201 KAR 21:075. Peer review procedures and fees.
RELATES TO: KRS 312.200
STATUTORY AUTHORITY: KRS Chapter 13A, 31.200, 312.015, 312.019
NECESSITY, FUNCTION, AND CONFORMITY: KRS 312.010 empowers the Board of Examiners to adopt administrative regulations. KRS 312.200 requires the board to appoint a peer review committee and establish procedures and fees for the review of submitted claims. The function of this administrative regulation is to establish those fees and procedures.
Section 1. Definitions. (1) "Board" means the Kentucky State Board of Chiropractic Examiners.
(2) "Committee" means the peer review committee established by KRS 312.200.
(3) "Accepted standards" for the peer review committee means those standards of care, skill, and treatment which are recognized by a reasonably prudent chiropractor as being acceptable under similar conditions and circumstances.
(4) "Appropriate chiropractic treatment" means a determination made of treatment and other services performed, which by virtue of a substantiated and properly diagnosed condition appears to be a type consistent with that diagnosis as reviewed by the peer review committee.
(5) "Unconscionable fees" means charges or bills for treatment submitted for services performed that are unnecessary or unreasonable charges in the judgment of the peer review committee. In determining the unconscionability of costs, the committee may consider, among other appropriate factors, the usual and customary charges by chiropractors and by health care providers other than chiropractors for the same or similar services in the locality where the complaint originated.
(6) "Bill for treatment" means all services provided to a customer, regardless of the monetary consideration paid to the chiropractor.
(7) "Patient" means an individual who receives treatment from a chiropractor.
(8) "Properly utilized services" means appropriate treatment services rendered, including frequency and duration, which are substantiated as being necessary and reasonable by clinical records and reports of the provider or any other facts or evidence pertinent to the controversy as reviewed by the peer review committee.
Section 2. Procedures. (1) Before peer review can take place, the patient shall execute a release permitting photocopies of the applicable treatment or billing records prepared by the chiropractor in the regular course of business. No treatment records shall be released for peer review without the patient's authorization. The acceptance of, or the request for, payment by a chiropractor constitutes the consent of the chiropractor to the submission of all necessary records and other information concerning the treatment or its cost to the peer review committee. Six (6) copies of all records or other data shall be submitted to the committee.
(2) Each claim shall be assigned to an individual member of the committee who shall review the submitted records and response from the charged party and report his findings to the full committee, which shall review the findings and either adopt those findings or modify them as deemed appropriate by majority vote. Copies of the findings shall be forwarded to the board, the patient, the chiropractor, insurer or other third party payor.
(3) The peer review committee shall elect a chairman. The committee may recommend for the board's approval a contract with or employment of third parties to perform administrative functions or to aid in obtaining records necessary for appropriate review of claims.
(4) The peer review committee shall recommend to the board that a complaint be filed against any chiropractor if it appears from the review of any claim that reasonable cause exists to believe that the chiropractor has violated any portion of KRS Chapter 312 or the administrative regulations adopted pursuant thereto for which a chiropractor may be disciplined. The peer review committee shall transmit all complaint information it possesses to the board.
(5) A chiropractor, insurer or other third party payor requesting review shall submit with the request a service fee of fifty (50) dollars payable to "B.C.E. Peer Review." An additional fee shall be charged for claims requiring more than one (1) hour of review by the committee calculated at fifty (50) dollars per hour, which sum shall be due prior to the delivery of committee findings to all parties. All fees shall be paid by the chiropractor, insurer or other third party payor requesting the review.
Section 3. Annual Report. An annual summary of the findings of the peer review committee shall be prepared by the committee and submitted to the board. The report may be made available to interested persons upon request and upon payment of the cost of reproduction. No report or summary submitted to the public by the board may disclose the name or identity of any patient without the patient's consent. (16 Ky.R. 94; Am. 345; 535; eff. 10-8-89.)