SENATE BILL 51
52nd legislature - STATE OF NEW MEXICO - first session, 2015
INTRODUCED BY
Carrol H. Leavell
AN ACT
RELATING TO WORKERS' COMPENSATION; AMENDING SECTIONS OF THE WORKERS' COMPENSATION ACT TO DIRECT THE WORKERS' COMPENSATION ADMINISTRATION TO ESTABLISH A FEE SCHEDULE FOR INTRASTATE AIR AMBULANCE SERVICES; ESTABLISHING PEER GROUP UTILIZATION REVIEW FOR INTRASTATE AIR AMBULANCE SERVICES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. Section 52-4-1 NMSA 1978 (being Laws 1983, Chapter 116, Section 1, as amended by Laws 2007, Chapter 325, Section 11 and by Laws 2007, Chapter 327, Section 1 and also by Laws 2007, Chapter 328, Section 3) is amended to read:
"52-4-1. DEFINITION--HEALTH CARE PROVIDER.--As used in Chapter 52 NMSA 1978, "health care provider" means:
A. a hospital maintained by the state or a political subdivision of the state or any place currently licensed as a hospital by the department of health that has:
(1) accommodations for resident bed patients;
(2) a licensed professional registered nurse always on duty or call;
(3) a laboratory; and
(4) an operating room where surgical operations are performed;
B. an optometrist licensed pursuant to the provisions of Chapter 61, Article 2 NMSA 1978;
C. a chiropractic physician licensed pursuant to the provisions of Chapter 61, Article 4 NMSA 1978;
D. a dentist licensed pursuant to the provisions of Chapter 61, Article [5] 5A NMSA 1978;
E. a physician licensed pursuant to the provisions of Chapter 61, Article 6 NMSA 1978;
F. a podiatrist licensed pursuant to the provisions of Chapter 61, Article 8 NMSA 1978;
G. an osteopathic physician licensed pursuant to the provisions of Chapter 61, Article 10 NMSA 1978;
H. a physician assistant licensed pursuant to the provisions of Section 61-6-7 NMSA 1978;
I. a certified nurse practitioner licensed pursuant to Section 61-3-23.2 NMSA 1978;
J. a physical therapist licensed pursuant to the provisions of Chapter 61, Article 12 NMSA 1978;
K. an occupational therapist licensed pursuant to the provisions of Chapter 61, Article 12A NMSA 1978;
L. a doctor of oriental medicine licensed pursuant to the provisions of Chapter 61, Article 14A NMSA 1978;
M. an athletic trainer licensed pursuant to the provisions of Chapter 61, Article 14D NMSA 1978;
N. a psychologist who is duly licensed or certified in the state where the service is rendered, holding a doctorate degree in psychology and having at least two years of clinical experience in a recognized health setting, or who has met the standards of the national register of health [services providers in psychology] service psychologists;
O. a certified nurse-midwife licensed by the board of nursing as a registered nurse and registered with the [behavioral health services] public health division of the [human services] department of health as a certified nurse-midwife;
[O.] P. a pharmacist licensed pursuant to the provisions of Chapter 61, Article 11 NMSA 1978; [or]
Q. an air ambulance provider that:
(a) does not provide proof to the director that it operates as an interstate air carrier under a certificate of authority from the United States federal aviation administration; and
(b) is certified as an air ambulance by the department of health; or
[P.] R. any person or facility that provides health-related services in the health care industry, as approved by the director."
SECTION 2. Section 52-4-2 NMSA 1978 (being Laws 1990 (2nd S.S.), Chapter 2, Section 50, as amended) is amended to read:
"52-4-2. UTILIZATION REVIEW--PENALTIES.--
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 or the New Mexico Occupational Disease Disablement Law. 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. Air ambulance services shall be subject to utilization review.
[D.] E. The director may contract with an independent utilization review organization to provide utilization review, including peer review.
[E.] F. Nothing in this section shall prevent an employer from electing to provide [his] the employer's 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.] G. 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."
SECTION 3. Section 52-4-5 NMSA 1978 (being Laws 1990 (2nd S.S.), Chapter 2, Section 52, as amended) is amended to read:
"52-4-5. FEE SCHEDULE.--
A. The director shall adopt and promulgate regulations establishing a schedule of maximum charges as deemed necessary for treatment or attendance, service, devices, apparatus or medicine provided by a health care provider. The rates in the schedules of maximum charges shall not fall below the sixtieth percentile or above the eightieth percentile of current rates for health care providers. In determining current rates for health care providers, the director shall utilize a variety of health care provider charges, including the charges of those providers serving low-income, medicare and medicaid patients.
B. A health care provider shall be paid [his] the provider's usual and customary fee for services rendered or the maximum charge established pursuant to Subsection A of this section, whichever is less. However, in no case shall the usual and customary fee exceed the maximum charge allowable.
C. The fee schedule shall be revised annually by the director.
D. No amount in excess of the amount required by Subsection B of this section for a service shall be paid by the employer, the employer's insurer, the worker, a representative of the worker or any other person to a health care provider for rendering that service in connection with an injury or disablement within the purview of the Workers' Compensation Act or the New Mexico Occupational Disease Disablement Law.
E. If it is determined by the person primarily responsible for payment that the charges of a health care provider exceed the amount established pursuant to Subsection B of this section or that a health care provider over-utilized or otherwise rendered or ordered inappropriate health care or health care services, and payment is withheld on those grounds, the health care provider may appeal to the director regarding that determination. The director shall establish by regulation procedures for an appeal by a health care provider.
F. The director shall establish an advisory committee that shall:
(1) be appointed and serve at the pleasure of the director;
(2) consist of members, a majority of whom represent health care providers;
(3) reflect the diversity of authorized licensed health care providers available for workers' compensation and occupational disease disablement cases;
(4) assist in establishing the schedules of maximum charges [under] pursuant to provisions of Subsection A of this section for any fees that are payable to health care providers;
(5) assist the director in adopting regulations for employers' utilization review procedures and the establishment and conduct of utilization review boards; and
(6) report its findings, upon request, to the director and the advisory council on workers' compensation.
G. The schedule of maximum charges specified in this section shall not apply to hospital charges. The director shall establish a separate schedule of maximum charges for hospital charges no later than April 1, 1991.
H. The director shall establish a fee schedule for air ambulance services. The maximum reasonable fee for air ambulance services shall not exceed the fee specified in the fee schedule.
[H.] I. Nothing in this section shall prevent an employer from contracting with a health care provider for fees less than the maximum charges allowable."
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