59A-12.0072. Accreditation Organizations

The accreditation organization must have nationally recognized experience in HMO accreditation activities and in the appraisal of medical practice and quality assurance in an HMO setting. As a minimum requirement for approval of the accreditation organization, the following criteria must be met:

(1) The accreditation organization must allow representatives from the agency to accompany the accreditation organization throughout the accreditation process, but the agency representatives shall not participate in the final accreditation or assessment determination.

(2) The accreditation organization must have at least 3 years of experience in reviewing all of the types of HMOs commonly found doing business in the State of Florida.

(3) The accreditation organization must have experience in conducting accreditation reviews for HMOs in at least 5 states of the United States or 2 regions of the Health Care Financing Administration, United States Department of Health and Human Services.

(4) Standards for accreditation must be developed with the input of the medical community, the HMO industry and health care consumers.

(5) The accreditation program shall, at a minimum, include standards for the following aspects of HMO operations:

(a) Quality Assurance Program;

(b) Provider Credentialing;

(c) Utilization Review Program;

(d) HMO Member Rights and Responsibilities;

(e) Medical Records;

(f) HMO Governance; and,

(g) Preventive Health Services.

(6) The accreditation program may include standards for the following services:

(a) Clinical laboratory services;

(b) Diagnostic and therapeutic radiology services;

(c) Pharmacy;

(d) Plant, technology, and safety management; and,

(e) Surgical and anesthesia services.

(7) The standards for accreditation shall be reviewed and updated at regular intervals not to exceed 2 years by the accreditation organization.

(8) The accreditation organization shall be required to submit its standards for HMO accreditation to the agency every 3 years for approval.

(9) Accreditation review teams shall include at least 1 physician experienced in HMO quality assurance program management. Reviewers shall undergo formal training in using the established standards for the HMO reviews.

(10) The accreditation organization shall maintain an internal quality assurance program to ensure the quality and continuity of the review program.

(11) The accreditation organization shall not currently be involved in the operation of the HMO or PHC, nor in the delivery of health care services to its subscribers.

(12) The accreditation organization shall not have contracted with or conducted consultations with the HMO or PHC seeking accreditation within the last 2 years for other than accreditation purposes.

Rulemaking Authority 641.56 FS. Law Implemented 641.512 FS. History–New 3-11-92, Formerly 10D-100.0072, Amended 4-10-03.