WSR 97-22-057

DEPARTMENT OF CORRECTIONS

[Filed November 3, 1997, 10:15 a.m.]

Reviser's note: The following material has not been adopted under the Administrative Procedure Act, chapter 34.05 RCW, but has been filed in the office of the code reviser and is published in the Register exactly as filed.

The following enclosed Department of Corrections WAC rules, 137-91-010, 137-91-020, 137-91-030, 137-91-040, 137-91-050, 137-91-075, 137-91-080, 137-91-090, and 137-91-100 are submitted for publication in the Register and the Washington Administrative Code. Pertinent information is as follows:

a. WAC 137-91-010, 137-91-020, 137-91-030, 137-91-040, 137-91-075, 137-91-090, and 137-91-100 are new sections and are adopted as of October 22, 1997.

b. WAC 137-91-050 and 137-91-080 are amended sections are adopted as of the same date.

c. The effective date of these amended rules is December 5, 1997.

d. I certify pursuant to RCW 34.05.030 that the rules as stated above are exempt from the Administrative Procedure Act.

e. The purpose is to bring these rules into compliance with the new health standards pertaining to offender health care within the Department of Corrections.

Joseph D. Lehman

Secretary

NEW SECTION

WAC 137-91-010 Health care--General policy. The policy of the department of corrections (the department) with regard to health care for offenders in adult correctional facilities is to provide that care, consistent with the Offender Health Plan (OHP), which is medically necessary to respond to the offender's medical, dental, and mental health needs. Medically necessary is defined as that care that is determined by the department to:

Be consistent with applicable department policies and procedures;

Be ordered by an authorized department health care provider;

Be required to prevent significant deterioration in the offender's health or permanent functional impairment if not rendered during the period of incarceration;

Not be considered experimental or be lacking in medically recognized professional documentation of efficacy; and

Not be administered solely for the convenience of the offender or the health care provider.

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NEW SECTION

WAC 137-91-020 Contracts for services. The department intends to purchase health care in a prudent, cost-effective manner without unduly restricting offenders' access to appropriate and medically necessary care. Therefore, notwithstanding any other provisions of law, the secretary may enter into contracts with health care practitioners, health care facilities, and other entities or agents qualified to provide such services as may be necessary to provide health care to offenders in accordance with the provisions of RCW 72.10.030.

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NEW SECTION

WAC 137-91-030 Utilization review. When purchasing health care services and establishing medical necessity of services, the secretary is authorized to implement health care utilization management methods to assure the appropriateness of the care rendered to the offender. These methods may include but are not limited to: Prior authorization; hospital length of stay review; case management; treatment guidelines; and audit of billed charges and services rendered.

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NEW SECTION

WAC 137-91-040 Purchasing health care services. The secretary is authorized to institute any reasonable reimbursement mechanism for purchasing health care services from health care practitioners or health care facilities. These reimbursement mechanisms shall include, but are not limited to: Capitation; per diems, global fees; diagnosis-related groups (DRG); fee schedules, or any other prudent cost-effective payment method which shall be established by rule adopted in accordance with chapter 34.05 RCW.

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AMENDATORY SECTION (Amending Order 84-11, filed 7/30/84, effective 9/4/84 WAC 137-91-050 ((Use of allied health professionals.)) Audits and recovery in purchasing health care services. ((Allied health professionals may be used in the medical and dental health programs at each institution. When operating under the supervision of a licensed physician or dentist, an allied health professional may conduct initial screening, treat minor illnesses, and do related tasks.)) The secretary may establish rules and procedures for selectively and/or randomly auditing the accuracy of fees and the medical billings submitted to the department. The department, or its agent, may review the offender's community health care record to assure that the offender received the services for which the bill was submitted.

Whenever an audit establishes that the services rendered were not authorized or medically necessary, the department shall not pay the cost for such services nor shall the offender be held accountable for such costs.

The secretary is authorized to seek recovery when the department identifies that a health care practitioner or facility is not entitled to the billed fees. The practitioner or facility is liable for any excess payment received and must repay the excess payment plus accrued interest on the excess payment at the rate of one percent per month for each month for the period from the date which the payment was made to the date upon which payment is made to the department.

[Statutory Authority: RCW 72.01.050, 72.01.090 and 72.09.050. 84-16-066 (Order 84-11), 137-91-050, filed 7/30/84, effective 9/4/84. Formerly WAC 275-91-050.]

NEW SECTION

WAC 137-91-075 Other health care coverage. If an offender is eligible for health care benefits through the veterans administration, the department of labor and industries (L&I), automobile insurance claims, or any other third-party payer or insurer determined to be primarily responsible for the offender's health condition, through coordination of benefits rules, the department of corrections shall be considered a secondary payer.

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AMENDATORY SECTION (Amending WSR 96-21-014, filed 10/4/96, effective 11/5/96)

WAC 137-91-080 ((Copayment program.)) Health care services. ((Offenders shall pay a nominal amount as determined by the secretary in policy. Such copayments may be made by subsequent visits if they are related to the initial visit. Offenders will not be required to pay for emergency treatment, treatment of serious health care needs as defined by the secretary, or for services initiated by health care staff. No offender will be refused health care because of indigency. All copayments that are not able to be collected at the time of the visit will be debited to the offender's account.)) The health care program operated by the department of corrections shall include the following services:

(1) Initial examination when the offender enters the adult correction system. This examination shall include:

(a) Health history;

(b) An initial physical examination including laboratory, radiology and other diagnostic studies, as indicated;

(c) Dental examination;

(2) Immunizations, as indicated;

(3) Evaluation of capacity for work, educational programs, special housing assignment, and recreation;

(4) Consultations, examinations and treatment as required for the health maintenance of each offender in accordance with the policy discussed at WAC 137-91-010.

[96-21-014, 137-91-080, filed 10/4/96, effective 11/5/96.]

NOTES:

Reviser's note: Under RCW 34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter 34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.

NEW SECTION

WAC 137-91-090 Use of allied health professionals. Allied health professionals, those licensed certified or registered health care providers other than physicians or dentists, may be used in the health care programs at each correctional facility. Allied health professionals may deliver such care as their licensure, certification, registration or statute governing their profession permits.

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NEW SECTION

WAC 137-91-100 Health record. The health record shall be maintained at the facility where an offender is housed. Health records of offenders housed at work release facilities shall be maintained at a location(s) designated by the director, division of community corrections. Upon transfer of the offender between state facilities, that offender's record shall be transferred along with the offender. The health record shall be archived ninety days following the offender's release from the department's jurisdiction. The health record shall include:

(1) Detailed reports of admission, medical, dental and mental health evaluations and recommendations;

(2) All primary encounter and progress notes regarding continuing health status including illnesses, hospitalization, surgery, results of consultations and examinations, reports of tests done, immunizations, and problem lists;

(3) Reports completed by outside consultants.

Information contained in the offender health record is confidential. Access to and release of information contained in the offender health record shall be in strict compliance with chapter 70.02 RCW.

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REPEALER

The following sections of the Washington Administrative Code are repealed:

WAC 137-91-011 Medical/dental care--General policy.

WAC 137-91-021 Medical/dental services.