1. Technical Advisory Group (TAG) December 11, 2013 Dr. Daniel Lessler, Chief Medical Officer

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3. ICD 10 Implementation Paul Price paul.price@hca.wa.gov Project Manager

4. ICD10 Diagnostic Codes October 1, 2014 CMS Mandated Change All HIPAA covered entities 9/30/14 - last date-of-service for ICD9 codes 10/1/14 - first date-of-service for ICD10 codes Deadline was delayed 1 year CMS says no more delays HCA WA Medicaid planning on 10/1/2014 4

5. Overview Diagnosis/PCS Codes – Analysis/Remediation – In-House Review and Remediation – CNSI Review and Remediation Medicaid Provider Guides – Update Providers/Plans – Outreach and Testing – Listserv messages – Website content – Testing instructions 5

6. Partners & Stakeholders CMS Noblis - Guidance and Support OneHealthPort – Plans/Providers Discussions Health Plans – Encounter Processing Hospitals & Providers– End to End Testing Medicare – Cross Over Claims 6

7. Timeline 7 Clinical Review / Mapping of 2012 Vendor CR 2 – Design, Dev, Test, Impl Provider Communications and Readiness Provider Testing Medicaid Provider Guide Review and Update Nov Go Live! Vendor Analysis Vendor CR 1 – Design, Dev, Test, Impl DecJanFebMarAprMayJunJulAugSepOct Prior OMSD Program Review RFP QA & IVV Staff Recruiting Vendor- UAT HCA In-House – P1 Design, Dev, Test, Impl HCA In-House – P1 UAT UAT - Contingency Clinical Review & Support

8. Questions? Paul Price, Project Manager ETS ICD10 Project paul.price@hca.wa.gov Tel: 360-280-1842 8

9. ICD-10 Conversion Technical Advisory Group update

10. L&I will convert from ICD-9 to ICD-10 effective October 1, 2014  Although worker’s compensation is technically exempt, L&I is converting to ICD-10 to align with industry standards. Doing so will: –Minimize the administrative burden to medical providers by not requiring them to maintain a separate billing system using ICD-9 codes –Result in the allowance of more accurate diagnoses on claims –Result in more precise data collection by L&I

11. Key Dates  September 1, 2013 –ICD-10 end to end testing with trading partners begins  March 17, 2014 –L&I begins testing internal ICD-9 to ICD-10 conversion process  April 1, 2014 –All State Fund bills must be submitted in the 5010 format.  July 1, 2014 –Department makes the new CMS 1500 form available  August 1, 2014 –Department begins conversion of ICD-9 codes to ICD-10 codes  October 1, 2014 –Compliance date for ICD-10 CM –New CMS 1500 form becomes manditory

12. Resources at Labor & Industries  Additional information can be found at –www.lni.wa.govwww.lni.wa.gov –www.onehealthport.comwww.onehealthport.com  If you have specific questions, please contact –Emily Stinson 360-902-5974 them235@Lni.wa.govthem235@Lni.wa.gov –Shalene Petrich 360-902-5651 pesh235@Lni.wa.govpesh235@Lni.wa.gov

13. COHE Expansion and New Best Practices: L&I Updates Diana Drylie, Occupational Health Services Manager

14. 14 Highlight of L&I Quality Efforts 2013 and Beyond  COHE Expansion  New Best Practices  Top Tier

15. 15 2011 Workers Comp Reform Legislation: Substitute Senate Bill 5801  Reduce disability by providing higher quality medical care  Promote occupational health best practices  Improve worker outcomes Background on Reform Goals :

16. 16 Substitute Senate Bill 5801: Key Provisions  Designate a “top tier” and provide incentives for network providers who demonstrate best practices  Expand Centers of Occupational Health & Education (COHEs)  Create a tracking system for occupational-health best practices in COHE and Top Tier  Identify and pilot emerging best practices The new law directs L&I to:

17. Distribution of Quality of Care Clinical Efficiency Poor Good Community Physicians Zone 1Zone 2Zone 3Zone 4 Excellent Health and Disability Outcomes Moderate or Average Medical and Disability Costs Questionable Health/ Disability Outcomes Average Medical and Disability Costs Poor Health and Disability Outcomes Average to High Medical and Disability Costs Very Poor Health/ Disability Outcomes High Medical and Disability Costs (Quality & Value) COHE High Adopters COHE Model: Identify high performers to serve as mentors COHE High Adopters COHE Model: Identify high performers to serve as mentors COHE MODEL plus Incentives for quality indicators known to improve outcomes Resources to help docs apply them (CME, HSCs, reminders) Geared toward improving well-intentioned Zone 2 & 3 COHE MODEL plus Incentives for quality indicators known to improve outcomes Resources to help docs apply them (CME, HSCs, reminders) Geared toward improving well-intentioned Zone 2 & 3 Network Minimum Standards Risk of Harm Education and other interventions Network Minimum Standards Risk of Harm Education and other interventions 17

