WSR 07-17-165

PROPOSED RULES

OFFICE OF

INSURANCE COMMISSIONER

[ Insurance Commissioner Matter No. R 2005-04 -- Filed August 22, 2007, 7:47 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 05-22-113.

Title of Rule and Other Identifying Information: Substitution of providers (a/k/a "locum tenens") rules.

Hearing Location(s): Insurance Commissioner's Office, 5000 Capitol Boulevard, Room TR-120, Tumwater, WA 98504-0255, on September 26, 2007, at 1:00 p.m.

Date of Intended Adoption: October 3, 2007.

Submit Written Comments to: Kacy Scott, P.O. Box 40255, Olympia, WA 98504-0258, e-mail Kacys@oic.wa.gov, fax (360) 586-3109, by September 25, 2007.

Assistance for Persons with Disabilities: Contact Lorie Villaflores by September 25, 2007, TTY (360) 586-0241 or (360) 725-7087.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: On January 10, 2007, the office of insurance commissioner (OIC) held a rule-making hearing on a prior version of these substitution of providers rules. After careful consideration of the testimony and written comments received, these rules are proposed.

Proposed WAC 284-43-260 would require health carriers to permit a contracted provider to select another provider who will serve as a substitute in the absence of the contracted provider. The substitute provider is not required to be a member of the carrier's network. The applicable categories of providers are doctors of medicine, osteopathy, dental surgery, chiropractic, podiatry or surgical chiropody, optometry, naturopathic medicine and advanced registered nurse practitioners.

In proposed WAC 384-43-262, providers returning to civilian practice after a period of active duty military service would be allowed to request reinstatement to the carrier's network, and the carrier would have to reinstate the provider, if the provider timely applies for reinstatement and meets the carrier's then-current credentialing standards, even if the carrier's network is "closed." This rule would apply to all providers covered by RCW 48.43.045, the "every category of provider" statute.

Reasons Supporting Proposal: The Washington State Chiropractic Association petitioned the insurance commissioner for adoption of a rule to require carriers to include a "locum tenens" provision in contracts with chiropractors. After careful consideration the commissioner decided to include all provider types in proposed regulations. The resulting rule will affect all provider types who have a state license to "diagnose and treat human disease, ailment, or pain." This includes, but is not limited to, chiropractors.

Statutory Authority for Adoption: RCW 48.02.060 and 48.43.515.

Statute Being Implemented: RCW 48.43.515.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Mike Kreidler, insurance commissioner, governmental.

Name of Agency Personnel Responsible for Drafting: Melodie Bankers, P.O. Box 40258, (360) 725-7039; Implementation: Beth Berendt, P.O. Box 40255, (360) 725-7117; and Enforcement: Carol Sureau, P.O. Box 40255, (360) 725-7050.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The cost of compliance with this proposed rule for small businesses regulated by the OIC would be minor or negligible.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Kacy Scott, P.O. Box 40258, Olympia, WA 98504-0258, phone (360) 725-7041, fax (360) 586-3109, e-mail Kacys@oic.wa.gov.

August 22, 2007

Mike Kreidler

Insurance Commissioner

OTS-9368.7


NEW SECTION
WAC 284-43-260   Standards for temporary substitution of contracted network providers -- "Locum tenens" providers.   It is a longstanding and widespread practice for contracted network providers to retain substitute providers to take over their professional practices when the contracted network providers are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the contracted network provider to bill and receive payment for the substitute providers' services as though they were provided by the contracted network provider. The contracted network provider generally pays the substitute provider based on an agreement between the contracted network provider and the substitute provider, and the substitute provider has the status of an independent contractor rather than an employee of the contracted network provider. These substitute providers are commonly called "locum tenens" providers. The following are minimum standards for temporary provider substitution and do not prevent a carrier from entering into other agreed arrangements with its contracted network providers for terms that are less restrictive or more favorable to providers.

Carriers must permit the following categories of contracted network provider to arrange for temporary substitution by a substitute provider: Doctor of medicine, osteopathic physician or surgeon, doctor of dental surgery or dental medicine, doctor of chiropractic, podiatric physician and surgeon, doctor of optometry, doctor of naturopathic medicine and advanced registered nurse practitioners.

(1) At the time of substitution, the substitute provider:

(a) Must have a current Washington license and be legally authorized to practice in this state;

(b) Must provide services under the same scope of practice as the contracted network provider;

(c) Must not be suspended or excluded from any state or federal health care program; and

(d) Must have professional liability insurance coverage.

(2)(a) Carriers must allow substitution for at least sixty days during any calendar year.

(b) A carrier must grant an extension if a contracted network provider demonstrates that exceptional circumstances require additional time away from his or her practice.

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NEW SECTION
WAC 284-43-262   Rule concerning contracted network providers called to active duty.   In lieu of substitution of a provider during a period of active duty military service longer than sixty continuous days, carriers must provide contracted network providers with the opportunity to return to the carrier's network after the provider's active duty military service is completed.

(1) A carrier may not terminate the contract of a network provider for the sole reason that he or she has been called to active duty military service.

(2)(a) A carrier must allow the provider a period of at least one hundred twenty days to request a return to contracted network provider status after the provider returns to civilian status.

(b) The one hundred twenty-day period must begin no earlier than the date the provider's period of active duty ends.

(3)(a) As a condition for return to the carrier's network, the carrier may require that the provider provide evidence that he or she meets the carrier's then-current standards for credentialing.

(b) If the provider meets or exceeds the credentialing standards of the carrier and timely requests a return to contracted network provider status, the carrier must grant the request whether or not the carrier's network is otherwise closed.

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Washington State Code Reviser's Office