(a) Personnel employed by or under contract with the
IRO to perform independent reviews must be appropriately trained,
qualified, and, if applicable, currently licensed, registered, or
certified. These personnel must be currently involved in an active
practice. An exception to the active practice requirement is the medical
director of the IRO. Personnel who obtain information directly from
a physician, dentist, or other health care provider, either orally
or in writing, and who are not physicians or dentists, must be nurses,
physician assistants, or health care providers qualified to provide
the service requested by the provider. This provision must not be
interpreted to require such qualifications for personnel who perform
clerical or administrative tasks.
(1) Personnel conducting independent reviews for health
services must hold an unrestricted license, an administrative license,
or otherwise be authorized to provide the same or similar specialty
health services by a licensing agency in the United States.
(2) Personnel conducting independent reviews for workers'
compensation health care services must hold an unrestricted license,
an administrative license, or otherwise be authorized to provide the
same or similar specialty workers' compensation health care services
by a licensing agency in this state.
(b) The IRO is required to provide to the commissioner:
(1) the name, type, license number, state of licensure,
date of contract, and minimum qualifications of the personnel either
employed or under contract to perform the independent review; and
(2) written procedures used to determine whether physicians
or other health care providers used by the IRO are licensed, qualified,
in good standing, and appropriately trained.
(c) An IRO must be under the direction of a medical
director who is a physician currently licensed and in good standing
to practice medicine by a state licensing agency in the United States.
The medical director functions must include, but are not limited to,
conducting:
(1) annual review and approval of review criteria;
(2) annual quality assurance audits of at least 25
percent of all decisions to ensure appropriate reviews are conducted,
and to provide quality assurance reports to the department when requested;
and
(3) annual quality assurance audits of at least 25
percent of all assignments to ensure appropriate reviewers are assigned
to cases, and to provide quality assurance reports to the department
when requested.
(d) The IRO must maintain credentialing and recredentialing
files of personnel who are either employed or under contract to perform
independent reviews. At a minimum, the IRO must keep the following
credentialing and recredentialing information current and available
for review by the department and TDI-DWC on request:
(1) verification obtained from the applicable state
licensing board that licensure, certification, or registration is
in effect at the time of the credentialing decision;
(2) active practice in effect at the time of the credentialing
decision;
(3) board certification, if applicable. The IRO may
obtain verification from the American Board of Medical Specialties
Compendium, the American Osteopathic Association, the American Medical
Association MasterFile, or an applicable specialty board. The certification
must be in effect at the time of the credentialing decision; and
(4) any sanctions or revocations by any state licensing
agencies in the United States or the U.S. Department of Health and
Human Services (HHS) in effect at the time of the credentialing decision.
The IRO must verify sanctions or revocations with state licensing
agencies, TDI-DWC, and the HHS Office of Inspector General.
(e) Notwithstanding subsections (c) and (d) of this
section, a physician, dentist, or other person who performs independent
review whose license has been revoked by any state licensing agency
in the United States is not eligible to direct or conduct independent
review.
(f) Notwithstanding subsection (c) of this section,
an IRO that performs independent review of a health care service provided
under Labor Code Title 5 or Insurance Code Chapter 1305 must comply
with the licensing and professional specialty requirements for personnel
performing independent review as provided by Labor Code §§408.0043
- 408.0045 and 413.031; Insurance Code §1305.355; and Chapters
133 and 180 of this title.
(g) The IRO must require physicians and other providers
who conduct independent reviews to sign and date the certification
of independence and qualifications of the reviewer in the format prescribed
by the department. The certification of independence and qualifications
of the reviewer includes certification that the physician or other
provider who conducts the independent review:
(1) holds an unrestricted license, certification, or
registration and lists the relevant states, license numbers, and expiration
dates;
(2) has no sanctions or revocations of the reviewer's
license, certification, or registration by any state licensing agency
in the United States or HHS;
(3) currently practices and lists the states;
(4) has no previous knowledge of or participation in
the case before it is assigned to the reviewer;
(5) has no disqualifying associations, including business
or personal relationships, with any involved parties in the case;
(6) does not have admitting privileges or ownership
interest in, and is not a member of the board of directors, advisor
to the board of directors, or officer of the health care facilities
where care was provided or is recommended to be provided;
(7) does not have a contract with or an ownership interest
in the utilization review agent, insurer, health maintenance organization,
other managed care entity, payor, or any other party to the case and
is not a member of the board or advisor to the board of directors
or an officer for any of the above referenced entities; and
(8) performed the review without bias for or against
the utilization review agent, the insurer, health maintenance organization,
other managed care entity, payor, or any other party to this case.
(h) The information required in this section must be
available for examination and review by the department and TDI-DWC
personnel on request.
(i) The IRO must require those physicians and other
providers who conduct independent reviews to notify the IRO of any
changes in the information in subsection (d) of this section.
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