§ 122.616. External quality assessment of CCOs.
(a) To ensure that CCOs are providing the high-quality care required by the act and that provision of care through CCOs is not resulting in inadequate treatment, poor quality care or inappropriate release of injured workers to return to work, the Department may arrange for external quality reviews of CCOs.
(b) The Department may direct that an external quality review of a CCO be conducted at any time.
(c) The Department may arrange for external quality reviews of a sample of CCOs to independently determine the quality of care being provided by CCOs. If a sample analysis reveals significant quality of care problems or lack of CCO commitment to documented and effective oversight of quality of care being provided to injured workers, the Department may then require all CCOs to undergo an external quality assessment.
(d) An external quality assessment shall be conducted by an external quality review organization acceptable to the Department and selected by the CCO from a list of Department-approved review entities.
(e) An external quality assessment is designed to study the quality of care being provided to injured workers and the effectiveness of the CCO’s formal quality assurance structure and activities. It shall include a review of randomly selected medical records of injured workers treated by the CCO to judge matters such as compliance with medical record standards, appropriateness of diagnosis and treatment, appropriateness of referrals, continuity of care and underutilization of services.
(f) The CCO shall be responsible for contracting with the external quality review organization and paying for its services.
(g) The external quality review organization and the CCO shall arrange an acceptable date, time, place and agenda for the external review with the Department and provide Department staff with full rights of participation in and observation of the external review.
(h) The CCO shall arrange for the external quality review organization to issue a formal written report of its findings to the board of directors of the CCO and to the Department. The Department will utilize this report as an independent fact finding report and consider it in the Department’s decision as to whether to require a corrective action plan of the CCO, and what the components of that plan should be, or whether the Department should pursue action to suspend or revoke the CCO certification.
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