N.Y. Comp. Codes R. & Regs. tit. 12 § 325-2.10

Current through Register Vol. 46, No. 25, June 18, 2024

Section 325-2.10 - Investigation of complaints

(a) The chair or the chair's designee shall investigate any complaints regarding direction of care outside of the PPO program under article 10-A of the Workers' Compensation Law or the alternative dispute resolution pilot program under section 25(2-c) of the Workers' Compensation Law as well as complaints regarding employer or carrier recommendation of a designated network or provider which is not in compliance with the provisions of this Subpart.

(b) At the chair's discretion, the chair or the chair's designee may collect and examine:

(1) the list of health care providers offering treatment in accordance with the employer/carrier-recommended arrangement;

(2) any contracts between these providers and employers or carriers with respect to workers' compensation related treatment;

(3) any informational materials distributed to employees regarding their workers' compensation related treatment;

(4) any forms or documentation required of injured employees or providers during the course of treatment; and

(5) such other information as may be requested for the purpose of ensuring the accessibility and adequacy of the network as well as the injured employees' voluntary participation in the treatment arrangement.

(c) An attempt to improperly interfere with the injured employee's selection of a provider in violation of section 13-a(6) may constitute a misdemeanor. Such non-compliance may also reflect an attempt to make a false statement or representation for the purpose of affecting benefits in violation of section 114 and thus, may constitute a felony. As such, following an investigation by the board, alleged violators of these provisions may be referred to prosecutorial authorities.

In addition to the above criminal penalties, parties who allegedly violate these provisions will be referred to the following agencies for consideration of administrative penalties. Workers' compensation insurance carriers who allegedly violate these provisions will be referred to the Insurance Department. Networks who allegedly violate these provisions will be referred to the Department of Health. Self-insured employers and individual authorized providers who allegedly violate these provisions will be referred to the board's compliance bureau.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 325-2.10