44-510j.Medical benefits; fee disputes; utilizationand peer review.When an employer's insurance carrier or a self-insured employerdisputes all or a portion of a billfor services rendered for the care and treatment of an employee under this act,the followingprocedures apply:
(a) (1) The employer or carrier shall notify the service provider within 30days of receiptof the bill of the specific reason for refusing payment or adjusting the bill.Such notice shallinform the service provider that additional information may be submittedwith the bill andreconsideration of the bill may be requested. The provider shall send anyrequest forreconsideration within 30 days of receiving written notice of the bill dispute.If the employer orcarrier continues to dispute all or a portion of the bill after receivingadditional information fromthe provider, the employer, carrier or provider may apply for an informalhearing before thedirector.
(2) If a provider sends a bill to such employer or carrier and receivesno responsewithin 30 days as allowed in subsection (a) and if a provider sends a secondbill and receives noresponse within 60 days of the date the provider sent the first bill, theprovider may apply for aninformal hearing before the director.
(3) Payments shall not be delayed beyond 60 days for any amounts not indispute. Acceptanceby anyprovider of a payment amount which is less than the full amount charged for theservices shallnot affect the right to have a review of the claim for the outstanding orremaining amounts.
(b) The application for informal hearing shall include copies of the disputedbills, allcorrespondence concerning the bills and any additional written information theparty deemsappropriate. When anyone applies for an informal hearing before the director,copies of theapplication shall be sent to all parties to the dispute and the employee.Within 20 days ofreceiving the application for informal hearing, the other parties to thedispute shall send anyadditional written information deemed relevant to the dispute to the director.
(c) The director or the director's designee shall hold the informal hearingto hear anddetermine all disputes as to such bills and interest due thereon. Evidence inthe informal hearingshall be limited to the written submissions of the parties. The informalhearing may be held byelectronic means. Any employer, carrier or provider may personally appear in orbe representedat the hearing. If the parties are unable to reach a settlement regarding thedispute, the officerhearing the dispute shall enter an order so stating.
(d) After the entry of the order indicating that the parties have not settledthe dispute afterthe informal hearing, the director shall schedule a formal hearing.
(1) Prior to the date of the formal hearing, the director may conduct autilizationreview concerning the disputed bill. The director shall develop and implement,or contract with aqualified entity to develop and implement, utilization review proceduresrelating to the servicesrendered by providers and facilities, which services are paid for in whole orin part pursuant tothe workers compensation act. The director may contract with one or moreprivate foundations ororganizations to provide utilization review of service providers pursuant tothe workerscompensation act. Such utilization review shall result in a report to thedirector indicating whether a provider improperly utilized or otherwiserendered or ordered unjustified treatment orservices or that the fees for such treatment or services were excessive and astatement of the basisfor the report's conclusions. After receiving the utilization review report,the director also may order a peer review. A copy of such reports shall beprovided to allparties to the dispute at least 20 daysprior to the formal hearing. No person shall be subject to civil liability forlibel, slander or anyother relevant tort cause of action by virtue of performing a peer orutilizationreviewunder contract withthe director.
(2) The formal hearing shall be conducted by hearing officers, the medicaladministrator orboth asappointed bythe director.During the formal hearing parties to the dispute shall have the rightto appear or berepresented and may produce witnesses, including expert witnesses, and suchother relevantevidence as may be otherwise allowed under the workers compensation act. Ifthe director findsthat a provider or facility has made excessive charges or provided or orderedunjustifiedtreatment, services, hospitalization or visits, the provider or facility may,subject to the director's order, receive paymentpursuant to this section from the carrier, employer or employee for theexcessive fees orunjustified treatment, services, hospitalization or visits and such providermay be ordered to repay any fees orcharges collected therefor. If it is determined after the formal hearing that aprovider improperlyutilized or otherwise rendered or ordered unjustified treatment or services orthat the fees forsuch treatment or services were excessive, the director may provide a reportto the licensingboard of the service provider with full documentation of any suchdetermination, except that nosuch report shall be provided until after judicial review if the order isappealed. Any decisionrendered under this section may be reviewed by the workers compensation board.A party must file a notice of appeal within 10 days of the issuance of anydecision under this section. The record on appeal shall be limited only to theevidence presented to the hearing officer. The decision of the directorshall be affirmed unless the board determines that the decision was notsupported by substantial competent evidence.
