N.Y. Comp. Codes R. & Regs. tit. 23 § 400.4

Current through Register Vol. 46, No. 45, November 2, 2024

Section 400.4 - Conflict of interest

(a) No proposed IDRE shall be qualified for certification as an IDRE if it owns or controls, is owned or controlled by, or is under common control with any of the following:

(1) any national, state or local illness, health benefit or public advocacy group;

(2) any national, state or local society or association of hospitals, physicians, or other providers of health care services; or

(3) any national, state or local association of health care plans.

(b) An IDRE shall submit a sworn statement, as described in section 400.3(a)(2) of this Part, setting forth that none of the control affiliations proscribed in subdivision (a) of this section apply to the IDRE, and that the IDRE, its medical director and each of its owners, officers, directors and managers, either:

(1) has no material familial, financial, or professional affiliation with any person or entity listed in paragraph (2) of this subdivision; or

(2) provides a list of those material familial, financial and professional affiliations, each of which may, upon certification, result in a prohibited conflict of interest in connection with a dispute because of such affiliation with:

(i) any health care plan; or

(ii) any owner, officer, director, or manager of any health care plan; or

(iii) any health care provider, physician's medical group, independent practice association, or provider of pharmaceutical products or services or durable medical equipment; or

(iv) any facility at which a health service would be provided;

(v) any officer, director, partner, or manager of a physician's medical group, independent practice association, or facility at which a health care service would be provided; or

(vi) any developer or manufacturer of a health service or product.

(c) Following certification:

(1) if an IDRE acquires control of, becomes controlled by, or comes under common control with any entity described in subdivision (a) of this section, the IDRE shall notify the superintendent in writing within three business days of the acquisition or exercise of control and shall no longer be eligible to review disputes; and

(2) the sworn statement required by subdivision (b) of this section shall be amended and resubmitted to the superintendent within three business days of the addition or deletion of any material affiliation as described in subdivision (a) of this section.

(d) An IDRE or officer, director, or manager thereof; or reviewer or reviewing physician employed or engaged thereby to conduct any dispute resolution pursuant to Financial Services Law article 6 shall not have any material professional affiliation, material familial affiliation, or material financial affiliation with:

(1) the health care plan;

(2) any officer, director, or manager of the health care plan;

(3) any health care provider, physician's medical group, independent practice association, or provider of pharmaceutical products or services or durable medical equipment, that provided or supplied the health care service;

(4) the facility at which the health service was provided;

(5) any officer, director, partner, or manager of the physician's medical group, independent practice association, or facility that provided the heath care service;

(6) the developer or manufacturer of the principal health service that is the subject of the dispute resolution; or

(7) the patient whose health care service is the subject of the dispute resolution.

(e)Unavoidable conflicts; minimization.

(1)

(i) If the superintendent determines that a conflict is unavoidable because every IDRE certified pursuant to this Part or their medical directors, owners, officers, directors or managers have a disqualifying material familial, financial or professional affiliation with one or more of the persons or entities listed in subdivision (b) of this section to the dispute to be assigned, the superintendent will make a random assignment of the dispute provided, however, that the IDRE assigned shall, within two business days of the assignment certify to the superintendent by sworn statement that the reviewer and reviewing physician who will review the dispute have been assigned in accordance with paragraph (2) of this subdivision.

(ii) When a dispute must be assigned pursuant to this paragraph, the superintendent will notify the health care plan, physician, and, as applicable, the provider and patient, that all IDREs have a proscribed material familial, financial or professional affiliation; of the need to randomly assign the dispute to a certified IDRE in order that a determination of the dispute be obtained; the nature of the affiliation involving the IDRE assigned to the dispute; and that the IDRE's reviewer and reviewing physician who review the dispute shall not have any affiliation proscribed by this section.

(2) An IDRE assigned pursuant to this Part shall not assign a dispute resolution to a reviewer or reviewing physician who has a material familial, financial or professional affiliation with any of those persons listed in subdivision (d) of this section.

N.Y. Comp. Codes R. & Regs. Tit. 23 § 400.4

Adopted New York State Register June 3, 2015/Volume XXXVII, Issue 22, eff.6/3/2015