D.C. Mun. Regs. tit. 26, r. 26-A3503

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 26-A3503 - QUALITY ASSURANCE PROGRAM

3503.1

An 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.

3503.2

At 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.

3503.3

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

3503.4

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

3503.5

The 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.

3503.6

The 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.

3503.7

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

3503.8

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

3503.9

When 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.

3503.10

The 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.

3503.11

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

3503.12

An 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.

D.C. Mun. Regs. tit. 26, r. 26-A3503

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