(e) By accepting payment pursuant to this section for treatment or servicesrendered to aninjured employee, the provider shall be deemed to consent to submittingall necessaryrecords to substantiate the nature and necessity of the service or charge andother informationconcerning such treatment to utilization review under this section. Suchhealth care providershall comply with any decision of the director pursuant to this section.
(f) Except as provided in K.S.A. 60-437 and amendments thereto and thissection,findings and records which relate to utilization and peer review conductedpursuant tothis sectionshall be privilegedand shall not besubject to discovery, subpoena or other means of legal compulsion for releaseto any person orentity and shall not be admissible in evidence in any judicial oradministrative proceeding, exceptthose proceedings authorized pursuant to this section. In any proceedings wherethere is anapplication by an employee, employer, insurance carrier or the workerscompensationfund for ahearing pursuant to K.S.A. 44-534a, and amendments thereto, for a change ofmedical benefitswhich has been filed after a health care provider, employer, insurance carrieror the workerscompensation fund has made application to the medical services section of thedivision for theresolution of a dispute or matter pursuant to the provisions of this section,all reports, information, statements, memoranda, proceedings, findingsand recordswhich relate to utilization and peer review including the records of contractreviewersand findings and records of the medical servicessection of thedivision shall be admissible at the hearing before the administrative law judgeon the issue of themedical benefits to which an employee is entitled.
(g) A provider may not improperly overcharge or charge for services whichwere not provided for the purpose of obtaining additional payment. Any disputeregarding such actionsshall be resolved in the same manner as other bill disputes as provided bythis section. Anyviolation of the provisions of this section or K.S.A. 44-510i, andamendments thereto, which is willful or which demonstrates a pattern ofimproperly charging or overcharging for services rendered pursuant to this actconstitutesgrounds for the director to impose a civil fine not to exceed $5,000. Any civilfine imposed underthis section shall be subject to reviewby the board. Allmoneys received forcivil fines imposed under this section shall be deposited in the state treasuryto the credit of theworkers compensation fund.
(h) Any health care provider, nurse, physical therapist, any entity providingmedical,physical or vocational rehabilitation services or providing reeducation ortraining pursuant toK.S.A. 44-510g and amendments thereto, medical supply establishment, surgicalsupplyestablishment, ambulance service or hospital which accept the terms of theworkers compensationact by providing services or material thereunder shall be bound by the feesapproved by thedirector and no injured employee or dependent of a deceased employee shall beliable for anycharges above the amounts approved by the director. If the employer hasknowledge of the injuryand refuses or neglects to reasonably provide the services of a health careprovider required bythis act, the employee may provide the same for such employee, and the employershall be liablefor such expenses subject to the regulations adopted by the director. No actionshall be filed inany court by a health care provider or other provider of services under thisact for the payment ofan amount for medical services or materials provided under the workerscompensation act and noother action to obtain or attempt to obtain or collect such payment shall betaken by a health careprovider or other provider of services under this act, including employing anycollection service,until after final adjudication of any claim for compensation for which anapplication for hearingis filed with the director under K.S.A. 44-534 and amendments thereto. In thecase of any suchaction filed in a court prior to the date an application is filed under K.S.A.44-534 andamendments thereto, no judgment may be entered in any such cause and the actionshall bestayed until after the final adjudication of the claim. In the case of anaction stayed hereunder,any award of compensation shall require any amounts payable for medicalservices or materialsto be paid directly to the provider thereof plus an amount of interest at therate provided bystatute for judgments. No period of time under any statute of limitation, whichapplies to a causeof action barred under this subsection, shall commence or continue to run untilfinal adjudicationof the claim under the workers compensation act.
(i) As used in this section, unless the context or the specific provisionsclearly requireotherwise, "carrier" means a self-insured employer, an insurance company or aqualified group-funded workers compensation pool and "provider" means anyhealth care provider, vocational rehabilitationservice provideror any facility providing health care services or vocational rehabilitationservices, or both,including any hospital.
