52-4-2. Utilization review; penalties.
359 words·~2 min read·
/nm/chapter-52-workers-compensation/article-4-health-care-providers/52-4-2·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
A. The director shall establish a system of peer group utilization review of selected outpatient and inpatient health care provider services to workers claiming benefits under the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978] or the New Mexico Occupational Disease Disablement Law [52-3-1 NMSA 1978]. Subject to the provisions of this section, the decisions issued pursuant to the utilization review system shall be binding on the affected health care providers, workers, employers, insurers and their representatives.
B. As used in this section, "utilization review" means an evaluation of the necessity, appropriateness, efficiency and quality of health care services provided to an injured or disabled worker based on medically accepted standards and an objective evaluation of the health care services provided.
C. The director shall also establish a system of pre-admission review of all hospital admissions, except for emergency services. Utilization review shall commence within one working day of all emergency hospital admissions.
D. The director may contract with an independent utilization review organization to provide utilization review, including peer review.
E. Nothing in this section shall prevent an employer from electing to provide his own utilization review; however, if the worker, provider or any other party not contractually bound to the employer's utilization review program disagrees with that employer's utilization review, then that worker, provider or other party shall have recourse to the workers' compensation administration's utilization review program.
F. Pursuant to utilization review conducted by the director, including providing an opportunity for a hearing, any health care provider who imposes excessive charges or renders inappropriate services shall be subject to:
(1)a forfeiture of the right to payment for those services that are found to be excessive or inappropriate or payment of excessive charges;
(2)a fine of not less than one hundred dollars ($100) or more than one thousand dollars ($1,000); or
(3)a temporary or permanent suspension of the right to provide health care services for workers' compensation or occupational disease disablement claims if the health care provider has established a pattern of violations.
History: 1978 Comp., § 52-4-2, enacted by Laws 1990 (2nd S.S.), ch. 2, § 50; 1993, ch. 193, § 8.