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PDFWAC 182-502-0030

Termination of provider enrollment—For cause.

(1) The medicaid agency may immediately terminate a provider's enrollment 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 according to chapter 246-16 WAC or in profession specific rules of the department of health (DOH);
(iii) A statement of allegations or statement of charges by DOH or equivalent from other state licensing boards;
(iv) Restrictions or limitations placed by any state licensing, credentialing, or certification agency on the provider's current credentials or practice;
(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 use disorder, or failure to refer the patient for substance use disorder treatment once 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 provider with a substance use disorder(s) 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 disorder 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) Civil or criminal findings of fraudulent or abusive billing practices through an investigation or other review (e.g., audit or record review);
(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 to the agency during or after enrollment including on the application for a core provider agreement (CPA), a nonbilling provider agreement, or servicing providers enrolled under a core provider agreement;
(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's enrollment is terminated for cause, the agency pays only for authorized services provided up to the date of termination of enrollment if other program requirements are met including, but not limited to, the requirements in WAC 182-502-0016.
(3) When the agency terminates enrollment of a servicing provider who is also a full or partial owner of an enrolled group practice, the agency terminates the enrolled group practice and all enrolled servicing providers who are not linked to another enrolled group practice contracted with the agency. The remaining practitioners in the group practice may reapply for participation with the agency subject to WAC 182-502-0010.
(4) Effective date. The effective date of the termination of a provider's enrollment is the date stated in the notice. The filing of an appeal as provided in subsection (5) of this section does not stay the effective date of termination.
(5) Administrative hearing.
(a) The provider may appeal the agency decision to terminate the provider's enrollment for cause by submitting a written request to the address contained in the decision notice within 28 calendar days of the date on the notice and in a manner that provides proof of receipt by the agency. The agency does not allow good cause exception related to this subsection.
(b) If the agency receives a timely appeal, the presiding officer will schedule a prehearing conference in accordance with WAC 182-526-0195.
(c) The administrative hearing process is governed by the Administrative Procedure Act, chapter 34.05 RCW, and chapter 182-526 WAC.
(d) Burden of proof.
(i) The provider has the burden of proof.
(ii) The standard of proof in a provider termination hearing is "clear and convincing evidence" meaning the evidence is highly and substantially more likely to be true than untrue. This is a higher standard of proof than proof by a preponderance of the evidence, but it does not require proof beyond a reasonable doubt.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-21-061, § 182-502-0030, filed 10/12/23, effective 11/12/23; 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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