44-510j.Medical benefits; fee disputes; utilizationand peer review.When an employer's insurance carrier or a self-insured employerdisputes all or a portion of a billfor services rendered for the care and treatment of an employee under this act,the followingprocedures apply:
(a) (1) The employer or carrier shall notify the service provider within 30days of receiptof the bill of the specific reason for refusing payment or adjusting the bill.Such notice shallinform the service provider that additional information may be submittedwith the bill andreconsideration of the bill may be requested. The provider shall send anyrequest forreconsideration within 30 days of receiving written notice of the bill dispute.If the employer orcarrier continues to dispute all or a portion of the bill after receivingadditional information fromthe provider, the employer, carrier or provider may apply for an informalhearing before thedirector.
(2) If a provider sends a bill to such employer or carrier and receivesno responsewithin 30 days as allowed in subsection (a) and if a provider sends a secondbill and receives noresponse within 60 days of the date the provider sent the first bill, theprovider may apply for aninformal hearing before the director.
(3) Payments shall not be delayed beyond 60 days for any amounts not indispute. Acceptanceby anyprovider of a payment amount which is less than the full amount charged for theservices shallnot affect the right to have a review of the claim for the outstanding orremaining amounts.
(b) The application for informal hearing shall include copies of the disputedbills, allcorrespondence concerning the bills and any additional written information theparty deemsappropriate. When anyone applies for an informal hearing before the director,copies of theapplication shall be sent to all parties to the dispute and the employee.Within 20 days ofreceiving the application for informal hearing, the other parties to thedispute shall send anyadditional written information deemed relevant to the dispute to the director.
(c) The director or the director's designee shall hold the informal hearingto hear anddetermine all disputes as to such bills and interest due thereon. Evidence inthe informal hearingshall be limited to the written submissions of the parties. The informalhearing may be held byelectronic means. Any employer, carrier or provider may personally appear in orbe representedat the hearing. If the parties are unable to reach a settlement regarding thedispute, the officerhearing the dispute shall enter an order so stating.
(d) After the entry of the order indicating that the parties have not settledthe dispute afterthe informal hearing, the director shall schedule a formal hearing.
(1) Prior to the date of the formal hearing, the director may conduct autilizationreview concerning the disputed bill. The director shall develop and implement,or contract with aqualified entity to develop and implement, utilization review proceduresrelating to the servicesrendered by providers and facilities, which services are paid for in whole orin part pursuant tothe workers compensation act. The director may contract with one or moreprivate foundations ororganizations to provide utilization review of service providers pursuant tothe workerscompensation act. Such utilization review shall result in a report to thedirector indicating whether a provider improperly utilized or otherwiserendered or ordered unjustified treatment orservices or that the fees for such treatment or services were excessive and astatement of the basisfor the report's conclusions. After receiving the utilization review report,the director also may order a peer review. A copy of such reports shall beprovided to allparties to the dispute at least 20 daysprior to the formal hearing. No person shall be subject to civil liability forlibel, slander or anyother relevant tort cause of action by virtue of performing a peer orutilizationreviewunder contract withthe director.
(2) The formal hearing shall be conducted by hearing officers, the medicaladministrator orboth asappointed bythe director.During the formal hearing parties to the dispute shall have the rightto appear or berepresented and may produce witnesses, including expert witnesses, and suchother relevantevidence as may be otherwise allowed under the workers compensation act. Ifthe director findsthat a provider or facility has made excessive charges or provided or orderedunjustifiedtreatment, services, hospitalization or visits, the provider or facility may,subject to the director's order, receive paymentpursuant to this section from the carrier, employer or employee for theexcessive fees orunjustified treatment, services, hospitalization or visits and such providermay be ordered to repay any fees orcharges collected therefor. If it is determined after the formal hearing that aprovider improperlyutilized or otherwise rendered or ordered unjustified treatment or services orthat the fees forsuch treatment or services were excessive, the director may provide a reportto the licensingboard of the service provider with full documentation of any suchdetermination, except that nosuch report shall be provided until after judicial review if the order isappealed. Any decisionrendered under this section may be reviewed by the workers compensation board.A party must file a notice of appeal within 10 days of the issuance of anydecision under this section. The record on appeal shall be limited only to theevidence presented to the hearing officer. The decision of the directorshall be affirmed unless the board determines that the decision was notsupported by substantial competent evidence.
