§ 22:263 — Requirements of provider contracts; prohibited incentives; definitions

A. Every contract between a health maintenance organization and a provider of health care services shall be in writing, and shall set forth:
(1) That in the event the health maintenance organization fails to pay for covered health care services as set forth in the evidence of coverage, the subscriber or enrollee shall not be liable to the provider for any sums owed by the health maintenance organization.
(2) The methodology by which payment will be made.
(3) The procedure for processing and resolving grievances as required under R.S. 22:267. Such information shall include the location and telephone number where grievances may be submitted.
B. In the event that the contract has not been reduced to writing as required by this Section or that the contract fails to contain the required prohibition, the contracting provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health maintenance organization.
C. No contracting provider, or agent, trustee, or assignee thereof, may maintain any action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization.
D.(1) A health care provider that does not contract with a health maintenance organization may pursue collection from a health maintenance organization for emergency services rendered, provided that the health care provider has no direct knowledge or information that a patient is an enrollee of a health maintenance organization. The health care provider shall only collect:
(a) From the health maintenance organization the amount paid to participating providers for the same services.
(b) From the patient, subscriber, or enrollee the difference, if any, between the amount charged for such services and the amount received from the health maintenance organization.
(2) An anesthesiologist, pathologist, or a radiologist who is not a participating provider but who provides health care services at a facility that contracts with a health maintenance organization may pursue collection from the health maintenance organization for health care services rendered provided that the anesthesiologist, pathologist, or radiologist has no direct knowledge or information that a patient is an enrollee of the health maintenance organization. The provider shall only collect:
(a) From the health maintenance organization the amount paid to participating providers for the same services.
(b) From the patient, subscriber, or enrollee the difference, if any, between the amount charged for such services and the amount received from the health maintenance organization.
E. A health maintenance organization, managed care organization, or their contracting entities shall not include provisions in their contracts with health care providers which include an incentive or specific payment made directly, in any form, to a health care provider or health care provider group as an inducement to deny, reduce, limit, or delay specific, medically necessary, and appropriate services provided with respect to a specific insured or groups of insureds with similar medical conditions.
F. Nothing in this Section shall be construed to prohibit contracts that contain incentive plans that involve general payments, such as capitation payments, or shared-risk arrangements that are not tied to specific medical decisions involving a specific insured or groups of insureds with similar medical conditions. The payments rendered or to be rendered to physicians, physician groups, or other licensed health care practitioners under these arrangements shall be deemed confidential information.
G. As used in Subsections E and F of this Section, the following definitions shall apply:
(1) "Managed care organization" means a licensed insurance company, hospital, or medical benefit plan or program, health maintenance organization, integrated health care delivery system, an employer or employee organization, or a managed care contractor which operates a managed care plan. A managed care entity may include but it is not limited to a preferred provider organization, health maintenance organization, exclusive provider organization, independent practice association, clinic without walls, management services organization, managed care services organization, physician hospital organization, and hospital physician organization.
(2) "Managed care plan" means a plan operated by a managed care organization which provides for the financing and delivery of health care and treatment services to individuals enrolled in such plan through its own employed health care providers or contracting with selected specific providers that conform to explicit selection, standards, or both. A managed care plan shall also mean a plan that has a formal organizational structure for continual quality assurance, a certified utilization review program, dispute resolution, and financial incentives for individual enrollees to use the plan's participating providers and procedures.

Legislative History

Acts 1986, No. 1065, §1; Acts 1995, No. 1159, §1; Acts 1997, No. 238, §1, eff. June 16, 1997; Acts 1997, No. 897, §1; Redesignated from R.S. 22:2018 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.