Current through Reg. 50, No. 13; March 28, 2025
(a) A
network must develop and maintain a continuous and comprehensive quality
improvement program designed to monitor and evaluate objectively and
systematically the quality and appropriateness of health care and network
services, and to pursue opportunities for improvement. The quality improvement
program must include return-to-work and medical case management programs. The
network must dedicate adequate resources, including personnel and information
systems, to the quality improvement program.
(b) Required documentation of the quality
improvement program, at a minimum, includes:
(1) Written description. The network must
develop a written description of the quality improvement program that outlines
the program's organizational structure, functional responsibilities, and
committee meeting frequency;
(2)
Work plan. The network must develop an annual quality improvement work plan
designed to reflect the type of services and the population served by the
network in terms of age groups, disease or injury categories, and special risk
status, such as type of industry. The work plan must include:
(A) objective and measurable goals, planned
activities to accomplish the goals, time frames for implementation, individuals
responsible, and evaluation methodology;
(B) evaluation of each program, including:
(i) network adequacy, which encompasses
availability and accessibility of care and assessment of providers who are and
are not accepting new patients;
(ii) continuity of health care and related
services;
(iv) the adoption and
periodic updating of treatment guidelines, return-to-work guidelines,
individual treatment protocols, and the list of services requiring
preauthorization;
(v) employee and
provider satisfaction;
(vi) the
complaint-and-appeal process, complaint data, and identification and removal of
communication barriers that may impede employees and providers from effectively
making complaints against the network;
(vii) provider billing and provider payment
processes, if applicable;
(viii)
contract monitoring, including delegation oversight, if applicable, and
compliance with filing requirements;
(ix) utilization review processes, if
applicable;
(xi) employee
services, including after-hours telephone access logs;
(xii) return-to-work processes and outcomes;
and
(xiii) medical case management
outcomes.
(3)
Annual evaluation. The network must prepare an annual written report on the
quality improvement program that includes:
(A)
completed activities;
(B) trending
of clinical and service goals;
(C)
analysis of program performance; and
(D) conclusions regarding the effectiveness
of the program.
(c) The network is presumed to be in
compliance with statutory and regulatory requirements regarding quality
improvement requirements, including credentialing, if:
(1) the network has received nonconditional
accreditation or certification by the National Committee for Quality Assurance,
The Joint Commission, URAC, or the Accreditation Association for Ambulatory
Health Care;
(2) the accreditation
includes all quality improvement requirements set forth in this
section;
(3) the certification for
a function, including credentialing, includes all requirements set forth in
this section;
(4) the national
accreditation organization's requirements are the same as, substantially
similar to, or more stringent than the department's quality improvement
requirements; and
(5) the network
has and will maintain documentation demonstrating that doctors who provide
certifications of maximum medical improvement or assign impairment ratings to
injured employees are authorized under §
130.1 of this title (relating to
Certification of Maximum Medical Improvement and Evaluation of Permanent
Impairment).
(d) The
network governing body is ultimately responsible for the quality improvement
program and must:
(1) appoint a quality
improvement committee that includes network providers;
(2) approve the quality improvement
program;
(3) approve an annual
quality improvement work plan;
(4)
meet no less than annually to receive and review reports of the quality
improvement committee or group of committees, and take action when appropriate;
and
(5) review the annual
evaluation of the quality improvement program.
(e) The quality improvement committee must
evaluate the overall effectiveness of the quality improvement program. The
committee may delegate and oversee quality improvement activities to
subcommittees that may, if applicable, include practicing doctors and employees
from the service area. All subcommittees must:
(1) collaborate and coordinate efforts to
improve the quality, availability, and accessibility of health care services;
and
(2) meet regularly and
routinely report findings, recommendations, and resolutions in writing to the
quality improvement committee for the network.
(f) The network must have a medical case
management program with certified case managers whose certifying organization
must be accredited by an established accrediting organization, including the
National Commission for Certifying Agencies, the American Board of Nursing
Specialties, or another national accrediting agency with similar standards. In
accordance with Labor Code §
413.021(a),
concerning Return-to-Work Coordination Services, a claims adjuster may not
serve as a case manager. The case manager must work with providers, employees,
doctors, and employers to facilitate cost-effective health care and the
employee's return to work, and must be certified in one or more of the
following areas:
(2) case management
administration;
(3) rehabilitation
case management;
(5) disability management;
or