HRS §432E-9
How health plans review care quality and use
This section requires managed care plans to set up ongoing reviews of care quality, provider performance, health service use, facilities, and costs. It protects reviewers from lawsuits if they act in good faith, keeps review records private, and says reviews cannot lower care standards or override a doctor's judgment.
everyone
The statute, as written — Utilization review
(a) Every managed care plan shall establish procedures for continuous review of quality of care, performance of providers, utilization of health services, facilities, and costs. (b) Notwithstanding any other provision of law, there shall be no monetary liability on the part of, and no cause of action for damages shall arise against, any person who participates in quality of care or utilization reviews by peer review committees for any act performed during the reviews if the person acts without malice, makes a reasonable effort to obtain the facts, and believes that the action taken is warranted by the facts. (c) No peer review committee under this section shall be subject to discovery, and no person in attendance at the reviews shall be required to testify as to what transpired at the reviews. The utilization review requirements and administrative treatment guidelines of the health maintenance organization shall not fall below the appropriate standard of care and shall not impinge upon the independent medical judgment of the treating health care provider. (d) Nothing in this section shall be construed to prevent a health maintenance organization from conducting a utilization review and quality assurance program.
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