Texas Register, Volume 37, Number 30, Pages 5519-5676, July 27, 2012 Page: 5,559
5519-5676 p. ; 28 cm.View a full description of this periodical.
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as a result of a consent order and performed in accordance with criteria
adopted under Labor Code 413.05115. The medical quality review
process does not include medical case review performed for the pur-
pose of:
(1) certification and recertification of designated doctors;
(2) performance based oversight;
(3) administrative violations that do not require an expert
medical opinion; or
(4) complaints regarding professionalism that do not re-
quire an expert medical opinion.
(b) A complaint must be documented in accordance with the
provisions of 180.2 of this title (relating to Filing a Complaint).
(c) Nothing in this subchapter prevents referrals of complaints
to another licensing or law enforcement authority.
180.70. MQRP Training.
An MQRP member must receive training by the division prior to any
assignments and at least every two years thereafter on the following
topics:
(1) The requirements of this subchapter concerning the
medical quality review process under 180.68 of this title (relating to
Medical Quality Review Process);
(2) The division's goals regarding the medical quality re-
view process;
(3) Administrative violations that affect the delivery of ap-
propriate medical care;
(4) Confidentiality requirements of Labor Code
402.083, 402.092 and 413.0513;
(5) Immunity from liability under Labor Code 413.054;
(6) The medical quality review criteria adopted under La-
bor Code 413.05115;
(7) The current division adopted edition of the AMA
Guides to the Evaluation of Permanent Impairment and the division's
adopted treatment and return-to-work guidelines; and
(8) Other topics as determined by the medical advisor and
commissioner.
180.72. Conflict of interest.
(a) If the selected MQRP member has a conflict of interest,
that member may not review the case. If all MQRP members in a par-
ticular 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 (d) 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 ac-
quaintance;
(3) has ever treated the injured employee whose records are
being reviewed;
(4) has a financial interest in a matter as set forth in 180.24
of this title (relating to Financial Disclosure);(5) is a medical director for an Insurance Carrier, Utiliza-
tion Review Agent, or a workers' compensation health care network
certified under Chapter 1305 of the Insurance Code or a political sub-
division as described in Labor Code 504.053(b)(2). Medical directors
can perform all functions of the MQRP and the QAP except perform-
ing individual medical case reviews or serving as Arbiters in a informal
settlement conference (ISC); or
(6) 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, in-
cluding enforcement decisions and recommendations, for that particu-
lar 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.
180.74. MQRP Notification of Case Status.
The division shall notify MQRP panel members in writing at least quar-
terly of the status of and enforcement outcomes resulting from cases
in the medical quality review process. A MQRP panel member shall
comply with all confidentiality laws that apply to information provided
under this section including Labor Code 402.083 - 402.086, 402.091,
402.092 and 413.0513.
180. 76. Rights and Responsibilities ofPersons Involved in the Med-
ical Quality Review Process.
(a) The person subject to the medical quality review process
has the right:
(1) to be notified that the person has been selected for the
medical quality review process;
(2) to be notified of the disposition of the medical quality
review process;
(3) to communicate with the office of the medical advisor
at any time during the medical quality review process;
(4) to be represented by legal counsel, including legal
counsel at the informal settlement process (ISC); and
(5) to an ISC in accordance with the provisions of this sec-
tion. The ISC provides a person subject to the medical quality review
process an opportunity to discuss and resolve their medical case review
with Arbiters. An ISC is available under the following conditions:
(A) The case has been referred to enforcement.
(B) The request for an ISC must be in writing.
(C) The division will notify the requestor of the sched-
uled date of the ISC.
(D) The requestor has the right to receive all documents
given to the Arbiters for review for that particular case.
(E) All information the requestor wishes the Arbiters to
consider at the ISC must be received by the division no later than 15
days before the ISC. The Arbiters may refuse to consider any informa-
tion not timely received by the division.PROPOSED RULES July 27, 2012 37 TexReg 5559
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Texas. Secretary of State. Texas Register, Volume 37, Number 30, Pages 5519-5676, July 27, 2012, periodical, July 27, 2012; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth243959/m1/41/: accessed April 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.