RCW 51.36.010
Findings -- Minimum standards for
providers -- Health care provider network -- Advisory group -- Best
practices treatment guidelines -- Extent and duration of
treatment -- Centers for occupational health and
education -- Rules -- Reports.
(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.
[2011 c 6 § 1; 2007 c 134 § 1; 2004 c 65 § 11; 1986 c 58 § 6; 1977 ex.s. c 350 § 56; 1975 1st ex.s. c 234 § 1; 1971 ex.s. c 289 § 50; 1965 ex.s. c 166 § 2; 1961 c 23 § 51.36.010. Prior: 1959 c 256 § 2; prior: 1943 c 186 § 2, part; 1923 c 136 § 9, part; 1921 c 182 § 11, part; 1919 c 129 § 2, part; 1917 c 28 § 5, part; Rem. Supp. 1943 § 7714, part.]
NOTES:
Effective date -- 2011 c 6: "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." [2011 c 6 § 2.]
Report to legislature -- 2007 c 134: "By December 1, 2009, the department of labor and industries must report to the senate labor, commerce, research and development committee and the house of representatives commerce and labor committee, or successor committees, on the implementation of this act." [2007 c 134 § 2.]
Effective date -- 2007 c 134: "This act takes effect January 1, 2008." [2007 c 134 § 3.]
Report to legislature -- Effective date -- Severability -- 2004 c 65: See notes following RCW 51.04.030.
Effective dates -- Severability -- 1971 ex.s. c 289: See RCW 51.98.060 and 51.98.070.