10.07.11.04

.04 Peer Review.

A. Internal Review. The HMO shall have an internal peer review system that will evaluate the utilization of services and the quality of health care provided enrollees. The review system shall:

(1) Provide for review by appropriate health professionals of the process followed in the provision of health services;

(2) Use systematic data collection of performances and patient results;

(3) Provide interpretation of this data to the practitioners;

(4) Review and update continuing education programs for health professionals providing services to enrollees;

(5) Identify needed change and proposed modifications to implement;

(6) Maintain written records of the internal peer review process;

(7) Conduct focused studies directly related to major health problems and preventive health needs identified in Regulation .03B and C of this chapter; and

(8) Assure that at least three focused studies related to the HMO specific plan under Regulation .03 of this chapter are conducted each year.

B. External Review.

(1) The Department shall conduct an external review of the quality of health care services of the HMO when and in a manner the Department considers appropriate.

(2) The external review shall be conducted by:

(a) A panel of physicians and other health professionals consisting of persons who:

(i) Have been approved by the Department;

(ii) Have substantial experience in the delivery of health care in an HMO setting but who are not members of the HMO staff or performing professional services for the HMO concerned;

(iii) Reside outside the area serviced by the HMO; or

(b) The Department.

(3) The final decision on which type of external review is to be employed rests solely with the Department.

(4) The external review shall consist of a review and evaluation of the following:

(a) Internal peer review system and reports;

(b) The HMO program plan to determine if it is adequate and being followed;

(c) The professional standards and practices of the HMO in every area of services provided;

(d) The grievances relating specifically to the delivery of medical care, including their final disposition;

(e) The physical facilities and equipment; and

(f) A statistically representative sample of enrollee records.

(5) A health maintenance organization accredited by an accreditation organization approved by the Secretary in accordance with Health-General Article, §192302, Annotated Code of Maryland, shall be exempt from the external review.