WSR 08-02-019

PERMANENT RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed December 21, 2007, 9:04 a.m. , effective January 21, 2008 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: ESSB 5290 (chapter 282, Laws of 2007) established the industrial insurance medical advisory committee to advise the department on medical issues to assure workers receive safe, effective treatment in a cost-effective manner. The rule specifies how the committee will work administratively and how it will interact with the other agency advisory committees.

Citation of Existing Rules Affected by this Order: Amending WAC 296-20-01001.

Statutory Authority for Adoption: ESSB 5290 (chapter 282, Laws of 2007), RCW 51.04.02 [51.04.020], 51.04.030.

Adopted under notice filed as WSR 07-15-074 [07-19-096] on July 17, 2007 [September 18, 2007].

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: December 21, 2007.

Judy Schurke

Director

OTS-9855.3


AMENDATORY SECTION(Amending Order 77-27, filed 11/30/77, effective 1/1/78)

WAC 296-20-01001   ((Medical advisory)) Industrial insurance medical advisory committee.   (((1) The Washington state medical association shall appoint an advisory and utilization review committee composed of nine members, one of whom shall be an osteopathic physician nominated by the Washington state osteopathic medical association. The remaining members should be selected from the following specialty groups: Family or general practice, orthopaedics, neurology or neurosurgery, general surgery, physical medicine and rehabilitation, psychiatry, internal medicine, and industrial medicine.

(2) The committee will function as an advisor to the department with respect to policies affecting medical care and rehabilitation, quality control and supervision of medical care, and the establishment of rules and regulations. It shall also advise and assist the department in the resolution of controversies, disputes and problems between the department and the providers of medical care. It will also advise and assist the department in the education of members of the medical community with regard to the roles of the physician, the department and the employer in providing the needs and care of the injured worker.

(3) The committee shall normally meet on a monthly basis or as necessity dictates. The department will reimburse members of the committee for each meeting.)) (1)(a) The director shall appoint an industrial insurance medical advisory committee (committee) composed of up to fourteen members.

(b) The appointments shall include twelve members from the nominations provided by statewide clinical groups, specialties, and associations and shall be consistent with the specialty types required by law.

(c) At least two of the total fourteen members must be physicians who are recognized for expertise in evidence-based medicine.

(d) The director may choose up to two of the fourteen members, not necessarily from the nominations submitted, who have expertise in occupational medicine.

(e) To the extent possible, members shall be chosen from nominees with experience or knowledge of treating injured workers or evidence-based medicine, or both.

(f) The director may, at his or her discretion, exclude or remove any nominee, committee member, or hired expert if the person does not meet a condition of appointment, including but not limited to:

(i) Having, or failing to disclose, a conflict of interest;

(ii) Breaching a statute, rule, or the committee's bylaws, including a quality of care concern or professional related action alleged by a government agency; or

(iii) If the committee or committee chair recommends removal for good cause shown.

(g) Appointments to the committee shall be up to three year terms, which the department may renew.

(2)(a) The committee will function as an advisor to the department with respect to the provision of safe, effective, and cost-effective health care for injured workers, including but not limited to the development of practice guidelines, and coverage criteria, review of coverage decisions and technology assessments, review of medical programs, and review of rules pertaining to health care issues.

(b) The committee may provide peer review and advise and assist the department in the resolution of controversies, disputes, and issues between the department and the providers of medical care.

(c) After approval by the department, the committee may consult with experts, services, and form ad hoc groups, committees, or subcommittees for the purpose of advising the department on specific topics to fulfill the purposes of the committee. Such experts or ad hoc groups will develop recommendations for the committee's approval.

(d) The committee's function may include but is not limited to the following:

(i) Advising the department on coverage decisions from technology assessments based on the best available scientific evidence, from which the department may use the committee's advice for making coverage decisions and for making proper and necessary industrial insurance claim decisions for covered services (see WAC 296-20-02704 for medical coverage decision criteria);

(ii) Advising the department on treatment guidelines for covered services based on proper and necessary standards, the best available scientific evidence, and the expert opinion of the medical advisory committee. The department may use the committee's advice for provider education, for criteria for the department's utilization review program, and for making proper and necessary industrial insurance claim decisions;

(iii) Advising the department on criteria related to definitions of quality of care and patterns of harmful care;

(iv) Advising the department on issues related to emerging medical conditions and the scientific evidence related to them; and

(v) Advice to the department in (d)(i) through (iv) of this subsection shall not pertain to nor include the review of a specific individual claim.

(e) Committee approval regarding advice to the department shall be based on a consensus of the members present. If after all reasonable efforts a consensus cannot be reached, the committee shall vote using the procedure described in the bylaws. A quorum, which shall be half plus one of the appointed members, must be present to vote and provide approval regarding advice to the department. Implementation of the committee's advice by the department is discretionary and solely the responsibility of the department.

(3) The members of the committee, including hired experts and any ad hoc group or subcommittee:

(a) Are immune from civil liability for any official acts performed in good faith to further the purposes of the industrial insurance medical advisory committee; and

(b) May be compensated for participation in the work of the industrial insurance medical advisory committee in accordance with a personal services contract to be executed after appointment and before commencement of activities related to the work of the industrial insurance medical advisory committee.

(4) The committee shall coordinate with the state health technology assessment program and the state prescription drug program. With regard to issues in which the committee's opinion may differ with findings of the state health technology assessment program or the state prescription drug program, the department must give greater weight to the findings of the state's health technology assessment program and the state's prescription program.

(5) The committee shall operate under conditions set out in bylaws as approved by the department and ratified by the committee.

(6)(a) The committee and ad hoc group or subcommittee shall meet on a schedule as set by the department.

(b) The department shall collaborate with the committee to prepare the agenda for each meeting, including prioritization of issues to be addressed, with the final approval of the agenda given to the department.

(c) All meetings of the committee or ad hoc subcommittee(s) are subject to chapter 42.30 RCW, the Open Public Meetings Act. Notice as to the date, time, location and agenda or topics shall be published on the department's web site, and in the Washington State Register. Additional notification via electronic communication shall be provided to committee members and other interested parties. Publication of the committee meeting shall occur with enough notice to ensure committee members or members of the public who have disabilities have an equal opportunity to participate.

[Order 77-27, 296-20-01001, filed 11/30/77, effective 1/1/78; Emergency Order 77-26, 296-20-01001, filed 12/1/77; Emergency Order 77-16, 296-20-01001, filed 9/6/77; Order 76-34, 296-20-01001, filed 11/24/76, effective 1/1/77.]

Washington State Code Reviser's Office