Section 26-A3503. QUALITY ASSURANCE PROGRAM

 

3503.1An HMO shall continually maintain an internal quality assurance program. This program shall monitor and evaluate the services provided by the HMO, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and noninstitutional settings.

 

3503.2At a minimum the internal quality assurance program shall include at a minimum, the following items:

 

(a)A written statement of goals and objectives that emphasizes improved health status in evaluating the quality of care rendered to enrollees;

 

(b)A written quality assurance plan that describes:

 

(1)the HMO's scope and purpose in quality assurance;

 

(2)the organizational structure responsible for quality assurance activities;

 

(3)contractual arrangements for delegation of quality assurance activities;

 

(4)policies and procedures for confidentiality;

 

(5)a system of ongoing evaluation activities;

 

(6)a system of focused evaluation activities;

 

(7)a system for credentialing providers and performing peer review activities; and

 

(8)the duties and responsibilities of the designated physician responsible for quality assurance activities;

 

(c)A written description of the system of ongoing quality assurance activities which shall include:

 

(1)problem assessment, identification, selection, and study;

 

(2)corrective action, monitoring, evaluation, and reassessment; and

 

(3)interpretation and analysis of patterns of care rendered to individual patients by individual providers;

 

(d)A written statement describing the system focused quality assurance activities based on representative samples of the enrolled population which identifies the method of topic selection, study, data collection, analysis, interpretation, and report format; and

 

(e)A written plan for taking appropriate corrective action whenever inappropriate or substandard services have been provided to enrollees or services that should have been provided to enrollees have not been provided.

 

3503.3The HMO shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner.

 

3503.4Minutes from the quality assurance program shall be available to the Commissioner.

 

3503.5The HMO shall ensure the use and maintenance of a patient record system to facilitate the documentation and retrieval of clinical information for the purpose of evaluating the continuity and coordination of patient care, and assessing the quality of the health and medical care rendered to enrollees.

 

3503.6The Commissioner or his or her authorized designee may review the clinical records of an enrollee to determine whether the HMO has complied with this section or for any other purposes he or she considers necessary.

 

3503.7The HMO shall establish a mechanism for the governing body, providers, and appropriate staff to receive periodic reports on quality assurance program activities.

 

3503.8Quality assurance programs approved by the States of Maryland or Virginia, or by the District of Columbia Medicaid Program shall be deemed approved.

 

3503.9When an applicant has received a certificate of authority from Maryland or Virginia, a Quality Assurance Program Inquiry form shall be filed with the initial application for certificate of authority in the District. The HMO shall submit a copy of the quality assurance report.

 

3503.10The discussions between a patient and provider concerning medical treatment options and the financial coverage of those options shall not be prohibited, impeded or interfered with by the provider's contract with the HMO.

 

3503.11The contract between the HMO and the provider shall permit the provider to discuss medical treatment options with its patients.

 

3503.12An HMO's decision to terminate or refuse to contract with a provider shall not be based in whole or in part on the fact that the provider discussed medical treatment options with the enrollee.

 

source

Final Rulemaking published at 46 DCR 7291(September 17, 1999).