Assembly Bill No. 470–Assemblymen Goldwater and Buckley

March 10, 1999

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Referred to Committee on Commerce and Labor

 

SUMMARY—Makes various changes concerning provision of benefits for workers’ compensation. (BDR 53-1298)

FISCAL NOTE: Effect on Local Government: No.

Effect on the State or on Industrial Insurance: Yes.

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EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted. Green numbers along left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15).

 

AN ACT relating to workers’ compensation; prohibiting organizations for managed care that provide medical and health care services to injured employees from engaging in certain practices that restrict the actions of a provider of health care; requiring a response to a request for prior authorization for medical treatment to be issued within a certain number of days; allowing an injured employee whose employer’s insurer has entered into a contract with an organization for managed care or providers of health care to change treating physicians or chiropractors under certain circumstances; allowing hearing officers and appeals officers to refer an injured employee to a physician or chiropractor to determine the necessity of certain medical treatment; and providing other matters properly relating thereto.

 

THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:

1-1 Section 1. Chapter 616B of NRS is hereby amended by adding thereto

1-2 the provisions set forth as sections 2, 3 and 4 of this act.

1-3 Sec. 2. An organization for managed care shall not restrict or

1-4 interfere with any communication between a provider of health care and

1-5 an injured employee regarding any information that the provider of

1-6 health care determines is relevant to the health care of the injured

1-7 employee.

1-8 Sec. 3. An organization for managed care shall not terminate a

1-9 contract with, demote, refuse to contract with or refuse to compensate a

1-10 provider of health care solely because the provider, in good faith:

1-11 1. Advocates in private or in public on behalf of an injured

1-12 employee;

2-1 2. Assists an injured employee in seeking reconsideration of a

2-2 determination by the organization for managed care to deny coverage for

2-3 a medical or health care service; or

2-4 3. Reports a violation of law to an appropriate authority.

2-5 Sec. 4. 1. An organization for managed care shall not offer or pay

2-6 any type of material inducement, bonus or other financial incentive to a

2-7 provider of health care to deny, reduce, withhold, limit or delay specific

2-8 medically necessary medical or health care services to an injured

2-9 employee.

2-10 2. The provisions of this section do not prohibit an arrangement for

2-11 payment between an organization for managed care and a provider of

2-12 health care that uses financial incentives, if the arrangement is designed

2-13 to provide an incentive to the provider of health care to use medical and

2-14 health care services effectively and consistently in the best interest of the

2-15 treatment of the injured employee.

2-16 Sec. 5. NRS 616B.515 is hereby amended to read as follows:

2-17 616B.515 1. Except as otherwise provided in NRS 616B.518, the

2-18 manager may enter into a contract or contracts with one or more

2-19 organizations for managed care, including health maintenance

2-20 organizations, to provide comprehensive medical and health care services

2-21 to injured employees whose employers are insured by the system for

2-22 injuries and diseases that are compensable under chapters 616A to 617,

2-23 inclusive, of NRS. The contract or contracts must be awarded pursuant to

2-24 reasonable competitive bidding procedures as established by the manager.

2-25 2. After the selection of an organization for managed care, the bids

2-26 received by the manager and the records related to the bidding are subject

2-27 to review by any member of the public upon request.

2-28 3. An organization for managed care or a health maintenance

2-29 organization [shall] chosen pursuant to this section:

2-30 (a) Shall not discriminate against or exclude a provider of health care

2-31 from participation in the organization’s proposed plan for providing

2-32 medical and health care services because of race, creed, sex, national

2-33 origin, age or disability.

2-34 (b) Shall comply with the provisions of sections 2, 3 and 4 of this act.

2-35 Sec. 6. NRS 616B.527 is hereby amended to read as follows:

2-36 616B.527 A self-insured employer, an association of self-insured

2-37 public or private employers or a private carrier may:

2-38 1. Enter into a contract or contracts with one or more organizations for

2-39 managed care to provide comprehensive medical and health care services to

2-40 employees for injuries and diseases that are compensable pursuant to

2-41 chapters 616A to 617, inclusive, of NRS.

2-42 2. Enter into a contract or contracts with providers of health care,

2-43 including, without limitation, physicians who provide primary care,

3-1 specialists, pharmacies, physical therapists, radiologists, nurses, diagnostic

3-2 facilities, laboratories, hospitals and facilities that provide treatment to

3-3 outpatients, to provide medical and health care services to employees for

3-4 injuries and diseases that are compensable pursuant to chapters 616A to

3-5 617, inclusive, of NRS.

3-6 3. Use the services of an organization for managed care that has

3-7 entered into a contract with the manager pursuant to NRS 616B.515, but is

3-8 not required to use such services.

