The Basics

This standard provides specific guidelines to ensure that the individual reviewer or reviewers handling a file do not have an individual conflict of interest that would disqualify the reviewer from handling the file.  The reviewer must not have a conflict of interest (professional, family, or monetary) in connection with:

• the entity referred the file;
• the health plan;
• the consumer;
• any healthcare provider that has been (or might yet be) involved in the case, including facilities; or
• the manufacturer or developer of any therapy, procedure, device, or medication being considered for the consumer.

In addition, the standard prohibits the reviewer from accepting compensation from anyone for his/her activities in connection with the Independent review that relates to the specific outcome of the case.  Finally, the standard prohibits a reviewer from having any previous involvement with the case under review.

Note that it is individual conflict of interest that is affected here, to be contrasted with the organizational conflict of interest described in the previous two standards.  

Your organization's policy and procedures will decide whether this can be met via an attestation signed by the reviewer or some other procedure.  Be sure you know which of the various possible methods your organization uses.

Management Tips

Your organization should have a specific policy and procedure dealing with individual conflicts of interest that complies with the standard.  URAC allows you some flexibility as to how you address this, but the most common approach involves an attestation signed by the reviewers that specifically addresses each of the points of the standard.  Therefore, in addition to the policy and procedure, you probably should develop a standardized conflict of interest template, being sure to address every single component of the standard.  In addition, make sure that both your reviewers and employees handling the review files are trained in whatever mechanism you choose.

URAC Accreditation Tips

Every element of the standard carries a weight of 4.

For the desktop review, be sure to submit the policy and procedure as well as any attestation forms or other tools documenting whether the reviewer has a conflict of interest with the particular case.  In addition, submit written documentation of training of your reviewers in your policy and procedure.

The on-site review will involve not only an examination of your written documentation regarding conflict of interest, but also an interview of employees who handle case files to make sure they understand how to implement this phase of the file process.  In addition, and perhaps more importantly, the reviewer will look for documentation in each case file that he/she pulls that this important step in the file review process has been taken in every case.