S-1209

AN ACT Relating to chiropractic peer review; and adding new sections to chapter 18.26 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. Unless the context clearly requires otherwise, the definitions used in this section apply throughout sections 2 through 10 of this act.

(1) "Accepted standards" for peer review means those standards of practice, skill, and treatment that are recognized by a reasonably prudent chiropractor as being acceptable under similar conditions and circumstances.

(2) "Appropriate chiropractic treatment" means a determination made of treatment and other services performed, which, by virtue of a substantiated and properly documented condition, appears to be consistent with that diagnosis or analysis as reviewed by the peer review committee.

(3) "Bill for services" means all services provided to a consumer, regardless of the monetary consideration paid to the health care provider.

(4) "Excessive" fees or costs means charges submitted for services performed that are unnecessary, or unreasonable charges in the judgment of the peer review committee.

(5) "Patient" means an individual who receives chiropractic evaluation or treatment, or both.

(6) "Peer review" means an evaluation, based on accepted standards, by a peer review committee of the appropriateness, quality, utilization, and cost of health services provided to a patient.

(7) "Peer review committee" means the committee established under section 2 of this act.

(8) "Properly utilized services" means appropriate services rendered, including the frequency and duration of such services, which are documented as being necessary and reasonable by clinical records and reports or by any other facts, presentations, or evidence reviewed by the peer review committee.

NEW SECTION. Sec. 2. The peer review committee shall consist of one member from each congressional district. Members shall be chiropractors licensed under this chapter. There shall be one additional member representative of the health insurance industry. No member shall be in a direct business relationship with the provider, insurer, or patient whose case is being reviewed. The committee shall be appointed by the board. The board may appoint additional pro tempore members as necessary. The term of appointment of peer review committee members shall be one year. No member shall serve more than two consecutive terms. The board shall adopt rules establishing qualifications for appointment to the peer review committee, but all appointees to the committee shall represent the mainstream practice of chiropractic in Washington state, have five years of active practice in Washington state, and be current residents. A member of the peer review committee may be removed by the board for neglect of duty, misconduct, or misfeasance in office, after being given a written statement of charges against him or her and sufficient opportunity to be heard.

NEW SECTION. Sec. 3. Peer review occurs upon submission by a patient, the patient's representative, insurer, or chiropractor, in accordance with the procedures approved by the board, of an inquiry about a bill for services rendered to a patient by a chiropractor. The peer review committee shall examine each inquiry submitted to it, report its findings and recommendations to the program manager of the board, and furnish copies of the findings to the patient, chiropractor, and third party payor. The peer review committee on each inquiry reviewed shall include in its findings a determination of whether the chiropractor improperly utilized services, rendered or ordered inappropriate treatment or services, and whether the cost of the treatment was excessive.

The board shall charge a fee, to defray the administrative costs of the review, from a patient, patient's representative, insurer, or chiropractor making a peer review request. The requesting party shall be responsible for the complete cost of the review. The board may waive the fee under extraordinary circumstances.

The reviewed party may appeal the finding and recommendation of the committee to the entire committee or to the superior court of the county of the reviewed party's place of business.

NEW SECTION. Sec. 4. The peer review committee shall advise the board as to its findings. The peer review committee may hear, without qualification or threshold, any submission regarding the appropriateness, quality, or utilization of chiropractic services. The board may establish additional criteria for screening requests for peer review. The screening shall occur upon submission by a patient, the patient's representative, insurer, or chiropractor of an inquiry about a bill for services rendered to a patient by a health care provider. Peer review shall not be used to replace the independent medical/chiropractic examination.

The acceptance of, request for, or payment for review rendered to a patient constitutes the consent to the submission of all necessary records and other information concerning the services to the peer review committee.

NEW SECTION. Sec. 5. The departments of labor and industries, health, and social and health services, and the state employees benefits board must utilize peer review as described under this chapter when controversy exists as to the appropriateness, quality, utilization, and cost of health care and health services provided to a patient by a provider licensed under chapter 18.25 RCW.

NEW SECTION. Sec. 6. The peer review committee shall file with the board a complaint against a health care provider if the committee determines that reasonable cause exists to believe the health care provider has violated any portion of this chapter, or rules adopted under it, for which a licensed chiropractor may be disciplined. The peer review committee shall transmit all complaint information it possesses to the board. The data, information, and records are classified as private data on individuals for purposes of confidentiality. The patient records obtained by the board pursuant to this section must be used solely for the purposes of the board relating to peer review or the disciplinary process.

NEW SECTION. Sec. 7. All data and information acquired by the board or the peer review committee, in the exercise of their duties and functions, shall be subject to the same disclosure and confidentiality protections as provided for data and information of other review organizations under RCW 4.24.250.

This section does not limit or restrict the board or the peer review committee from fully performing their prescribed peer review duties and functions, nor does it apply to disciplinary and enforcement proceedings under Washington law.

NEW SECTION. Sec. 8. An annual summary of the findings of the peer review committee shall be prepared by the committee and submitted to the board. The board shall make the report available to interested persons upon request and upon payment of necessary administrative costs to defray the expenses of reproduction. The board may not disclose the name or identifier of a patient without the patient's consent in a report or summary issued to the public.

NEW SECTION. Sec. 9. The board may adopt rules it considers necessary and appropriate to implement a voluntary mediation process.

NEW SECTION. Sec. 10. The board may adopt rules it considers necessary and appropriate to implement the peer review system and activities established under this chapter.

NEW SECTION. Sec. 11. It is the intention of the legislature that the peer review system and activities established under this chapter, including the board and the peer review committee and their officers, members, employees, and agents, shall be exempt from challenge under federal or state antitrust laws or other similar laws regulating trade or commerce.

NEW SECTION. Sec. 12. Sections 1 through 11 of this act are each added to chapter 18.26 RCW.