74.09.280  <<  74.09.290 >>   74.09.295

Audits and investigations of providersPatient recordsPenalties.

The secretary or director shall have the authority to:
(1) Conduct audits and investigations of providers of medical and other services furnished pursuant to this chapter or other applicable law, except that the Washington state medical quality assurance commission shall generally serve in an advisory capacity to the secretary or director in the conduct of audits or investigations of physicians. Any overpayment discovered as a result of an audit of a provider under this authority shall be offset by any underpayments discovered in that same audit sample. In order to determine the provider's actual, usual, customary, or prevailing charges, the secretary or director may examine such random representative records as necessary to show accounts billed and accounts received except that in the conduct of such examinations, patient names, other than public assistance applicants or recipients, shall not be noted, copied, or otherwise made available to the department or authority. In order to verify costs incurred by the department or authority for treatment of public assistance applicants or recipients, the secretary or director may examine patient records or portions thereof in connection with services to such applicants or recipients rendered by a health care provider, notwithstanding the provisions of RCW 5.60.060, 18.53.200, 18.83.110, or any other statute which may make or purport to make such records privileged or confidential: PROVIDED, That no original patient records shall be removed from the premises of the health care provider, and that the disclosure of any records or information by the department or the authority is prohibited and shall be punishable as a class C felony according to chapter 9A.20 RCW, unless such disclosure is directly connected to the official purpose for which the records or information were obtained: PROVIDED FURTHER, That the disclosure of patient information as required under this section shall not subject any physician or other health services provider to any liability for breach of any confidential relationship between the provider and the patient, but no evidence resulting from such disclosure may be used in any civil, administrative, or criminal proceeding against the patient unless a waiver of the applicable evidentiary privilege is obtained: PROVIDED FURTHER, That the secretary or director shall destroy all copies of patient medical records in their possession upon completion of the audit, investigation or proceedings;
(2) Approve or deny applications to participate as a provider of services furnished pursuant to this chapter or other applicable law;
(3) Terminate or suspend eligibility to participate as a provider of services furnished pursuant to this chapter or other applicable law; and
(4) Adopt, promulgate, amend, and repeal administrative rules, in accordance with the administrative procedure act, chapter 34.05 RCW, to carry out the policies and purposes of this section and RCW 74.09.200 through 74.09.280.

NOTES:

FindingsIntentEffective date2018 c 201: See notes following RCW 41.05.018.
Effective dateFindingsIntentReportAgency transferReferences to head of health care authorityDraft legislation2011 1st sp.s. c 15: See notes following RCW 74.09.010.
SeverabilityHeadings and captions not lawEffective date1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.
Severability1983 1st ex.s. c 41: See note following RCW 26.09.060.
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