| (a) If the selected MQRP member has a conflict of interest
in a case under medical review, that member may not review the case
or serve as an arbiter. If all MQRP members in a particular health
care specialty field as the subject of a medical case review have
conflicts of interest in a case under medical case review, and the
division is unable to enter into an interagency agreement pursuant
to subsection (e) of this section, then the division may refer the
case to the appropriate licensing authority.
(b) A conflict of interest exists if the selected MQRP
member:
(1) has a familial relationship within the third degree
of affinity with any party or witness related to the case;
(2) has a relationship with the subject beyond a mere
acquaintance;
(3) has ever treated the injured employee whose records
are being reviewed;
(4) in regard to a particular injured employee's claim,
has served as a:
(A) peer review doctor;
(B) designated doctor; or
(C) required medical examination doctor.
(5) has a financial interest in a matter as set forth
in §180.24 of this title (relating to Financial Disclosure);
(6) is a medical director for an Insurance Carrier,
Utilization Review Agent, or a workers' compensation health care network
certified under Chapter 1305 of the Insurance Code or a political
subdivision as described in Labor Code §504.053(b)(2). Medical
directors can perform all functions of the MQRP and the QAP except
performing individual medical case reviews or serving as Arbiters
in a informal settlement conference (ISC); or
(7) has other issues deemed to be a conflict of interest
by the medical advisor.
(c) If an MQRP member selected for a medical case review
has a conflict of interest, the member must notify the medical advisor
of the conflict before taking any further action on the case.
(d) If the medical advisor has a conflict of interest
in a case, the medical advisor must recuse himself from the case.
If the medical advisor recuses himself, the commissioner will delegate
the duties of the medical advisor, including enforcement decisions
and recommendations, for that particular case, to an arbiter.
(e) The division may enter into agreements with other
state agencies to access, as necessary, expertise in health care specialty
fields as determined by the medical advisor.
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