HEALTH CARE AUTHORITY

[Filed December 27, 2019, 1:09 p.m.]

Preproposal statement of inquiry was filed as WSR 19-22-071.

Title of Rule and Other Identifying Information: WAC 182-530-4050 Drug use and claims review.

Hearing Location(s): On February 4, 2020, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Sue Crystal Room 106A, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf or directions can be obtained by calling 360-725-1000.

Date of Intended Adoption: Not sooner than February 5, 2020.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by February 4, 2020.

Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication relay services 711, email amber.lougheed@hca.wa.gov, by January 24, 2020.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is revising this rule to comply with the requirements of section 1004 of the Support for Patients and Communities Act under 42 U.S.C. 1396a(a) by more accurately detailing the drug use review (DUR) activities to include reference to prior authorization requirements adding subsections (1)(a)(iv) and (2)(c) and include the activities of prescribing practitioners in addition to dispensing pharmacies in subsections (2) and (2)(b). The agency is also revising subsection (1)(b) to update language in accordance with the Support Act including prescribing billing practices that indicate abuse or excessive utilization.

Reasons Supporting Proposal: See purpose.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160, H.R. 6, Section 1004, 42 U.S.C. 1396a(a) and 42 U.S.C. 1396r-8(g).

Statute Being Implemented: RCW 41.05.021, 41.05.160, H.R. 6, Section 1004, 42 U.S.C. 1396a(a) and 42 U.S.C. 1396r-8(g).

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting: Valerie Freudenstein, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1344; Implementation and Enforcement: Charles Agte, P.O. Box 45502, Olympia, WA 98504-5502, 360-725-1301.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rule does not impose any costs on businesses.

AMENDATORY SECTION(Amending WSR 16-01-046, filed 12/9/15, effective 1/9/16)

WAC 182-530-4050Drug use and claims review.

(1) The agency's drug use review (DUR) consists of:

(a) A prospective drug use review (Pro-DUR) that requires all pharmacy providers to:

(i) Obtain patient histories of allergies, idiosyncrasies, or chronic condition or conditions which may relate to drug utilization;

(ii) Screen for potential drug therapy problems; ((and))

(iii) Counsel the patient in accordance with existing state pharmacy laws and federal regulations; and

(iv) Obtain authorization prior to dispensing when required by the agency or an agency designee.

(b) A retrospective drug use review (Retro-DUR), in which the agency provides for the ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, ((or))excessive utilization, inappropriate or medically unnecessary care, or prescribing billing practices that indicate abuse or excessive utilization among physicians, pharmacists, and individuals receiving benefits.

(2) The agency reviews a periodic sampling of claims to determine if drugs are appropriately ordered, prescribed, administered, dispensed, and billed. If a review of the sample finds that a provider is inappropriately ordering, prescribing, administering, dispensing, or billing for drugs, the agency may implement corrective action that includes, but is not limited to:

(a) Educating the provider regarding the problem practice or practices;

(b) Requiring the provider to maintain specific documentation in addition to the normal documentation requirements regarding the provider's ordering, prescribing, administering, dispensing, or billing ((actions))practices;

(c) Applying additional provider-specific requirements for obtaining authorization prior to ordering, prescribing, administering, dispensing, or billing for drugs;

(d) Recouping the payment for the drug or drugs; or

(((d)))(e) Terminating the provider's core provider agreement (CPA).