Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter E - NETWORK OPERATIONS › Section 10.81 - Quality Improvement Program

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  network must develop and maintain a continuous and comprehensive quality
				  improvement program designed to monitor and evaluate objectively and
				  systematically the quality and appropriateness of health care and network
				  services, and to pursue opportunities for improvement. The quality improvement
				  program must include return-to-work and medical case management programs. The
				  network must dedicate adequate resources, including personnel and information
				  systems, to the quality improvement program.
(b) Required documentation of the quality
				  improvement program, at a minimum, includes:
(1) Written description. The network must
				  develop a written description of the quality improvement program that outlines
				  the program's organizational structure, functional responsibilities, and
				  committee meeting frequency;
(2)
				  Work plan. The network must develop an annual quality improvement work plan
				  designed to reflect the type of services and the population served by the
				  network in terms of age groups, disease or injury categories, and special risk
				  status, such as type of industry. The work plan must include:
(A) objective and measurable goals, planned
				  activities to accomplish the goals, time frames for implementation, individuals
				  responsible, and evaluation methodology;
(B) evaluation of each program, including:
(i) network adequacy, which encompasses
				  availability and accessibility of care and assessment of providers who are and
				  are not accepting new patients;
(ii) continuity of health care and related
				  services;
(iii) clinical
				  studies;
(iv) the adoption and
				  periodic updating of treatment guidelines, return-to-work guidelines,
				  individual treatment protocols, and the list of services requiring
				  preauthorization;
(v) employee and
				  provider satisfaction;
(vi) the
				  complaint-and-appeal process, complaint data, and identification and removal of
				  communication barriers that may impede employees and providers from effectively
				  making complaints against the network;
(vii) provider billing and provider payment
				  processes, if applicable;
(viii)
				  contract monitoring, including delegation oversight, if applicable, and
				  compliance with filing requirements;
(ix) utilization review processes, if
				  applicable;
(x)
				  credentialing;
(xi) employee
				  services, including after-hours telephone access logs;
(xii) return-to-work processes and outcomes;
				  and
(xiii) medical case management
				  outcomes.
(3)
				  Annual evaluation. The network must prepare an annual written report on the
				  quality improvement program that includes:
(A)
				  completed activities;
(B) trending
				  of clinical and service goals;
(C)
				  analysis of program performance; and
(D) conclusions regarding the effectiveness
				  of the program.