Effective 28 Aug 1997

354.609. Termination of a contract, procedure. — 1. A health carrier and a participating provider shall provide at least sixty days written notice to each other before terminating the contract without cause. The written notice shall include an explanation of why the contract is being terminated. The health carrier shall provide written notice within thirty working days of receipt or issuance of a notice of termination to all enrollees who are patients seen on a regular basis by the provider whose contract is terminating, irrespective of whether the termination was for or without cause. Where a contract termination involves a primary care professional, all enrollees who are patients of such professional shall be notified. Within fifteen working days of the date that the provider either gives or receives notice of termination, the provider shall supply the health carrier with a list of those patients of the provider that are covered by a plan of the health carrier.

2. (1) A health carrier shall not terminate a contract with a health care professional unless the health carrier provides to the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing as hereinafter provided. This subsection shall not apply in cases involving imminent harm to patients, a determination of fraud, or a final disciplinary action by a state licensing board or other governmental agency.

(2) The notice of the proposed contract termination provided by the health carrier to the health care professional shall include:

(a) The reasons for the proposed action;

(b) Notice that the health care professional has the right to request a hearing or review, at the professional's discretion, before a panel appointed by the health carrier;

(c) A time limit of not less than thirty days within which a health care professional may request a hearing; and

(d) A time limit for a hearing date which shall be held within thirty days after the date of receipt of a request for a hearing.

(3) The hearing panel shall be comprised of at least three persons appointed by the health carrier. At least one person on such panel shall be a clinical peer in the same discipline and the same or similar specialty as the health care professional under review. The hearing panel may consist of more than three persons, provided however that the number of clinical peers on such panel shall constitute one-third or more of the total membership of the panel.

(4) The hearing panel shall render a decision on the proposed action within fifteen days after a hearing. Such decision shall include reinstatement of the health care professional by the health carrier, provisional reinstatement subject to conditions set forth by the health carrier or termination of the health care professional. Such decision shall be provided in writing to the health care professional.

(5) A decision by the hearing panel to terminate a health care professional shall be effective not less than thirty days after the receipt by the health care professional of the hearing panel's decision.

(6) In no event shall termination be effective earlier than sixty days from the receipt of the notice of termination.

3. Either party to a contract may exercise a right of nonrenewal at the expiration of the contract period set forth therein or upon sixty days' notice to the other party; provided, however, that any nonrenewal shall not constitute a termination for purposes of this section.

4. A health carrier shall develop and implement policies and procedures to ensure that a health care professional is regularly informed of information maintained by the health carrier to evaluate the performance or practice of the health care professional. The health carrier shall consult with health care professionals in developing methodologies to collect and analyze health care professional profiling data. The health carrier shall provide any such information and profiling data and analysis to the health care professionals. Such information, data or analysis shall be provided on a periodic basis appropriate to the nature and amount of data and the volume and scope of services provided. Any profiling data used to evaluate the performance or practice of a health care professional shall be measured against stated criteria and an appropriate group of health care professionals using similar treatment modalities serving a comparable patient population. Upon presentation of such information or data, each health care professional shall be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the health care professional's profile and to work cooperatively with the health carrier to improve performance.

5. No health carrier shall terminate a contract or employment solely or in part because a health care provider in good faith:

(1) Advocates on behalf of an enrollee;

(2) Files a complaint against the health carrier;

(3) Appeals a decision of the health carrier;

(4) Provides information or files a report with the department of commerce and insurance; or

(5) Requests a hearing or review pursuant to this section.

6. A health carrier shall give a provider at least thirty days to review a managed care contract.

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(L. 1997 H.B. 335)