The state health department will launch an HMO quality assurance unit, Dr. Martin P. Wasserman, the state health secretary, said yesterday.
"We've always had the responsibility for quality, but we had read the statute narrowly in the past," Wasserman said.
Last year, he said, he decided that a "more expansive" reading of the department's authority was "consistent with what everybody wanted us to do."
The new unit will divide the work of monitoring health maintenance organizations with the Maryland Insurance Administration, which has a complaint unit and, under a new law effective this year, a hearing process for determining if HMOs are denying medically necessary care.
Wasserman said the insurance administration will focus on "contractual issues" while the health department will monitor "quality of care."
For example, Wasserman said, his department will review such areas as timeliness of referrals, appropriateness of referrals and appropriateness of medication.
Steven B. Larsen, the insurance commissioner, said his department will continue to serve as "the single point of entry for the consumer," but will refer some problems to the health department. He also said he would expect recommendations from the health department that could lead to insurance administration orders to HMOs.
The insurance administration will continue its appeals-and-grievances procedure under a law that took effect Jan. 1.
It has held one hearing under the new law, resulting in an order last month for Prudential HealthCare to pay for in-hospital rehabilitation for an 18-year-old honors student nearly paralyzed by a case of viral encephalitis. Until the hearing, Prudential had said it would pay for care in a nursing home or other nonhospital facility.
The new health department unit will be located within the department's Licensing and Certification Administration, which will be renamed the Office of Quality Assurance. It will also report directly to the secretary; it has been reporting to a deputy secretary.
Wasserman said the department will hire a physician and two other people to staff the unit, which he hoped to have operating by summer.
Pub Date: 3/03/99