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PDFWAC 182-502-0030

Termination of a provider agreement—For cause.

(1) The medicaid agency may immediately terminate a provider's core provider agreement (CPA) for any one or more of the following reasons, each of which constitutes cause:
(a) Provider exhibits significant risk factors that endanger client health or safety. These factors include, but are not limited to:
(i) Moral turpitude;
(ii) Sexual misconduct as defined in WAC 246-934-100 or in profession specific rules of the department of health (DOH);
(iii) A statement of allegations or statement of charges by DOH;
(iv) Restrictions placed by DOH on provider's current practice such as chaperone required for rendering treatment, preceptor required to review practice, or prescriptive limitations;
(v) Limitations, restrictions, or loss of hospital privileges or participation in any health care plan or failure to disclose the reasons to the agency;
(vi) Negligence, incompetence, inadequate or inappropriate treatment, or lack of appropriate follow-up treatment;
(vii) Patient drug mismanagement, failure to identify substance abuse or addiction, or failure to refer the patient for substance abuse treatment once abuse or addiction is identified;
(viii) Use of health care providers or health care staff who are unlicensed to practice or who provide health care services that are outside their recognized scope of practice or the standard of practice in the state of Washington;
(ix) Failure of the health care provider to comply with the requirements of WAC 182-502-0016;
(x) Failure of the health care practitioner with an alcohol or chemical dependency to furnish documentation or other assurances as determined by the agency to adequately safeguard the health and safety of Washington apple health clients that the provider:
(A) Is complying with all conditions, limitations, or restrictions to the provider's practice both public and private; and
(B) Is receiving treatment adequate to ensure that the dependency problem will not affect the quality of the provider's practice.
(xi) Infection control deficiencies;
(xii) Failure to maintain adequate professional malpractice coverage;
(xiii) Medical malpractice claims or professional liability claims that constitute a pattern of questionable or inadequate treatment, or contain any gross or flagrant incident of malpractice; or
(xiv) Any other act that the agency determines is contrary to the health and safety of its clients.
(b) Provider exhibits significant risk factors that affect the provider's credibility or honesty. These factors include, but are not limited to:
(i) Failure to meet the requirements in WAC 182-502-0010 and 182-502-0020;
(ii) Dishonesty or other unprofessional conduct;
(iii) Investigatory (e.g., audit), civil, or criminal finding of fraudulent or abusive billing practices;
(iv) Exclusion from participation in medicare, medicaid, or any other federally funded health care program;
(v) Any conviction, no contest plea, or guilty plea relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct;
(vi) Any conviction, no contest plea, or guilty plea of a criminal offense;
(vii) Failure to comply with a DOH request for information or an ongoing DOH investigation;
(viii) Noncompliance with a DOH or other state health care agency's stipulation to disposition, agreed order, final order, or other similar licensure restriction;
(ix) Misrepresentation or failure to disclose information on the enrollment application for a core provider agreement (CPA), failure to supply requested information, or failure to update CPA as required;
(x) Failure to comply with an agency request for information;
(xi) Failure to cooperate with an agency investigation, audit, or review;
(xii) Providing health care services that are outside the provider's recognized scope of practice or the standard of practice in the state of Washington;
(xiii) Unnecessary medical, dental, or other health care procedures;
(xiv) Discriminating in the furnishing of health care services, supplies, or equipment as prohibited by 42 U.S.C. § 2000d; and
(xv) Any other dishonest or discreditable act that the agency determines is contrary to the interest of the agency or its clients.
(2) If a provider is terminated for cause, the agency pays for authorized services provided up to the date of termination only.
(3) If the agency terminates a provider who is also a full or partial owner of a group practice, the agency also terminates all providers linked to the group practice. The remaining practitioners in the group practice may reapply for participation with the agency subject to WAC 182-502-0010(2).
(4) A provider who is terminated for cause may dispute an agency decision under the process in WAC 182-502-0050.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0030, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0030, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0030, filed 7/17/00, effective 8/17/00.]
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