1869-S AMH COND ELGE 069
SHB 1869 - H AMD 85
By Representative Condotta
ADOPTED AS AMENDED 02/26/2011
Strike everything after the enacting clause and insert the following:
"Sec. 1. RCW 51.36.010 and 2007 c 134 s 1 are each amended to read as follows:
(1) The legislature finds that high quality medical
treatment and adherence to occupational health best practices can prevent
disability and reduce loss of family income for workers, and lower labor and
insurance costs for employers. Injured workers deserve high quality medical
care in accordance with current health care best practices. To this end, the
department shall establish minimum standards for providers who treat workers
from both state fund and self-insured employers. The department shall establish
a health care provider network to treat injured workers, and shall accept
providers into the network who meet those minimum standards. The department
shall convene an advisory group made up of representatives from or designees
of the workers' compensation advisory committee and the industrial insurance
medical and chiropractic advisory committees to consider and advise the
department related to implementation of this section, including development of
best practices treatment guidelines for providers in the network. The
department shall also seek the input of various health care provider groups and
associations concerning the network's implementation. Network providers must
be required to follow the department's evidence-based coverage decisions and treatment
guidelines, policies, and must be expected to follow other national treatment
guidelines appropriate for their patient. The department, in collaboration
with the advisory group, shall also establish additional best practice
standards for providers to qualify for a second tier within the network, based
on demonstrated use of occupational health best practices. This second tier is
separate from and in addition to the centers for occupational health and
education established under subsection (5) of this section.
(2)(a) Upon the occurrence of any injury to a worker entitled to
compensation under the provisions of this title, he or she shall receive proper
and necessary medical and surgical services at the hands of a physician or
licensed advanced registered nurse practitioner
of his or her own choice, if conveniently located, except as provided in (b)
of this subsection, and proper and necessary hospital care and services
during the period of his or her disability from such injury.
(b) Once the provider
network is established in the worker's geographic area, an injured worker may
receive care from a nonnetwork provider only for an initial office or emergency
room visit. However, the department or self-insurer may limit reimbursement to
the department's standard fee for the services. The provider must comply with
all applicable billing policies and must accept the department's fee schedule
as payment in full.
(c) The department, in collaboration with the advisory group, shall
adopt policies for the development, credentialing, accreditation, and continued
oversight of a network of health care providers approved to treat injured
workers. Health care providers shall apply to the network by completing the
department's provider application which shall have the force of a contract with
the department to treat injured workers. The advisory group shall recommend
minimum network standards for the department to approve a provider's
application, to remove a provider from the network, or to require peer review such
as, but not limited to:
(i) Current malpractice insurance coverage exceeding a dollar amount
threshold, number, or seriousness of malpractice suits over a specific time
frame;
(ii) Previous malpractice judgments or settlements that do not exceed a
dollar amount threshold recommended by the advisory group, or a specific number
or seriousness of malpractice suits over a specific time frame;
(iii) No licensing or disciplinary action in any jurisdiction or loss of
treating or admitting privileges by any board, commission, agency, public or
private health care payer, or hospital;
(iv) For some specialties such as surgeons, privileges in at least one
hospital;
(v) Whether the provider has been credentialed by another health plan
that follows national quality assurance guidelines; and
(vi) Alternative criteria for providers that are not credentialed by
another health plan.
The department shall develop alternative criteria for providers that are
not credentialed by another health plan or as needed to address access to care
concerns in certain regions.
(d) Network provider contracts will automatically renew at the end of
the contract period unless the department provides written notice of changes in
contract provisions or the department or provider provides written notice of
contract termination. The industrial insurance medical advisory committee
shall develop criteria for removal of a provider from the network to be
presented to the department and advisory group for consideration in the
development of contract terms.
(e) In order to monitor quality of care and assure efficient management
of the provider network, the department shall establish additional criteria and
terms for network participation including, but not limited to, requiring
compliance with administrative and billing policies.
(f) The advisory group shall recommend best practices standards to the
department to use in determining second tier network providers. The
department shall develop and implement financial and nonfinancial incentives
for network providers who qualify for the second tier. The department is
authorized to certify and decertify second tier providers.
