Current through Register Vol. 42, No. 5, February 29, 2024
(1) A health maintenance organization shall
develop and implement a quality improvement program subject to the approval of
the State Health Officer that includes organizational arrangements and ongoing
procedures for the identification, evaluation, resolution, and follow-up of
potential and actual problems in health care administration and delivery to
enrollees.
(2) The quality
improvement organizational arrangements and ongoing procedures must be fully
described in written form, provided to all members of the governing body,
providers, and staff, and made available, upon request, to enrollees of the
health maintenance organization.
(3) The organizational arrangements for the
quality improvement program must be clearly defined and transmitted to all
individuals involved in the quality improvement program and should include, but
not be limited to, the following:
(a) A
quality improvement committee responsible for quality improvement activities
and utilization review activities;
(b) Accountability of the committee to the
administrator and the governing body of the health maintenance organization
including annual written and oral reports to the governing body. The written
reports shall contain;
1. Studies undertaken,
results, subsequent actions, and aggregate data on utilization and quality of
services rendered to enrollees.
(c) Participation from an appropriate base of
providers and support staff;
(d)
Supervision by medical director;
(e) A minimum of quarterly meetings at
appropriate location;
(f) Minutes
or records of the meeting of the quality improvement committee describing the
actions of the committee including problems discussed, recommendations made,
and any other pertinent discussions and activities; and
(g) Information concerning quality
improvement shall be treated as confidential information in accordance with
Code of Ala. 1975, §
27-21A-24
and 25.
(4) The quality
improvement procedures shall include defined methods for the identification and
selection of clinical and administrative problems. Input for problem
identification shall come from multiple sources including, but not limited to,
medical chart reviews, enrollee complaints, utilization review, enrollee
assessment audits, and should cover all health maintenance organization
services. Methods should be established by which potential problems are
selected and scheduled for further study.
(5) A health maintenance organization shall
document the manner by which it examines actual and potential problems in
health care administration and delivery to enrollees. While a variety of
methods may be utilized, the following components shall be present:
(a) The existence of procedures for the
analysis using standards certified by the State Health Officer. The procedures
shall be structured to encompass;
1. The
total episode of illness for which the health maintenance organization is
responsible.
2. The structure or
organizational framework within which care is provided.
3. The process or method by which care is
given.
4. The outcome of care
including morbidity and mortality rates.
(6) The quality improvement activities shall
include the development of timely and appropriate recommendations for problems
in health care administration and delivery to enrollees that are identified,
and the health maintenance organization shall demonstrate an operational
mechanism for responding to those problems. Such a mechanism shall include:
(a) Development of appropriate
recommendations for corrective action, or when no action is indicated, an
appropriate response;
(b)
Assignment of responsibility at the appropriate level or with the appropriate
person for the implementation of the recommendation; and
(c) Implementation of action which is
appropriate to the subject or problem in health care administration and
delivery to enrollees.
(7) There shall be evidence of adequate
follow-up on recommendations. The health maintenance organization shall be able
to demonstrate that recommendations of the committee responsible for quality
improvement activities are reviewed in a timely manner in order to:
(a) Assure the implementation of action
relative to the recommendations;
(b) Assess the results of such action;
and
(c) Provide for revision of
recommendations or actions and continued monitoring when necessary.
(8) Review of the quality of care
shall not be limited to technical aspects of care alone but shall also include
availability, accessibility, and continuity of care provided to
enrollees.
(9) A utilization review
process shall be specified to assure that only those services which represent
proper utilization of health care services and conform with contractual
provisions are provided.
(a) "Utilization
Review" means prospective, concurrent, and retrospective review and analysis of
data related to utilization of health care resources in terms of cost
effectiveness, efficiency, control, and quality.
(b) "Retrospective Review" means the
mechanism to review medical necessity and appropriateness of medical services
through the compilation and analysis of data after medical care is rendered and
shall include the comparison of contracted provider practice patterns with
parameters established by the utilization review committee, recommendation of
changes in contracted provider practice patterns based on analysis and review,
and analyzation of care to enrollees to determine need for educational programs
and benefit restructuring.
(c) Data
on utilization of health care services shall be collected and shall be analyzed
to identify for further in depth investigation of potential over-utilization,
under- utilization, or misutilization of health care services by enrollees or
providers. Such data shall include, but not be limited to, the following:
1. The analysis of utilization
statistics;
2. The analysis of
referral trends;
3. Assessment of
ambulatory treatment patterns;
4.
Assessment of a pre-hospitalization admission program;
5. Evaluation of a hospital inpatient
monitoring program;
6. Evaluation
of a retrospective review program; and
7. Monitoring of the effectiveness of a
discharge planning procedure.
(d) Data on utilization shall be treated as
confidential information in accordance with Code of Ala.
1975, §
27-21A-24
and 25 with the exception of the aggregate utilization data required in
quarterly and annual reports in
420-5-6-.14(1)(d)(e),
(2)(d)(e).
(10) A health maintenance organization shall
specify in the provider manual procedures for maintenance of the provider's
medical records which shall include, but not be limited to, the following:
(a) Medical records shall be maintained in a
current, detailed, organized, and comprehensive manner;
1. Medical records shall be legible and
should reflect all aspects of patient care, including ancillary
services.
2. Records shall be
available to health care practitioners at each encounter and for internal and
external and Department review.
3.
The health maintenance organization shall have an explicit statement of its
policy for assuring confidentiality of patient records.
(b) The inpatient and outpatient care records
shall demonstrate conformity with good professional medical practices and
permit effective quality improvement review;
1. For a given encounter, there shall be a
complete, dated, and signed progress note containing the following information.
(i) Reason for visit
(ii) Evaluation
(iii) Problem/diagnosis
(iv) Therapeutic plan
(v) Follow-up
2. For subsequent encounters, there shall be
evidence of adherence to the follow-up plan.
(c) Appropriate health management and
continuity of care shall be clearly reflected in the medical records.
Author: Department of Public
Health
Statutory Authority:
Code of Ala.
1975, §§
22-2-2(6),
et
seq.,
22-21-20,
et
seq.,
27-21A-1,
et
seq.
