[atlas:bill]

AN ACT Relating to health plan medical director licensure and accountability; and adding a new chapter to Title 18 RCW.

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

NEW SECTION. Sec. 1. (1) The legislature finds that cost containment measures in the delivery of health care often involve third-party payors reviewing the care delivered by physicians or physician assistants for coverage under the terms of the patient's insurance policy, including medical efficacy, cost-effectiveness, quality assurance, utilization review, and similar provisions.

(2) The utilization of persons to make operation decisions requiring evaluation of medical review who are not licensed to provide the medical services being reviewed in the state of Washington creates an undue risk of harm to patients because of uncertainties regarding their training and lack of accountability to the same authority that treating practitioners are accountable. Having treating and reviewing physicians similarly accountable to the public and held to the same standard of performance and ethics is in the public interest.

(3) While reviewing physicians do not actually deliver care they make financial and related decisions which often determine and always influence whether care will be delivered and under what financial arrangements. Therefore, the reviewing decision has a material effect on the delivery of health care in the state of Washington.

NEW SECTION. Sec. 2. The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Full contractual coverage" means full coverage in accordance with the terms of the insured's contract with the third-party payor except for the effect of the decision regarding medical necessity or the equivalent.

(2) "Medical necessity or the equivalent" means whether a health service or item:

(a) Is a clinically appropriate choice;

(b) Has a reasonable probability of achieving the intended clinical outcome, particularly in consideration of expected enrollee compliance with treatment requirements; and

(c) Is consistent with recognized professional standards of the physician or physician assistant providing or prescribing the health care service or item.

(3) "Operational decision" means a decision that does not require further approval within a third-party payor to be effective for any purpose relevant to full contractual coverage. The fact that such a decision is subject to appeal does not mean that it is not operational.

(4) "Third-party payor" means any third-party insuring entity, public or private, fully insured or self-insured doing business in the state of Washington and specifically includes, but is not limited to, any insuring entity regulated under chapter 48.20, 48.21, 48.44, or 48.46 RCW.

NEW SECTION. Sec. 3. Each third-party payor that makes coverage decisions described in section 4 of this act shall designate a medical director, who is licensed under chapter 18.57 or 18.71 RCW, to make the operational decision or assume full responsibility for those decisions. Each third-party payor will be responsible for ensuring that organizations acting on its behalf or at its direction will comply with this chapter.

NEW SECTION. Sec. 4. No person may make an operational decision failing to provide a third-party payor's full contractual coverage of a health care service or item based on the medical necessity or the equivalent of the service or item provided or prescribed by a physician or physician assistant licensed under chapter 18.57, 18.57A, 18.71, or 18.71A RCW for care delivered in the state of Washington unless that person is licensed in the state of Washington under chapter 18.57 or 18.71 RCW.

NEW SECTION. Sec. 5. The medical quality assurance commission and the state board of osteopathic medicine and surgery may jointly adopt rules to implement this chapter.

NEW SECTION. Sec. 6. Nothing in this chapter affects the practitioner-patient relationship under which health care is delivered. This chapter applies to the relationship between the third-party payor and the patient.

NEW SECTION. Sec. 7. If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected.

NEW SECTION. Sec. 8. Sections 1 through 7 of this act constitute a new chapter in Title 18 RCW.