Regulatory Issues

The WSMA Legal Resource Center, in collaboration with the WSMA Practice Resource Center, provides information for WSMA members about state laws and statutes affecting physicians’ practices which are under development, reassessment, or have been adopted. Rules under development or reassessment may call for input from WSMA members, which will be indicated when applicable.

Adopted rules

ACA anti-discriminatory rules
Medical assistants
Management of chronic non-cancer pain
Anesthesia/analgesia in office-based settings
Non-surgical medical cosmetic procedures
Lasers in skin care treatment
Death with Dignity law and rules
Physician assistants

Rules under development

Suicide care and prevention requirement for health professionals


Appropriate use of telemedicine

Suicide care and prevention requirement for health professionals

Engrossed Substitute House Bill 2315 passed into law during the 2014 legislative session, requires that medical professionals, including physicians and physician assistants, complete a one-time, six-hour training related to recognizing suicide risks in patients.

Consistent with our policy to oppose all mandated CME, the WSMA opposed ESHB 2315 during the 2014 legislative session. As we were not successful in our opposition to the bill, we will now focus on educating physicians on how to stay in compliance with the new requirement.

The Medical Quality Assurance Commission has yet to finalize the rules that will clarify the specific compliance requirements for physicians and PAs. The WSMA intends to work with the commission to allow fair exceptions for physicians who (as ESHB 2315 states) have "only brief or limited patient contact." Once the proposed rule is released, members of the public can also submit comments. The WSMA will alert members when the commenting period is announced. The commission expects to have the rules finalized and filed by June 2016.

The WSMA is providing the following preliminary Q&A to clarify what the law will require of physicians and physician assistants (updated April 14, 2016).

New federal anti-discrimination rules

In 2016, the US Department of Health and Human Services released changes to federal regulations under Section 1557 of the Affordable Care Act, aligning the anti-discrimination protections already established by existing federal civil rights laws, and clarifying how HHS will apply Section 1557 and other laws to protect patients from discrimination based on their race, color, national origin, sex, age, or disability. The new changes will apply to any health program or practice that receives any Federal funds.

While the augmented federal protections may impose drastically different requirements on practices in other, less progressive states, Washington physicians already operate under a tapestry of overlapping state and federal laws and rules specifically aimed at eliminating discrimination, including discrimination based on gender identity, which other states have not prohibited in their state-level regulations.

Practices and facilities with 15 or more employees will need to designate one employee as the practice’s compliance coordinator, and have procedures in place to investigate and resolve grievances alleging prohibited discrimination. Note that smaller practices (those with 14 employees or fewer) are not required to designate an employee as a compliance coordinator, nor are they required to establish policies and procedures to address 1557 grievances.

Additionally, practices should post materials alerting patients to their right to have accessibility aids, such as translators, and explaining to patients how they can request these services and accommodations. If your practice has a 1557 compliance coordinator, you will also need to make that person’s name contact information available. Additionally, if your practice has grievance procedures in place, you’ll need to post information on how to initiate a 1557 grievance procedure. Finally, you must also post information explaining how to file a discrimination complaint with the HHS Office of Civil Rights. These notices must be conspicuously displayed where patients can easily read them, including on your practices website. For more information on what you must post for patients, and how, visit the HHS website, where you can read a helpful FAQ document.

HHS has also released other resources, like training tools for your employees and sample translated notices you can display in your office, which are available through the HHS website.

For additional information, please contact Tierney Edwards, JD at

Physician assistants

The WSMA has prepared a document that summarizes the scope of practice of physician assistants and discusses how they contribute in the care team model. This is a valuable resource for PAs and those who may wish to use them in their practice setting. The Medical Quality Assurance Commission has developed new rules for PAs.

Medical assistants

Washington state now recognizes the profession of medical assistants as a result of legislation passed in the 2012 legislative session, and effective on July 1, 2013. SB 6237 established the MA credential and did away with the previous system of health care assistants in Washington. HB 1515, passed in the 2013 session, added refinements to the structure for the MA credential established the previous year. Until now, Washington law did not adequately address how assistive personnel are currently used in medical practices. In addition, the Centers for Medicare & Medicaid Services has directed some attention to reimbursement for procedures “incident to” physicians’ services provided by personnel who do not have a scope of practice defined in state law. Updating Washington law regarding assistive personnel and creating a defined scope of practice for MAs comports much better with federal guidelines and the manner in which practices utilize assistive personnel.

The WSMA has prepared a question and answer document which provides detailed information about MAs, and the laws and rules which pertain to them. For further information about the background of legislation and rules related to medical assistive personnel, please see this summary .

Brief summary: There are now two categories of general MA credential, that of MA-certified (MA-C), and that of MA-registered (MA-R). Individuals in either category assist health care practitioners with patient care, execute administrative and clinical procedures, and perform certain functions set forth in law. MA-Cs must meet certain training requirements and must pass an approved examination. MA-Rs must be endorsed by a health care practitioner, clinic, or group practice. There are also two specialized categories of credentials for MAs, MA-phlebotomist (MA-P) and MA-hemodialysis technician (MA-HT).

The Department of Health has published rules which went into effect on July 1, 2013, which establish minimum standards for MAs. The rules set forth the requirements for education and training of all categories of MAs and establish the requirements for endorsement for MA-Rs. MA-Cs may perform a broader set of tasks than MA-Rs. Prior to delegation of any of the tasks listed below to a MA-C or MA-R, the health care practitioner must determine the task is within his/her scope of practice, is indicated for the patient and the appropriate for the level of supervision, the MA is competent to perform the task, and that the task is safe, even if performed

The certification of a MA-C is portable—it follows the individual from practice to practice. The registration of a MA-R is tied to the practice which endorsed the individual. The rationale for these two categories is to provide flexibility for practices; they can hire a MA who meets the requirements for certification, or they can endorse an individual who does not meet that standard, but meets the minimum standards for endorsement set by the DOH. For more information see the Department of Health medical assistant webpage.

