New Laws Impacting Practice Management

Physician Assistant Practice, HB 2378

Updates the physician assistant profession, including making several changes to delegation agreements, now referred to as "practice agreements." The agreements are now maintained at the practice level, rather than submitted to the Department of Health (the Washington Medical Commission may request copies). Increases the maximum number of PAs a physician may supervise to 10 and allows physicians to petition the Medical Commission to raise that limit. Removes the restrictions on PAs working at remote sites. Many of the key provisions of the bill take effect July 1, 2021.

PRACTICE IMPACT: If your practice employs PAs, practice agreements will need to be updated. For a complete list and guidance on the new requirements, please contact policy@wsma.org .

Industrial Insurance Employer Penalties, HB 2409

Increases the civil penalty from $250 to $500 for physicians and other health care providers who fail to file a timely report to the Department of Labor and Industries for treatment provided to an injured worker, or who fail or refuse to render all necessary assistance to an injured worker. The bill takes effect on Sept. 1, 2020, except sections 8 and 9, relating to fair conduct and licensure of claims administrators, which take effect July 1, 2021.

PRACTICE IMPACT: The original version of the bill would have increased the penalty to $850. WSMA advocacy ensured the updated penalty (originally implemented in the 1980s) is more aligned with adjustments in inflation, ensuring practices that experience an administrative error or oversight are not burdened with unfair penalties.

Health Care Provider Credentialing, HB 1552

Requires retroactive reimbursement when a physician or provider is waiting to be credentialed by an insurance carrier. Prohibits an insurance carrier from requiring a physician to submit credentialing information through a means other than ProviderSource. The bill also permits "substitute providers" to bill Medicaid managed care organizations under certain circumstances. Eligible provider types at hospitals, rural health clinics, or rural provider groups (including physicians, physician assistants, and ARNPs) may bill MCOs for services for up to 60 days when there is a vacancy at a practice or when the practice is recruiting to fill an open position. Effective June 11, 2020.

PRACTICE IMPACT: Physicians waiting to be credentialed under a new contract with an insurance carrier must be reimbursed retroactively for services provided to patients starting on the effective date of the new contract, should the credentialing process extend beyond the effective date of the new contract. When a physician or health care provider is being added to an existing contract between a health care facility and an insurance carrier, the carrier must reimburse for services provided to patients retroactively to the point a completed credentialing application for the new health care provider was submitted to the carrier. Prohibiting carriers from requiring physicians to submit credentialing information outside of ProviderSource is intended to standardize and streamline the credentialing process.

Telemedicine Payment Parity, SB 5385

Requires payment for services delivered via telemedicine to be on par with the contracted rate paid for in-person visits. This change applies to commercial and state employee health plans executed on or after Jan. 1, 2021, and to all new contracts with Medicaid managed care organizations. As a result of WSMA advocacy during the COVID-19 crisis, Gov. Jay Inslee signed a proclamation implementing this law on a temporary, emergency basis so that physicians could continue to provide services to patients in their community.

PRACTICE IMPACT: This legislation is a huge win for physician practices seeking to implement a viable telemedicine program. In addition to mandating payment parity, the measure also eliminates the requirement that telemedicine services delivered via storeand- forward technology be preceded by an in-person visit. There is allowance for groups of 11 or more physicians and other providers to negotiate a rate that differs from their in-person service rate. If you're interested in learning more about the law or beginning to offer services via telemedicine, reach out to policy@wsma.org .

Requiring Consent For Pelvic Exams, SB 5282

Generally prohibits non-consensual pelvic exams from being performed by a physician or health care provider, or a student practicing under their authority, on patients who are under anesthesia or unconscious. Effective June 11, 2020.

PRACTICE IMPACT: From a practical standpoint, current practice around the administration of pelvic exams is now codified in statute. Exceptions to the prohibition include when the patient or patient's representative provides informed consent, the exam is necessary for diagnostic or treatment purposes, or sexual assault is suspected.

Effective July 28, 2019

Medical Debt Collection, HB 1531 & HB 1602

Caps interest rates on medical debt at 9 percent. Under HB 1531, practices are prohibited from selling or assigning medical debt to a collection agency until 120 days after the initial bill statement is sent to the patient. Both measures establish new requirements for collection agencies in the state, including increasing the limits on wage garnishment in some instances and notification of a debtor's possible qualification for charity care.

