Performance Based Oversight (PBO) - Health Care Provider
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Health Care Provider 2011 Methodology
Download Overall 2011 Health Care Provider Methodology Paper (June 2010 - pdf)
Selection Criteria | Weighted Measures | Timeframe and Data Source | Tier Structure and Placement Methodology | Overall Performance Standard
Selection Criteria
DWC Form-073, Work Status Report category:
The 127 health care providers who billed and received reimbursement of more than $0, for 75 or more DWC Form-073s, Work Status Report, with dates of injury on or after August 1, 2009 and were included in the TDI-DWC medical bill and payment data between August 1, 2009 and November 30, 2009.
DWC Form-069, Report of Medical Evaluation category:
The 150 health care providers who filed 25 or more DWC Form-069s, Report of Medical Evaluation, with the TDI-DWC, where an examination occurred between August 1, 2009 and November 30, 2009. This list includes only those health care providers on the Approved Designated Doctor List.
Lumbar Spine Magnetic Resonance Imaging (MRI) category:
The 48 health care providers who saw 25 or more injured employees with a low back injury where the date of injury was between August 1, 2009 and October 31, 2009.
Weighted Measures
The selected health care providers will be assessed on the following measures for the 2011 PBO assessment:
DWC Form-073, Work Status Report, category
1. Completeness of the DWC Form-073, Work Status Report – 50% weight
2. Timely release to return to work1 – 50% weight
DWC Form-069, Report of Medical Evaluation category
1. Timely filing of the DWC-069, Report of Medical Evaluation – 100% weight
Lumbar Spine Magnetic Resonance Imaging
1. Timeliness of MRIs – 0% weight
Data Timeframe For 2011 Assessment & Data Sources
DWC Form-073 category
The DWC Form-073s to be reviewed are those with dates of injury on or after August 1, 2010 and where there has been reimbursement, of more than $0. The DWC Form-073s will be identified through the medical bill and payment data submitted by the insurance carriers to the TDI-DWC on or before November 30, 2010.
DWC Form-069 category
DWC Form-069s filed with the TDI-DWC where examinations occurred and the form was received between August 1, 2010 and November 30, 2010.
Lumbar Spine Magnetic Resonance Imaging category
The health care providers will be selected based on the name of the health care provider listed as having an office visit just prior to the date the MRI was rendered. The MRIs selected for review will be those for dates of injuries between August 1, 2010 and October 31, 2010. The MRIs will be identified through the medical bill and payment data submitted by insurance carriers to the TDI-DWC on or before February 28, 2011. The selected MRIs are on low back injury claims only.
For the insurance carriers, the data sources used to assess performance of the above measures comes from the claim and medical data submitted electronically via EDI to TDI-DWC.
Tier Structure and Placement Methodology
TDI-DWC will have three regulatory tiers that distinguish among poor, average, and high performers in the system. Those assessed are deemed to have an impact on the system due to their volume of filings or MRIs. TDI-DWC is not asserting that a high volume has a negative impact on the system. Those health care providers who are not assessed due to low volume are not absolved from regulatory duties or regulatory oversight when necessary.
In placing the selected health care providers into regulatory tiers, TDI-DWC will conduct several steps to place each health care provider into an overall tier for each category. The first step is to calculate the performance score (percentage) for each measure. Next, the performance score for each measure will be multiplied by the assigned weight value. This calculation of two percentages will then be multiplied by 100 to obtain a weighted value. The weighted value of each measure will then be added together to calculate the final score. The final score will identify the overall performance standard for the assessed entity. The overall performance standard is defined below.
The final scores will be placed into three regulatory tiers based on pre-determined performance standards that distinguish among poor, average, and high performers in the system.
Overall Performance Standard
The overall performance standard for insurance carriers is:
High Tier: 95 or greater
Average Tier: 80.00 through 94.99
Poor Tier: 79.99 or less
For more information contact:
Last updated: 12/18/2011
