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