Washington State Department of Social and Health Services Quality Program

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Washington StateDepartment of Social and Health
ServicesQuality Program

• Jeffery Thompson, MD, MPH
• Chief Medical Officer

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Case example

• HRSA terminated a pediatric physician whose
  license was summarily suspended for becoming
  sexually involved with patients family members
• This termination was disputed by the MD with the
  summary suspension lifted and a 10 year
  probation was imposed
• In order to resolve the dispute, HRSA required
  this MD to agree to an independent medical exam
  conducted by a psychiatrist.
• The final dispute decision was for this MD to
  remain terminated to protect the health and
  safety of Medicaid clients
• 2 years later, he submitted an application to
  again become a Medicaid provider. This was
  denied
• 17 months later after this denial, he submitted
  another application to become a Medicaid
  provider. Again, this was denied

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Medical Dental Advisory Committee Principles

• Protect the health and safety of clients
• Manage HRSA risk of Core Provider Agreement
• Improve outcomes of dispute conferences
• Reduce tort liability
• Disseminate critical information in a timely
  manner
• Manage impact on access

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Severity Levels

• Level 0 Not quality of care Already terminated
  in MMIS or Insufficient information.
• Level 1 Does not endanger client health or
  safety
• Level 2 Potential risk to client health or
  safety
• Level 3 Significant risk to client health or
  safety

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Quality Management Team Staffing

• This unit is made up of 5.95 FTEs.
• 2 FTEs registered nurse analysts managing the
  medical cases.
• 2 FTEs analysts managing dental cases, new CPA
  cases, and special projects.
• 0.95 FTE Unit shares an administrative
  assistant in which 0.95 of the FTE is QMT work.
• 1 FTE the senior dental administrator for the
  administration is also the supervisor of the QMT
  unit.

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264 open cases 46 at level 3, 183 at level 2,
31 at level 1, and 4 at level 0
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Case example

• Osteopathic Physician referred for prescribing
  excessive quantities of controlled substances
  without medical justification
• This prescribing pattern continued despite signs
  of patients prescription abuse and related
  patient deaths
• HRSA terminated this provider, the clinic and the
  physician assistant employed by this DO
• 11 months later, Washington Department of Health
  issued a summary suspension of this DOs license
• 21 months later, U.S. Department of Justice
  charged this DO and PA in a 24 count indictment
  for illegally prescribing drugs for other than
  legitimate medical purposes and for health care
  fraud

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Top 5 categories for open cases currently open
as of July 31, 2008

• Physicians
• Drug Mismanagement / Over prescribing
• Treatment Below the Standard
• Other (e.g. enrollment without HIPDB action or
  license action that falls in multiple categories)
• HIPDB Report Requesting Enrollment
• Medical Complication or Injury from treatment
• Dentists
• Treatment Below the Standard
• Client Issue Quality of Service
• Other (e.g. enrollment without HIPDB action or
  license action that falls in multiple categories)
• HIPDB Report Requesting Enrollment
• Infection Control
• Other (Denturists, Nurses, Midwives, Non CPA and
  Other)
• HIPDB Report Requesting Enrollment
• Drug Mismanagement / Over prescribing
• Other (e.g. enrollment without HIPDB action or
  license action that falls in multiple categories)
• Treatment Below the Standard

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Top 5 Case Categories 2006-2008
1 Not Contracting
1 Termination
10
Provider Terminations and Contracting Denials
July 2008
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Case example

• Denturist with 9 client complaints since 2004.
  Referred by audit in 2006 with client concerns
  about quality of dentures or services
• Department of Health took action in 2006 for
  quality of dentures. Was ordered to refund
  client, pay fine and take continuing education
• Audit findings were a 8,971.20 overpayment and
  fraudulent billing
• 3 months later the department terminated his
  contract with Medicaid
• 5 months later he was arrested on suspicion of
  1st degree theft and Medicaid fraud