The QI program for basic, single service, and limited service
HMOs must be continuous and comprehensive, addressing both the quality
of clinical care and the quality of services. The HMO must dedicate
adequate resources, such as personnel and information systems, to
the QI program.
(1) Written description. The QI program must include
a written description of the QI program that outlines program organizational
structure, functional responsibilities, and meeting frequency.
(2) Work plan. The QI program must include an annual
QI work plan designed to reflect the type of services and the population
served by the HMO in terms of age groups, disease categories, and
special risk status. The work plan must:
(A) include objective and measurable goals, planned
activities to accomplish the goals, time frames for implementation,
responsible individuals, and evaluation methodology; and
(B) address each program area, including:
(i) network adequacy, which includes availability and
accessibility of care, including assessment of open and closed physician
and individual provider panels;
(ii) continuity of health care and related services;
(iii) clinical studies;
(iv) the adoption and periodic updating of clinical
practice guidelines or clinical care standards, which the QI program
must ensure:
(I) are approved by participating physicians and individual
providers;
(II) are communicated to physicians and individual
providers; and
(III) include preventive health services;
(v) enrollee, physician, and individual provider satisfaction;
(vi) the complaint and appeals process, complaint data,
and identification and removal of communication barriers that may
impede enrollees, physicians, and providers from effectively making
complaints against the HMO;
(vii) preventive health care through health promotion
and outreach activities;
(viii) claims payment processes;
(ix) contract monitoring, including delegation oversight
and compliance with filing requirements;
(x) utilization review processes;
(xi) credentialing;
(xii) member services; and
(xiii) pharmacy services, including drug utilization.
(3) Evaluation. The QI program must include an annual
written report on the QI program, which includes completed activities,
trending of clinical and service goals, analysis of program performance,
and conclusions.
(4) Credentialing. An HMO must implement a documented
process for selection and retention of contracted physicians and providers.
The credentialing process must comply with NCQA or American Accreditation
HealthCare Commission, Inc., standards, to the extent that those standards
do not conflict with the laws of this state. An HMO must have a documented
process for expedited credentialing of physicians, podiatrists, and
therapeutic optometrists, including a documented process for payment
of claims during the expedited credentialing process, in compliance
with Insurance Code Chapter 1452 (concerning Physician and Provider
Credentials).
(5) Site visits for cause.
(A) The HMO must have procedures for detecting deficiencies
after a site visit. When the HMO identifies new deficiencies, the
HMO must reevaluate the site and institute actions for improvement.
(B) An HMO may conduct a site visit to the office of
any physician or provider at any time for cause. The HMO may conduct
the site visit to evaluate a complaint or other precipitating event,
which may include an evaluation of any facilities or services related
to a complaint or event and an evaluation of medical records, equipment,
space, accessibility, appointment availability, or confidentiality
practices, as appropriate.
(6) Peer Review. The QI program must provide for a
peer review procedure for physicians and individual providers, as
required by the Medical Practice Act, Occupations Code, Chapter 151,
Subchapter A, (concerning General Provisions). The HMO must designate
a credentialing committee that uses a peer review process to make
recommendations regarding credentialing decisions.
(7) Delegation of Credentialing. If the HMO delegates
credentialing functions to other entities, its credentialing process
must comply with the standards promulgated by the NCQA, to the extent
that those standards do not conflict with other laws of this state.
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