PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 00-09-037.
Title of Rule: Amending WAC 388-502-0230 Fair hearings -- Providers.
Purpose: To comply with the Governor's Executive Order 97-02 on regulatory reform. To update rule to reflect current department policy.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 34.05.020, 34.05.220.
Statute Being Implemented: RCW 34.05.020, 34.05.220.
Summary: The proposed rule is being amended to clearly state existing policy regarding how the department reviews and monitors how a medical assistance provider complies with program requirements, and how the provider may appeal department actions resulting from the review. The department originally intended merely to restate the brief existing rule in clearer language, but upon review, decided that the regulated community would be better served with more information about existing department policy.
Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02 on regulatory reform. To ensure that department rules reflect current policy and practice.
Name of Agency Personnel Responsible for Drafting: Ann Myers, DPS/RIP, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1345; and Implementation: Casey Zimmer, DSHQS/QS, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1552.
Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule updates and clarifies the department's process of reviewing and monitoring medical assistance providers to ensure they are complying with program regulations and providing appropriate quality of care. The rule also states the actions that the department may take as a result of the review, and how providers may appeal any actions resulting from the review. The proposed rule codifies existing policy and practice.
The purpose of the proposed rule is to clearly state current policy and practice so that providers may understand the department's requirements and the recourse available to them when the department takes action based on the review or monitoring.
The anticipated effects of the proposed rule are to make department policy and practice clearly understood by those it affects.
Proposal Changes the Following Existing Rules: The rule proposed above amends existing rule by stating what a provider review may consist of, what actions the department may take as a result of a review, and how a provider may appeal a department action that results from a review.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule and concludes that there will be not more than a minor impact on businesses affected by the rule. This is because the rule codifies current department policy and practice, so there should be little or no effect on providers.
RCW 34.05.328 does not apply to this rule adoption. The proposed rule does not meet the definition of a "significant legislative rule."
Hearing Location: Blake Office Building East, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on October 3, 2000, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Kelly Cooper, Rules Coordinator, by September 26, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail coopeKD@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by October 3, 2000.
Date of Intended Adoption: No sooner than October 4, 2000.
August 17, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2740.7
((A certified provider of medical care services who
is assessed a civil penalty under RCW 74.09.210 or otherwise
served with notice that repayment of excess benefits is due under
RCW 74.09.210, shall have the right to a fair hearing as provided
by chapter 388-08 WAC)) (1) As authorized by chapter 74.09 RCW,
the medical assistance administration (MAA) monitors and reviews
all providers who furnish medical, dental, or other services to
eligible medical assistance clients. MAA determines whether the
providers are complying with the rules and regulations of the
program(s) and providing appropriate quality of care, and
recovers any identified overpayments. Examples of provider
reviews are:
(a) A review of all billing/medical/dental/service records for medical assistance clients;
(b) A statistical sampling of billing/medical/dental/service records for medical assistance clients, extrapolated per WAC 388-502-0240(9), (10), and (11); and
(c) A review focused on selected billing/medical/dental/service records for medical assistance clients.
(2) The Washington State Health Professions Quality Assurance Commissions serve in an advisory capacity to MAA in conducting provider reviews and monitoring.
(3) MAA may determine that a provider's billing does not comply with program regulations or the provider is not meeting quality of care practices. MAA may do, but is not limited to, any of the following:
(a) Conduct pre-pay reviews of all claims the provider submits to MAA;
(b) Refer the provider to MAA's auditors (see WAC 388-502-0240);
(c) Refer the provider to Medicaid's Fraud Control Unit;
(d) Refer the provider to the appropriate state health professions quality assurance commission;
(e) Impose provisional stipulations for the provider to continue on medical assistance programs;
(f) Terminate the provider's participation in medical assistance programs;
(g) Assess a civil penalty against the provider, per RCW 74.09.210; and
(h) Recover any monies that the provider received as a result of inappropriate payments.
(4) When any part of the time period that is reviewed or monitored falls on or before June 30, 1998, the following process applies. A provider who disagrees with a department action regarding overpayment recovery may request an administrative review hearing to dispute the action(s).
(a) The request for an administrative review hearing must be in writing and:
(i) Be sent within twenty-eight days of the date of the notice of action(s);
(ii) State the reason(s) why the provider thinks the action(s) are incorrect;
(iii) Be sent by certified mail (return receipt) or other means that provides proof of delivery to:
The Medical Assistance Administration
Attn: Deputy Assistant Secretary
P.O. Box 45500
Olympia WA 98504-5500
(b) The administrative review hearing consists of a review by MAA's deputy assistant secretary of all documents submitted by the provider and MAA. At the deputy assistant secretary's discretion, the administrative review hearing may be conducted in person, as a telephone conference, in written submissions, or a combination thereof.
(c) When a final decision is issued, the office of financial recovery collects any amount the provider is ordered to repay.
(d) The administrative review hearing referenced in this subsection is the final level of administrative review.
(5) When the entire time period that is reviewed or monitored falls on or after July 1, 1998, the following process applies. A provider who disagrees with a department action regarding overpayment recovery may request a hearing to dispute the action(s).
(a) The request for hearing must be in writing and;
(i) Be sent within twenty-eight days of the date of the notice of action(s), by certified mail (return receipt) or other means that provides proof of delivery to:
The Office of Financial Recovery
P.O. Box 9501
Olympia, WA 98507-5501; and
(ii) State the reason(s) why the provider thinks the action(s) are incorrect.
(b) The office of administrative hearings schedules and conducts the hearing under the Administrative Procedure Act, chapter 34.05 RCW. MAA offers a pre-hearing/alternative dispute conference prior to the hearing.
(c) The office of financial recovery collects any amount the provider is ordered to repay.
(d) The hearing referenced in this subsection is the final level of administrative review.
(6) A provider who disagrees with a department action regarding termination may appeal the action per WAC 388-502-0260. The provider may request a dispute conference; the request must be:
(a) In writing;
(b) Sent within thirty days of the date the provider received the termination notice;
(c) Include a statement of the action(s) appealed and supporting justification; and
(d) Sent to:
DSHS Central Contract Services
P.O. Box 45811
Olympia, WA 98504-5811
(7) See WAC 388-502-0220 for rate reimbursement appeals. See WAC 388-502-0240 for appeals of audit findings. See WAC 388-502-0260 for appeals related to contracts other than MAA's core provider agreements.
[Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-502-0230, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-042.]