(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.
