PROVIDERS
Approved examiners listThe authority given the Director to make decisions regarding a physician's exclusion from the approved examiner's list allows the Director to consider any of the criteria listed in the rule and does not require the existence of all of the criteria. WAC 296-23-26503. ….Kenneth Sawyer, M.D., 01 P0078 (2002)[Editors note: The Board's decision was appealed to superior court under Thurston County Cause No. 02-2-01400-1]
Audits
The Department is entitled to reimbursement even if the Department had authorized the use of specific billing codes that are subsequently found to be incorrect. If payment is made in an incorrect amount it must be repaid in a manner required by statute. ....Integrated Medical Examiners, LLC, 04 P0067, 2006 [Editors Note: The Board's decision was appealed to superior court under Thurston County Cause No. 06-2-00762-7]
Legislative provisions granting authority to the Department to conduct audits and investigations of providers to determine whether the services were appropriate and to enforce sanctions, if appropriate, must be in effect during the audit of the provider's treatment practices. Otherwise, legislative changes which created new obligations and imposed new duties on providers could operate prospectively only. ....Gary Bruner, G. C. D.C., 91 P045 (1992) [Editors note: Reversed by implication, Department of Labor & Indus. v. Kantor, 94 Wn.App. 764 (1999), review denied, 139 Wn.2d 1002 (1999).]
Department's authority to regulate out-of-state providers
Every health care provider, defined in statute as "any person, firm, corporation, partnership, association, agency, institution, or other legal entity providing any kind of services related to the treatment of an industrially injured worker" must, as a condition of payment, adhere to the Department's medical aid rules. The Department has authority to compel compliance of out-of-state providers with state regulations for the purposes of Title 51 and the Department's authority to revoke the provider's authorization to treat injured workers was within its delegated authority. ….St. Alphonsus Regional Medical Center, 96 P051 (2000)
Limitations of actions
The provider of medical services provides a service pursuant to a contract with the Department. Accordingly, a six-year statute of limitations for actions under contract applies to the amount of time the Department has to request repayment from a provider. ....Integrated Medical Examiners, LLC, 04 P0067, 2006 [Editors Note: The Board's decision was appealed to superior court under Thurston County Cause No. 06-2-00762-7]
Peer review
Where the Department based its determination that a provider received payments to which he was not entitled, upon peer review of the services provided, the Board concluded that after-the-fact review, conducted considerably after the services were provided, for the purpose of recovering monies which the Department had previously determined were properly payable, seems an unwarranted extension of the intent of RCW 51.48.260. ....Gary Bruner, G. C. D.C., 91 P045 (1992) [Editors note: Reversed by implication, Department of Labor & Indus. v Kantor, 94 Wn.App. 764 (1999), review denied, 139 Wn.2d 1002 (1999)]
Provider appeals
The Department, in a provider appeal involving recoupment of treatment costs paid, must support its order based on the statutory and administrative provisions in effect during the time of the audit. ....Gary Bruner, G.C. D.C., 91 P045 (1992) [Editor's Note: The decision refers to specific effective dates of certain regulations (WAC 296-20-01002, effective January 1, 1988) which are incorrect.] [Editors note: Reversed by implication, Department of Labor & Indus. v. Kantor, 94 Wn.App. 764 (1999), review denied, 139 Wn.2d 1002 (1999).]
Treatment
The standard by which treatment services are judged is whether they were "proper and necessary" within the meaning of RCW 51.36.010. Where the Department modified its regulations to add a definition of the term "medically necessary", the modified definition applies only to the extent the audit period followed the effective date. ....Gary Bruner, G.C. D.C., 91 P045 (1992) [Editor's Note: The decision refers to specific effective dates of certain regulations (WAC 296-20-01002, effective January 1, 1988) which are incorrect.] [Editors note: Reversed by implication, Department of Labor & Indus. v. Kantor, 94 Wn.App. 764 (1999), review denied, 139 Wn.2d 1002 (1999).]