Quality assurance – Wis. Stat. Ann. § 609.32

Defined network plans must create quality assurance standards in order to identify and resolve issues relating care quality, access, and continuity. The quality assurance standards must include: (1) a, written internal quality assurance program; (2) “specific written guidelines for quality of care monitoring; (3) performance and clinical outcomes-based criteria; (4) procedures for correcting quality problems; (5) a plan for gathering and assessing data; and (6) a peer review process.

Defined network plans must create procedures for selecting and reevaluation participating providers. The selection procedures must include a review of potential providers’ licensing, history of licensing suspensions, and history of liability claims. The reevaluation procedures must include a review of the selection criteria and an assessment of basethe provider’s performd on specific criteria, such as enrollee clinical outcomes, number of complaints, and malpractice actions.

Preferred provider plans do not need to create quality assurance standards, but must create procedures for remedying and correcting quality problems.