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Performance Based Oversight (PBO) - Health Care Provider

 

Health Care Provider Methodology

Downloads:
2017 Health Care Provider Methodology Paper (2/24/2016 - pdf)
Management Response Workbook - 2017 DWC Form-073 Measures (8/14/2017 - xls)
Management Response Workbook - 2017 DWC Form-069 Measure (8/21/17 - xls)


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 2017 PBO assessment are selected based on several criteria.

For the completeness of the DWC Form-073, Work Status Report, AND documentation supporting why the injured employee is prevented 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 29, 2016;
  • DWC Form-073s with a date of service 30 or more days after the date of injury (June 1, 2015 or greater); and
  • The injured employee’s initiation of temporary income benefits, which occurred between July 1, 2015, and September 30, 2015.


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 August 1, 2015, and November 30, 2015; 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, 2016, and February 28, 2017, 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, 2016, where the injured employee’s initiation of temporary income benefits occurred between July 1, 2016, and September 30, 2016. 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, 2017. The review will include DWC Form-069s where examinations occurred between January 1, 2017, and April 30, 2017.

 

Calculations and Weighted Measures

Selected health care providers will be assessed on the following measures for the 2017 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

There are three regulatory tiers that distinguish among poor, average, and high performers in the workers’ compensation system. Those assessed are deemed 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. 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 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. 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 workers’ compensation system.

 

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: 08/21/2017

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