Montana Code 33-1-803. Sanction because of medical communication prohibited
33-1-803. Sanction because of medical communication prohibited. A health carrier or managed care organization may not take any of the following actions with regard to a health care provider because the provider made a medical communication to an enrollee or to the guardian or legal representative of the enrollee:
Terms Used In Montana Code 33-1-803
- Enrollee: means the individual to whom a health care service is provided or will be provided under a health plan. See Montana Code 33-1-801
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- Health carrier: means an entity that is subject to the insurance laws and rules of this state and that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Montana Code 33-1-801
- Managed care organization: means an entity that manages, owns, contracts with, or employs health care providers to provide health care services under a health plan. See Montana Code 33-1-801
- Medical communication: means :
(a)a communication made by a health care provider to an enrollee or to the guardian or other legal representative of an enrollee receiving health care services from the provider:
(i)concerning the mental or physical health care needs or treatment of the enrollee and the provisions, terms, or requirements of the health plan or another health plan relating to the needs or treatment of the enrollee; and
(ii)including a communication concerning:
(A)a test, consultation, or treatment option and a risk or benefit associated with the test, consultation, or option;
(B)variation among health care providers and health care facilities, as defined in 50-5-101, in experience, quality of health care services, or health outcomes;
(C)the basis or standard for the decision of the enrollee's health carrier or managed care organization to authorize or deny a health care service;
(D)the process used by the enrollee's health carrier or managed care organization to determine whether to authorize or deny a health care service; or
(E)a financial incentive or disincentive provided by the enrollee's health carrier or managed care organization to a health care provider to authorize or deny a health care service;
(b)a communication made by a health care provider to another health care provider, an employee or contractor of the enrollee's managed care organization, or an employee of the health carrier advocating a particular method of treatment on behalf of an enrollee. See Montana Code 33-1-801
- provider: means a health care professional or facility. See Montana Code 33-1-801
(1)terminate an agreement between the health carrier or managed care organization and the health care provider to provide health care services;
(2)reduce compensation to the provider;
(3)demote the provider in regard to relative seniority within the managed care organization;
(4)transfer the provider to other duties within the managed care organization;
(5)deny the provider admitting or other privileges; or
(6)take other action against the provider in retaliation for a medical communication made by the provider to an enrollee.