Managed
Care Organizations
(Representative
Clients/ Legal Projects, Attorneys)
Are quality
management activities shielded from discovery in a lawsuit?
Up to now, Colorado law protected the confidentiality solely of
physician peer review carried out by federally-qualified HMOs.
This protection is found in Rule 360 of the Colorado Board of
Medical Examiners. Under that Rule, professional review committees
established by HMOs are approved professional review committees
under the Professional Review of Health Care Providers Act, CRS §
12-36.5-101 et seq. However, in order to obtain the immunities of
the Act, an HMO must meet all of the process requirements in the
Act.
As of April 17, Colorado law protects the confidentiality of
all quality management activities (not involving physician peer
review) undertaken by any health carrier (not just HMOs). H.B.
03-1255, enacted during the 2003 legislative session, extends the
protection previously available only to health care facilities for
quality management activities, to both health carriers and
professional practices. Confidential quality management records,
reports and other information are expressly protected from
discovery in any civil or administrative proceeding. Moreover,
persons participating in the reporting, collection, evaluation or
use of quality management information may not testify regarding
such information in any civil or administrative proceeding. The
new law is codified as part of CRS § 25-3-109. All of the
provisions (and exceptions) of the section apply to health
carriers.
What are the benefits of conducting an in-house self audit prior to a DOI market conduct examination?
Division of Insurance (“DOI”) market conduct examinations are frequently “eye openers” regarding the nuances of the insurance laws and how just a few words can make the difference between compliance and noncompliance. The difference only becomes clear after the DOI provides its rationale in its report. While a health plan’s compliance analyst is usually well-versed in state insurance laws, that person, after repeated modifications to the same basic forms and policies, soon loses the keen eye to the potentially troublesome details. It takes an objective review by a knowledgeable third person to uncover the outmoded definition, or the missed procedural step, or the ambiguous phrasing on which DOI fines are based. The value of a self audit before the DOI conducts its examination is that the health plan will have the opportunity to consider and correct an area of noncompliance before the DOI schedules the health plan’s next examination. Because DOI market conduct examinations usually concentrate on policies and forms in use for one full calendar year prior to the examination, the DOI may never review the non-compliant policies and forms, and fines may be avoided. Even if a DOI market conduct examination follows closely behind a self audit, the value of the self audit still is not lost because the Commissioner of Insurance has stated that he is less apt to impose punitive fines when companies self-evaluate and correct their practices.
Representative
Clients/ Legal Projects, Attorneys
Managed Care Organizations/Insurance Plans (HMOs, PPOs, PIP Networks, Uninsured Plans)
- Administrative and Legislative Matters – State
- Bond Financing – Health Care
- Civil and Criminal Health Care Investigations
- Corporate Law and Business Organization
- Compliance Training
- Contract Drafting and Review
- Credentialing
- DOI Audit Preparation and Review
- Honda motorcycles miami dealer Hospital and Health Care Facility Representation
- Human Resources Law
- Intellectual Property Law
- Litigation
- Managed Care
- Medical Records Management
- Medical Staff Relations
- Mergers
- Medical Records Confidentialing and Release
- Mock DOI Audits
- Physician Networks, Provider Networks and Integrated Delivery Systems
- Physician Recruitment and Retention
- PIP Litigationü Provider Contracting
- Provider Discipline
- Regulatory Compliance
- Reorganizations
- Risk Management/Professional and General Liability
- State License
- Tax Law Issues – Health Care
- Third Party Payor, Licensing Issues, Credentialing and Certification Issues
Attorneys practicing in this area:
Wallis S. Stromberg, Henry C.
Cleveland, III, Barbara L.
Crawford, Michael M. Schmidt,
Paul D. Godec, Taylor T.
Pollock, Peter C. Middleton
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