§ 27-41-16 - Examination.
SECTION 27-41-16
§ 27-41-16 Examination. – (a) The director of business regulation may make an examination of the affairsof any health maintenance organization and the providers with whom theorganization has contracts, agreements, or other arrangements pursuant to itshealth care plan as often as is reasonably necessary for the protection of theinterests of the people of this state. The examination shall be performed andthe associated costs shall be borne by the company in accordance with all theprovisions of § 27-13.1.
(b) The director of health may make an examination concerningthe quality of health care services of any health maintenance organization andthe providers with whom the organization has contracts, agreements, or otherarrangements as often as is reasonably necessary for the protection of theinterests of the people of this state.
(c) Each health maintenance organization shall establish andmaintain on an ongoing basis a quality assurance program which involves theassessment of all quality assurance activities conducted in the provision ofits 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 otherhealth professionals; and
(3) Utilization and systematic data collection.
(d) Every health maintenance organization and provider shallsubmit its books and records to those examinations and in every way facilitatethem. For the purpose of examinations, the director of business regulation andthe director of health may administer oaths to, and examine, the officers andagents of the health maintenance organization and the principals of theirproviders concerning their business.
(e) The expenses of examinations under this section shall beassessed against the organization being examined and remitted to the directorof the department for whom the examination is being conducted. The total costof those examinations, whether made by the director of business regulation orby the director of health, shall be borne by the examined health maintenanceorganizations 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 theexamination for deposit as general revenues. That assessment shall be inaddition to any taxes and fees payable to the state. In instances where theexamination is performed by outside accountants, the expenses of theexamination shall be borne by the examined health maintenance organization.
(f) In lieu of any state examination, the director ofbusiness regulation or the director of health may accept the report of anexamination made by the director of business regulation or the director ofhealth of another state.