Section 284-43A-120 - Grounds for action against an applicant or a certified IRO(1) The commissioner may deny an application for certification, or suspend, revoke, or modify certification if the applicant, certified IRO, its agents, officers, directors, or any person with any interest: (a) Makes a misrepresentation of, false statement of, or fails to disclose, a material fact to the commissioner. This applies to any data attached to any record requested or required by the commissioner or matter under investigation or in a self-assessment;(b) Obtains or attempts to obtain certification by fraudulent means or misrepresentation;(c) Fails or refuses to comply with the requirements of RCW 48.43.537, 48.43.535(5), or this chapter;(d) Conducts business or advertising in a misleading or fraudulent manner;(e) Refuses to allow the commissioner access to records, or fails to promptly produce for inspection any book, record, document, or item requested by the commissioner, or willfully interferes with an investigation;(f) Accepts referral of cases from the commissioner under RCW 48.43.535 without certification, or with certification which has been terminated, or is subject to sanction;(g) Was the holder of a license, certification, or contract issued by the commissioner or by any competent authority in any state, federal, or foreign jurisdiction that was terminated for cause and never reissued, or sanctioned for cause and the terms of the sanction have not been fulfilled;(h) Had accreditation from a recognized national or state IRO accrediting body that was terminated for cause and never reissued, or sanctioned for cause and the terms of the sanction have not been fulfilled;(i) Willfully prevents, interferes with, or attempts to impede in any way the work of any representative of the commissioner and the lawful enforcement of any provision of this chapter. This includes, but is not limited to: Willful misrepresentation of facts during an investigation, or administrative proceeding, or any other legal action; or use of threats or harassment against any patient, client, customer, or witness; or use of financial inducements to any patient, client, customer, or witness to prevent or attempt to prevent him or her from providing evidence during an investigation, in an administrative proceeding, or any other legal action involving the commissioner;(j) Willfully prevents or interferes with any commissioner representative in the preservation of evidence;(k) Misrepresented or was fraudulent in any aspect of the conduct of business;(l) Within the last five years, has been found in a civil or criminal proceeding to have committed any act that reasonably relates to the person's fitness to establish, maintain, or administer an IRO;(m) Violates any state or federal statute, or administrative rule regulating the IRO;(n) Fails to comply with an order issued by the insurance commissioner or designee;(o) Uses interference, coercion, discrimination, reprisal, or retaliation against a patient, client, or customer exercising his or her rights;(p) Offers, gives, or promises anything of value or benefit to any federal, state, or local employee or official for the purpose of influencing that employee or official to circumvent federal, state, or local laws, regulations, or ordinances governing the certification holder or applicant.(2) A person including, but not limited to, enrollees, carriers, and providers, may submit a written complaint to the commissioner alleging that a certified IRO committed conduct described in this section.(3) An applicant or certified IRO may contest a commissioner decision or action according to the provisions of RCW 43.70.115, 48.43.535, chapter 34.05 RCW, and this chapter.Wash. Admin. Code § 284-43A-120
Adopted by WSR 16-23-168, Filed 11/23/2016, effective 1/1/2017