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Performance Based Oversight (PBO) - Health Care Provider

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Health Care Provider Methodology

Downloads:
2019 Health Care Provider Methodology Paper (3/22/2018 - pdf)

HCP Selection | Data Source for Assessment |Calculations and WeightsTier Structure and Placement Methodology | Overall Performance Standard

Health Care Provider Selection

The health care providers selected for the 2019 PBO assessment are selected based on several criteria.

For both the completeness of the DWC Form-073, Work Status Report, AND how the injury prevents the injured employee from returning to work measures:

  • Health care providers that request reimbursement for 20 or more DWC Form-073s based on the medical billing data received by February 28, 2018;
  • DWC Form-073s with a date of service 30 or more days after the date of injury (June 1, 2017 or greater); and
  • The injured employee’s initiation of temporary income benefits, which occurred between July 1, 2017, and September 30, 2017.

For the timeliness of filing the DWC Form-069, Report of Medical Evaluation, measure:

  • Health care providers that filed 20 or more DWC Form-069s with TDI-DWC;
  • Examination date occurred between January 1, 2018, and April 30, 2018; and
  • Health care provider is on the Approved Designated Doctor List.

Data Sources for Assessment

The following describes where the data for the assessment will be obtained.

DWC Form-073, Work Status Report, measures

The DWC Form-073s will be identified through the medical bill and payment data submitted by insurance carriers to TDI-DWC between June 1, 2018, and February 28, 2019, with a date of service 30 or more days after the date of injury. The review will include DWC Form-073s with dates of injuries on or after June 1, 2018, where the injured employee’s initiation of temporary income benefits occurred between July 1, 2018, and September 30, 2018. Selected health care providers will be responsible for submitting the specific DWC Form-073s as requested through a data call.

DWC Form-069, Report of Medical Evaluation, measure

The DWC Form-069s will be identified from TDI-DWC database where the form is received on or before May 31, 2019. The review will include DWC Form-069s where examinations occurred between January 1, 2019, and April 30, 2019.

Calculations and Weighted Measures

Selected health care providers will be assessed on the following measures for the 2019 PBO assessment:

Completeness of the DWC Form-073, Work Status Report measures  - 100% weight

NumeratorTotal number of forms reviewed - Total number of forms with errors found
Denominator:  Total number of forms reviewed

Documentation of why an injured employee is prevented from returning to work  - 100% weight

NumeratorTotal number of forms reviewed - Total number of forms with insufficient documentation to justify an off work status
DenominatorTotal number of forms reviewed

Timeliness of filing the DWC Form-069, Report of Medical Evaluation measure  - 100% weight

NumeratorTotal number of forms reviewed - Total number of late forms
DenominatorTotal number of forms reviewed

Tier Structure and Placement Methodology

Three regulatory tiers are used to make a distinction between poor, average, and high performers in the workers’ compensation system. The health care providers assessed are considered to have an impact on the workers’ compensation system due to their volume of filings. TDI-DWC is not asserting that a high volume has a negative impact on the system. Health care providers who are not assessed due to low volume are not absolved from regulatory duties or regulatory oversight.

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 will then be multiplied by 100 to obtain a weighted value. The weighted value becomes the overall score for the measure. The overall score will identify the performance standard for the assessed entity.

Overall Performance Standard

The performance standard for health care providers are:

High Tier:        95 or greater
Average Tier:   80.00 through 94.99
Poor Tier:        79.99 or less

For more information, contact:

Last updated: 4/23/2018