(a) A health maintenance organization shall establish procedures to assure that the health care services provided to enrollees shall be rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. Such procedures shall include mechanisms to assure availability, accessibility, and continuity of care.

(b) A health maintenance organization shall have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and noninstitutional settings. The program shall include, at a minimum, the following:

(1) A written statement of goals and objectives which emphasizes improved health status in evaluating the quality of care rendered to enrollees;

(2) A written quality assurance plan which describes the following:

(A) The health maintenance organization’s scope and purpose in quality assurance;

(B) The organizational structure responsible for quality assurance activities;

(C) Contractual arrangements, where appropriate, for delegation of quality assurance activities;

(D) Confidentiality policies and procedures;

(E) A system of ongoing evaluation activities;

(F) A system of focused evaluation activities;

(G) A system for credentialing providers and performing peer review activities; and

(H) Duties and responsibilities of the designated physician responsible for the quality assurance activities;

(3) A written statement describing the system on ongoing quality assurance activities including:

(A) Problem assessment, identification, selection, and study;

(B) Corrective action, monitoring, evaluation, and reassessment; and

(C) Interpretation and analysis of patterns of care rendered to individual patients by individual providers;

(4) A written statement describing the system focused quality assurance activities based on representative samples of the enrolled population which identifies method of topic selection, study, data collection, analysis, interpretation, and report format; and

(5) Written plans for taking appropriate corrective action whenever, as determined by the quality assurance program, inappropriate or substandard services have been provided or services which should have been provided have not been provided.

(c) The organization shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes shall be available to the Commissioner.

(d) The organization shall ensure the use and maintenance of an adequate patient record system which will facilitate documentation and retrieval of clinical information for the purpose of the health maintenance organization evaluating continuity and coordination of patient care and assessing the quality of health and medical care provided to enrollees.

(e) Enrollee clinical records shall be available to the Commissioner or an authorized designee for examination and review to ascertain compliance with this section, or as deemed necessary by the Commissioner.

(f) The organization shall establish a mechanism for periodic reporting of quality assurance program activities to the governing body, providers, and appropriate staff.

(g) If a quality assurance program has received approval in Maryland or Virginia, or if a quality assurance program has been approved by the D.C. Medicaid Program, it shall be deemed approved.

(h) The following shall apply to health maintenance organizations, carriers, and providers:

(1) No contract between a health maintenance organization and a provider shall prohibit, impede, or interfere in the discussions between a patient and a provider of medical treatment option including discussions regarding financial coverage of those treatment options.

(2) A contract between a carrier and a provider shall permit and require the provider to discuss medical treatment options with the patient.

(3) A health maintenance organization may not terminate or refuse to contract with a provider solely because the provider discussed medical treatment options with an enrollee.

(i) The Commissioner may accept all or part of a quality assurance report and supporting documentation of an approved accrediting organization acceptable to the Commissioner to satisfy the review requirements under this section; provided, that such acceptance shall not preclude the Commissioner from performing the examination function.

(j) The expense of the quality assurance examination shall be borne by the entity applying for the health maintenance organization certificate of authority or otherwise seeking to comply with this section.

(Apr. 9, 1997, D.C. Law 11-235, § 7, 44 DCR 818; Mar. 27, 2003, D.C. Law 14-252, § 2(c), 50 DCR 225.)

1981 Ed., § 35-4506.

This section is referenced in § 31-3403 and § 31-3426.

D.C. Law 14-252 added subsecs. (i) and (j).