Mergers and Acquisitions, HB 1607

Hospitals, hospital systems, and provider organizations are required to provide written notice to the state attorney general at least 60 days prior to the effective date of any transaction that results in a material change in governance or operations. Notice must include the names of the parties and their current business addresses; identification of all locations where health services are provided by each party; and a brief description of the nature and purpose of the material change and the anticipated effective date of the proposal. If the transaction requires the parties to file under federal premerger notice requirements (Hart-Scott-Rodino Act), a copy shall be provided to the state attorney general. Noncompliance could result in a civil penalty of no more than $200 per day while in violation.

Telemedicine and Physician Credentialing, SB 5387

Permits an originating-site hospital to rely on a distant-site hospital's credentialing and privileging process for telemedicine services. Physicians seeking credentials or clinical privileges to perform services related to telemedicine and/or store and forward must provide the name of any hospital or facility with which you have had any association during the prior five years. You must also disclose: whether you have been or are in the process of being denied, revoked, terminated, suspended, restricted, reduced, limited, sanctioned, placed on probation, monitored, or not renewed for any professional activity listed; or ever voluntarily or involuntarily relinquished, withdrawn, or failed to proceed with an application for any professional activity listed in order to avoid an adverse action or to preclude an investigation or while under investigation relating to professional competence or conduct.

Vaccines, HB 1638

You may no longer sign certification forms exempting children from the MMR vaccine based on personal or philosophical objection. The Department of Health will provide updated certificate of exemption forms prior to the law's effective date. For more information, the DOH has created a dedicated webpage at doh.wa.gov/MMRexemption.

Whistleblower Protections, HB 1049

Expands protections to non-employee health care providers who whistleblow in good faith and provides a civil remedy to non-employee whistleblowers who experience retaliatory action. If subject to retaliatory action, review your rights and protection under the law. A directive from the WSMA House of Delegates, this legislation responds to an evolving health care delivery landscape that often finds physicians providing care at facilities at which they are not an employee. Protections also apply to the peer review setting.

Wrongful Death, SB 5163

Increases physician, physician assistant, medical group practice, and other providers' exposure to liability by broadly expanding who can sue in cases of wrongful injury or death and what types of damages they can recover. This applies prospectively and retroactively and may result in increased medical malpractice premiums. To learn more, contact your Physician's Insurance representative.

Effective Oct. 1, 2019

Sexual Misconduct Disclosure, HB 1198

Requires physicians and other health care providers who have been sanctioned for sexual misconduct to provide written notice of the misconduct to any patient scheduled for an appointment. Once signed by the patient (or their surrogate decision-maker), the disclosure must be kept in the patient's file. The disclosure must include:

• A copy of the public order or stipulation.
• A description of all sanctions placed on the license.
• The duration of all sanctions.
• The disciplining authority's telephone number.
• An explanation of how the patient can find more information about the license holder on the DOH or disciplinary authority's website.

The notice may be provided to the patient by a designee, such as a medical assistant.

Effective Jan. 1, 2020

Balance Billing, HB 1065

Prohibits out-of-network physicians, providers, and facilities from balance billing for emergency or non-emergency surgical or ancillary services provided to an enrollee at an in-network hospital or ambulatory surgical facility. Applies to fully insured health plans, as well as self-insured health plans that opt to comply with the law. For care that is provided under those circumstances, insurers must pay a "commercially reasonable amount" within 30 days of receiving a claim, based on the insurer's payments for similar services provided in a similar geographic area. The payment must be sent directly to the provider rather than routed through a patient. Enrollees are responsible for the equivalent of their in-network cost-sharing for the services (as delineated by the insurer). If an out-of-network provider or facility wishes to dispute the insurer's payment, they may initiate a dispute resolution process. The process consists of a 30-day informal negotiation period between the two parties, followed by arbitration. Claims bundling for arbitration is allowed provided that the claims occurred within two-months; involved the same two parties (i.e. insurer and provider/facility); and involved the same or related CPT codes relevant to a particular procedure.

HB 1065 is a detailed and complex law and there are other important provisions, including requirements relating to network adequacy and transparency. If you have questions or are interested in a comprehensive summary of the law, contact Sean Graham at sean@wsma.org.

