The Vermont Statutes Online

Title 18 : Health

Chapter 221 : Health Care Administration

Subchapter 002 : Claims Processing and Contract Standards

• § 9418g. Enforcement

  In addition to any other remedy provided by law, the Commissioner may, in the Commissioner’s sole discretion, enforce the provisions of this subchapter as specified in this section. In determining whether to undertake an enforcement action, the Commissioner may consider the relative resources of the complaining party and the alleged noncompliant party, the Commissioner’s other enforcement responsibilities, and such other factors as the Commissioner deems appropriate.

  (1) The Commissioner shall have the power to examine and investigate any health plan, contracting entity, covered entity, or payer to determine if the health plan, contracting entity, covered entity, or payer has violated the provisions of this subchapter, or any rules or order of the Commissioner adopted or issued pursuant to this subchapter.

  (2) If the Commissioner finds that a health plan, contracting entity, covered entity, or payer has violated this subchapter, or any rules or order of the Commissioner adopted or issued pursuant to this subchapter, the Commissioner may order the health plan, contracting entity, covered entity, or payer to cease and desist from further violations and may order the health plan, contracting entity, covered entity, or payer to remediate the violation.

  (3) If the Commissioner finds that a health plan, contracting entity, covered entity, or payer has violated this subchapter or any rules or order of the Commissioner adopted or issued pursuant to this subchapter, the Commissioner may impose an administrative penalty against the health plan, contracting entity, covered entity, or payer of not more than $1,000.00 for each violation and not more than $10,000.00 for each willful violation. In determining the amount of the penalty to be assessed, the Commissioner shall consider the following factors:

  (A) the appropriateness of the penalty with respect to the financial resources and good faith of the health plan, contracting entity, covered entity, or payer;

  (B) the gravity of the violation or practice;

  (C) the history of previous violations or practices of a similar nature;

  (D) the economic benefit derived by the health plan, contracting entity, covered entity, or payer and the economic impact on the health care facility or health care provider resulting from the violation; and

  (E) any other relevant factors.

  (4) Any dispute arising out of or relating to the provisions of this subchapter shall, at the option of either party, be settled by arbitration in accordance with the commercial rules of the American Arbitration Association or the rules or procedures of another mutually agreed upon alternative dispute resolution forum, such as the American Health Lawyers Association. Judgment upon the arbitrator’s award may be entered in any court having jurisdiction, and the arbitrator’s award shall be binding on both parties.

  (5) Nothing in this subchapter shall be construed to prohibit a health plan, contracting entity, covered entity, or payer from applying payment policies that are consistent with applicable federal or State laws and regulations, or to relieve a health plan, contracting entity, covered entity, or payer from complying with payment standards established by federal or State laws and regulations, including rules adopted by the Commissioner. (Added 2009, No. 61, § 36; amended 2023, No. 6, § 236, eff. July 1, 2023.)