(a) For a complaint filed with the Commissioner under this subtitle that involves a question of whether the health care service provided or to be provided to a member is medically necessary, the Commissioner:
(1) shall select an independent review organization or medical expert to advise on the complaint; and
(2) may accept and base the final decision on the complaint on the professional judgment of an independent review organization or medical expert.
List of independent review organizations and medical experts compiled by Commissioner
(b) To ensure access to advice when needed, the Commissioner, in consultation with the Secretary of Health and carriers, shall compile a list of independent review organizations and medical experts.
Expert reviewer requirements
(c) Any expert reviewer assigned by an independent review organization or medical expert shall be a physician or other appropriate health care provider who meets the following minimum requirements:
(1) be an expert in the treatment of the member's medical condition, and knowledgeable about the recommended health care service or treatment through actual clinical experience;
(2) hold:
(i) a nonrestricted license in a state of the United States; and
(ii) in addition, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of review; and
(3) have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that the Commissioner, in accordance with regulations adopted by the Commissioner, considers relevant in meeting the requirements of this subsection.
Restrictions relating to independent review organizations
(d) An independent review organization may not be a subsidiary of, or in any way owned or controlled by, a health benefit plan, or a trade association of health benefit plans, or a trade association of health care providers.
Information submitted to Commission by independent review organization
(e) In addition to subsection (d) of this section, to be included on the list compiled under subsection (b) of this section, an independent review organization shall submit to the Commissioner the following information:
(1) if the independent review organization is a publicly held organization, the names of all stockholders and owners of more than 5% of any stock or options of the independent review organization;
(2) the names of all holders of bonds or notes in excess of $100,000, if any;
(3) the names of all corporations and organizations that the independent review organization controls or is affiliated with, and the nature and extent of any ownership or control, including the affiliated organization's type of business;
(4) the names of all directors, officers, and executives of the independent review organization as well as a statement regarding any relationships the directors, officers, and executives may have with any carrier or health care provider group; and
(5) evidence, in the form required by the Commissioner, that the independent review organization is accredited by a nationally recognized private accrediting organization.
Conflicts of interest prohibited
(f) An expert reviewer assigned by an independent review organization or the independent review organization or medical expert selected by the Commissioner under this section may not have a material professional, familial, or financial conflict of interest with any of the following:
(1) the carrier that is the subject of the complaint;
(2) any officer, director, or management employee of the carrier that is the subject of the complaint;
(3) the health care provider, the health care provider's medical group, or the independent practice association that rendered or is proposing to render the health care service that is under review;
(4) the health care facility at which the health care service was provided or will be provided; or
(5) the developer or manufacturer of the principal drug, device, procedure, or other therapy that is being proposed for the member.
Quality assurance mechanisms used by independent review organizations
(g) For any independent review organization selected by the Commissioner under subsection (a) of this section, the independent review organization shall have a quality assurance mechanism in place that ensures:
(1) the timeliness and quality of the reviews;
(2) the qualifications and independence of the expert reviewers; and
(3) the confidentiality of medical records and review materials.
Payment of expenses of independent review organization or medical expert
(h)(1) The carrier that is the subject of the complaint shall be responsible for paying the reasonable expenses of the independent review organization or medical expert selected by the Commissioner in accordance with subsection (a) of this section.
(2) The independent review organization or medical expert shall:
(i) present to the carrier for payment a detailed account of the expenses incurred by the independent review organization or medical expert; and
(ii) provide a copy of the detailed account of expenses to the Commissioner.
(3) The carrier that is the subject of the complaint may not pay and an independent review organization or medical expert may not accept any compensation in addition to the payment for reasonable expenses under paragraph (1) of this subsection.
Credits
Added by Acts 1998, c. 111, § 2, eff. Jan. 1, 1999; Acts 1998, c. 112, § 2, eff. Jan. 1, 1999. Amended by Acts 2011, c. 3, § 1, eff. July 1, 2011; Acts 2011, c. 4, § 1, eff. July 1, 2011; Acts 2017, c. 62, § 6.
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
