TITLE 27
Insurance

CHAPTER 27-41
Health Maintenance Organizations

SECTION 27-41-16


§ 27-41-16 Examination.

(a) The director of business regulation may make an examination of the affairs of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements pursuant to its health care plan as often as is reasonably necessary for the protection of the interests of the people of this state. The examination shall be performed and the associated costs shall be borne by the company in accordance with all the provisions of § 27-13.1.

(b) The director of health may make an examination concerning the quality of health care services of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state.

(c) Each health maintenance organization shall establish and maintain on an ongoing basis a quality assurance program which involves the assessment of all quality assurance activities conducted in the provision of its health care services to its subscribers, which shall include no less than:

(1) Assessment of health outcomes;

(2) Ongoing review of health services by physicians and other health professionals; and

(3) Utilization and systematic data collection.

(d) Every health maintenance organization and provider shall submit its books and records to those examinations and in every way facilitate them. For the purpose of examinations, the director of business regulation and the director of health may administer oaths to, and examine, the officers and agents of the health maintenance organization and the principals of their providers concerning their business.

(e) The expenses of examinations under this section shall be assessed against the organization being examined and remitted to the director of the department for whom the examination is being conducted. The total cost of those examinations, whether made by the director of business regulation or by the director of health, shall be borne by the examined health maintenance organizations and shall be in the same amount as provided for in § 27-13-1, and shall be paid to the director of the department conducting the examination for deposit as general revenues. That assessment shall be in addition to any taxes and fees payable to the state. In instances where the examination is performed by outside accountants, the expenses of the examination shall be borne by the examined health maintenance organization.

(f) In lieu of any state examination, the director of business regulation or the director of health may accept the report of an examination made by the director of business regulation or the director of health of another state.

History of Section.
(P.L. 1983, ch. 225, § 2; P.L. 1992, ch. 133, art. 24, § 1; P.L. 1994, ch. 404, § 13; P.L. 1995, ch. 370, art. 40, § 88.)