Cal. Code Regs. Tit. 8, § 9774 - Quality of Care
(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.
Notes
Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.5 and 4628, Labor Code.
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