BP BHEAD INT S [atlas:bill]

AN ACT Relating to the establishment of a process for credentialing and recredentialing of providers contracting with health carriers; adding a new section to chapter 48.43 RCW; and creating a new section.

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

NEW SECTION. Sec. 1. The legislature finds that, in managed care, the primary care physician acts as a "gatekeeper" to other services. Consumers must see their primary care physician in order to be referred to other services or treatment, making the primary care physician a critically important component of consumer health care services. Yet, consumers frequently have little information about the quality or credentials of their health care providers when they sign up for a primary care physician. Health carriers must carefully review and credential providers, while informing consumers about the providers with which the health carrier contracts.

NEW SECTION. Sec. 2. A new section is added to chapter 48.43 RCW to read as follows:

The health care quality assurance board shall establish a process for credentialing and recredentialing of providers by health carriers that, at a minimum:

(1) Establishes written policies and procedures that are reviewed and approved by the health carrier's governing body and that are based on objective standards of quality developed in consultation with appropriately qualified health care providers;

(2) Affords all health care providers within the health carrier's geographic service area the ability to apply for such credentials and to have their applications reviewed by a credentialing committee with appropriate representation of the provider's specialty or professional discipline; and if a health carrier denies credentials, informs the provider of the reasons for such denial, including economic consideration, in writing;

(3) Guarantees access to specialized treatment expertise by entering into agreements with centers of specialized care;

(4) For individual practitioners, requires verification of current license, history of suspension or revocation, medical school and residency, work history, clinical privileges and history of suspension, liability claims history, history of sanctions by medicare or medicaid, history of chemical dependence or abuse within the last twelve months, and compliance with continuing education requirements;

(5) Includes initial quality assessments of health delivery organizations, including but not limited to hospitals, home health agencies, nursing, and group practices, with which the health carrier intends to contract including confirmation of review and approval by a recognized accrediting body, if appropriate, history of sanctions by medicare or medicaid, and an initial site visit;

(6) Prohibits the use of economic considerations or economic profiling of providers unless such considerations or profiles utilize objective criteria adjusted to recognize case mix, severity of illness, and age;

(7) Prohibits the termination without cause of any provider;

(8) Prohibits the discharge of, demotion of, termination of a contract with, denial of privileges to, or other sanctions of, a provider for making public any financial incentives within the health carrier to deny care;

(9) Prohibits the discharge of, demotion of, termination of a contract with, denial of privileges to, or other sanctions of, a provider for advocating for a particular treatment or service on behalf of an enrollee or filing an appeal or appearing on behalf of any enrollee;

(10) Provides a written notice of termination proceeding and an opportunity to complete a corrective action plan, unless termination is necessary to protect the life, health, or safety of health carrier enrollees;

(11) Includes a process to recredential providers, at least every two years, considering member complaints, medical record reviews, member satisfaction surveys, and results of quality reviews; and

(12) Establishes appeals mechanism and procedure by which credential denials, credential reductions, or provider terminations may be challenged including:

(a) Notice of complaint;

(b) Opportunity to be heard; and

(c) Opportunity to take corrective action, unless action is needed to protect the life, health, or safety of health carrier enrollees.