Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 122 - GENERAL PROVISIONS OF ACT 57 OF 1996-STATEMENT OF POLICY › Subchapter G - COORDINATED CARE ORGANIZATIONS-STATEMENT OF POLICY › Section 122.613 - Standards for quality assurance program

Current through Register Vol. 54, No. 28, July 13, 2024
A CCO shall establish, operate and maintain a quality
					 assurance program which includes a record on file of and provides for the
					 following:
(1) A formal quality
				  assurance committee consisting of participating coordinated care providers,
				  under the direction of a medical director, which shall be responsible for
				  approving quality assurance standards and criteria, assessing the performance
				  of the CCO's health service delivery system, identifying quality problems and
				  taking appropriate corrective action.
(2) A written description of the structure
				  and organization of its quality assurance committee and plans for documenting
				  quality assurance activities.
(3)
				  Formal minutes and reports documenting the activities of the quality assurance
				  committee, which shall be available for review by the Department and external
				  quality review agencies.
(4) An
				  adequate staff of quality assurance professionals, particularly quality
				  assurance registered nurses, to implement the quality assurance plan and
				  objectives developed by the quality assurance committee and medical
				  director.
(5) The resume and job
				  description of its medical director and other professionals responsible for
				  conducting quality assurance activities.
(6) A 2-year quality assurance work plan
				  listing specific quality assurance activities the CCO will undertake in terms
				  of focused medical care chart audits, adverse outcome reviews, credentialing
				  activities and other activities; the estimated time frames for completion of
				  each activity; and responsible personnel. As part of its 2-year quality
				  assurance work plan, the CCO shall review a statistically significant sample of
				  medical records pertaining to the treatment of injured workers. Injured workers
				  treated by the CCO shall be selected for review and the medical records of the
				  participating coordinated care providers that treated the injured worker shall
				  be independently reviewed by the quality assurance system to ascertain the
				  following:
(i) The quality of care provided by
				  each provider.
(ii) The timeliness
				  and appropriateness of treatment provided.
(iii) Verification that each physician who is
				  a participating coordinated care provider has staff admitting privileges in at
				  least one hospital that is a participating coordinated care provider.
(iv) A requirement that there be disclosure
				  to the CCO by the provider of a financial interest in another provider to which
				  the credentialed provider may be making referrals.
(v) Verification of the provider's training
				  and experience.
(vi) Verification
				  of compliance with another standard the CCO adopts as part of its credentialing
				  process, and with treatment protocols established by the CCO through its
				  quality assurance system.
(vii)
				  Establishment of standards for medical records and periodic review of medical
				  records/charts to verify provider compliance with the standards.
(viii) For providers for which Health Care
				  Cost Containment Council data is available, consideration of the data in the
				  credentialing and recredentialing of participating coordinated care
				  providers.