Current through Reg. 50, No. 187; September 24, 2024
(1) Each insurer
or delegated entity shall have an ongoing quality assurance program designed to
objectively and systematically monitor and evaluate the quality of patient
care, based upon the prevailing standards of medical practice in the
community.
(2) The scope of the
quality assurance program shall include the following:
(a) Peer review;
(b) Satisfaction survey;
(c) Utilization management;
(d) Case management;
(e) Complaints and grievances;
(f) Credentialing and
recredentialing;
(g) Medical
records;
(h) Return to
work;
(i) Cost analysis;
(j) Data collection;
(k) Outcome studies;
(l) Education; and,
(m) Provider dispute
resolution.
(3) The
quality assurance plan shall be in writing, updated annually, and shall
describe the program's objectives, organization and problem-solving activities
for improvement of medical services. The plan shall specify:
(a) Those specific activities under
subsection (1) that will be conducted;
(b) The timeframes and the responsible
individual for each quality assurance activity; and,
(c) The follow-up activities including
written procedures for taking remedial action.
(4) The insurer or delegated entity shall
have a quality assurance committee that meets quarterly to review the progress
of quality assurance activities, completion of the written work plan, findings,
and to develop recommendations for corrective action and follow-up. The
committee shall keep minutes of meetings to document the committee's
activities. Activities of the committee shall include:
(a) Identification of data to be
collected;
(b) Evaluation of data
collected;
(c) Recommendation of
improvements utilizing data collected;
(d) Communication of the committee's findings
to accountable authorities for implementation of improvements; and,
(e) Evaluation and documentation of the
results of the implementation of improvements.
(5) The insurer or delegated entity shall
perform a quality assurance review of the processes and outcomes of care, at
least annually, using current state and nationally recognized practice
guidelines.
(6) All findings,
conclusions, recommendations, actions taken and results of actions taken shall
be documented, shared with contracted entities and reported through
organizational channels that have been established within the workers'
compensation managed care arrangement.
(7) The insurer or delegated entity shall
provide, as part of the quality assurance program, an ongoing peer review
process which:
(a) Resolves issues regarding
provision of medical services; and,
(b) Evaluates clinical performance at least
annually. The evaluation process shall include: medical record audits of a
representative sample of providers to evaluate medical necessity; provision of
medical service(s) appropriate to the diagnosis; use of current state and
nationally accepted practice parameters; timeliness and access to treatment;
and the development and use of a plan of care. The insurer or delegated entity
shall have a written methodology for determining the size and scope of the
medical record audits that shall reflect the volume and complexity of services
provided by the provider network.
(8) Utilization Management. The insurer or
delegated entity shall have written policies and procedures for approving or
denying requests for care in accordance with the agency's practice parameters
and with nationally recognized standards based on medical necessity. The
program shall evaluate quality of care and services, and provide review
prospectively, concurrently, and retrospectively including pre-certification
mechanisms for elective admissions and non-emergency surgeries.
(a) The utilization management program shall
ensure that:
1. All elective admissions and
non-emergency services must be precertified;
2. Utilization management policies and
procedures are clearly defined in writing and any advisory responsibilities are
assigned to individuals with training and education in a health care field
sufficient to evaluate the consistency of the proposed treatment with the
relevant standards;
3. The
utilization management program uses nationally recognized written criteria
based on clinical evidence to determine medical necessity. Treating providers
shall have access to the criteria used for determining medical necessity upon
request;
4. The medical care
coordinator is involved in the decision process and consultation regarding
decisions with the treating physician. Any decision to deny a request for
treatment shall be made by a licensed medical or osteopathic physician. A
physician not involved in the initial decision shall review any denial based on
medical necessity;
5. Decisions are
made in a timely manner to accommodate the clinical urgency of the situation.
There are policies and procedures and a process for making timely decisions
including those involving urgent care;
6. The utilization management program
documents and communicates the reasons for each denial of requested medical
services to treating providers and the injured employees;
7. The information obtained through the
quality assurance program is considered in evaluating the timeliness and
necessity of medical services;
8.
There is a procedure for handling requests for experimental
procedures;
9. There is a procedure
for resolution of provider disputes regarding reimbursement and utilization
review;
10. There is a procedure
for ensuring that referrals are made to network providers who are available and
accessible within the service area. The insurer or delegated entity shall
monitor the utilization of network and out-of-network services to improve
network access; and,
11. There is a
procedure for authorization of out-of-network services.
(b) Utilization management is responsible
for:
1. Selection and application of
nationally recognized review criteria and protocols;
2. Recommendation of general utilization
management program policies;
3.
Overall program monitoring; and,
4.
Review of all appeals of denials of requests for treatment or
referrals.
(9)
Case Management. The insurer or delegated entity shall develop and implement
policies and procedures for aggressive medical care coordination, which may be
provided via internal and external case management services in association with
utilization management activities. The insurer or delegated entity shall
specify the types and severity of injuries which require internal and external
case management.
(a) Internal case management
activities shall include:
1. Coordinating,
facilitating, and monitoring all aspects of the ongoing medical care of the
injured employee;
2. Communicating
utilization management decisions to the medical care coordinator and treating
providers;
3. Assisting the injured
employee in resolving complaints and obtaining medically necessary
services;
4. Educating injured
employees regarding their rights, responsibilities, and limitations of the
workers' compensation managed care arrangement;
5. Coordinating, facilitating, and monitoring
the injured employee's return to work status including communicating to the
claims representative the services required pursuant to Section
440.491, F.S.; and,
6. Communicating the injured employee's
status to the employer and to the injured employee.
(b) Internal case management activities shall
be performed in consultation with the treating physician and the medical care
coordinator.
(c) Internal case
management services shall be provided by individuals with the experience and
training required to perform their assigned responsibilities.
(d) External case management shall be
provided for catastrophic injuries as defined under Section
440.02(37),
F.S., and for such other injuries as determined by the insurer or delegated
entity. External case management services shall be performed by certified
rehabilitation providers approved pursuant to Section
440.491, F.S.
(e) The insurer or delegated entity shall
develop and implement procedures for communication of information regarding
medical services and return to work between internal and external case
management, the medical care coordinator, claims administration, the employer,
and injured employee.
Rulemaking Authority 440.134(25) FS. Law Implemented
440.134(6)(c)1.-8., 11., (7), (9), (10)(d), (11), (14)(a), (d), (15)
FS.
New 9-12-94, Amended 10-8-01,
1-22-02.
