Quality assurance program; second medical opinion requirement.
See bold sections below:
(1) The organization shall ensure that the health care services provided to subscribers shall be rendered under reasonable standards of quality of care consistent with the prevailing standards of medical practice in the community.
(2) Each organization shall have an ongoing internal quality assurance program for its health care services. The program shall include, but not be limited to, the following:
(a) A written statement of goals and objectives which stress health outcomes as the principal criteria for the evaluation of the quality of care rendered to subscribers;
(b) A written statement describing how state-of-the-art methodology has been incorporated into an ongoing system for monitoring of care which is individual case oriented and, when implemented, can provide interpretation and analysis of patterns of care rendered to individual patients by individual providers;
(c) Written procedures for taking appropriate remedial action whenever, as determined under the quality assurance program, inappropriate or substandard services have been provided or services which should have been furnished have not been provided;
(d) A written plan for providing review of physicians and other licensed medical providers which includes ongoing review within the organization.
(3) The health maintenance organization shall not have the right to control the professional judgment of a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461 concerning the proper course of treatment of a subscriber. However, this subsection shall not be considered to restrict a utilization management program established by an organization or to affect an organization’s decision as to payment for covered services. Except in cases in which the health care provider is an employee of the health maintenance organization, the health maintenance organization shall not be vicariously liable for the medical negligence of the health care provider, whether such claim is alleged under a theory of actual agency, apparent agency, or employer-employee relationship.
Medical Necessity Decisions-Deadlines
(4) The organization shall ensure that only a physician holding an active, unencumbered license issued under chapter 458 or chapter 459 may render an adverse determination regarding a service provided by a physician licensed in this state. The organization shall submit to the treating provider and the subscriber written notification regarding the organization’s adverse determination within 2 working days after the subscriber or provider is notified of the adverse determination. The written notification must include the utilization review criteria or benefits provisions used in the adverse determination, identify the physician who rendered the adverse determination, and be signed by an authorized representative of the organization or the physician who rendered the adverse determination. The organization must include with the notification of an adverse determination information concerning the appeal process for adverse determinations. This provision does not create authority for the Board of Medicine or the Board of Osteopathic Medicine to regulate the organization; however, the Board of Medicine and the Board of Osteopathic Medicine each continue to have jurisdiction over licensees of their respective boards.
(a) Each organization shall give the subscriber the right to a second medical opinion in any instance in which the subscriber disputes the organization’s or the physician’s opinion of the reasonableness or necessity of surgical procedures or is subject to a serious injury or illness.
(b) The second opinion, if requested, is to be provided by a physician chosen by the subscriber who may select:
1. A contract or employed physician listed in a directory that shall be provided by the organization; or
2. A noncontract physician located in the same geographical service area of the organization.
(c) For second opinions provided by contract physicians, the organization is prohibited from charging a fee to the subscriber in an amount in excess of the subscriber fees established by contract for referral contract physicians. The organization shall pay the amount of all charges, which are usual, reasonable, and customary in the community, for second opinion services performed by a physician not under contract with the organization, but may require the subscriber to be responsible for up to 40 percent of such amount. The organization may require that any tests deemed necessary by a noncontract physician shall be conducted by the organization. The organization may deny reimbursement rights granted under this section in the event the subscriber seeks in excess of three such referrals per year if such subsequent referral costs are deemed by the organization to be evidence that the subscriber has unreasonably overutilized the second opinion privilege. A subscriber denied reimbursement under this section has recourse to grievance procedures as specified in ss. 641.495 and 641.511. The organization’s physician’s professional judgment concerning the treatment of a subscriber derived after review of a second opinion is controlling as to the treatment obligations of the health maintenance organization. Treatment not authorized by the health maintenance organization is at the subscriber’s expense.
(6) Each organization shall develop and maintain a policy to determine when exceptional referrals to out-of-network specially qualified providers should be provided to address the unique medical needs of a subscriber. All financial arrangements for the provision of these services shall be agreed to prior to the services being rendered.
(7) Each organization shall develop and maintain written policies and procedures for the provision of standing referrals to subscribers with chronic and disabling conditions which require ongoing specialty care.
Continuity of Care Post-Contract; Amendments
(8) When a contract between an organization and a treating provider is terminated for any reason other than for cause, each party shall allow subscribers for whom treatment was active to continue coverage and care when medically necessary, through completion of treatment of a condition for which the subscriber was receiving care at the time of the termination, until the subscriber selects another treating provider, or during the next open enrollment period offered by the organization, whichever is longer, but not longer than 6 months after termination of the contract. Each party to the terminated contract shall allow a subscriber who has initiated a course of prenatal care, regardless of the trimester in which care was initiated, to continue care and coverage until completion of postpartum care. This does not prevent a provider from refusing to continue to provide care to a subscriber who is abusive, noncompliant, or in arrears in payments for services provided. For care continued under this subsection, the organization and the provider shall continue to be bound by the terms of the terminated contract. Changes made within 30 days before termination of a contract are effective only if agreed to by both parties.
(9) Each organization shall release to the agency data that are indicators of access and quality of care. The agency shall develop rules specifying data-reporting requirements for these indicators. The indicators shall include the following characteristics:
(a) They must relate to access and quality of care measures.
(b) They must be consistent with data collected pursuant to accreditation activities and standards.
(c) They must be consistent with frequency requirements under the accreditation process.
(d) They must include measures of the management of chronic diseases.
(e) They must include preventive health care for adults and children.
(f) They must include measures of prenatal care.
(g) They must include measures of health checkups for children.
The agency shall develop by rule a uniform format for publication of the data for the public which shall contain explanations of the data collected and the relevance of such data. The agency shall publish such data no less frequently than every 2 years.
(10) Each organization shall adopt recommendations for preventive pediatric health care which are consistent with the requirements for health checkups for children developed for the Medicaid program. Each organization shall establish goals to achieve 90-percent compliance by July 1, 1999, for their enrolled pediatric population.
(11) Each organization shall allow, without prior authorization, a female subscriber, to visit a contracted obstetrician/gynecologist for one annual visit and for medically necessary followup care detected at that visit. Nothing in this subsection shall prevent an organization from requiring that an obstetrician/gynecologist treating a covered patient coordinate the medical care through the patient’s primary care physician, if applicable.
(12) If a contracted primary care physician, licensed under chapter 458 or chapter 459, determines that a subscriber requires examination by a licensed ophthalmologist for medically necessary, contractually covered services, then the organization shall authorize the contracted primary care physician to send the subscriber to a contracted licensed ophthalmologist.