3-9 4. Require employees to obtain medical and health care services for

3-10 their industrial injuries from those organizations and persons with whom

3-11 the self-insured employer, association or private carrier has contracted

3-12 pursuant to subsections 1 and 2, or as the self-insured employer, association

3-13 or private carrier otherwise prescribes.

3-14 5. Require employees to obtain the approval of the self-insured

3-15 employer, association or private carrier before obtaining medical and health

3-16 care services for their industrial injuries from a provider of health care who

3-17 has not been previously approved by the self-insured employer, association

3-18 or private carrier.

3-19 6. An organization for managed care with whom a self-insured

3-20 employer, association of self-insured public or private employers or a

3-21 private carrier has contracted pursuant to this section shall comply with

3-22 the provisions of sections 2, 3 and 4 of this act.

3-23 Sec. 7. Chapter 616C of NRS is hereby amended by adding thereto a

3-24 new section to read as follows:

3-25 1. An insurer, organization for managed care or third-party

3-26 administrator shall respond to a written request for prior authorization

3-27 for:

3-28 (a) Treatment;

3-29 (b) Diagnostic testing; or

3-30 (c) Consultation,

3-31 within 5 working days after receiving the written request.

3-32 2. If the insurer, organization for managed care or third-party

3-33 administrator fails to respond to such a request within 5 working days,

3-34 authorization shall be deemed to be given. The insurer, organization for

3-35 managed care or third-party administrator may subsequently deny

3-36 authorization.

3-37 3. If the insurer, organization for managed care or third-party

3-38 administrator subsequently denies a request for authorization submitted

3-39 by a provider of health care for additional visits or treatments, it shall

3-40 pay for the additional visits or treatments actually provided to the injured

3-41 employee, up to the number of treatments for which payment is requested

3-42 by the provider of health care before the denial of authorization is

3-43 received by the provider.

4-1 Sec. 8. NRS 616C.090 is hereby amended to read as follows:

4-2 616C.090 1. The administrator shall establish a panel of physicians

4-3 and chiropractors who have demonstrated special competence and interest

4-4 in industrial health to treat injured employees under chapters 616A to

4-5 616D, inclusive, of NRS. Every employer whose insurer has not entered

4-6 into a contract with an organization for managed care or with providers of

4-7 health care services pursuant to NRS 616B.515 or 616B.527 shall

4-8 maintain a list of those physicians and chiropractors on the panel who are

4-9 reasonably accessible to his employees.

4-10 2. An injured employee whose employer’s insurer has not entered into

4-11 a contract with an organization for managed care or with providers of

4-12 health care services pursuant to NRS 616B.515 or 616B.527 may choose

4-13 his treating physician or chiropractor from the panel of physicians and

4-14 chiropractors. If the injured employee is not satisfied with the first

4-15 physician or chiropractor he so chooses, he may make an alternative choice

4-16 of physician or chiropractor from the panel if the choice is made within 90

4-17 days after his injury. The insurer shall notify the first physician or

4-18 chiropractor in writing. The notice must be postmarked within 3 working

4-19 days after the insurer receives knowledge of the change. The first physician

4-20 or chiropractor must be reimbursed only for the services he rendered to the

4-21 injured employee up to and including the date of notification. Any further

4-22 change is subject to the approval of the insurer, which must be granted or

4-23 denied within 10 days after a written request for such a change is received

4-24 from the injured employee. If no action is taken on the request within 10

4-25 days, the request shall be deemed granted. Any request for a change of

4-26 physician or chiropractor must include the name of the new physician or

4-27 chiropractor chosen by the injured employee.

4-28 3. An injured employee [employed or residing in any county in this

4-29 state] whose employer’s insurer has entered into a contract with an

4-30 organization for managed care or with providers of health care services

4-31 pursuant to NRS 616B.515 or 616B.527 must choose his treating

4-32 physician or chiropractor pursuant to the terms of that contract. If the

4-33 injured employee is not satisfied with the first physician or chiropractor

4-34 he so chooses, he may make an alternative choice of physician or

4-35 chiropractor pursuant to the terms of the contract if the choice is made

4-36 within 90 days after his injury. If the injured employee, after choosing his

4-37 treating physician or chiropractor, moves to a county which is not served by

4-38 the organization for managed care or providers of health care named in

4-39 the contract and the insurer determines that it is impractical for the injured

4-40 employee to continue treatment with the physician or chiropractor, the

4-41 injured employee must choose a treating physician or chiropractor who has

4-42 agreed to the terms of that contract unless the insurer authorizes the injured

4-43 employee to choose another physician or chiropractor.