(3) The department shall work with self-insurers and the department
utilization review provider to implement utilization review for the
self-insured community to ensure consistent quality, cost-effective care for
all injured workers and employers, and to reduce administrative burden for
providers.
(4) The department for state fund claims shall pay, in accordance
with the department's fee schedule, for any alleged injury for which a worker
files a claim, any initial prescription drugs provided in relation to that
initial visit, without regard to whether the worker's claim for benefits is
allowed. In all accepted claims, treatment shall be limited in point of
duration as follows:
In the case of permanent partial disability, not to extend beyond the date when compensation shall be awarded him or her, except when the worker returned to work before permanent partial disability award is made, in such case not to extend beyond the time when monthly allowances to him or her shall cease; in case of temporary disability not to extend beyond the time when monthly allowances to him or her shall cease: PROVIDED, That after any injured worker has returned to his or her work his or her medical and surgical treatment may be continued if, and so long as, such continuation is deemed necessary by the supervisor of industrial insurance to be necessary to his or her more complete recovery; in case of a permanent total disability not to extend beyond the date on which a lump sum settlement is made with him or her or he or she is placed upon the permanent pension roll: PROVIDED, HOWEVER, That the supervisor of industrial insurance, solely in his or her discretion, may authorize continued medical and surgical treatment for conditions previously accepted by the department when such medical and surgical treatment is deemed necessary by the supervisor of industrial insurance to protect such worker's life or provide for the administration of medical and therapeutic measures including payment of prescription medications, but not including those controlled substances currently scheduled by the state board of pharmacy as Schedule I, II, III, or IV substances under chapter 69.50 RCW, which are necessary to alleviate continuing pain which results from the industrial injury. In order to authorize such continued treatment the written order of the supervisor of industrial insurance issued in advance of the continuation shall be necessary.
The supervisor of industrial insurance, the supervisor's designee, or a self-insurer, in his or her sole discretion, may authorize inoculation or other immunological treatment in cases in which a work- related activity has resulted in probable exposure of the worker to a potential infectious occupational disease. Authorization of such treatment does not bind the department or self-insurer in any adjudication of a claim by the same worker or the worker's beneficiary for an occupational disease.
(5)(a) The legislature
finds that the department and its business and labor partners have collaborated
in establishing centers for occupational health and education to promote best
practices and prevent preventable disability by focusing additional
provider-based resources during the first twelve weeks following an injury.
The centers for occupational health and education represent innovative
accountable care systems in an early stage of development consistent with
national health care reform efforts. Many Washington workers do not yet have
access to these innovative health care delivery models.
(b) To expand evidence-based occupational health best practices, the
department shall establish additional centers for occupational health and education,
with the goal of extending access to at least fifty percent of injured and ill
workers by December 2013 and to all injured workers by December 2015. The
department shall also develop additional best practices and incentives that
span the entire period of recovery, not only the first twelve weeks.
(c) The department shall certify and decertify centers for occupational
health and education based on criteria including institutional leadership and
geographic areas covered by the center for occupational health and education,
occupational health leadership and education, mix of participating health care
providers necessary to address the anticipated needs of injured workers, health
services coordination to deliver occupational health best practices, indicators
to measure the success of the center for occupational health and education, and
agreement that the center's providers shall, if feasible, treat certain injured
workers if referred by the department or a self-insurer.
(d) Health care delivery organizations may apply to the department for
certification as a center for occupational health and education. These
may include, but are not limited to, hospitals and affiliated clinics and
providers, multispecialty clinics, health maintenance organizations, and
organized systems of network physicians.
(e) The centers for occupational health and education shall implement
benchmark quality indicators of occupational health best practices for
individual providers, developed in collaboration with the department. A center
for occupational health and education shall remove individual providers who do
not consistently meet these quality benchmarks.
(f) The department shall develop and implement financial and
nonfinancial incentives for center for occupational health and education
providers that are based on progressive and measurable gains in occupational
health best practices, and that are applicable throughout the duration of an
injured or ill worker's episode of care.
