Louisiana Revised Statutes 22:2441 – Minimum qualifications for independent review organizations
Terms Used In Louisiana Revised Statutes 22:2441
- Authorized representative: means any of the following:
(a) A person to whom a covered person has given express written consent to represent the covered person for purposes of this Chapter. See Louisiana Revised Statutes 22:2392
- Clinical peer: means a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review. See Louisiana Revised Statutes 22:2392
- Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health insurance issuer to determine the medical necessity and appropriateness of health care services including those used in the determination of an item or health care service as experimental. See Louisiana Revised Statutes 22:2392
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
- Contract: A legal written agreement that becomes binding when signed.
- Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:2392
- entity: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Louisiana Revised Statutes 22:2392
- Facility: means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, rehabilitation and other therapeutic health settings, and inpatient hospice facilities. See Louisiana Revised Statutes 22:2392
- Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Louisiana Revised Statutes 22:2392
- Health insurance issuer: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
- Immediately: means as expeditiously as the medical situation of the covered person requires but in no event longer than one day for expedited reviews or one business day for standard reviews. See Louisiana Revised Statutes 22:2392
- Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Louisiana Revised Statutes 22:2392
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- provider: means a health care professional or a facility. See Louisiana Revised Statutes 22:2392
A. To be approved under La. Rev. Stat. 22:2440 to conduct external reviews, an independent review organization shall not be a health insurance issuer and shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process provided for in this Part. At a minimum, these shall include the following:
(1) A quality assurance mechanism in place that:
(a) Ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner.
(b) Ensures the selection of qualified and impartial clinical peers to conduct external reviews on behalf of the independent review organization and suitable matching of peers to specific cases and ensures that the independent review organization employs or contracts with an adequate number of clinical peers to meet this objective.
(c) Ensures the confidentiality of medical and treatment records and clinical review criteria.
(d) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this Part.
(2) A toll-free telephone service to receive information on a twenty-four-hour-a-day, seven-day-a-week basis related to external reviews that is capable of accepting, recording, or providing appropriate instructions to incoming telephone callers during other than normal business hours.
(3) An agreement to maintain and provide to the commissioner the information required pursuant to La. Rev. Stat. 22:2443.
B. Any clinical peer assigned by an independent review organization to conduct external reviews shall be a physician or other appropriate health care provider who meets the following minimum qualifications:
(1) Is an expert in the treatment of the covered person‘s medical condition that is the subject of the external review.
(2) Is knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person.
(3) Has a nonrestrictive medical license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review.
(4) Does not have a 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 raise a substantial question as to the clinical peer’s physical, mental, or professional competence or moral character.
C. In addition to the requirements specified in Subsection A of this Section, an independent review organization shall not own or control, be a subsidiary of, or in any way be owned or controlled by, or exercise control with, a health benefit plan, a national, state, or local trade association of health benefit plans, or a national, state, or local trade association of health care providers.
D.(1) In addition to the requirements specified in Subsections A, B, and C of this Section, in order to be approved pursuant to La. Rev. Stat. 22:2440 to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical peer assigned by the independent organization to conduct the external review may have a material professional, familial, or financial conflict of interest with any of the following:
(a) The health insurance issuer that is the subject of the external review.
(b) The covered person whose treatment is the subject of the external review or his authorized representative.
(c) Any officer, director, or management employee of the health insurance issuer that is the subject of the external review.
(d) The health care provider, his medical group, or his independent practice association recommending the health care service or treatment that is the subject of the external review.
(e) The facility at which the recommended health care service or treatment would be provided.
(f) The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose treatment is the subject of the external review.
(2) In determining whether an independent review organization or a clinical peer of the independent review organization has a material professional, familial, or financial conflict of interest for purposes of Paragraph (1) of this Subsection, the commissioner shall take into consideration situations in which the independent review organization or clinical peer to be assigned by the independent review organization to conduct an external review of a specified case may have such a relationship or connection with a person specified in Paragraph (1) of this Subsection, but that the characteristics of such relationship or connection are not a material conflict of interest that would result in the disapproval of the independent review organization or the clinical peer from conducting the external review.
E.(1) An independent review organization that is accredited by a nationally recognized private accrediting entity that has independent review accreditation standards that the commissioner has determined are equivalent to or exceed the minimum qualifications of this Section shall be presumed in compliance with this Section and be eligible for approval pursuant to La. Rev. Stat. 22:2440. An independent review organization submitting proof of accreditation in support of an application for approval shall immediately inform the commissioner of any subsequent loss, revocation, or other material change to any accreditation.
(2) The commissioner shall initially review and periodically review the independent review organization accreditation standards of a nationally recognized private accrediting entity to determine whether the entity’s standards are, and continue to be, equivalent to or exceed the minimum qualifications provided for in this Section.
(3) Upon request, a nationally recognized private accrediting entity shall make its current independent review organization accreditation standards available to the commissioner in order for the commissioner to determine if the entity’s standards are equivalent to or exceed the minimum qualifications provided for in this Section.
F. An independent review organization shall be unbiased. An independent review organization shall establish and maintain written procedures to ensure that it is unbiased in addition to any other procedures required by this Section.
Acts 2013, No. 326, §1, eff. Jan. 1, 2015; Acts 2017, No. 14, §1.