1.1                          A bill for an act 
  1.2             relating to health; modifying the Minnesota 
  1.3             Utilization Review Act; adding criteria specifying 
  1.4             when the board of medical practice may impose 
  1.5             disciplinary action; amending Minnesota Statutes 2000, 
  1.6             sections 62M.06, subdivision 3; 62M.09, subdivisions 
  1.7             3, 3a, 6, by adding a subdivision; 62M.10, subdivision 
  1.8             7; 147.091, by adding a subdivision. 
  1.9   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.10     Section 1.  Minnesota Statutes 2000, section 62M.06, 
  1.11  subdivision 3, is amended to read: 
  1.12     Subd. 3.  [STANDARD APPEAL.] The utilization review 
  1.13  organization must establish procedures for appeals to be made 
  1.14  either in writing or by telephone. 
  1.15     (a) A utilization review organization shall notify in 
  1.16  writing the enrollee, attending health care professional, and 
  1.17  claims administrator of its determination on the appeal within 
  1.18  30 days upon receipt of the notice of appeal.  If the 
  1.19  utilization review organization cannot make a determination 
  1.20  within 30 days due to circumstances outside the control of the 
  1.21  utilization review organization, the utilization review 
  1.22  organization may take up to 14 additional days to notify the 
  1.23  enrollee, attending health care professional, and claims 
  1.24  administrator of its determination.  If the utilization review 
  1.25  organization takes any additional days beyond the initial 30-day 
  1.26  period to make its determination, it must inform the enrollee, 
  1.27  attending health care professional, and claims administrator, in 
  2.1   advance, of the extension and the reasons for the extension. 
  2.2      (b) The documentation required by the utilization review 
  2.3   organization may include copies of part or all of the medical 
  2.4   record and a written statement from the attending health care 
  2.5   professional. 
  2.6      (c) Prior to upholding the initial determination not to 
  2.7   certify for clinical reasons, the utilization review 
  2.8   organization shall conduct a review of the documentation by a 
  2.9   physician who did not make the initial determination not to 
  2.10  certify. 
  2.11     (d) The process established by a utilization review 
  2.12  organization may include defining a period within which an 
  2.13  appeal must be filed to be considered.  The time period must be 
  2.14  communicated to the enrollee and attending health care 
  2.15  professional when the initial determination is made. 
  2.16     (e) An attending health care professional or enrollee who 
  2.17  has been unsuccessful in an attempt to reverse a determination 
  2.18  not to certify shall, consistent with section 72A.285, be 
  2.19  provided the following: 
  2.20     (1) a complete summary of the review findings; 
  2.21     (2) qualifications of the reviewers, including any license, 
  2.22  certification, or specialty designation; and 
  2.23     (3) the relationship between the enrollee's diagnosis and 
  2.24  the review criteria used as the basis for the decision, 
  2.25  including the specific rationale for the reviewer's decision. 
  2.26     (f) In cases of appeal to reverse a determination not to 
  2.27  certify for clinical reasons, the utilization review 
  2.28  organization must, upon request of the attending health care 
  2.29  professional, ensure that a physician of the utilization review 
  2.30  organization's choice in the same or a similar general specialty 
  2.31  as typically manages the medical condition, procedure, or 
  2.32  treatment under discussion is reasonably available to review the 
  2.33  case. 
  2.34     (g) If the initial determination is not reversed on appeal, 
  2.35  the utilization review organization must include in its 
  2.36  notification the right to submit the appeal to the external 
  3.1   review process described in section 62Q.73 and the procedure for 
  3.2   initiating the external process. 
  3.3      Sec. 2.  Minnesota Statutes 2000, section 62M.09, 
  3.4   subdivision 3, is amended to read: 
  3.5      Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] (a) A physician 
  3.6   must review all cases in which the utilization review 
  3.7   organization has concluded that a determination not to certify 
  3.8   for clinical reasons is appropriate.  
  3.9      (b) The physician conducting the review must be licensed in 
  3.10  this state.  This paragraph does not apply to reviews conducted 
  3.11  in connection with policies issued by a health plan company that 
  3.12  is assessed less than three percent of the total amount assessed 
  3.13  by the Minnesota comprehensive health association.  
  3.14     (c) The physician should be reasonably available by 
  3.15  telephone to discuss the determination with the attending health 
  3.16  care professional.  
  3.17     (d) This subdivision does not apply to outpatient mental 
  3.18  health or substance abuse services governed by subdivision 3a. 
