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RULE §10.81Quality Improvement Program

(a) A network must develop and maintain a continuous and comprehensive quality improvement program designed to monitor and evaluate objectively and systematically the quality and appropriateness of health care and network services, and to pursue opportunities for improvement. The quality improvement program must include return-to-work and medical case management programs. The network must dedicate adequate resources, including personnel and information systems, to the quality improvement program.

(b) Required documentation of the quality improvement program, at a minimum, includes:

  (1) Written description. The network must develop a written description of the quality improvement program that outlines the program's organizational structure, functional responsibilities, and committee meeting frequency;

  (2) Work plan. The network must develop an annual quality improvement work plan designed to reflect the type of services and the population served by the network in terms of age groups, disease or injury categories, and special risk status, such as type of industry. The work plan must include:

    (A) objective and measurable goals, planned activities to accomplish the goals, time frames for implementation, individuals responsible, and evaluation methodology;

    (B) evaluation of each program, including:

      (i) network adequacy, which encompasses availability and accessibility of care and assessment of providers who are and are not accepting new patients;

      (ii) continuity of health care and related services;

      (iii) clinical studies;

      (iv) the adoption and periodic updating of treatment guidelines, return-to-work guidelines, individual treatment protocols, and the list of services requiring preauthorization;

      (v) employee and provider satisfaction;

      (vi) the complaint-and-appeal process, complaint data, and identification and removal of communication barriers that may impede employees and providers from effectively making complaints against the network;

      (vii) provider billing and provider payment processes, if applicable;

      (viii) contract monitoring, including delegation oversight, if applicable, and compliance with filing requirements;

      (ix) utilization review processes, if applicable;

      (x) credentialing;

      (xi) employee services, including after-hours telephone access logs;

      (xii) return-to-work processes and outcomes; and

      (xiii) medical case management outcomes.

  (3) Annual evaluation. The network must prepare an annual written report on the quality improvement program that includes:

    (A) completed activities;

    (B) trending of clinical and service goals;

    (C) analysis of program performance; and

    (D) conclusions regarding the effectiveness of the program.

(c) The network is presumed to be in compliance with statutory and regulatory requirements regarding quality improvement requirements, including credentialing, if:

  (1) the network has received nonconditional accreditation or certification by the National Committee for Quality Assurance, The Joint Commission, URAC, or the Accreditation Association for Ambulatory Health Care;

  (2) the accreditation includes all quality improvement requirements set forth in this section;

  (3) the certification for a function, including credentialing, includes all requirements set forth in this section;

  (4) the national accreditation organization's requirements are the same as, substantially similar to, or more stringent than the department's quality improvement requirements; and

  (5) the network has and will maintain documentation demonstrating that doctors who provide certifications of maximum medical improvement or assign impairment ratings to injured employees are authorized under §130.1 of this title (relating to Certification of Maximum Medical Improvement and Evaluation of Permanent Impairment).

(d) The network governing body is ultimately responsible for the quality improvement program and must:

  (1) appoint a quality improvement committee that includes network providers;

  (2) approve the quality improvement program;

  (3) approve an annual quality improvement work plan;

  (4) meet no less than annually to receive and review reports of the quality improvement committee or group of committees, and take action when appropriate; and

  (5) review the annual evaluation of the quality improvement program.

(e) The quality improvement committee must evaluate the overall effectiveness of the quality improvement program. The committee may delegate and oversee quality improvement activities to subcommittees that may, if applicable, include practicing doctors and employees from the service area. All subcommittees must:

  (1) collaborate and coordinate efforts to improve the quality, availability, and accessibility of health care services; and

  (2) meet regularly and routinely report findings, recommendations, and resolutions in writing to the quality improvement committee for the network.

(f) The network must have a medical case management program with certified case managers whose certifying organization must be accredited by an established accrediting organization, including the National Commission for Certifying Agencies, the American Board of Nursing Specialties, or another national accrediting agency with similar standards. In accordance with Labor Code §413.021(a), concerning Return-to-Work Coordination Services, a claims adjuster may not serve as a case manager. The case manager must work with providers, employees, doctors, and employers to facilitate cost-effective health care and the employee's return to work, and must be certified in one or more of the following areas:

  (1) case management;

  (2) case management administration;

  (3) rehabilitation case management;

  (4) continuity of care;

  (5) disability management; or

  (6) occupational health.

Source Note: The provisions of this §10.81 adopted to be effective December 5, 2005, 30 TexReg 8099; amended to be effective August 2, 2022, 47 TexReg 4534

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