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Top Tier Program Complex Claims

Top Tier Program Complex Claims. ACHIEv October 23, 2014. Discussion Topic. What is the Top T ier P rovider’s role with complex claims? Roles mentioned during past ACHIEv discussions include: Prevent Manage Accept Consult. Complex Claim as Part of Top Tier Criteria. Our approach:

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Top Tier Program Complex Claims

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  1. Top Tier ProgramComplex Claims ACHIEv October 23, 2014

  2. Discussion Topic • What is the Top Tier Provider’s role with complex claims? • Roles mentioned during past ACHIEv discussions include: • Prevent • Manage • Accept • Consult

  3. Complex Claim as Part of Top Tier Criteria • Our approach: • Identify possible roles in each category (prevent, manage, accept, consult), • Discuss and document pros and cons for each role, • Review roles against the Top Tier model and assumptions, and • Gather your recommendation about which criteria/criterion to use.

  4. Top Tier Model and Assumptions Top Tier Initial Visit Provider Top Tier Initial Visit Provider COHE COHE Provider Network Provider Network • 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)

  5. Prevent Complex Claims • Require that no more than X% of claims initiated by a Top Tier Provider become complex. Target: ≤ 5% of initiated claims* become complex * L&I currently has the ability to measure using state fund claims only.

  6. Manage Complex Claims • Require Top Tier Providers to follow best practices while managing complex claims. • Review complex claims related to Top Tier core competencies and best practices.

  7. Accept Complex Claims (Example 1) • Require that a Top Tier Provider has accepted at least X complex claims over a specific timeframe. Target: X claims a year accepted over the last N years

  8. Accept Complex Claims (Example 2) • Require Top Tier Provider to accept complex claims if requested by L&I. Target: 100% of Top Tier Providers are available to accept L&I referrals

  9. Consult on Complex Claims • Require Top Tier Providers to offer consultations on complex claims. The consultation must result in a detailed treatment plan. Target: X consultations per year as a Top Tier Provider

  10. Example 5: Your Suggestions? • Other complex claim criteria?

  11. More Opportunities to Collaborate on Top Tier • Top Tier work groups beginning work. Would you like to participate?: • Assessing existing best practices for Top Tier • Assessing “demonstrated best practices” • Creating Top Tier provider reporting Contact Noha.Gindy@lni.wa.gov (360) 902-6564 to sign up.

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