59A-23.004. Quality Assurance

(1) Each insurer or delegated entity shall have an ongoing quality assurance program designed to objectively and systematically monitor and evaluate the quality of patient care, based upon the prevailing standards of medical practice in the community.

(2) The scope of the quality assurance program shall include the following:

(a) Peer review;

(b) Satisfaction survey;

(c) Utilization management;

(d) Case management;

(e) Complaints and grievances;

(f) Credentialing and recredentialing;

(g) Medical records;

(h) Return to work;

(i) Cost analysis;

(j) Data collection;

(k) Outcome studies;

(l) Education; and,

(m) Provider dispute resolution.

(3) The quality assurance plan shall be in writing, updated annually, and shall describe the program’s objectives, organization and problem-solving activities for improvement of medical services. The plan shall specify:

(a) Those specific activities under subsection (1) that will be conducted;

(b) The timeframes and the responsible individual for each quality assurance activity; and,

(c) The follow-up activities including written procedures for taking remedial action.

(4) The insurer or delegated entity shall have a quality assurance committee that meets quarterly to review the progress of quality assurance activities, completion of the written work plan, findings, and to develop recommendations for corrective action and follow-up. The committee shall keep minutes of meetings to document the committee’s activities. Activities of the committee shall include:

(a) Identification of data to be collected;

(b) Evaluation of data collected;

(c) Recommendation of improvements utilizing data collected;

(d) Communication of the committee’s findings to accountable authorities for implementation of improvements; and,

(e) Evaluation and documentation of the results of the implementation of improvements.

(5) The insurer or delegated entity shall perform a quality assurance review of the processes and outcomes of care, at least annually, using current state and nationally recognized practice guidelines.

(6) All findings, conclusions, recommendations, actions taken and results of actions taken shall be documented, shared with contracted entities and reported through organizational channels that have been established within the workers’ compensation managed care arrangement.

(7) The insurer or delegated entity shall provide, as part of the quality assurance program, an ongoing peer review process which:

(a) Resolves issues regarding provision of medical services; and,

(b) Evaluates clinical performance at least annually. The evaluation process shall include: medical record audits of a representative sample of providers to evaluate medical necessity; provision of medical service(s) appropriate to the diagnosis; use of current state and nationally accepted practice parameters; timeliness and access to treatment; and the development and use of a plan of care. The insurer or delegated entity shall have a written methodology for determining the size and scope of the medical record audits that shall reflect the volume and complexity of services provided by the provider network.

(8) Utilization Management. The insurer or delegated entity shall have written policies and procedures for approving or denying requests for care in accordance with the agency’s practice parameters and with nationally recognized standards based on medical necessity. The program shall evaluate quality of care and services, and provide review prospectively, concurrently, and retrospectively including pre-certification mechanisms for elective admissions and non-emergency surgeries.

(a) The utilization management program shall ensure that:

1. All elective admissions and non-emergency services must be precertified;

2. Utilization management policies and procedures are clearly defined in writing and any advisory responsibilities are assigned to individuals with training and education in a health care field sufficient to evaluate the consistency of the proposed treatment with the relevant standards;

3. The utilization management program uses nationally recognized written criteria based on clinical evidence to determine medical necessity. Treating providers shall have access to the criteria used for determining medical necessity upon request;

4. The medical care coordinator is involved in the decision process and consultation regarding decisions with the treating physician. Any decision to deny a request for treatment shall be made by a licensed medical or osteopathic physician. A physician not involved in the initial decision shall review any denial based on medical necessity;

5. Decisions are made in a timely manner to accommodate the clinical urgency of the situation. There are policies and procedures and a process for making timely decisions including those involving urgent care;

6. The utilization management program documents and communicates the reasons for each denial of requested medical services to treating providers and the injured employees;

7. The information obtained through the quality assurance program is considered in evaluating the timeliness and necessity of medical services;

8. There is a procedure for handling requests for experimental procedures;

9. There is a procedure for resolution of provider disputes regarding reimbursement and utilization review;

10. There is a procedure for ensuring that referrals are made to network providers who are available and accessible within the service area. The insurer or delegated entity shall monitor the utilization of network and out-of-network services to improve network access; and,

11. There is a procedure for authorization of out-of-network services.

(b) Utilization management is responsible for:

1. Selection and application of nationally recognized review criteria and protocols;

2. Recommendation of general utilization management program policies;

3. Overall program monitoring; and,

4. Review of all appeals of denials of requests for treatment or referrals.

(9) Case Management. The insurer or delegated entity shall develop and implement policies and procedures for aggressive medical care coordination, which may be provided via internal and external case management services in association with utilization management activities. The insurer or delegated entity shall specify the types and severity of injuries which require internal and external case management.

(a) Internal case management activities shall include:

1. Coordinating, facilitating, and monitoring all aspects of the ongoing medical care of the injured employee;

2. Communicating utilization management decisions to the medical care coordinator and treating providers;

3. Assisting the injured employee in resolving complaints and obtaining medically necessary services;

4. Educating injured employees regarding their rights, responsibilities, and limitations of the workers’ compensation managed care arrangement;

5. Coordinating, facilitating, and monitoring the injured employee’s return to work status including communicating to the claims representative the services required pursuant to Section 440.491, F.S.; and,

6. Communicating the injured employee’s status to the employer and to the injured employee.

(b) Internal case management activities shall be performed in consultation with the treating physician and the medical care coordinator.

(c) Internal case management services shall be provided by individuals with the experience and training required to perform their assigned responsibilities.

(d) External case management shall be provided for catastrophic injuries as defined under Section 440.02(37), F.S., and for such other injuries as determined by the insurer or delegated entity. External case management services shall be performed by certified rehabilitation providers approved pursuant to Section 440.491, F.S.

(e) The insurer or delegated entity shall develop and implement procedures for communication of information regarding medical services and return to work between internal and external case management, the medical care coordinator, claims administration, the employer, and injured employee.

Rulemaking Authority 440.134(25) FS. Law Implemented 440.134(6)(c)1.-8., 11., (7), (9), (10)(d), (11), (14)(a), (d), (15) FS. History–New 9-12-94, Amended 10-8-01, 1-22-02.