B&O Tax Increase, HB 2158

Imposes a 20 percent business and occupation surcharge on the income from service and other activities of select businesses to train Washington students for Washington jobs. The tax increase imposes disproportionate harm to the economic viability of doctors in private practice and independent medical clinics. Most notably:

• The Legislature enacted no notable rate increases for Medicaid reimbursement. As a result, this surcharge may put physician practices in the position of having to limit or close access to Medicaid patients.
• May exacerbate the trend toward consolidation of health care facilities and necessitate more sales of physician practices to hospital systems.
• Limits physician practices' ability to make investments in areas like staffing and technological improvements.

Non-Competition Clauses, HB 1450

Limits the circumstances under which non-compete clauses may be validly used. Non-compete clauses will only be enforceable if: an employee earns more than $100,000 a year; an independent contractor earns $250,000 a year from the employer proposing a non-compete; the employer discloses terms of the non-compete at or prior to making an employment offer; the employer compensates employees who are laid off but still subject to non-compete agreements; and the non-compete agreement covers a period no longer than 18 months. If you are imposing or subject to a non-compete agreement, review non-compete policies and contracts and be aware of applicable laws.

Public Option Health Plan (aka Cascade Care), SB 5526

Caps reimbursement for care provided under the new "public option" health plan at 160 percent of Medicare rates, based on an insurer's average aggregate contracting in the plan. For primary care services (as defined by the HCA) provided by a family physician, general internist or pediatrician, reimbursement must be at least 135 percent of Medicare rates. Creates a B&O tax exemption for "amounts received by a health care provider for services performed on patients covered by a Cascade Care plan, including reimbursement from the QHP and any amounts collected from the patient as part of his or her cost-sharing obligation."

The statutory limitations on reimbursement could impact your ability to participate in the public option plan. When entering 2020 negotiations, pay close attention to your contracting practices as these caps may impact the payment you receive from certain insurers and plans. Note that the bill prohibits insurers from requiring as a condition of participating in the public option plan that a provider or facility accept a reimbursement rate for other health plans offered by the insurer at the same rate as the public Cascade Care plan.

More information about how this change will affect your practice will be available in upcoming publications.

Reproductive Health Care, SB 5602

Prohibits discrimination based on an individual's gender identity or expression for reproductive health services purchased or contracted for by the Health Care Authority, including the use of automatic denials of coverage by managed care organizations. Effective Jan. 1, 2021, health plans and student health plans must provide coverage for certain reproductive treatments and services. Insurers must bill and collect payment with a single invoice that includes all covered benefits and services, and segregation plans must include a certification that the billing and payment processes meet the Office of the Insurance Commissioner's requirements.

Step Therapy, HB 1879

If all necessary information is provided for a step therapy exception request, insurance carriers must approve or deny your request within one business day; if this timeline isn't met, the exception is deemed granted. If an exception is denied, the clinical review criteria used to make the determination must be clearly provided in the denial notice. It's critical that practices notify the WSMA and/or the Office of the Insurance Commissioner when insurance carriers are not meeting these new requirements. For more details, contact billie@wsma.org.

Substance and Opioid Use Disorder, HB 5380

While containing important provisions to improve the treatment of pain and increasing access to medication-assisted treatment and naloxone, HB 5380 contains several notable provisions impacting medical practice:

1. No prior authorization: Requires insurance companies to cover, without prior authorization, at least one federal Food and Drug Administration-approved product for the treatment of opioid use disorder in the drug classes opioid agonists, opioid antagonists, and opioid partial agonists;
2. PMP and prescribing mandates: Requires groups with 10 or more "prescribers" to integrate their certified electronic health record with the state's prescription monitoring program by 2021 and requires prescriptions for controlled substances to be communicated electronically beginning Jan. 1, 2021.

The WSMA was able to obtain exemption processes for both mandates that consider economic hardship, technological limitations, or other exceptional circumstances. The WSMA will report to members when the Department of Health drafts rules outlining the exemption process.

Contact your EHR vendor and the state PMP to assess your connectivity. You should also ensure your practice managers are aware of these changes. For practice management support, contact the Washington State Medical Group Management Association.. More information will be forthcoming from WSMA publication once these policies go into effect.

Workplace Violence Prevention, HB 1931

Hospitals, ambulatory surgical centers, and other facilities such as home care agencies and psychiatric facilities must develop and implement a violence prevention plan every three years that outlines strategies focused on security considerations and risk of violence factors. A review of workplace violence incidents and issues must be conducted annually. Violence prevention training must be provided to employees, volunteers, and contracted security personnel by July 1, 2020. Records of violent acts must be kept for at least five years after the act reported.