(a) An HCO must include a written program designed to ensure a level of care for occupational injuries and illnesses which meets professionally recognized standards of care. The program must be designed and directed by providers to document that the quality of care provided is reviewed, that problems are identified, that effective action is taken to improve care where deficiencies are identified, that follow-up measures are planned where indicated, and that all of the requirements of this division are met. The plans must describe the goals and objectives of the program and organizational arrangements, including staffing, the methodology for on-going monitoring and evaluation of health services, the scope of the program, and required levels of activity. Quality of care problems must be identified and corrected. The program must demonstrate that the HCO's utilization review activities are designed to improve the quality of care provided.
The HCO shall describe and implement a program, including the following:
(1) A description of the process whereby the medical reasonableness or medical necessity of requests for authorization are reviewed and decisions on such requests are made by the HCO. The description shall include the specific criteria utilized in the review and throughout the decision-making process, including treatment protocols or standards in any software, database, or other resource used in the process. Treatment protocols must be consistent with any guidelines adopted pursuant to paragraph (8) of subdivision (e) of Section 139 of the Labor Code.
(2) A description of the qualifications of the personnel involved in reviewing and making decisions concerning requests for authorization, including the professional qualifications of the personnel, and the manner in which such personnel are involved in the review process. Medical decisions must be rendered by physicians with licenses unrestricted by their licensing board.
(3) A description of manual and automated data storage and retrieval systems for medical and utilization review; and the types of data analyses, reports, and manner in which results are communicated to providers.
(b) The HCO's quality assurance committee shall meet on at least a quarterly basis or more frequently if problems have been identified, to oversee its quality assurance program responsibilities. Reports to the HCO's governing body shall be sufficiently detailed to include findings and actions taken as a result of the quality assurance program and to identify those internal or contracting provider components which the quality assurance program had identified as presenting significant or chronic quality of care issues.
(c) The HCO is responsible for establishing a quality assurance program to monitor and evaluate the care provided by each contracting provider group or facility. Medical groups or other provider entities may have active quality assurance programs which the HCO may use. However, the HCO must retain responsibility for reviewing the overall quality of care delivered to HCO enrollees. To the extent that the HCO's quality assurance responsibilities are delegated within the HCO or to a contracting provider or facility, the HCO shall provide evidence of an oversight mechanism for ensuring that delegated quality assurance functions are adequately performed.
(d) Physicians must be an integral part of the quality assurance program. Design and implementation of the quality assurance program shall be supervised by designated physicians. Physician participation in quality assurance activity must be adequate to monitor the full scope of clinical services rendered, resolve problems and ensure that corrective action is taken when indicated. Specialist providers must also be involved in peer review of like specialties.
(e) The HCO may delegate inpatient quality assurance functions to hospitals, however in such case a HCO must fully describe and monitor that hospital's quality assurance program.
(f) The HCO must insure that all comprehensive medical-legal reports are prepared in an objective, fair, and unbiased manner, and that such reports are prepared in accordance with Section 4628 of the Labor Code, any applicable procedures promulgated under Section 139.2 of the Labor Code, and the requirements of Section 10606. The HCO or physician shall retain, for no less than three years, copies of all comprehensive medical evaluation reports which are prepared by any of its physicians to determine an employee's eligibility for compensation. These reports shall be made available to the administrative director upon request. The administrative director may review such reports as he or she deems necesary to insure compliance with this subdivision, and the results of this review may be used to deny recertification if it is determined that a significant number of an HCO's reports show bias or are legally inadequate.
(g) The HCO must describe how it will assess its activities as required by Sections 9776 and 9776.1 and the HCO's system for assuring data quality.
NOTE: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.5 and 4628, Labor Code.
1. New section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53).
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