Texas Workers' Compensation

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§ 180.72. Conflict of Interest

(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 and appoint the associate medical advisor to perform the role of the medical advisor in the case, including enforcement decisions and recommendations. If the associate medical advisor also has a conflict of interest in the case, the commissioner shall 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.

The provisions of this §180.72 adopted to be effective January 1, 2013, 37 TexReg 8839.

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At a Glance:

Title:

§ 180.72. Conflict of Interest

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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