A. The director shall establish a system of peer group utilization review of selected outpatient and inpatient health care provider services to workers claiming benefits under the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978] or the New Mexico Occupational Disease Disablement Law [52-3-1 NMSA 1978]. Subject to the provisions of this section, the decisions issued pursuant to the utilization review system shall be binding on the affected health care providers, workers, employers, insurers and their representatives.

B. As used in this section, "utilization review" means an evaluation of the necessity, appropriateness, efficiency and quality of health care services provided to an injured or disabled worker based on medically accepted standards and an objective evaluation of the health care services provided.

C. The director shall also establish a system of pre-admission review of all hospital admissions, except for emergency services. Utilization review shall commence within one working day of all emergency hospital admissions.

D. The director may contract with an independent utilization review organization to provide utilization review, including peer review.

E. Nothing in this section shall prevent an employer from electing to provide his own utilization review; however, if the worker, provider or any other party not contractually bound to the employer's utilization review program disagrees with that employer's utilization review, then that worker, provider or other party shall have recourse to the workers' compensation administration's utilization review program.

F. Pursuant to utilization review conducted by the director, including providing an opportunity for a hearing, any health care provider who imposes excessive charges or renders inappropriate services shall be subject to:

(1) a forfeiture of the right to payment for those services that are found to be excessive or inappropriate or payment of excessive charges;

(2) a fine of not less than one hundred dollars ($100) or more than one thousand dollars ($1,000); or

(3) a temporary or permanent suspension of the right to provide health care services for workers' compensation or occupational disease disablement claims if the health care provider has established a pattern of violations.

History: 1978 Comp., § 52-4-2, enacted by Laws 1990 (2nd S.S.), ch. 2, § 50; 1993, ch. 193, § 8.

Repeals and reenactments. — Laws 1990 (2nd S.S.), ch. 2, § 50 repealed former 52-4-2 NMSA 1978, as enacted by Laws 1990, ch. 65, § 1, and enacted a new section, effective April 4, 1991.

The 1993 amendment, effective June 18, 1993, in Subsection A, inserted "peer group" preceding "utilization", substituted "provider services" for "providers", and added the second sentence; in Subsection C, deleted "However, a" at the beginning of the second sentence, deleted "pursuant to Subsections A and B of this section" following "review" in the second sentence, and made a minor stylistic change; deleted "Pursuant to the director's established system of utilization review" at the beginning of Subsection D; deleted "as provided for in this section" at the end of Subsection E; and made a minor stylistic change in Subsection F.

Law reviews. — For survey of 1990-91 workers' compensation law, see 22 N.M.L. Rev. 845 (1992).