An HMO shall continually maintain an internal quality assurance program. This program shall monitor and evaluate the services provided by the HMO, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and noninstitutional settings.
At a minimum the internal quality assurance program shall include at a minimum, the following items:
The HMO shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner.
Minutes from the quality assurance program shall be available to the Commissioner.
The HMO shall ensure the use and maintenance of a patient record system to facilitate the documentation and retrieval of clinical information for the purpose of evaluating the continuity and coordination of patient care, and assessing the quality of the health and medical care rendered to enrollees.
The Commissioner or his or her authorized designee may review the clinical records of an enrollee to determine whether the HMO has complied with this section or for any other purposes he or she considers necessary.
The HMO shall establish a mechanism for the governing body, providers, and appropriate staff to receive periodic reports on quality assurance program activities.
Quality assurance programs approved by the States of Maryland or Virginia, or by the District of Columbia Medicaid Program shall be deemed approved.
When an applicant has received a certificate of authority from Maryland or Virginia, a Quality Assurance Program Inquiry form shall be filed with the initial application for certificate of authority in the District. The HMO shall submit a copy of the quality assurance report.
The discussions between a patient and provider concerning medical treatment options and the financial coverage of those options shall not be prohibited, impeded or interfered with by the provider's contract with the HMO.
The contract between the HMO and the provider shall permit the provider to discuss medical treatment options with its patients.
An HMO's decision to terminate or refuse to contract with a provider shall not be based in whole or in part on the fact that the provider discussed medical treatment options with the enrollee.
D.C. Mun. Regs. tit. 26, r. 26-A3503