(e) By accepting payment pursuant to this section for treatment or servicesrendered to aninjured employee, the provider shall be deemed to consent to submittingall necessaryrecords to substantiate the nature and necessity of the service or charge andother informationconcerning such treatment to utilization review under this section. Suchhealth care providershall comply with any decision of the director pursuant to this section.
(f) Except as provided in K.S.A. 60-437 and amendments thereto and thissection,findings and records which relate to utilization and peer review conductedpursuant tothis sectionshall be privilegedand shall not besubject to discovery, subpoena or other means of legal compulsion for releaseto any person orentity and shall not be admissible in evidence in any judicial oradministrative proceeding, exceptthose proceedings authorized pursuant to this section. In any proceedings wherethere is anapplication by an employee, employer, insurance carrier or the workerscompensationfund for ahearing pursuant to K.S.A. 44-534a, and amendments thereto, for a change ofmedical benefitswhich has been filed after a health care provider, employer, insurance carrieror the workerscompensation fund has made application to the medical services section of thedivision for theresolution of a dispute or matter pursuant to the provisions of this section,all reports, information, statements, memoranda, proceedings, findingsand recordswhich relate to utilization and peer review including the records of contractreviewersand findings and records of the medical servicessection of thedivision shall be admissible at the hearing before the administrative law judgeon the issue of themedical benefits to which an employee is entitled.
(g) A provider may not improperly overcharge or charge for services whichwere not provided for the purpose of obtaining additional payment. Any disputeregarding such actionsshall be resolved in the same manner as other bill disputes as provided bythis section. Anyviolation of the provisions of this section or K.S.A. 44-510i, andamendments thereto, which is willful or which demonstrates a pattern ofimproperly charging or overcharging for services rendered pursuant to this actconstitutesgrounds for the director to impose a civil fine not to exceed $5,000. Any civilfine imposed underthis section shall be subject to reviewby the board. Allmoneys received forcivil fines imposed under this section shall be deposited in the state treasuryto the credit of theworkers compensation fund.
(h) Any health care provider, nurse, physical therapist, any entity providingmedical,physical or vocational rehabilitation services or providing reeducation ortraining pursuant toK.S.A. 44-510g and amendments thereto, medical supply establishment, surgicalsupplyestablishment, ambulance service or hospital which accept the terms of theworkers compensationact by providing services or material thereunder shall be bound by the feesapproved by thedirector and no injured employee or dependent of a deceased employee shall beliable for anycharges above the amounts approved by the director. If the employer hasknowledge of the injuryand refuses or neglects to reasonably provide the services of a health careprovider required bythis act, the employee may provide the same for such employee, and the employershall be liablefor such expenses subject to the regulations adopted by the director. No actionshall be filed inany court by a health care provider or other provider of services under thisact for the payment ofan amount for medical services or materials provided under the workerscompensation act and noother action to obtain or attempt to obtain or collect such payment shall betaken by a health careprovider or other provider of services under this act, including employing anycollection service,until after final adjudication of any claim for compensation for which anapplication for hearingis filed with the director under K.S.A. 44-534 and amendments thereto. In thecase of any suchaction filed in a court prior to the date an application is filed under K.S.A.44-534 andamendments thereto, no judgment may be entered in any such cause and the actionshall bestayed until after the final adjudication of the claim. In the case of anaction stayed hereunder,any award of compensation shall require any amounts payable for medicalservices or materialsto be paid directly to the provider thereof plus an amount of interest at therate provided bystatute for judgments. No period of time under any statute of limitation, whichapplies to a causeof action barred under this subsection, shall commence or continue to run untilfinal adjudicationof the claim under the workers compensation act.
(i) As used in this section, unless the context or the specific provisionsclearly requireotherwise, "carrier" means a self-insured employer, an insurance company or aqualified group-funded workers compensation pool and "provider" means anyhealth care provider, vocational rehabilitationservice provideror any facility providing health care services or vocational rehabilitationservices, or both,including any hospital.
