Oklahoma § 85-328 - Repealed by Laws 2013, c. 208, § 171, eff. Feb. 1, 2014

§ 85-328. Repealed by Laws 2013, c. 208, § 171, eff. Feb. 1, 2014

NOTE: Subsequent to repeal, this section was amended by Laws 2013,

c. 254, § 39 to read as follows:

A. If a self-insured employer, group self-insurance association plan, an

employer's workers' compensation insurance carrier or an insured, which shall

include any member of an approved group self-insured association,

policyholder or public entity, has contracted with a workplace medical plan

that is certified by the State Commissioner of Health as provided in this

act, the employer shall select for the injured employee a treating physician

from the physicians listed within the network of the certified workplace

medical plan. The claimant may apply to the certified workplace medical plan

for a one-time change of physician to another appropriate physician within

the network of the certified workplace medical plan by utilizing the dispute

resolution process set out in the certified workplace medical plan on file

with the State Department of Health. Notwithstanding any other provision of

law, those employees who are subject to such certified workplace medical plan

shall receive medical treatment in the manner prescribed by the plan.

B. The provisions of this section shall not preclude an employee, who

has exhausted the dispute resolution process of the certified workplace

medical plan, from petitioning the Workers' Compensation Court for a change

of treating physician within the certified workplace medical plan or, if a

physician who is qualified to treat the employee's injuries is not available

within the plan, for a change of physician outside the plan, if the physician

agrees to comply with all the rules, terms and conditions of the certified

workplace medical plan; or an employee from seeking emergency medical

treatment.

C. Any person or entity may make written application to the State

Commissioner of Health to have a workplace medical plan certified that

provides management of quality treatment to injured employees for injuries

and diseases compensable under the Workers' Compensation Code. Each

application for certification shall be accompanied by a fee of One Thousand

Five Hundred Dollars ($1,500.00). A workplace medical plan may be certified

to provide services to a limited geographic area. A certificate is valid for

a five-year period, unless revoked or suspended. Application for

certification shall be made in the form and manner and shall set forth

information regarding the proposed program 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 medical providers who will provide

services under the plan, together with appropriate evidence of compliance

Oklahoma Statutes - Title 85. Workers' Compensation

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.

D. 1. The Commissioner shall not certify a plan unless the Commissioner

finds that the plan:

a.

proposes to provide quality services for all medical services

which:

(1)

may be required by the Workers' Compensation Code in a

manner that is timely, effective and convenient for the

employee, and

(2)

utilizes medical treatment guidelines and protocols

substantially similar to those established for use by

medical service providers which have been recommended by

the Physician Advisory Committee and adopted by the

Administrator pursuant to this act. If the Administrator

has not adopted medical treatment guidelines and

protocols, the Commissioner may certify a plan that

utilizes medical guidelines and protocols established by

the plan if, at the discretion of the Commissioner, the

guidelines and protocols are reasonable and will carry out

the intent of the Workers' Compensation Code. Certified

plans must utilize medical treatment guidelines and

protocols substantially similar to those adopted by the

Administrator pursuant to this act, as such guidelines and

protocols become adopted,

b.

is reasonably geographically convenient to residents of the

area for which it seeks certification,

c.

provides appropriate financial incentives to reduce service

costs and utilization without sacrificing the quality of

service,

d.

provides adequate methods of peer review, utilization review

and dispute resolution to prevent inappropriate, excessive or

medically unnecessary treatment, and excludes participation in

the plan by those providers who violate these treatment

standards,

e.

requires the dispute resolution procedure of the plan to

include a requirement that disputes on an issue, including a

subsequent change of physician as described in the provisions

of this section, related to medical care under the plan, be

attempted to be resolved within ten (10) days of the time the

dispute arises and if not resolved within ten (10) days, the

employee may pursue remedies in the Court,

f.

provides aggressive case management for injured employees and

a program for early return to work,

g.

provides workplace health and safety consultative services,

h.

provides a timely and accurate method of reporting to the

Commissioner necessary information regarding medical service

costs and utilization to enable the Commissioner to determine

the effectiveness of the plan,

i.

authorizes necessary emergency medical treatment for an injury

provided by a provider of medical, surgical, and hospital

services who is not a part of the plan,

j.

does not discriminate against or exclude from participation in

the plan any category of providers of medical, surgical, or

hospital services and includes an adequate number of each

category of providers of medical, surgical, and hospital

Oklahoma Statutes - Title 85. Workers' Compensation

services to give participants access to all categories of

providers and does not discriminate against ethnic minority

providers of medical services, and

k.

complies with any other requirement the Commissioner

determines is necessary to provide quality medical services

and health care to injured employees.

