4121.441 Health care partnership program - adoption of rules.

(A) The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, shall adopt rules under Chapter 119. of the Revised Code for the health care partnership program administered by the bureau of workers' compensation to provide medical, surgical, nursing, drug, hospital, and rehabilitation services and supplies to an employee for an injury or occupational disease that is compensable under this chapter or Chapter 4123., 4127., or 4131. of the Revised Code, and to regulate contracts with managed care organizations pursuant to this chapter.

(1) The rules shall include, but are not limited to, the following:

(a) Procedures for the resolution of medical disputes between an employer and an employee, an employee and a provider, or an employer and a provider, prior to an appeal under section 4123.511 of the Revised Code. Rules the administrator adopts pursuant to division (A)(1)(a) of this section may specify that the resolution procedures shall not be used to resolve disputes concerning medical services rendered that have been approved through standard treatment guidelines, pathways, or presumptive authorization guidelines.

(b) Prohibitions against discrimination against any category of health care providers;

(c) Procedures for reporting injuries to employers and the bureau by providers;

(d) Appropriate financial incentives to reduce service cost and insure proper system utilization without sacrificing the quality of service;

(e) Adequate methods of peer review, utilization review, quality assurance, and dispute resolution to prevent, and provide sanctions for, inappropriate, excessive or not medically necessary treatment;

(f) A timely and accurate method of collection of necessary information regarding medical and health care service and supply costs, quality, and utilization to enable the administrator to determine the effectiveness of the program;

(g) Provisions for necessary emergency medical treatment for an injury or occupational disease provided by a health care provider who is not part of the program;

(h) Discounted pricing for all in-patient and out-patient medical services, all professional services, and all pharmaceutical services;

(i) Provisions for provider referrals, pre-admission and post-admission approvals, second surgical opinions, and other cost management techniques;

(j) Antifraud mechanisms;

(k) Standards and criteria for the bureau to utilize in certifying or recertifying a health care provider or a managed care organization for participation in the health partnership program;

(l) Standards for the bureau to utilize in penalizing or decertifying a health care provider from participation in the health partnership program.

(2) Notwithstanding section 119.061 of the Revised Code, the rules may include provisions limiting, restricting, or regulating any marketing or advertising by a managed care organization, or by any individual or entity that is affiliated with or acting on behalf of the managed care organization, under the health partnership program.

(B) The administrator shall implement the health partnership program according to the rules the administrator adopts under this section for the provision and payment of medical, surgical, nursing, drug, hospital, and rehabilitation services and supplies to an employee for an injury or occupational disease that is compensable under this chapter or Chapter 4123., 4127., or 4131. of the Revised Code."

Amended by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 09-17-1996; 2006 SB7 06-30-2006; 2007 HB100 09-10-2007