Top Tier Program Complex Claims ACHIEv January 22, 2015

Discussion Topic  Review Top Tier complex claim feedback and conduct an advisory vote.

Top Tier Model and Assumptions COHE Initial Visit Provider Provider Network Top Tier COHE Initial Visit Provider 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