Ala. Admin. Code r. 420-5-6-.07
Current through Register Vol. 43, No. 02, November 27, 2024
Section 420-5-6-.07 - Quality Improvement And Utilization Review(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; and7. 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. 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
Ala. Admin. Code r. 420-5-6-.07
Filed September 1, 1982. Repealed and New Rule adopted in lieu thereof: Filed March 31, 1987. Amended: Filed January 20, 1999; effective February 24, 1999.Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.