(a) The commissioner of commerce and insurance, in cooperation with the commissioner of health, shall coordinate the regulation of any HMO holding a certificate of authority to ensure the financial viability of the HMO and that the HMO is currently providing and shall in the future provide health care services efficiently, effectively and economically. The commissioner of commerce and insurance and the commissioner of health shall develop an interdepartmental agreement to coordinate the functions necessary for the proper administration of this section.
Contract: A legal written agreement that becomes binding when signed.
Health care services: means any services included in the furnishing to any individual of medical or dental care, or hospitalization, or incidental to the furnishing of the care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability. See Tennessee Code 56-32-102
State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(b) The commissioner of commerce and insurance may make an examination of the affairs of any HMO and any providers with whom the HMO has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state. The examinations of HMOs shall occur not less frequently than once every five (5) years. The commissioner of commerce and insurance may also contract, at reasonable fees for work performed, with qualified, impartial outside sources to perform audits or examinations, or portions of audits or examinations, pertaining to the qualification of an entity for issuance for a certificate of authority to operate as an HMO or to determine the continued compliance of any operating HMO. Any contracted assistance shall be under the direct supervision of the commissioner of commerce and insurance. The results of any contracted assistance shall be subject to the review of, and approval, disapproval, or modification by, the commissioner of commerce and insurance.(c) The commissioner of health or the commissioner’s designee may make an examination concerning an HMO’s capability to provide health care services efficiently, effectively and economically, and any providers with whom the HMO has contracts, agreements, or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state. The examinations of HMOs shall occur not less frequently than once every three (3) years. The commissioner of health shall report findings to the commissioner of commerce and insurance, who may then suspend or revoke a certificate of authority issued to the HMO as provided in § 56-32-116.(d) Every HMO shall submit its books and records for the examinations and in every way facilitate the completion of the examinations. For the purpose of examinations, the commissioner of commerce and insurance and the commissioner of health may administer oaths to, and examine, officers and agents of the HMO.(e) The expenses of examinations of HMOs under this section shall be assessed against the HMO being examined and remitted to the commissioner for whom the examination is being conducted.(f) In lieu of the examinations, the commissioner of commerce and insurance or the commissioner of health may accept the report of an examination made by the commissioner of insurance or the commissioner of health of another state.
