OAR 436-015-0120: Sanctions and Civil Penalties

(1) Complaints pertaining to violations of these rules must be sent to the director. (2) The director may investigate an alleged rule violation. The investigation may include, but is not limited to, request for and review of pertinent medical treatment and payment records, interviews with the parties to the complaint, or consultation with an appropriate panel of the medical provider’s peers, chosen in the manner provided in OAR 436-010-0330. (3) If the director finds any violation of OAR 436-015, or if the MCO fails to meet any of the requirements of the certified plan, the director may impose one or more of the following sanctions against an MCO: (a) Reprimand by the director; (b) Civil penalty as provided under ORS 656.745(2). In determining the amount of penalty to be assessed, the director will consider: (A) The degree of harm inflicted on the worker, insurer, or medical provider; (B) Previous violations; and (C) Evidence of willful violation; or (c) Suspension or revocation of the MCO’s certification under OAR 436-015-0080. (4) If the director determines that an insurer has entered into a contract with an MCO that violates OAR 436-015 or the MCO’s certified plan, the insurer will be subject to civil penalties as provided in ORS 656.745. (5) If an insurer or someone who is not a certified MCO acting on the insurer's behalf engages in managed care activities prohibited under these rules, the director may impose a sanction or civil penalty.