(1) An IRO:
(a) Must not be a subsidiary of, or in any way owned or controlled by, a carrier or an association of health care providers or carriers;
(b) Shall provide information to the department on its own organizational affiliations and potential conflicts of interest at the time of application and when material changes occur;
(c) Shall immediately turn down a case referred by the insurance commissioner if accepting it would constitute an organizational conflict of interest; and
(d) Shall ensure that reviewers are free from any actual or potential conflict of interest in assigned cases.
(2) An IRO, as well as its reviewers, must not have any material familial, professional, or financial affiliation, as defined in WAC 246-305-010
, with the health carrier, 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. An affiliation with any director, officer or executive of an IRO must be considered to be an affiliation with the IRO.
(3) The following do not constitute violations of this section:
(a) Staff affiliation with an academic medical center or National Cancer Institute-designated clinical cancer research center;
(b) Staff privileges at a health care facility;
(c) Maintaining a provider contract with a carrier which provides no more than five percent of the provider's or clinical group's annual revenue; or
(d) An IRO's receipt of a carrier's payment for independent reviews assigned by the insurance commissioner under RCW 48.43.535
(4) Notwithstanding the provisions of subsection (3) of this section, a potential reviewer must be considered to have a conflict of interest 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, the health plan, or a provider 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 reviewer, and no alternate reviewer with necessary special expertise is available; or
(b) The conflict involves an IRO and the insurance commissioner determines that seeking a waiver of conflict is preferable to reassigning the review to a different IRO.
[Statutory Authority: RCW 43.70.235
and 48.43.535. WSR 11-23-124, § 246-305-030, filed 11/21/11, effective 11/26/11; WSR 01-08-023, § 246-305-030, filed 3/28/01, effective 4/28/01.]