The Basics

This standard requires that, if you discover that your organization has a conflict of interest in the initial review described in the previous standard, your organization must return the case to the client/referring entity.  The only exception to this rule is if, after you fully disclose the existence of that conflict of interest to the consumer, health plan, and referring entity, all of those parties execute a written consent for your organization to go ahead and conduct the independent review.

How might this happen?  When would any of these parties consent to having an independent review conducted by an organization with a conflict of interest?  This could happen if your organization has unique or highly unusual expertise that would be difficult or impossible to find elsewhere, or if time for a decision is very short, or if the conflict of interest is so minor as to be harmless.

Your organization no doubt has a policy and procedure that addresses the notification of the affected parties of the existence of a conflict and the mechanism for obtaining written consent.  Make sure you are familiar with that P&P.

Management Tips

Again, the key will be to have a robust policy and procedure that addresses the mechanism by which you would obtain written consent from all of the affected parties after full disclosure of the existence of an organizational conflict of interest.  In addition, your filing mechanisms will need be able to keep track of that documentation, whether electronic or in paper form.  We strongly recommend that you have not only a template letter by which you notify the affected parties of the existence of a conflict of interest, but also a template consent form that you provide to the affected parties for them to execute.  Finally, it will be essential that your policy and procedure clearly states that no independent review will be performed by your organization until all of the parties have executed a written consent, where an organizational conflict of interest exists.

URAC Accreditation Tips

This is a mandatory standard.

The documentary submission for the desktop review should include not only your applicable policy and procedure, but also template letters and consent forms used to implement the policy and procedure.

The on-site review will involve a review of your policies and procedures regarding conflict of interest, as well as interviews of employees who are charged with implementing that policy and procedure.  Additionally, and perhaps more importantly, the reviewer will examine a significant sample of case files to make sure that your conflict of interest policies are fully executed in your day-to-day operations.