(a) A network shall 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 shall include return-to-work and medical case management programs. The network shall 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 shall develop a written description of the quality improvement program that outlines program organizational structure, functional responsibilities, and committee meeting frequency;
(2) Work plan. The network shall 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 shall 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 which 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 and retrospective review processes, if applicable;
(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 shall prepare an annual written report on the quality improvement program, which 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 (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Accreditation HealthCare Commission (URAC), or the Accreditation Association for Ambulatory Health Care (AAAHC);
(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; and
(4) the national accreditation organization's requirements are the same, substantially similar to, or more stringent than the department's quality improvement requirements.
(d) The network governing body is ultimately responsible for the quality improvement program and shall:
(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 shall 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 shall:
(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 shall 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 (NCCA), the American Board of Nursing Specialties, or another national accrediting agency with similar standards. In accordance with Labor Code § 413.021(a), a claims adjuster may not serve as a case manager. The case manager shall 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.
(g) Until January 1, 2007, non-certified case managers may assist in providing the required medical case management services. The non-certified case managers must have prior experience in one of the areas delineated in subsection (f)(1)--(6) of this section, and may not serve as claim adjusters. The non-certified case managers must be under the direct supervision of a certified case manager as described in subsection (f) of this section at all times.
The provisions of this § 10.81 adopted to be effective December 5, 2005, 30 TexReg 8099.