2. The Commissioner may accept findings, licenses or certifications of

other state agencies as satisfactory evidence of compliance with a particular

requirement of this section.

E. If any insurer fails to contract with or provide access to a

certified workplace medical plan, an insured, after sixty (60) days' written

notice to its insurance carrier, shall be authorized to contract

independently with a plan of his or her choice for a period of one (1) year,

to provide medical care under the Workers' Compensation Code. The insured

shall be authorized to contract, after sixty (60) days' written notice to its

insurance carrier, for additional one-year periods if his or her insurer has

not contracted with or provided access to a certified workplace medical plan.

F. A workers' compensation insurance carrier or a group self-insurance

association plan may grant a ten-percent premium reduction to an employer who

is not experience rated when the employer participates in a certified

workplace medical plan.

G. The Commissioner shall refuse to certify or shall revoke or suspend

the certification of a plan if the Commissioner finds that the program 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 the plan.

H. The State Commissioner of Health shall implement a site visit

protocol for employees of the State Department of Health to perform an

inspection of a certified workplace medical plan to ensure that medical

services to a claimant and the medical management of the claimant's needs are

adequately met in a timely manner and that the certified workplace medical

plan is complying with all other applicable provisions of this act and the

rules of the State Department of Health. Such protocol shall include, but

not be limited to:

1. A site visit shall be made to each certified workplace medical plan

not less often than once every year, but not later than thirty (30) days

following the anniversary date of issuance of the initial or latest renewal

certificate;

2. A site visit shall conclude with a determination that a certified

workplace medical plan is or is not operating in accordance with its latest

application to the State Department of Health;

3. Compliant operations shall include, but not be limited to:

a.

timely and effective medical services available with

reasonable geographic convenience,

b.

appropriate treatment guidelines and protocols, and

c.

effective programs for utilization review, case management,

grievances, and dispute resolution;

4. Performance of a site visit shall include:

a.

inspection of organizational documentation,

b.

inspection of systems documentation and processes,

c.

random or systematic sampling of closed and open case

management cases (files),

d.

random or systematic sampling, or a one-hundred-percent

inspection of all dispute resolution, grievance, and

Department of Health request for assistance files,

e.

workplace medical plan employee and management interviews, as

appropriate;

Oklahoma Statutes - Title 85. Workers' Compensation

5. An initial site visit may occur with an interval of less than twelve

(12) months to a recently certified plan, or a site visit may occur more

often than once in every twelve (12) months if the State Commissioner of

Health has reason to suspect that a plan is not operating in accordance with

its certification;

6. If a deficient practice is identified during a site visit, the State

Department of Health shall require a certified workplace medical plan to

submit a timely and acceptable written plan of correction, and then may

perform a follow-up visit or visits to ensure that the deficient practice has

been eliminated;

7. A deficient practice that is not remedied by a certified workplace

medical plan on a timely basis shall require the State Commissioner of Health

to revoke or to suspend the certification of a plan;

8. The fees payable to the State Department of Health shall be:

a.

One Thousand Five Hundred Dollars ($1,500.00) for an initial,

annual site visit,

b.

One Thousand Dollars ($1,000.00) if a follow-up visit is

performed,

c.

separate from the once in five (5) years certification

application fee, and

d.

charged only if less than two site visits occur in a twelvemonth period; and

9. In addition to the site visit fee, employees of the State Department

of Health may charge to the certified workplace medical plan reasonable

travel and travel-related expenses for the site visit such as overnight

lodging and meals. A certified workplace medical plan shall reimburse travel

expenses to the State Department of Health at rates equal to the amounts then

currently allowed under the State Travel Reimbursement Act.

I. The State Board of Health shall adopt such rules as may be necessary

to implement the provisions of this act and this section. Such rules shall

authorize any person to petition the State Commissioner of Health for

decertification of a certified workplace medical plan for material violation

of any rules promulgated pursuant to this section.