| (a) In addition to the general by-law requirements
set forth herein for health organizations seeking certification under §162.001(b)
of the Act, any health organization in which a member is either a
person who is not a physician actively engaged in the practice of
medicine or an entity or organization that is not wholly owned and
controlled by physicians actively engaged in the practice of medicine
must comply with the following requirement:
(1) All credentialing, quality assurance, utilization
review and peer review policies shall be made exclusively by the board
of directors; however, following consultation with the board of directors,
the member(s) may retain the right to approve, or in the case of a
health organization seeking to obtain or maintain tax exempt status
the right to make, any financial decision of the health organization
including, but not limited to, decisions regarding capital and operating
budgets, physician compensation and benefits, expenditures of monies,
and managed care contracts in which the health organization is at
financial risk, the substance of which requirements shall be provided
for in the by-laws of the health organization.
(2) Subsequent to the appointment of the initial board
of directors, a member may not appoint or elect any director without
the approval of at least a majority of the board of directors unless
required by law including requirements to obtain or maintain tax exemption.
(3) Without the approval of at least a majority of
the board of directors, the member may not unilaterally amend the
bylaws of the health organization unless required by law including
requirements to obtain or maintain tax exemption.
(b) The board of directors for the organization must
develop policies and the organization must adopt, maintain, and enforce
policies to ensure that physicians employed by the organization exercise
independent medical judgment when providing care to patients. The
policies must include policies relating to:
(1) credentialing and privileging;
(2) quality assurance;
(3) utilization review; and
(4) peer review.
(c) A health organization may not interfere with, control,
or otherwise direct a physician's professional judgment in violation
of the Act, Board rules, or any other provision of law. The health
organization's policies must reserve the sole authority to engage
in the practice of medicine to a physician participating in the health
organization, regardless of the physician's employment status with
the health organization. A physician retains independent medical judgment
and discretion in providing and supervising care to patients. A health
organization may not discipline a physician for reasonably advocating
for patient care.
(d) The requirements set out in Texas Occupations Code,
Chapter 162, Subchapter A, may not be voided or waived by contract.
However, a member of a health organization may establish ethical and
religious directives and a physician may contractually agree to comply
with those directives.
|
| Source Note: The provisions of this §177.5 adopted to be effective January 12, 1996, 21 TexReg 107; amended to be effective July 4, 2004, 29 TexReg 6089; amended to be effective July 4, 2012, 37 TexReg 4928 |
