TX DoI Proposes Amendments To IRO

Austin, TX (CompNewsNetwork) - The Texas Department of Insurance (Department) is accepting public comment on the proposed amendments to 28 Texas Administrative Code (TAC) §§12.1, 12.2, 12.4, 12.5, and 12.6; 12.101 - 12.106, 12.108, 12.110; 12.201, 12.202, and 12.204 - 12.208; 12.301 - 12.303, 12.402 - 12.406, 12.501, and 12.502 regarding Independent Review Organizations (IROs). 

The purpose of the proposal is to implement statutory amendments under House Bill (HB) 4519, 81st Legislature, Regular Session (effective September 1, 2009) and HB 4290, 81st Legislature, Regular Session (effective September 1, 2009). HB 4519 mandates that the Department adopt new requirements and restrictions for IROs. HB 4290 revises the definition of adverse determination in the Insurance Code Chapter 4201 to include retrospective reviews and determinations regarding the experimental or investigational nature of a service. Additional amendments are pursuant to authority in the Insurance Code §4202.002 and deemed necessary by the Department's Health and Workers' Compensation Network Division (HWCN) to streamline and clarify the IRO rules.

Some of the highlights of proposed amendments are that the IRO rules make modifications to address the definition of adverse determination in Insurance Code Chapter 4201 as revised by HB 4290. The proposed amendments update the definitions for adverse determination, medical and scientific evidence, patient, payor, and screening criteria. The proposed IRO rules also add definitions for best evidence, case-control studies, case-series, cohort studies, evidence-based standards, expert opinion, primary office, and randomized clinical trial. The proposed amendments clarify sections to reflect existing requirements for submission of fingerprints of officers, directors, and executives to be included in an application for certification. In addition, the proposed amendments update requirements concerning submission of officer, director, and executive conflicts in order to implement HB 4519. The proposed amendments have also revised several sections to address the assignment of reviews to IROs that need to comply with recertification requirements, specifically that IROs will not be assigned independent reviews during the 45-day period prior to the date on which a sale of the IRO is finalized.

The public comment period closes Monday, July 12, 2010 at 5 p.m. [Central Standard Time (CST)].

Public comment must be submitted in writing to:
Texas Department of Insurance
Gene C. Jarmon
General Counsel and Chief Clerk, Mail Code 113-2A
P. O. Box 149104
Austin, Texas 78714-9104
An additional copy of the comment must be simultaneously submitted to:
Texas Department of Insurance
Debra Diaz-Lara
Deputy Commissioner, Health and Workers' Compensation Network Certification and Quality Assurance Division, Mail Code 103-6A
P.O. Box 149104
Austin, Texas 78714-9104

A public hearing has been scheduled for Thursday, July 15, 2010 at 9:30 a.m. (CST) in Room 100 of the William P. Hobby, Jr. State Office Building, 333 Guadalupe Street in Austin under Docket No. 2714; the hearing information may be viewed at http://www.tdi.state.tx.us/alert/events.html. Written and oral comments presented at the hearing will be considered.

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