top tier program complex claims achiev january 22, 2015
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Top Tier ProgramComplex Claims
ACHIEvJanuary 22, 2015
Discussion Topic
Review Top Tier complex claim feedback and conduct an advisory vote.
Top Tier Model and Assumptions
COHEIniti
al V
isit
Prov
ider
Provider Network
Top Tier
COHEIniti
al V
isit
Prov
ider
Provider Network
Top Tier
Increase the availability of best practices Achieve positive outcomes Provide an alternative to COHEs Simple for providers to understand and L&I to administer Align with other incentive programs (such as COHE)
Top Tier Criteria
Focus on Attending Providers in non-emergent care Average of ≥ 12 claims annually In good standing Higher certification Committed to quality improvement Include patients with complex claims in practice Exceeding benchmarks in best practices: (examples: ROA, APF,
Provider/Employer contact) Committed care coordination Knowledge and expertise in core competencies:
– Collaboration & communication– Pain management– Workers’ Compensation knowledge
Demonstrated abilities in core competencies:– Collaboration & communication– Pain management– Workers’ Compensation knowledge
Complex Claims: Review of Previous Work Sessions
Our approach: 1. Identify possible roles in each category (prevent, manage, accept,
consult),2. Discuss and document pros and cons for each role,3. Review roles against the Top Tier model and assumptions, and 4. Gather your recommendation about which criteria/criterion to
use.
Provider Top Tier Application Time-Line
- Prevent complex claims - Manage complex claims
- Accept complex claims
- Consult on complex claims
- Prevent complex claims (for review)
- Manage complex claims (for review)
Provider Application
Complex Claims Recommendations
Current ACHIEv Feedback L&I Feedback
Preventing complex claims criteria difficult to control and
measure
Managing complex claims may work for the providers that
keep complex claims
Consulting on complex claims helpful in a limited way
Accepting complex claims is important and may dramatically
improve injured worker outcomes
Preventing complex claims criteria difficult to control and
measure
Managing complex claims may work for the providers that
keep complex claims
Consulting on complex claims helpful in a limited way
Accepting complex claims from L&I or other providers may not
be possible (ex: provider control of their panel)
ACHIEv Advisory Vote
Next Steps
Continuing staff work to operationalize definition of complex claims
Review complex claim criterion with L&I management
Finalize Top Tier criteria
July ACHIEv meeting: reviews Top Tier provider application criteria
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