Florida § 641.512 - Accreditation and external quality assurance assessment.

§ 641.512. Accreditation and external quality assurance assessment.

(1)(a) To promote the quality of health care services provided by health maintenance organizations and prepaid health clinics in this state, the office shall require each health maintenance organization and prepaid health clinic to be accredited within 1 year of the organization’s receipt of its certificate of authority and to maintain accreditation by an accreditation organization approved by the office, as a condition of doing business in the state. (b) In the event that no accreditation organization can be approved by the office, the office shall require each health maintenance organization and prepaid health clinic to have an external quality assurance assessment performed by a review organization approved by the office, as a condition of doing business in the state. The assessment shall be conducted within 1 year of the organization’s receipt of its certificate of authority and every 2 years thereafter, or when the office deems additional assessments necessary. (2) The accreditation or review organization must have nationally recognized experience in health maintenance organization activities and in the appraisal of medical practice and quality assurance in a health maintenance organization setting. The accreditation or review organization shall not currently be involved in the operation of the health maintenance organization or prepaid health clinic, nor in the delivery of health care services to its subscribers. The accreditation or review organization shall not have contracted or conducted consultations within the last 2 years for other than accreditation purposes of the health maintenance organization or prepaid health clinic seeking accreditation or under quality assurance assessment. (3) A representative of the office shall accompany the accreditation or review organization throughout the accreditation or assessment process, but shall not participate in the final accreditation or assessment determination. The accreditation or review organization shall monitor and evaluate the quality and appropriateness of patient care, the organization’s pursuance of opportunities to improve patient care and resolve identified problems, and the effectiveness of the internal quality assurance program required for health maintenance organization and prepaid health clinic certification pursuant to s. 641.49(3)(p). (4) The accreditation or assessment process shall include a review of: (a) All documentation necessary to determine the current professional credentials of employed health care providers or physicians providing service under contract to the health maintenance organization or prepaid health clinic. (b) At least a representative sample of not fewer than 50 medical records of individual subscribers. When selecting a sample, any and all medical records may be subject to review. The sample of medical records shall be representative of all subscribers’ records. (5) Every organization shall submit its books, documentations, and medical records and take appropriate action as may be necessary to facilitate the accreditation or assessment process. (6) The accreditation or review organization shall issue a written report of its findings to the health maintenance organization’s or prepaid health clinic’s board of directors. A copy of the report shall be submitted to the office by the organization within 30 business days of its receipt by the health maintenance organization or prepaid health clinic. (7) The expenses of the accreditation or assessment process of each organization, including any expenses incurred pursuant to this section, shall be paid by the organization.