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§ 180.62. Medical Quality Review Panel

(a) The purpose of the Medical Quality Review Panel (MQRP) is to assist the medical advisor in the performance of the medical advisor’s duties under Labor Code § 413.0511 in accordance with the provisions of Labor Code § 413.0512 and § 413.05121.

(b) Members of the MQRP who prepare reports for medical case review shall be known as MQRP Experts.

(c) Applicants may be selected and appointed to the MQRP at the discretion of the medical advisor and the commissioner of workers’ compensation (commissioner) in accordance with this section. The MQRP shall be composed of health care practitioners appointed by the medical advisor and the commissioner in accordance with this section.

(1) The MQRP must have at least 25 members.

(2) The MQRP must, at a minimum, have members in the following health care specialty fields:

(A) Orthopedic Surgery–A medical doctor (MD) or a doctor of osteopathy (DO) with board certification in orthopedic surgery.

(B) Neurosurgery–An MD or DO with board certification in neurological surgery.

(C) Chiropractic–A licensed doctor of chiropractic.

(D) Occupational Medicine–An MD or DO with board certification in occupational medicine.

(E) Pain Medicine–An MD or DO with a board certification in a subspecialty of anesthesiology, neurology or physical medicine.

(3) The MQRP may have members that include other types of health care practitioners determined to be necessary by the medical advisor and the commissioner.

(d) To be eligible to serve on the MQRP, a health care practitioner must meet the following criteria, as applicable:

(1) Possess an unrestricted license to practice in Texas with the appropriate credentials, as defined by § 180.1 of this title (relating to Definitions);

(2) Board certified in a specialty or subspecialty. An MD or DO is board certified in a specialty or subspecialty if the MD or DO holds:

(A) a general certificate in the specialty or a subspecialty certificate from one of the member boards of the American Board of Medical Specialties (ABMS); or

(B) a primary certificate in the specialty and:

(i) a certificate of special qualifications from the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS); or

(ii) a certificate of added qualifications in the subspecialty from the AOABOS.

(3) An active practice in Texas. “Active practice” means, within either of the last two calendar years, at the time of appointment to the MQRP, the applicant has:

(A) actively diagnosed or treated persons at least 20 hours per week for 40 weeks duration during a given calendar year; or

(B) performed administrative, leadership, or advisory roles in the practice of medicine.

(4) The medical advisor and the commissioner may waive the requirements of paragraphs (2) and (3) of this section if needed to adequately perform medical case review.

(e) Term; Resignation; Removal.

(1) MQRP members shall be appointed for a term of two years. They shall serve until the expiration of their term, until their resignation, or until their removal from the MQRP.

(2) An MQRP member may not serve on the panel for more than 10 years. Years served prior to September 1, 2013 do not count toward the 10 year limit.

(3) An MQRP member may resign from the MQRP at any time.

(4) An MQRP member may be removed from the MQRP for cause at any time immediately upon notice to the MQRP member, or at such later date as the division may establish in such notice upon the occurrence of any of the following:

(A) Failure to maintain the eligibility requirements of this subchapter;

(B) Failure to timely inform the division of conflicts of interest;

(C) Repeated failure to timely review medical case review assignments or timely submit reports to the division;

(D) Repeated failure to prepare the reports in the prescribed format; or

(E) Other issues deemed sufficient by the medical advisor or commissioner.

(f) An MQRP member shall not use his or her position to influence an insurance carrier, agent, or other person or entity in connection with a personal or other insurance related matter beyond referring to their position to demonstrate qualifications except as otherwise provided by this subchapter.

(g) Quality Assurance Panel.

(1) The medical advisor shall establish the Quality Assurance Panel (QAP) within the MQRP. All members of the QAP are members of the MQRP. They perform all of the duties of an MQRP member under Labor Code § 413.0512 as well as the duties of a QAP member under Labor Code § 413.05121.

(2) A member of the QAP shall also be known as an Arbiter.

(3) QAP members may provide any services to the medical advisor provided by Labor Code § 413.0512 and § 413.05121, including, but not limited to:

(A) serve as the chair to the quality assurance committee;

(B) serve as expert witnesses in enforcement actions as appropriate;

(C) provide an additional level of medical expertise and quality assurance to assist the medical advisor in the medical advisor’s duties under Labor Code § 413.0511; and

(D) perform medical case review if no other MQRP member is available in a specific area of expertise. In this case the Arbiter would be ineligible from sitting on the ISC for the subject the Arbiter reviewed.

The provisions of this §180.62 adopted to be effective January 1, 2013, 37 TexReg 8839.

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At a Glance:

Title:

§ 180.62. Medical Quality Review Panel

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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