Section 296-20-01050. Health care provider network further review and denial.

(1) The department may further review a complete provider application based on information within the application or credentialing information obtained from other sources.

(2) For complete applications requiring further review, the department's medical director or designee has the authority to approve or deny consistent with department rules and policies, and may seek advice, expertise, consultation or recommendations on applications from:

(a) Peer or clinical review individuals or entities;

(b) The industrial insurance medical or chiropractic advisory committee (including a subcommittee);

(c) A department appointed credentialing committee.

(3) The department may deny a provider application during credentialing or recredentialing based on the provider's professional qualifications and practice history including:

(a) The provider fails to meet minimum health care provider network standards;

(b) The provider has been disciplined based on an allegation of sexual misconduct or admitted to sexual misconduct;

(c) The provider is noncompliant with the department of health's or other state health care agency's stipulation to informal disposition (STID), agreed order, or similar licensed restriction;

(d) The provider has any pending statement of charges or notice of proposed disciplinary action or equivalent from any state or governmental professional disciplinary board at the time of application or recredentialing;

(e) The provider is excluded, expelled, terminated, or suspended by medicare, medicaid or any other state or federally funded health care program;

(f) The provider has a denial, suspension or termination of participation or privileges by any health care institution, insurance plan, facility, or clinic; except where such decision was solely related to broad network or business management changes, instead of an individual determination;

(g) The provider has surrendered, voluntarily or involuntarily, his or her hospital privileges in any state while under investigation or due to findings resulting from the provider's acts, omissions, or conduct;

(h) The provider performs invasive or surgical procedures without:

(i) Clinical admitting and management privileges, in good standing; or

(ii) An inpatient coverage plan with participating practitioner(s), hospitalists, or inpatient service teams for the purpose of admitting patients. Any inpatient coverage plan must be specified by the provider and found to be acceptable by the department.

(i) The provider has significant malpractice claims or professional liability claims (based on materiality to current practice, severity, recency, frequency, or repetition);

(j) The provider has been materially noncompliant with the department's rules, administrative and billing policies, evidence-based coverage decisions and treatment guidelines, and policies and other national treatment guidelines appropriate for their patient (based on severity, recency, frequency, repetition, or any mitigating circumstances);

(k) The provider was or is found to be involved in acts of dishonesty, fraud, deceit or misrepresentation that, in the department's determination, could relate to or impact the provider's professional conduct or the safety or welfare of injured or ill workers;

(l) The provider was or is found to have committed negligence, incompetence, inadequate or inappropriate treatment or lack of appropriate follow-up treatment which results in injury to a worker or creates unreasonable risk that a worker may be harmed (based on severity, recency, frequency, repetition, or any mitigating circumstances);

(m) The provider uses health care providers or health care staff who are unlicensed to practice or who provide health care services outside their recognized scope of practice or the standard of practice in Washington state;

(n) The provider with a history of alcohol or chemical dependency fails to furnish documentation demonstrating that the provider complied or is complying with all conditions limitations, or restrictions to the provider's practice and received or is receiving treatment adequate to ensure that the dependency problem will not affect the quality of the provider's practice;

(o) The provider has informal licensure actions, conditions, agreements, orders;

(p) The provider has a history of probation, suspension, termination, revocation or a surrendered professional license, certification, accreditation, or registration listed in the National Provider Data Bank/Healthcare Integrity and Protection Data Bank or any like entity; or by a nationally recognized specialty board; or by a state authority in any jurisdiction including, but not limited to, the Washington state department of health, when such charges involve conduct or behavior as defined under chapter 18.130 RCW, Uniform Disciplinary Act;

(q) The provider engaged in billing fraud or abuse or has a history of other significant billing irregularities;

(r) There are material complaints or allegations demonstrating a pattern of behavior(s) or misrepresentations including, but not limited to incidents, misconduct, or inappropriate prescribing of controlled substances (based on severity, recency, frequency, repetition, or any mitigating circumstances);

(s) The provider has a criminal history which includes, but is not limited to, any criminal charges, criminal investigations, convictions, no contest pleas and guilty pleas; or

(t) A finding of risk of harm pursuant to WAC 296-20-01100.

(4) The department and self-insured employers will not pay for any care to injured workers, other than an initial visit, by a provider whose application has been denied.

[Statutory Authority: RCW 51.36.010, 51.04.020, and 51.04.030. WSR 12-02-058, § 296-20-01050, filed 1/3/12, effective 2/3/12.]

RCW 51.36.010, 51.04.020, and 51.04.030. WSR 12-02-058, § 296-20-01050, filed 1/3/12, effective 2/3/12.

Rules

296-20-01100,