Medical Provider Network: Provider Re-credentialing

1. Medical Provider Network: Provider Re-credentialing Karen Jost Health Services Analysis Program Manager October 23, 2014

2. Medical Provider Network (MPN) Status • Over 21,000 approved providers. • Access goal: ensure that the percent of injured workers within 15 miles of at least 5 attending provider types is within 5% of the January 2012 (pre-network baseline) for their county of residence. • Goal continues to be met: 99% statewide, and stable by county • Initial 3-year credentials up for re-credentialing January 2016

4. Average Health and DisabilityOutcomes Average Medical and Disability Costs Poor Health and Disability Outcomes Average to High Medical and Disability Costs Excellent Health and Disability Outcomes Low to ModerateMedical and DisabilityCosts CommunityPhysicians Very Poor Health andDisability Outcomes HighMedical and Disability Costs Clinical Efficiency Poor Good Zone 1 Zone 2 Zone 3 Zone 4 (Quality & Value) Distribution of Quality of Care IMPROVE COHE Participation, Education, Mentoring, Evidence-based best practice guidelines, Top Tier, Financial and Non-Financial Incentives, Care Coordination REMOVE Network Minimum Standards Risk of Harm Audit, Education and other interventions RECOGNIZE COHE High Adopters, Top Tier, Financial and Non-financial Incentives, Recognition, Mentors

5. Complementary processes • Risk of harm – opioid death reviews and re-operations • Department of Health (DOH) feed – licensure actions • Audit and fraud actions • One-year credentialing • Provider complaints • National Practitioner Data Bank (NPDB) updates

6. Requirements For Provider Monitoring or Reapproval • RCW 51.36.010(2)(d) • WAC 296-20-01030 Minimum health care provider network standards • WAC 296-20-01040 Health care provider network continuing requirements • Purpose: Ensure approved network providers remain in compliance with minimum standards and continuing requirements. • Secondary: Update demographics and credentials

7. Re-credentialing process considerations • Risk to injured workers • Meets purpose of MPN • Potential for Error • Impact on access • Provider ease • Yield – balance work vs. actionable findings • Technology / capacity • Staff impact / resource needs / Cost • Industry standard • Defensible process and standards • Coordination with related processes • Appropriate provider expectations / responsibility

8. Options for Re-credentialing • Standard process • Cyclical update of documentation (usually 3 years) • Requires provider submittal of forms (usually attestation, insurance, release of information) • Request staff input, review and verification • Continuous monitoring • Uses continuous updates from reporting sources • Provider submits information only when issue or concern identified • Staff review data feeds and respond to issues as they arise

9. Recommendation • Continuous monitoring • Over 99% of providers met network standards • Yield of re-review of approved providers is even lower • Data (changes) drive focused reviews and action taken, rather than cycle review of all • Lower provider and staff burden • Feedback from ACHIEV • Potential for error • Industry standard