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Technical Advisory Group (TAG)

Technical Advisory Group (TAG). December 11, 2013 Dr. Daniel Lessler, Chief Medical Officer. ICD 10 Implementation. Paul Price paul.price@hca.wa.gov Project Manager. ICD10 Diagnostic Codes October 1, 2014. CMS Mandated Change All HIPAA covered entities

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Technical Advisory Group (TAG)

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

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

  3. ICD10 Diagnostic CodesOctober 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. 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. 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. Timeline Go Live! Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Prior Clinical Review / Mapping of 2012 Clinical Review & Support Medicaid Provider Guide Review and Update Vendor Analysis Vendor CR 1 – Design, Dev, Test, Impl Vendor CR 2 – Design, Dev, Test, Impl Vendor- UAT UAT - Contingency HCA In-House – P1 UAT Provider Testing HCA In-House – P1 Design, Dev, Test, Impl OMSD Program Review Provider Communications and Readiness Staff Recruiting RFP QA & IVV

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

  8. ICD-10 Conversion Technical Advisory Group update

  9. 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

  10. 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

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

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

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

  14. 2011 Workers Comp Reform Legislation: Substitute Senate Bill 5801 Background on Reform Goals: • Reduce disability by providing higher quality medical care • Promote occupational health best practices • Improve worker outcomes

  15. Substitute Senate Bill 5801:Key Provisions The new law directs L&I to: • 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

  16. Questionable Health/Disability Outcomes Average Medical and Disability Costs Poor Health and Disability Outcomes Average to High Medical and Disability Costs Excellent Health and Disability Outcomes Moderate or AverageMedical and DisabilityCosts CommunityPhysicians Very Poor Health/Disability Outcomes High Medical and Disability Costs Clinical Efficiency Poor Good Zone 1 Zone 2 Zone 3 Zone 4 (Quality & Value) Network Minimum Standards Risk of Harm Education and other interventions • 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 Distribution of Quality of Care • COHE High Adopters • COHE Model: Identify high performers to serve as mentors

  17. Purpose and Goals COHE Expansion

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

  19. Access to COHE Services COHE Provider Enrollment (as of December 23, 2013)

  20. Expanding Access to COHE Services

  21. Expanding Access to COHE Services

  22. Purpose and Goals New Best Practices

  23. Emerging Best Practices: Current Pilots http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#2

  24. Emerging Best Practices: Current Pilots http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#3

  25. 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: m Transition of Care m Return to Work Creation of a Surgical Health Services Coordinator to: m Coordinate care and transitions m Help providers with complicated cases http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#4

  26. Purpose and Goals Top Tier

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

  28. 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. COHE Expansion and New Best Practices Questions?

  30. Washington Apple HealthManaged Care – 2014 Contract March 12, 2014

  31. 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. 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. 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. 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. 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. 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. Centers for Medicare & MedicaidUpdates WA HCA TAG March 12, 2014 Nancy L. Fisher, MD, MPH CMO. Region X

  38. What’s Up Doc ! • Competitive Bidding Implementation • Open Payment Program (Sunshine Act) • ICD-10 • Meaningful Use • EHR, PQRS, Value Modifier (VM) • Physician Compare • Midnight Rule

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