P.R. Laws tit. 26, § 9356
In addition to meeting the requirements of § 9355 of this title, a health insurance organization or issuer that issues a closed plan, or a combination plan having a closed component, shall develop and maintain the internal structures and activities necessary to improve the quality of its services as required by this section. For such purposes, a health insurance organization or issuer shall:
(a) Establish an internal system to identify opportunities to improve the healthcare services provided. This system shall be structured to identify: practices that result in improved healthcare, identify problematic utilization patterns, identify those providers that may be responsible for either exemplary or problematic patterns, and foster an environment of continuous quality improvement.
(b) Use the findings generated by the system to work, on a continuing basis, with participating providers and other staff within the health plan to improve the healthcare services delivered to covered persons or enrollees.
(c) Develop and maintain a program for designing, measuring, assessing, and improving the processes and outcomes of healthcare as identified in the health insurance organization or issuer's quality improvement program filed with the Commissioner. This program shall be under the direction of the medical or clinical staff of the health insurance organization or issuer and must include:
(1) A written statement of the objectives, lines of authority and accountability, evaluation tools, (including data collection responsibilities,) performance improvement activities and an annual effectiveness review of the quality improvement program.
(2) A written quality improvement plan that describes how the health insurance organization or issuer intends to:
(A) Analyze both processes and outcomes of healthcare, including focused review of individual cases as appropriate, to discern the causes of variation.
(B) Identify the targeted diagnoses and treatments to be reviewed by the quality improvement program each year. In determining which diagnoses and treatments to target for review, the health insurance organization or issuer shall consider practices and diagnoses that affect or could pose a risk to a substantial number of the plan's covered persons or enrollees. The foregoing shall not be construed to require a health insurance organization or issuer to review every disease, illness, and condition that may affect a member of a managed care plan.
(C) Use a range of appropriate methods to analyze the quality of service, including:
(i) Collection and analysis of information on over- utilization and under-utilization of services.
(ii) Evaluation of courses of treatment and outcomes of healthcare.
(iii) Collection and analysis of information specific to a covered person or enrollee or provider, gathered from multiple sources such as utilization management organizations, and claims processing, among others.
(D) Compare program findings with past performance, as appropriate, and with internal goals and external standards, where available, adopted by the health insurance organization or issuer.
(E) Measure the performance of participating providers and conduct peer review activities, such as:
(i) Identifying practices that do not meet the health insurance organization or issuer's standards;
(ii) taking appropriate action to correct deficiencies;
(iii) monitoring participating providers to determine whether they have implemented corrective action, and
(iv) taking appropriate action when the participating provider has not implemented corrective action.
(F) Utilize treatment protocols and practice parameters developed with appropriate clinical input and using the evaluations described in paragraphs (A) and (B) of this clause, or utilize acquired treatment protocols developed with appropriate clinical input; and provide participating providers with sufficient information about the protocols to enable participating providers to meet the standards established by these protocols.
(G) Evaluate access to healthcare services for covered persons or enrollees according to standards established by statute, regulation or the Commissioner. The quality improvement plan shall describe the health insurance organization or issuer's strategy for integrating public health goals with healthcare services offered, including a description of the health insurance organization or issuer's good faith efforts to initiate or maintain communication with public health agencies.
(H) Implement improvement strategies related to program findings.
(I) Evaluate periodically, but not less than annually, the effectiveness of the strategies implemented in paragraph (H) of this clause.
(d) Assure that participating providers have the opportunity to participate in developing, implementing, and evaluating the quality improvement system.
(e) Provide covered persons or enrollees the opportunity to comment on the quality improvement process.
History —Aug. 29, 2011, No. 194, added as § 20.060 on Aug. 23, 2012, No. 203, § 4, eff. 90 days after Aug. 23, 2012.