Section 296-20-01080. Management of the provider network.

(1) Appropriate action(s) by the department to monitor quality of care and assure efficient management of the provider network may include, but are not limited to:

(a) Monitoring the provider;

(b) Mentoring the provider;

(c) Restricting payment for services rendered by the provider;

(d) Suspending the provider from the network; or

(e) Removing the provider from the network.

(2) The department must first notify the provider, and may take action in any order or combination, depending on the severity of the issue or risk of harm.

(3) For risk of harm issues, where imminent or actual harm is not life-threatening or substantially disabling, the department may provide an opportunity for the provider to remediate through education or other less severe actions first. Where the department action includes suspension or removal from the network for risk of harm issues, the department may also request expedited hearing and immediate suspension of authority to provide services under RCW 51.52.075.

(4) In taking appropriate action for risk of harm issues, the department will take into account unique mitigating circumstances related to the clinical severity and complexity of the providers' patient population. Unique mitigating circumstances could include practice at a care facility recognized for its receipt of particularly severe cases, such as catastrophic injuries. Duration of disability and/or chronic pain shall not, in and of themselves, be considered uniquely mitigating.

The department may not take action against a provider for risk of harm, if the harm was related to an isolated instance of health care service delivery that was conducted within coverage policies and treatment guidelines established by the department or other evidence-based coverage decisions made by the Washington state health technology committee, or the prescription drug program and appropriate to the patient's specific circumstances.

(5) The department may also terminate a provider network agreement for cause based on the provider's professional qualifications, billing, and practice history including, but not limited to, the following:

(a) The provider fails to maintain the minimum health care provider network standards per WAC 296-20-01030;

(b) The provider fails to comply with health care provider network continuing requirements per WAC 296-20-01040;

(c) The provider engages in action or inaction for which the department may deny an application;

(d) The provider violates the terms of the agreement; or

(e) A finding of risk of harm, pursuant to WAC 296-20-01100 including, but not limited to, prescribing drug therapy in an unsafe manner and/or failure to identify substance abuse/addiction or failure to refer the patient for substance abuse treatment once abuse/addiction is identified.

(6) The department will notify the provider of agreement termination according to the terms of the agreement, identify the reason for agreement termination, and include an effective date of termination. If a provider agreement is terminated for cause, the department or self-insured employer will pay for authorized services provided only up to the date specified in the notice.

[Statutory Authority: RCW 51.36.010, 51.04.020, and 51.04.030. WSR 12-02-058, § 296-20-01080, filed 1/3/12, effective 2/3/12.]

RCW 51.36.010, 51.04.020, and 51.04.030. WSR 12-02-058, § 296-20-01080, filed 1/3/12, effective 2/3/12.

Rules

296-20-01030,296-20-01040,296-20-01100,