  3.19     Sec. 3.  Minnesota Statutes 2000, section 62M.09, 
  3.20  subdivision 3a, is amended to read: 
  3.21     Subd. 3a.  [MENTAL HEALTH AND SUBSTANCE ABUSE REVIEWS.] A 
  3.22  peer of the treating mental health or substance abuse provider 
  3.23  or a physician must review requests for outpatient services in 
  3.24  which the utilization review organization has concluded that a 
  3.25  determination not to certify a mental health or substance abuse 
  3.26  service for clinical reasons is appropriate, provided that any 
  3.27  final determination not to certify treatment is made by a 
  3.28  psychiatrist certified by the American Board of Psychiatry and 
  3.29  Neurology and appropriately licensed in the this state in which 
  3.30  the psychiatrist resides.  Notwithstanding the notification 
  3.31  requirements of section 62M.05, a utilization review 
  3.32  organization that has made an initial decision to certify in 
  3.33  accordance with the requirements of section 62M.05 may elect to 
  3.34  provide notification of a determination to continue coverage 
  3.35  through facsimile or mail.  This subdivision does not apply to 
  3.36  determinations made in connection with policies issued by a 
  4.1   health plan company that is assessed less than three percent of 
  4.2   the total amount assessed by the Minnesota comprehensive health 
  4.3   association. 
  4.4      Sec. 4.  Minnesota Statutes 2000, section 62M.09, 
  4.5   subdivision 6, is amended to read: 
  4.6      Subd. 6.  [PHYSICIAN CONSULTANTS.] A utilization review 
  4.7   organization must use physician consultants in the appeal 
  4.8   process described in section 62M.06, subdivision 3.  The 
  4.9   physician consultants should include, as needed and available, 
  4.10  specialists who are must be board-certified, or board-eligible 
  4.11  and working towards certification, in a specialty board approved 
  4.12  by the American Board of Medical Specialists or the American 
  4.13  Board of Osteopathy. 
  4.14     Sec. 5.  Minnesota Statutes 2000, section 62M.09, is 
  4.15  amended by adding a subdivision to read: 
  4.16     Subd. 9.  [ANNUAL REPORT.] A utilization review 
  4.17  organization shall file an annual report with the annual 
  4.18  financial statement it submits to the commissioner of commerce 
  4.19  that includes: 
  4.20     (1) per 1,000 claims, the number and rate of claims denied 
  4.21  based on medical necessity for each procedure or service; and 
  4.22     (2) the number and rate of denials overturned on appeal. 
  4.23     Sec. 6.  Minnesota Statutes 2000, section 62M.10, 
  4.24  subdivision 7, is amended to read: 
  4.25     Subd. 7.  [AVAILABILITY OF CRITERIA.] Upon request, a 
  4.26  utilization review organization shall provide to an enrollee or 
  4.27  to a, a provider, and the commissioner of commerce the criteria 
  4.28  used for a specific procedure to determine the medical 
  4.29  necessity, appropriateness, and efficacy of that a procedure or 
  4.30  service and identify the database, professional treatment 
  4.31  guideline, or other basis for the criteria. 
  4.32     Sec. 7.  Minnesota Statutes 2000, section 147.091, is 
  4.33  amended by adding a subdivision to read: 
  4.34     Subd. 1b.  [UTILIZATION REVIEW.] The board may investigate 
  4.35  allegations and impose disciplinary action as described in 
  4.36  section 147.141 against a physician performing utilization 
  5.1   review for a pattern of failure to exercise that degree of care 
  5.2   that a physician reviewer of ordinary prudence making 
  5.3   utilization review determinations for a utilization review 
  5.4   organization would use under the same or similar circumstances.  
  5.5   As part of its investigative process, the board shall receive 
  5.6   consultation or recommendation from physicians who are currently 
  5.7   engaged in utilization review activities.  The internal and 
  5.8   external review processes under sections 62M.06 and 62Q.73 must 
  5.9   be exhausted prior to an allegation being brought under this 
  5.10  subdivision.  Nothing in this subdivision creates, modifies, or 
  5.11  changes existing law related to tort liability for medical 
  5.12  negligence.  Nothing in this subdivision preempts state peer 
  5.13  review law protection in accordance with sections 145.61 to 
  5.14  145.67, federal peer review law, or current law pertaining to 
  5.15  complaints or appeals.