(g) The department shall develop electronic methods of tracking
evidence-based quality measures to identify and improve outcomes for injured
workers at risk of developing prolonged disability. In addition, these methods
must be used to provide systematic feedback to physicians regarding quality of care,
to conduct appropriate objective evaluation of progress in the centers for
occupational health and education, and to allow efficient coordination of
services.
(6) If a provider fails to meet the minimum network standards
established in subsection (2) of this section, the department is authorized to
remove the provider from the network or take other appropriate action regarding
a provider's participation. The department may also require remedial steps as
a condition for a provider to participate in the network. The department, with
input from the advisory group, shall establish waiting periods that may be
imposed before a provider who has been denied or removed from the network may
reapply.
(7) The department may permanently remove a provider from the network or
take other appropriate action when the provider exhibits a pattern of conduct
of low quality care that exposes patients to risk of physical or psychiatric
harm or death. Patterns that qualify as risk of harm include, but are not
limited to, poor health care outcomes evidenced by increased, chronic, or
prolonged pain or decreased function due to treatments that have not been shown
to be curative, safe, or effective or for which it has been shown that the
risks of harm exceed the benefits that can be reasonably expected based on
peer- reviewed opinion.
(8) The department may not remove a health care provider from the
network for an isolated instance of poor health and recovery outcomes due to
treatment by the provider.
(9) When the department terminates a provider from the network, the
department or self-insurer shall assist an injured worker currently under the
provider's care in identifying a new network provider or providers from whom
the worker can select an attending or treating provider. In such a case, the
department or self-insurer shall notify the injured worker that he or she must
choose a new attending or treating provider.
(10) The department may adopt rules related to this section.
(11) The department shall report to the workers' compensation advisory
committee and to the appropriate committees of the legislature on each December
1st, beginning in 2012 and ending in 2016, on the implementation of the
provider network and expansion of the centers for occupational health and education.
The reports must include a summary of actions taken, progress toward long-term
goals, outcomes of key initiatives, access to care issues, results of disputes
or controversies related to new provisions, and whether any changes are needed
to further improve the occupational health best practices care of injured
workers.
NEW SECTION. Sec. 2. This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2011."
Correct the title.
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EFFECT: Requires the Department of Labor and Industries (Department) to seek the input of various health care provider groups and associations regarding the network's implementation. Deletes provision adding podiatry to the list of groups, specialties, and associations from which nominations must be sought for the Industrial Insurance Medical Advisory Committee (Committee) members and expanding the Committee.
Requires network providers to follow the Department's evidence-based coverage decisions and treatment guidelines, policies, and be expected to follow other national treatment guidelines. (The Substitute Bill requires providers to consider guidelines, policies, and treatment guidelines and does not refer to "evidence-based.")
Strikes provision allowing providers to provide reasonable and necessary treatment ordered by the Board of Industrial Insurance Appeals or a court.
Requires the Department to collaborate with the advisory group in establishing second tier best practice standards.
Provides specificity regarding the malpractice insurance coverage standard to specify exceeding a dollar amount threshold, number, or seriousness of malpractice suits over a specific time frame. Requires, rather than allows, the Department to establish additional criteria and terms for network participation.
Requires the advisory group to recommend standards for requiring peer review.
Specifies that provider contracts automatically renew unless the Department provides written notice of changes in contract provisions or the provider or Department terminate the contract in writing. Requires the Committee to develop criteria for removal of a provider from the network to be presented to the Department and advisory group for consideration in the development of contract terms.
Requires the Department to obtain input from the advisory group regarding waiting periods before a provider who has been denied or removed from the network may reapply.
Strikes provision requiring Department decisions to remove a provider to be issued by appealable order.
Strikes provision requiring the Department to adopt rules allowing direct practices to be network providers and related direct practice provisions.
Clarifies that a worker may receive care from the provider the worker chooses except that once the network is established in the worker's geographic area, the worker may receive care from a nonnetwork provider only for the initial visit.
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