44-510j.Medical benefits; fee disputes; utilizationand peer review.When an employer's insurance carrier or a self-insured employerdisputes all or a portion of a billfor services rendered for the care and treatment of an employee under this act,the followingprocedures apply:
(a) (1) The employer or carrier shall notify the service provider within 30days of receiptof the bill of the specific reason for refusing payment or adjusting the bill.Such notice shallinform the service provider that additional information may be submittedwith the bill andreconsideration of the bill may be requested. The provider shall send anyrequest forreconsideration within 30 days of receiving written notice of the bill dispute.If the employer orcarrier continues to dispute all or a portion of the bill after receivingadditional information fromthe provider, the employer, carrier or provider may apply for an informalhearing before thedirector.
(2) If a provider sends a bill to such employer or carrier and receivesno responsewithin 30 days as allowed in subsection (a) and if a provider sends a secondbill and receives noresponse within 60 days of the date the provider sent the first bill, theprovider may apply for aninformal hearing before the director.
(3) Payments shall not be delayed beyond 60 days for any amounts not indispute. Acceptanceby anyprovider of a payment amount which is less than the full amount charged for theservices shallnot affect the right to have a review of the claim for the outstanding orremaining amounts.
(b) The application for informal hearing shall include copies of the disputedbills, allcorrespondence concerning the bills and any additional written information theparty deemsappropriate. When anyone applies for an informal hearing before the director,copies of theapplication shall be sent to all parties to the dispute and the employee.Within 20 days ofreceiving the application for informal hearing, the other parties to thedispute shall send anyadditional written information deemed relevant to the dispute to the director.
(c) The director or the director's designee shall hold the informal hearingto hear anddetermine all disputes as to such bills and interest due thereon. Evidence inthe informal hearingshall be limited to the written submissions of the parties. The informalhearing may be held byelectronic means. Any employer, carrier or provider may personally appear in orbe representedat the hearing. If the parties are unable to reach a settlement regarding thedispute, the officerhearing the dispute shall enter an order so stating.
(d) After the entry of the order indicating that the parties have not settledthe dispute afterthe informal hearing, the director shall schedule a formal hearing.
(1) Prior to the date of the formal hearing, the director may conduct autilizationreview concerning the disputed bill. The director shall develop and implement,or contract with aqualified entity to develop and implement, utilization review proceduresrelating to the servicesrendered by providers and facilities, which services are paid for in whole orin part pursuant tothe workers compensation act. The director may contract with one or moreprivate foundations ororganizations to provide utilization review of service providers pursuant tothe workerscompensation act. Such utilization review shall result in a report to thedirector indicating whether a provider improperly utilized or otherwiserendered or ordered unjustified treatment orservices or that the fees for such treatment or services were excessive and astatement of the basisfor the report's conclusions. After receiving the utilization review report,the director also may order a peer review. A copy of such reports shall beprovided to allparties to the dispute at least 20 daysprior to the formal hearing. No person shall be subject to civil liability forlibel, slander or anyother relevant tort cause of action by virtue of performing a peer orutilizationreviewunder contract withthe director.
(2) The formal hearing shall be conducted by hearing officers, the medicaladministrator orboth asappointed bythe director.During the formal hearing parties to the dispute shall have the rightto appear or berepresented and may produce witnesses, including expert witnesses, and suchother relevantevidence as may be otherwise allowed under the workers compensation act. Ifthe director findsthat a provider or facility has made excessive charges or provided or orderedunjustifiedtreatment, services, hospitalization or visits, the provider or facility may,subject to the director's order, receive paymentpursuant to this section from the carrier, employer or employee for theexcessive fees orunjustified treatment, services, hospitalization or visits and such providermay be ordered to repay any fees orcharges collected therefor. If it is determined after the formal hearing that aprovider improperlyutilized or otherwise rendered or ordered unjustified treatment or services orthat the fees forsuch treatment or services were excessive, the director may provide a reportto the licensingboard of the service provider with full documentation of any suchdetermination, except that nosuch report shall be provided until after judicial review if the order isappealed. Any decisionrendered under this section may be reviewed by the workers compensation board.A party must file a notice of appeal within 10 days of the issuance of anydecision under this section. The record on appeal shall be limited only to theevidence presented to the hearing officer. The decision of the directorshall be affirmed unless the board determines that the decision was notsupported by substantial competent evidence.
