2007 Minnesota Statutes

176.1351 MANAGED CARE.
    Subdivision 1. Application. Any person or entity, other than a workers' compensation insurer
or an employer for its own employees, may make written application to the commissioner to have
a plan certified that provides management of quality treatment to injured workers for injuries and
diseases compensable under this chapter. Specifically, and without limitation, an entity licensed
under chapter 62C or 62D or a preferred provider organization that is subject to chapter 72A is
eligible for certification under this section. Each application for certification shall be accompanied
by a reasonable fee prescribed by the commissioner which shall be deposited in the special
compensation fund. A plan may be certified to provide services in a limited geographic area. A
certificate is valid for the period the commissioner prescribes unless revoked or suspended.
Application for certification shall be made in the form and manner and shall set forth information
regarding the proposed plan for providing services as the commissioner may prescribe. The
information shall include, but not be limited to:
(1) a list of the names of all health care providers who will provide services under the
managed care plan, together with appropriate evidence of compliance with any licensing or
certification requirements for those providers to practice in this state; and
(2) a description of the places and manner of providing services under the plan.
    Subd. 2. Certification. The commissioner shall certify a managed care plan if the
commissioner finds that the plan:
(1) proposes to provide quality services that meet uniform treatment standards prescribed by
the commissioner and all medical and health care services that may be required by this chapter in
a manner that is timely, effective, and convenient for the worker;
(2) is reasonably geographically convenient to employees it serves;
(3) provides appropriate financial incentives to reduce service costs and utilization without
sacrificing the quality of service;
(4) provides adequate methods of peer review, utilization review, and dispute resolution to
prevent inappropriate, excessive, or not medically necessary treatment, and excludes participation
in the plan by those individuals who violate these treatment standards;
(5) provides a procedure for the resolution of medical disputes;
(6) provides aggressive case management for injured workers and provides a program for
early return to work and cooperative efforts by the workers, the employer, and the managed care
plan to promote workplace health and safety consultative and other services;
(7) provides a timely and accurate method of reporting to the commissioner necessary
information regarding medical and health care service cost and utilization to enable the
commissioner to determine the effectiveness of the plan;
(8) authorizes workers to receive compensable treatment from a health care provider who is
not a member of the managed care plan, if that provider maintains the employee's medical records
and has a documented history of treatment with the employee and agrees to refer the employee to
the managed care plan for any other treatment that the employee may require and if the health
care provider agrees to comply with all the rules, terms, and conditions of the managed care plan;
(9) authorizes necessary emergency medical treatment for an injury provided by a health care
provider not a part of the managed care plan;
(10) does not discriminate against or exclude from participation in the plan any category of
health care provider and includes an adequate number of each category of health care providers
to give workers convenient geographic accessibility to all categories of providers and adequate
flexibility to choose health care providers from among those who provide services under the plan;
(11) provides an employee the right to change health care providers under the plan at least
once; and
(12) complies with any other requirement the commissioner determines is necessary to
provide quality medical services and health care to injured workers.
The commissioner may accept findings, licenses, or certifications of other state agencies as
satisfactory evidence of compliance with a particular requirement of this subdivision.
    Subd. 3. Dispute resolution. An employee must exhaust the dispute resolution procedure
of the certified managed care plan prior to filing a petition or otherwise seeking relief from the
commissioner or a compensation judge on an issue related to managed care. If an employee has
exhausted the dispute resolution procedure of the managed care plan on the issue of a rating for a
disability, the employee may seek a disability rating from a health care provider outside of the
managed care organization. The employer is liable for the reasonable fees of the outside provider
as limited by the medical fee schedule adopted under this chapter.
    Subd. 4. Access to all health care disciplines. The commissioner may refuse to certify or
may revoke or suspend the certification of a managed care plan that unfairly restricts direct access
within the managed care plan to any health care provider profession. Direct access within the
managed care plan is unfairly restricted if direct access is denied and the treatment or service
sought is within the scope of practice of the profession to which direct access is sought and is
appropriate under the standards of treatment adopted by the managed care plan or, in instances
where the commissioner has adopted standards of treatment, the standards adopted by the
commissioner.
