitor the performance
of providers reimbursed by insurers.
(b) Approved utilization review agents shall
comply with all requests for onsite and desk audits for continued utilization
review approval.
(c) Utilization
review agents are required to pay all reasonable travel expenses for each
onsite audit of the OHP representatives.
(d) The OHP will determine the type of audit
to be conducted (onsite or desk). The utilization review agent will be notified
prior to the scheduled audit date. The agent shall submit a list of all
utilization reviews conducted for the period specified by OHP. The OHP will
notify the agent which files must be made available to the audit. The agent
will make each sample record available, in hard copy, for review on the audit
date.
(e) OHP audits are conducted
yearly. However, if at any time the OHP has reason to believe that the agent is
not in full compliance with the laws, rules, regulations, orders, and
requirements, by way of complaint or any other means, the agent's approval
status may be reviewed and an immediate audit may be conducted.
(f) The Office of Health Policy, at the
direction of the Commissioner, may implement internal OHP policies and
procedures at any time to ensure and improve the quality of the utilization
review program.
(8)
Fines.
(a) Failure to
comply with all applicable rales, regulations, orders and requirements of the
OHP may result in a fine of up to $300.00 per violation.
(b) Should the utilization review agent
violate a cease and desist order within one year from the issuance date,
additional fines may be assessed based on the violation. Penalties shall be
additional fines of up to $300.00 per occurrence, or may result in the
Commissioner revoking the utilization review agent's continued
approval.