18. 18 Purpose and Goals COHE Expansion 18

19. 19 Expanding Access to COHE Services The 6 current COHEs will serve 38 counties :

20. 20 Access to COHE Services Current # of Enrolled Providers Proposed # of Enrolled Providers COHE Name 1,2191,451Eastern Washington COHE at SLRI/INHS 222230The Everett Clinic COHE 3670Group Health Cooperative COHE 184233Harborview Medical Center COHE 269300Renton COHE at Valley Medical Center 1951,208Western Washington COHE at Franciscan 2,1253,492TOTAL COHE Provider Enrollment (as of December 23, 2013)

21. 21 Expanding Access to COHE Services

22. 22 Expanding Access to COHE Services

23. 23 Purpose and Goals New Best Practices 23

24. 24 Emerging Best Practices: Current Pilots Activity Coaching A provider in E. Washington said:  “This patient had 22 ‘red flags’ when I referred him to PGAP. At the next visit he was a completely different person.” Workers have said:  “It gives you a reason to get out of bed and how to be in control of your life again.”  “It teaches you how to relearn to manage your pain and life.” http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#2

25. 25 Emerging Best Practices: Current Pilots Functional Recovery  Functional Recovery Questionnaire (FRQ)  Early identification of potentially “at risk” workers  Functional Recovery Interventions (FRI)  Providers incorporate interventions to enhance recovery in addition to 4 the COHE Best Practices http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#3

26. 26 Emerging Best Practices: Upcoming Pilot Emerging Surgical Best Practices Four best practices selected from the literature by a focus group of attending providers & surgeons related to:  Transition of Care  Return to Work Creation of a Surgical Health Services Coordinator to:  Coordinate care and transitions  Help providers with complicated cases http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#4

27. 27 Purpose and Goals Top Tier 27

28. 28 Top Tier Visual COHE Initial Visit Provider Provider Network Top Tier

29. 29 TOP TIER  Give incentives to providers for demonstrated use of best practices  Top Tier Goals –Increase the use of best practices – Achieve positive outcomes for injured workers –Be simple for providers to understand and L&I to administer – Align with other incentive programs (such as COHE)  Advisory Group (ACHIEVE) Items for Dissions –Top Tier Timing –Top Tier Eligibility –Top Tier Incentives –Top Tier Administration 29

30. 30 COHE Expansion and New Best Practices

31. Washington Apple Health Managed Care – 2014 Contract March 12, 2014

32. Enrollee Assignment January 1 – June 30, 2014 – Assignment based on percentage of enrollment (25% or greater only receive assignment when there are not MCOs with less than 25% in service area; – Network adequacy also a factor in assignment MCO must have 80% coverage or higher for enrollment and assignment 60% and above for enrollment only <60% no enrollment or assignment 32

33. Assignment changes for July 1, 2014 July 1, 2014 begins assignment based on HCA’s analysis of MCO’s self-reported performance measure on completion of initial health screens MCOs will report screening performance for Jan/Feb on April 10 for July assignment; Mar/April on June 10 for August assignment, etc 33

34. ABP and other Benefit Changes Habilitative services added to benefits for Medicaid Expansion enrollees Shingles vaccine added for enrollees age 60 and over Family planning drugs, supplies, devices dispensed in 12 month supplies Mental health benefit modified to reflect mental health parity requirement 34

35. Mental Health Parity Previous mental health benefit: Evaluation plus 12 visits/year for adults; 20/year for children New benefit: MCOs authorize MH visits in same manner as other therapies; visits are limited by medical necessity Coordination required between MCOs/ RSNs; 35

36. Mental Health Parity/2 2014 contract requires close coordination and transition activities between systems – MCO assesses enrollee requesting MH services to determine potential for meeting Access to Care Standards (ACS) and authorizes Medically Necessary Services – If enrollee appears to meet ACS, transition to RSN is made so enrollee maintains greatest degree of continuity of care with providers 36

37. Payment and Sanctions Update and clarify risk adjustments including Risk Mitigation Strategy for Expansion Population Addition of a Low Birth Weight Baby Case Payment – one time payment made for LBW babies based on specific AP-DRG codes. Maximum 470 payments/year Update and clarify Encounter Data submission requirements 37

38. WA HCA TAG March 12, 2014 Nancy L. Fisher, MD, MPH CMO. Region X

39.  Competitive Bidding Implementation  Open Payment Program (Sunshine Act)  ICD-10  Meaningful Use  EHR, PQRS, Value Modifier (VM)  Physician Compare  Midnight Rule