1380
. (a) The department shall conduct periodically an onsite
medical survey of the health delivery system of each plan. The survey
shall include a review of the procedures for obtaining health
services, the procedures for regulating utilization, peer review
mechanisms, internal procedures for assuring quality of care, and the
overall performance of the plan in providing health care benefits
and meeting the health needs of the subscribers and enrollees.
(b) The survey shall be conducted by a panel of qualified health
professionals experienced in evaluating the delivery of prepaid
health care. The department shall be authorized to contract with
professional organizations or outside personnel to conduct medical
surveys and these contracts shall be on a noncompetitive bid basis
and shall be exempt from Chapter 2 (commencing with Section 10290) of
Part 2 of Division 2 of the Public Contract Code. These
organizations or personnel shall have demonstrated the ability to
objectively evaluate the delivery of health care by plans or health
maintenance organizations.
(c) Surveys performed pursuant to this section shall be conducted
as often as deemed necessary by the director to assure the protection
of subscribers and enrollees, but not less frequently than once
every three years. Nothing in this section shall be construed to
require the survey team to visit each clinic, hospital office, or
facility of the plan. To avoid duplication, the director shall
employ, but is not bound by, the following:
(1) For hospital-based health care service plans, to the extent
necessary to satisfy the requirements of this section, the findings
of inspections conducted pursuant to Section 1279.
(2) For health care service plans contracting with the State
Department of Health Services pursuant to the Waxman-Duffy Prepaid
Health Plan Act, the findings of reviews conducted pursuant to
Section 14456 of the Welfare and Institutions Code.
(3) To the extent feasible, reviews of providers conducted by
professional standards review organizations, and surveys and audits
conducted by other governmental entities.
(d) Nothing in this section shall be construed to require the
medical survey team to review peer review proceedings and records
conducted and compiled under Section 1370 or medical records.
However, the director shall be authorized to require onsite review of
these peer review proceedings and records or medical records where
necessary to determine that quality health care is being delivered to
subscribers and enrollees. Where medical record review is
authorized, the survey team shall insure that the confidentiality of
physician-patient relationship is safeguarded in accordance with
existing law and neither the survey team nor the director or the
director's staff may be compelled to disclose this information except
in accordance with the physician-patient relationship. The director
shall ensure that the confidentiality of the peer review proceedings
and records is maintained. The disclosure of the peer review
proceedings and records to the director or the medical survey team
shall not alter the status of the proceedings or records as
privileged and confidential communications pursuant to Sections 1370
and 1370.1.
(e) The procedures and standards utilized by the survey team shall
be made available to the plans prior to the conducting of medical
surveys.
(f) During the survey the members of the survey team shall examine
the complaint files kept by the plan pursuant to Section 1368. The
survey report issued pursuant to subdivision (i) shall include a
discussion of the plan's record for handling complaints.
(g) During the survey the members of the survey team shall offer
such advice and assistance to the plan as deemed appropriate.
(h) (1) Survey results shall be publicly reported by the director
as quickly as possible but no later than 180 days following the
completion of the survey unless the director determines, in his or
her discretion, that additional time is reasonably necessary to fully
and fairly report the survey results. The director shall provide the
plan with an overview of survey findings and notify the plan of
deficiencies found by the survey team at least 90 days prior to the
release of the public report.
(2) Reports on all surveys, deficiencies, and correction plans
shall be open to public inspection except that no surveys,
deficiencies, or correction plans shall be made public unless the
plan has had an opportunity to review the report and file a response
within 45 days of the date that the department provided the report to
the plan. After reviewing the plan's response, the director shall
issue a final report that excludes any survey information and legal
findings and conclusions determined by the director to be in error,
describes compliance efforts, identifies deficiencies that have been
corrected by the plan by the time of the director's receipt of the
plan's 45-day response, and describes remedial actions for
deficiencies requiring longer periods to the remedy required by the
director or proposed by the plan.
(3) The final report shall not include a description of
"acceptable" or of "compliance" for any uncorrected deficiency.
(4) Upon making the final report available to the public, a single
copy of a summary of the final report's findings shall be made
available free of charge by the department to members of the public,
upon request. Additional copies of the summary may be provided at the
department's cost. The summary shall include a discussion of
compliance efforts, corrected deficiencies, and proposed remedial
actions.
(5) If requested by the plan, the director shall append the plan's
response to the final report issued pursuant to paragraph (2), and
shall append to the summary issued pursuant to paragraph (4) a brief
statement provided by the plan summarizing its response to the
report. The plan may modify its response or statement at any time and
provide modified copies to the department for public distribution no
later than 10 days from the date of notification from the department
that the final report will be made available to the public. The plan
may file an addendum to its response or statement at any time after
the final report has been made available to the public. The addendum
to the response or statement shall also be made available to the
public.
(6) Any information determined by the director to be confidential
pursuant to statutes relating to the disclosure of records, including
the California Public Records Act (Chapter 3.5 (commencing with
Section 6250) of Division 7 of Title 1 of the Government Code), shall
not be made public.
(i) (1) The director shall give the plan a reasonable time to
correct deficiencies. Failure on the part of the plan to comply to
the director's satisfaction shall constitute cause for disciplinary
action against the plan.
(2) No later than 18 months following release of the final report
required by subdivision (h), the department shall conduct a follow-up
review to determine and report on the status of the plan's efforts
to correct deficiencies. The department's follow-up report shall
identify any deficiencies reported pursuant to subdivision (h) that
have not been corrected to the satisfaction of the director.
(3) If requested by the plan, the director shall append the plan's
response to the follow-up report issued pursuant to paragraph (2).
The plan may modify its response at any time and provide modified
copies to the department for public distribution no later than 10
days from the date of notification from the department that the
follow-up report will be made available to the public. The plan may
file an addendum to its response at any time after the follow-up
report has been made available to the public. The addendum to the
response or statement shall also be made available to the public.
(j) The director shall provide to the plan and to the executive
officer of the Board of Dental Examiners a copy of information
relating to the quality of care of any licensed dental provider
contained in any report described in subdivisions (h) and (i) that,
in the judgment of the director, indicates clearly excessive
treatment, incompetent treatment, grossly negligent treatment,
repeated negligent acts, or unnecessary treatment. Any confidential
information provided by the director shall not be made public
pursuant to this subdivision. Notwithstanding any other provision of
law, the disclosure of this information to the plan and to the
executive officer shall not operate as a waiver of confidentiality.
There shall be no liability on the part of, and no cause of action of
any nature shall arise against, the State of California, the
Department of Managed Health Care, the Director of the Department of
Managed Health Care, the Board of Dental Examiners, or any officer,
agent, employee, consultant, or contractor of the state or the
department or the board for the release of any false or unauthorized
information pursuant to this section, unless the release of that
information is made with knowledge and malice.
(k) Nothing in this section shall be construed as affecting the
director's authority pursuant to Article 7 (commencing with Section
1386) or Article 8 (commencing with Section 1390) of this chapter.