(a) An insurer must develop and maintain an ongoing
quality improvement (QI) program designed to objectively and systematically
monitor and evaluate the quality and appropriateness of care and services
provided within an exclusive provider benefit plan and to pursue opportunities
for improvement. The QI program must be continuous and comprehensive,
addressing both the quality of clinical care and the quality of services.
The insurer must dedicate adequate resources, like 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 exclusive provider benefit plan 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 medical and health care and related
services;
(iii) clinical studies;
(iv) the adoption and periodic updating of clinical
practice guidelines or clinical care standards that:
(I) are approved by participating physicians and individual
providers;
(II) are communicated to physicians and individual
providers; and
(III) include preventive health services;
(v) insured, physician, and individual provider satisfaction;
(vi) the complaint process, complaint data, and identification
and removal of barriers that may impede insureds, physicians, and
providers from effectively making complaints against the insurer;
(vii) preventive health care through health promotion
and outreach activities;
(viii) claims payment processes;
(ix) contract monitoring, including oversight and compliance
with filing requirements;
(x) utilization review processes;
(xi) credentialing;
(xii) insured 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 insurer must implement a documented
process for selection and retention of contracted preferred providers
that complies with §3.3706(c) of this title (relating to Designation
as a Preferred Provider, Decision to Withhold Designation, Termination
of a Preferred Provider, Review of Process).
(5) Peer review. The QI program must provide for a
peer review procedure for physicians and individual providers, as
required in the Medical Practice Act, Occupations Code Chapters 151
- 164. The insurer must designate a credentialing committee that uses
a peer review process to make recommendations regarding credentialing
decisions.
(b) The insurer's governing body is ultimately responsible
for the QI program.
(1) The governing body must appoint a quality improvement
committee (QIC) that:
(A) must include practicing physicians and individual
providers;
(B) may include one or more insured(s) from throughout
the exclusive provider benefit plan's service area; and
(C) must ensure that any insured appointed to the QIC
is not an employee of the insurer.
(2) The governing body must approve the QI program.
(3) The governing body must approve an annual QI plan.
(4) The governing body must meet no less than annually
to receive and review reports of the QIC or its subcommittees and
take action when appropriate.
(5) The governing body must review the annual written
report on the QI program.
(c) The QIC must evaluate the overall effectiveness
of the QI program.
(1) The QIC may delegate QI activities to other committees
that may, if applicable, include practicing physicians, individual
providers, and insureds from the service area.
(A) All committees must collaborate and coordinate
efforts to improve the quality, availability, and accessibility of
health care services.
(B) All committees must meet regularly and report the
findings of each meeting, including any recommendations, in writing
to the QIC.
(C) If the QIC delegates any QI activity to any subcommittee,
then the QIC must establish a method to oversee each subcommittee.
(2) The QIC must use multidisciplinary teams, when
indicated, to accomplish QI program goals.
(d) In reviewing an insurer's quality improvement program,
the department will presume that the insurer is in compliance with
statutory and regulatory requirements regarding the insurer's quality
improvement program if the insurer has received nonconditional accreditation
or certification specific and germane to the insurer's quality improvement
program by the National Committee for Quality Assurance, the Joint
Commission, URAC, or the Accreditation Association for Ambulatory
Health Care. However, if the department determines that an accreditation
or certification program does not adequately address a material Texas
statutory or regulatory requirement, the department will not presume
the insurer to be in compliance with that requirement.
|