    Subd. 5. Revocation, suspension, and refusal to certify; penalties and enforcement. (a)
The commissioner shall refuse to certify or shall revoke or suspend the certification of a managed
care plan if the commissioner finds that the plan for providing medical or health care services
fails to meet the requirements of this section, or service under the plan is not being provided in
accordance with the terms of a certified plan.
(b) In lieu of or in addition to suspension or revocation under paragraph (a), the
commissioner may, for any noncompliance with the managed care plan as certified or any
violation of a statute or rule applicable to a managed care plan, assess an administrative penalty
payable to the commissioner for deposit in the assigned risk safety account in an amount up to
$25,000 for each violation or incidence of noncompliance. The commissioner may adopt rules
necessary to implement this subdivision. In determining the level of an administrative penalty, the
commissioner shall consider the following factors:
(1) the number of workers affected or potentially affected by the violation or noncompliance;
(2) the effect or potential effect of the violation or noncompliance on workers' health, access
to health services, or workers' compensation benefits;
(3) the effect or potential effect of the violation or noncompliance on workers' understanding
of their rights and obligations under the workers' compensation law and rules;
(4) whether the violation or noncompliance is an isolated incident or part of a pattern of
violations; and
(5) the potential or actual economic benefits derived by the managed care plan or a
participating provider by virtue of the violation or noncompliance.
The commissioner shall give written notice to the managed care plan of the penalty
assessment and the reasons for the penalty. The managed care plan has 30 days from the date the
penalty notice is issued within which to file a written request for an administrative hearing and
review of the commissioner's determination pursuant to section 176.85, subdivision 1.
(c) If the commissioner, for any reason, has cause to believe that a managed care plan
has or may violate a statute or rule or a provision of the managed care plan as certified, the
commissioner may, before commencing action under paragraph (a) or (b), call a conference
with the managed care plan and other persons who may be involved in the suspected violation
or noncompliance for the purpose of ascertaining the facts relating to the suspected violation or
noncompliance and arriving at an adequate and effective means of correcting or preventing the
violation or noncompliance. The commissioner may enter into stipulated consent agreements with
the managed care plan for corrective or preventive action or the amount of the penalty to be paid.
Proceedings under this paragraph shall not be governed by any formal procedural requirements,
and may be conducted in a manner the commissioner deems appropriate under the circumstances.
(d) The commissioner may issue an order directing a managed care plan or a representative
of a managed care plan to cease and desist from engaging in any act or practice that is not in
compliance with the managed care plan as certified, or that it is in violation of an applicable
statute or rule. Within 30 days of service of the order, the managed care plan may request review
of the cease and desist order by an administrative law judge pursuant to chapter 14. The decision
of the administrative law judge shall include findings of fact, conclusions of law and appropriate
orders, which shall be the final decision of the commissioner. In the event of noncompliance
with a cease and desist order, the commissioner may institute a proceeding in district court to
obtain injunctive or other appropriate relief.
(e) A managed care plan, participating health care provider, or an employer or insurer that
receives services from the managed care plan, shall cooperate fully with an investigation by the
commissioner. For purposes of this section, cooperation includes, but is not limited to, attending a
conference called by the commissioner under paragraph (c), responding fully and promptly to any
questions relating to the subject of the investigation, and providing copies of records, reports,
logs, data, and other information requested by the commissioner to assist in the investigation.
(f) Any person acting on behalf of a managed care plan who knowingly submits false
information in any report required to be filed by a managed care plan is guilty of a misdemeanor.
    Subd. 6. Rules. The commissioner may adopt rules necessary to implement this section.
History: 1992 c 510 art 4 s 13; 1995 c 231 art 2 s 62,63; 1997 c 7 art 5 s 14,15; 2001
c 123 s 9; 2005 c 90 s 12