Performance Based Oversight (PBO) - Health Care Provider

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Health Care Provider Methodology

Downloads:
2021 Health Care Provider Methodology Paper (5/26/2020 - pdf)

Weighted Measures | Time Frames and Data Sources | Selection Criteria | Tier Structure and Placement Methodology | Overall Performance Standard

Weighted Measures

The health care providers selected will be assessed on the following measures:

DWC Form-073, Work Status Report Category

Documentation supporting how the injured employee’s medical condition prevents them from returning to (any) work as reported on the DWC Form-073, Work Status Report measure - 70% weight.
Completeness of the DWC Form-073, Work Status Report measures - 30% weight.

DWC Form-069, Report of Medical Evaluation Category

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

Time Frames and Data Sources Used for 2021 Assessment

The data used to assess performance of health care providers for the 2021 PBO assessment is based on the following parameters:

DWC Form-073, Work Status Report Category

DWC Form-073 services identified through the medical bill and payment data submitted by insurance carriers to DWC, between June 1, 2020, and February 28, 2021, with a date of service 30 or more days after the date of injury. The review will include DWC Form-073s with dates of injury on or after June 1, 2020, where the injured employee’s initiation of temporary income benefits occurred between June 1, 2020, and September 30, 2020.

Selected health care providers will be responsible for submitting the specific DWC Form-073s as requested through a data call.

Timeliness of filing the DWC Form-069, Report of Medical Evaluation Category

The designated doctor DWC Form-069s will be identified from the DWC database where the form is received on or before May 31, 2021. The review will include DWC Form-069s where examinations occurred between January 1, 2021, and April 30, 2021.

Selection Criteria

The following describes how the health care providers are selected for the 2021 PBO assessment:

DWC Form-073, Work Status Report Category

The health care providers selected for assessment on these measures are based on their volume of DWC Form-073, Work Status Reports identified in the data time frame. The minimum volume of forms will be determined based on the overall volume of the assessment data and DWC resources, but will not be less than 20 forms.

DWC Form-069, Report of Medical Evaluation Category

The health care providers selected for assessment on this measure is based on their volume of DWC Form-069, Report of Medical Evaluations identified in the assessment data timeframe. The minimum volume of forms will be determined based on the overall volume of the assessment data and DWC resources, but will not be less than 20 forms.

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. 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.

DWC will conduct several steps to place each health care provider into an overall regulatory 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 (the value is rounded up). This calculation of two percentages will then be multiplied by 100 to obtain a weighted value (the value is rounded up). For measures where the weight is 100%, the weighted value becomes the overall score for the measure. For multiple measures, the weight value of each measure will be added together to calculate the overall score (no rounding). The overall score identifies 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