5-1 4. Except when emergency medical care is required and except as

5-2 otherwise provided in NRS 616C.055, the insurer is not responsible for any

5-3 charges for medical treatment or other accident benefits furnished or

5-4 ordered by any physician, chiropractor or other person selected by the

5-5 injured employee in disregard of the provisions of this section or for any

5-6 compensation for any aggravation of the injured employee’s injury

5-7 attributable to improper treatments by such physician, chiropractor or other

5-8 person.

5-9 5. The administrator may order necessary changes in a panel of

5-10 physicians and chiropractors and shall suspend or remove any physician or

5-11 chiropractor from a panel for good cause shown.

5-12 6. An injured employee may receive treatment by more than one

5-13 physician or chiropractor if the insurer provides written authorization for

5-14 such treatment.

5-15 Sec. 9. NRS 616C.305 is hereby amended to read as follows:

5-16 616C.305 1. Except as otherwise provided in subsection 3, any

5-17 person who is aggrieved by a [decision] final determination concerning

5-18 accident benefits made by an organization for managed care which has

5-19 contracted with an insurer must, within 14 days of the [decision]

5-20 determination and before requesting a resolution of the dispute pursuant to

5-21 NRS 616C.345 to 616C.385, inclusive, appeal that [decision]

5-22 determination in accordance with the procedure for resolving complaints

5-23 established by the organization for managed care.

5-24 2. The procedure for resolving complaints established by the

5-25 organization for managed care must be informal and must include, but is

5-26 not limited to, a review of the appeal by a qualified physician or

5-27 chiropractor who did not make or otherwise participate in making the

5-28 [decision.] determination.

5-29 3. If a person appeals a final determination pursuant to a procedure for

5-30 resolving complaints established by an organization for managed care and

5-31 the dispute is not resolved within 14 days after it is submitted, he may

5-32 request a resolution of the dispute pursuant to NRS 616C.345 to 616C.385,

5-33 inclusive.

5-34 Sec. 10. NRS 616C.330 is hereby amended to read as follows:

5-35 616C.330 1. The hearing officer shall:

5-36 (a) Within 5 days after receiving a request for a hearing, set the hearing

5-37 for a date and time within 30 days after his receipt of the request;

5-38 (b) Give notice by mail or by personal service to all interested parties to

5-39 the hearing at least 15 days before the date and time scheduled; and

5-40 (c) Conduct hearings expeditiously and informally.

5-41 2. The notice must include a statement that the injured employee may

5-42 be represented by a private attorney or seek assistance and advice from the

5-43 Nevada attorney for injured workers.

6-1 3. If necessary to resolve a medical question concerning an injured

6-2 employee’s condition [,] or to determine the necessity of treatment for

6-3 which authorization for payment has been denied, the hearing officer may

6-4 refer the employee to a physician or chiropractor chosen by the hearing

6-5 officer. If the medical question concerns the rating of a permanent

6-6 disability, the hearing officer may refer the employee to a rating physician

6-7 or chiropractor. The rating physician or chiropractor must be selected in

6-8 rotation from the list of qualified physicians and chiropractors maintained

6-9 by the administrator pursuant to subsection 2 of NRS 616C.490, unless the

6-10 insurer and injured employee otherwise agree to a rating physician or

6-11 chiropractor. The insurer shall pay the costs of any medical examination

6-12 requested by the hearing officer.

6-13 4. The hearing officer may allow or forbid the presence of a court

6-14 reporter and the use of a tape recorder in a hearing.

6-15 5. The hearing officer shall render his decision within 15 days after:

6-16 (a) The hearing; or

6-17 (b) He receives a copy of the report from the medical examination he

6-18 requested.

6-19 6. The hearing officer shall render his decision in the most efficient

6-20 format developed by the chief of the hearings division of the department of

6-21 administration.

6-22 7. The hearing officer shall give notice of his decision to each party by

6-23 mail. He shall include with the notice of his decision the necessary forms

6-24 for appealing from the decision.

6-25 8. Except as otherwise provided in NRS 616C.380, the decision of the

6-26 hearing officer is not stayed if an appeal from that decision is taken unless

6-27 an application for a stay is submitted by a party. If such an application is

6-28 submitted, the decision is automatically stayed until a determination is

6-29 made on the application. A determination on the application must be made

6-30 within 30 days after the filing of the application. If, after reviewing the

6-31 application, a stay is not granted by the hearing officer or an appeals

6-32 officer, the decision must be complied with within 10 days after the refusal

6-33 to grant a stay.

6-34 Sec. 11. NRS 616C.345 is hereby amended to read as follows:

6-35 616C.345 1. Any party aggrieved by a decision of the hearing officer

6-36 relating to a claim for compensation may appeal from the decision by filing

6-37 a notice of appeal with an appeals officer within 30 days after the date of

6-38 the decision.

