Or. Admin. R. 836-053-1320

Current through Register Vol. 63, No. 8, August 1, 2024

Section 836-053-1320 - Conflict of Interest

(1) An independent review organization:

(a) Must not be a subsidiary of, or in any way owned or controlled by, an insurer or an association of insurers or of doctors, providers or other health care professionals;

(b) Must provide information to the Director of the Department of Consumer and Business Services on its own organizational affiliations and potential conflicts of interest at the time of its response to the director's request for proposals and thereafter when material changes occur;

(c) Must immediately turn down a case referred by the director if accepting it would constitute an organizational conflict of interest; and

(d) Must ensure that medical reviewers are free from any actual or potential conflict of interest in assigned cases.

(2) In connection with a case, neither an independent review organization nor any of its medical reviewers may have any material professional, familial or financial affiliation with the health insurer, enrollee, enrollee's provider, that provider's medical or practice group, the facility at which the service would be provided or the developer or manufacturer of a drug or device under review. For the purpose of this section, an affiliation with any director, officer or executive of an independent review organization shall be considered to be an affiliation with the independent review organization.

(3) Except as provided in section (4) of this rule, the following do not constitute violations of this rule:

(a) Staff affiliation with an academic medical center or National Cancer Institute-designated clinical cancer research center;

(b) Staff privileges at a health facility; or

(c) An independent review organization's receipt of an insurer's payment for independent reviews assigned by the director.

(4) A potential medical reviewer shall be considered to have a conflict of interest in connection with a case with regard to a facility or health plan, regardless of revenue from that source, if the potential reviewer is a member of a standing committee of the facility or the health plan, or a provider or other health care professional network that contracts with the health plan.

(5) A conflict of interest may be waived only if both the enrollee and the health plan agree in writing after receiving full disclosure of the conflict, and only if:

(a) The conflict involves a medical reviewer, and no alternate reviewer with necessary special expertise is available; or

(b) The conflict involves an independent review organization and the director determines that seeking a waiver of conflict is preferable to reassigning the dispute to a different independent review organization.

Or. Admin. R. 836-053-1320

ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 18-2018, minor correction filed 08/20/2018, effective 8/20/2018

Statutory/Other Authority: ORS 731.244 & ORS 743B.253

Statutes/Other Implemented: ORS 743B.253