1 / 11

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:

cedric-wilson
Télécharger la présentation

Top Tier Program Complex Claims

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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.

More Related