(e) By accepting payment pursuant to this section for treatment or servicesrendered to aninjured employee, the provider shall be deemed to consent to submittingall necessaryrecords to substantiate the nature and necessity of the service or charge andother informationconcerning such treatment to utilization review under this section. Suchhealth care providershall comply with any decision of the director pursuant to this section.
(f) Except as provided in K.S.A. 60-437 and amendments thereto and thissection,findings and records which relate to utilization and peer review conductedpursuant tothis sectionshall be privilegedand shall not besubject to discovery, subpoena or other means of legal compulsion for releaseto any person orentity and shall not be admissible in evidence in any judicial oradministrative proceeding, exceptthose proceedings authorized pursuant to this section. In any proceedings wherethere is anapplication by an employee, employer, insurance carrier or the workerscompensationfund for ahearing pursuant to K.S.A. 44-534a, and amendments thereto, for a change ofmedical benefitswhich has been filed after a health care provider, employer, insurance carrieror the workerscompensation fund has made application to the medical services section of thedivision for theresolution of a dispute or matter pursuant to the provisions of this section,all reports, information, statements, memoranda, proceedings, findingsand recordswhich relate to utilization and peer review including the records of contractreviewersand findings and records of the medical servicessection of thedivision shall be admissible at the hearing before the administrative law judgeon the issue of themedical benefits to which an employee is entitled.
(g) A provider may not improperly overcharge or charge for services whichwere not provided for the purpose of obtaining additional payment. Any disputeregarding such actionsshall be resolved in the same manner as other bill disputes as provided bythis section. Anyviolation of the provisions of this section or K.S.A. 44-510i, andamendments thereto, which is willful or which demonstrates a pattern ofimproperly charging or overcharging for services rendered pursuant to this actconstitutesgrounds for the director to impose a civil fine not to exceed $5,000. Any civilfine imposed underthis section shall be subject to reviewby the board. Allmoneys received forcivil fines imposed under this section shall be deposited in the state treasuryto the credit of theworkers compensation fund.
(h) Any health care provider, nurse, physical therapist, any entity providingmedical,physical or vocational rehabilitation services or providing reeducation ortraining pursuant toK.S.A. 44-510g and amendments thereto, medical supply establishment, surgicalsupplyestablishment, ambulance service or hospital which accept the terms of theworkers compensationact by providing services or material thereunder shall be bound by the feesapproved by thedirector and no injured employee or dependent of a deceased employee shall beliable for anycharges above the amounts approved by the director. If the employer hasknowledge of the injuryand refuses or neglects to reasonably provide the services of a health careprovider required bythis act, the employee may provide the same for such employee, and the employershall be liablefor such expenses subject to the regulations adopted by the director. No actionshall be filed inany court by a health care provider or other provider of services under thisact for the payment ofan amount for medical services or materials provided under the workerscompensation act and noother action to obtain or attempt to obtain or collect such payment shall betaken by a health careprovider or other provider of services under this act, including employing anycollection service,until after final adjudication of any claim for compensation for which anapplication for hearingis filed with the director under K.S.A. 44-534 and amendments thereto. In thecase of any suchaction filed in a court prior to the date an application is filed under K.S.A.44-534 andamendments thereto, no judgment may be entered in any such cause and the actionshall bestayed until after the final adjudication of the claim. In the case of anaction stayed hereunder,any award of compensation shall require any amounts payable for medicalservices or materialsto be paid directly to the provider thereof plus an amount of interest at therate provided bystatute for judgments. No period of time under any statute of limitation, whichapplies to a causeof action barred under this subsection, shall commence or continue to run untilfinal adjudicationof the claim under the workers compensation act.
(i) As used in this section, unless the context or the specific provisionsclearly requireotherwise, "carrier" means a self-insured employer, an insurance company or aqualified group-funded workers compensation pool and "provider" means anyhealth care provider, vocational rehabilitationservice provideror any facility providing health care services or vocational rehabilitationservices, or both,including any hospital.