6-39 2. If a dispute is required to be submitted to a procedure for resolving

6-40 complaints pursuant to NRS 616C.305 and:

6-41 (a) A final [decision] determination was rendered pursuant to that

6-42 procedure; or

7-1 (b) The dispute was not resolved pursuant to that procedure within 14

7-2 days after it was submitted,

7-3 any party to the dispute may file a notice of appeal within 70 days after the

7-4 date on which the final [decision] determination was mailed to the

7-5 employee, or his dependent, or the unanswered request for resolution was

7-6 submitted. Failure to render a written [decision] determination within 30

7-7 days after receipt of such a request shall be deemed by the appeals officer

7-8 to be a denial of the request.

7-9 3. Except as otherwise provided in NRS 616C.380, the filing of a

7-10 notice of appeal does not automatically stay the enforcement of the decision

7-11 of a hearing officer or a [decision] determination rendered pursuant to

7-12 NRS 616C.305. The appeals officer may order a stay, when appropriate,

7-13 upon the application of a party. If such an application is submitted, the

7-14 decision is automatically stayed until a determination is made concerning

7-15 the application. A determination on the application must be made within 30

7-16 days after the filing of the application. If a stay is not granted by the officer

7-17 after reviewing the application, the decision must be complied with within

7-18 10 days after the date of the refusal to grant a stay.

7-19 4. Except as otherwise provided in this subsection, the appeals officer

7-20 shall, within 10 days after receiving a notice of appeal pursuant to this

7-21 section or a contested claim pursuant to subsection 5 of NRS 616C.315,

7-22 schedule a hearing on the merits of the appeal or contested claim for a date

7-23 and time within 90 days after his receipt of the notice and give notice by

7-24 mail or by personal service to all parties to the matter and their attorneys or

7-25 agents at least 30 days before the date and time scheduled. A request to

7-26 schedule the hearing for a date and time which is:

7-27 (a) Within 60 days after the receipt of the notice of appeal or contested

7-28 claim; or

7-29 (b) More than 90 days after the receipt of the notice or claim,

7-30 may be submitted to the appeals officer only if all parties to the appeal or

7-31 contested claim agree to the request.

7-32 5. An appeal or contested claim may be continued upon written

7-33 stipulation of all parties, or upon good cause shown.

7-34 6. Failure to file a notice of appeal within the period specified in

7-35 subsection 1 or 2 may be excused if the party aggrieved shows by a

7-36 preponderance of the evidence that he did not receive the notice of the

7-37 [decision] determination and the forms necessary to appeal the [decision.]

7-38 determination. The claimant, employer or insurer shall notify the hearing

7-39 officer of a change of address.

7-40 Sec. 12. NRS 616C.360 is hereby amended to read as follows:

7-41 616C.360 1. A stenographic or electronic record must be kept of the

7-42 hearing before the appeals officer and the rules of evidence applicable to

7-43 contested cases under chapter 233B of NRS apply to the hearing.

8-1 2. The appeals officer must hear any matter raised before him on its

8-2 merits, including new evidence bearing on the matter.

8-3 3. If necessary to resolve a medical question concerning an injured

8-4 employee’s condition [,] or to determine the necessity of treatment for

8-5 which authorization for payment has been denied, the appeals officer may

8-6 refer the employee to a physician or chiropractor chosen by the appeals

8-7 officer. If the medical question concerns the rating of a permanent

8-8 disability, the appeals officer may refer the employee to a rating physician

8-9 or chiropractor. The rating physician or chiropractor must be selected in

8-10 rotation from the list of qualified physicians or chiropractors maintained by

8-11 the administrator pursuant to subsection 2 of NRS 616C.490, unless the

8-12 insurer and the injured employee otherwise agree to a rating physician or

8-13 chiropractor. The insurer shall pay the costs of any examination requested

8-14 by the appeals officer.

8-15 4. Any party to the appeal or the appeals officer may order a transcript

8-16 of the record of the hearing at any time before the seventh day after the

8-17 hearing. The transcript must be filed within 30 days after the date of the

8-18 order unless the appeals officer otherwise orders.

8-19 5. The appeals officer shall render his decision:

8-20 (a) If a transcript is ordered within 7 days after the hearing, within 30

8-21 days after the transcript is filed; or

8-22 (b) If a transcript has not been ordered, within 30 days after the date of

8-23 the hearing.

8-24 6. The appeals officer may affirm, modify or reverse any decision

8-25 made by the hearing officer and issue any necessary and proper order to

8-26 give effect to his decision.

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