MQAC rules for management of chronic non-cancer pain

The Medical Quality Assurance Commission final rules for management of chronic non-cancer pain became effective Jan. 2, 2012.

The MQAC has published an interpretive statement regarding how it views the pain rules. 

Summary of the MQAC pain rules: The WSMA department of legal affairs has prepared a detailed question and answer summary of the new MQAC rules for the management of chronic non-cancer pain. This summary discusses questions such as:

  • Do the pain rules apply to me and my practice?
  • What is chronic non-cancer pain?
  • What does "MED" mean?
  • Do I have to take CME in order to treat patients with chronic non-cancer pain?
  • What must I do before treating a patient with chronic non-cancer pain?
  • And many more...

The summary does not substitute for reading the rules and familiarizing yourself with the requirements. But the summary presents the most important information in a way that is easy to read and allows physicians to quickly identify topics of interest. To accompany the summary, a copy of the pain rules is also available.

CME recommendations: The WSMA has designed this flow chart to assist you regarding recommendations for pain rules CME. The flow chart, in a few short steps, helps guide you to CME recommendations which may be most appropriate for your practice.

Background: The rules include a preamble, or intent section, which describes some of the background for the rules, and outlines MQAC's approach to evaluating practitioners' compliance with the rules. The rules themselves list very detailed requirements for patient evaluation, treatment plans, informed consent and written agreement for treatment, periodic review, and a mandatory consultation requirement for any patient that meets or exceeds a per day dosage amount of 120 milligrams morphine equivalent dose (MED). In addition, the rules identify certain exemptions from the consultation requirement, and outline the requirements of pain management specialists. 

Educational outreach: The MQAC is offering an educational program on the new pain rules, which includes a video the commission has produced which can be part of a free four CME offering available through L&I. The MQAC has created a patient information pamphlet and FAQs. Go to the MQAC pain management website for details on their educational outreach. 

The University of Washington has developed a "Pain Medicine Provider Toolkit" which brings together a number of useful, informative, and important resources regarding the treatment of chronic pain and the pain rules.

Other pain management guidelines

  • NEW: CDC Guidance for Prescribing Opioids
  • The AMA's complimentary pain management continuing medical education series
  • Washington State Agency Medical Directors Group's Interagency Guideline on Prescribing Opioids for Pain

    MQAC rules for anesthesia/analgesia in office-based settings

    The Medical Quality Assurance Commission has implemented rules regarding office-based surgery and sedation. Previously, the Department of Health only had in place clinical guidelines for these types of procedures. The MQAC rules became effective in 2009.

    Whether or not your office would have to comply with the proposed rules depends on the degree of sedation which would be administered. The rules do not apply to physicians who perform procedures that require only minimal sedation, or infiltration of local anesthetic around peripheral nerves. The rules define “minimal anesthesia” as “a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilator and cardiovascular functions are unaffected.” The rules would apply if any deeper level of sedation is administered, or if major conductive anesthesia is administered. Major conductive anesthesia includes intravenous regional blocks, lumbar or brachial plexus nerve blocks, as well as epidural and spinal anesthesia.

    If your office is considering use of more than minimal sedation, or the use of major conductive anesthesia, then the proposed rules will apply. The rules require, among other things, certification or accreditation of your facility by the Centers for Medicare and Medicaid Services, Accreditation Association for Ambulatory Health Care, American Association for Accreditation of Ambulatory Surgery Facilities, or the Joint Commission. The rules also require proof of clinical competence, establish guidelines for assessment and management of sedation, require emergency care and transfer protocols, and establish standards for medical records. More information on the rules contact Denny Maher, WSMA director of legal affairs at The rules may be found online.

    MQAC rules for non-surgical medical cosmetic procedures

    The Medical Quality Assurance Commission adopted rules on non-surgical medical cosmetic procedures on Jan. 14, 2010, and went into effect on June 6, 2010.

    There are two rules. The first rule (WAC 246-919-606) establishes the duties and responsibilities of a physician who delegates the injection of medication or substance for cosmetic purposes or the use of prescription devices for cosmetic purposes.

    The second rule (WAC 246-918-126) establishes the duties and responsibilities of a physician assistant who injects medication or substances for cosmetic purposes or uses prescription devices for cosmetic purposes.

    The rules do not apply to: (a) surgery; (b) the use of prescription lasers, non-coherent light, intense pulsed light, radio frequency, or plasma as applied to the skin, which are covered in WAC 246-919-605 and 246-918-125; (c) the practice of a profession by a licensed health care professional under methods or means within the scope of practice permitted by such license; (d) the use of non-prescription devices; and (e) intravenous therapy.

    The explanation for the rules as stated by the Commission is an increase in the number of complaints about individuals with little or no training, and without appropriate license or adequate supervision, who are injecting medications or substances into patients and using prescription devices on patients. The Commission has disciplined several licensees for this conduct.

    For more information on the rules contact Denny Maher, MD, JD, WSMA director of legal affairs at The rules may be found online. Download an explanatory statement for office-based surgical setting regulation (WAC 246-619-601).

    Lasers in skin care treatment

    Rules pertaining to the use of laser, light, radio frequency, and plasma device adopted by the Washington State Medical Quality Assurance Commission may be found online.

    Death with Dignity: Law and rules

    To download and review comprehensive Death with Dignity Act information from the Washington Physicians' Guide to Health Law click here .

    The Department of Health has developed a website for Death with Dignity Act information

    The site contains links to: