About

With input from Washington surgeons, L&I developed the Orthopedic and Neurological Surgeon Quality Pilot (“the pilot”) as a pay-for-quality initiative to improve workers’ outcomes through more timely access to high quality surgical care.  Surgeons participating in the pilot receive incentive pay for demonstrating high quality and efficient patient care.

To determine the appropriate level of incentive pay for individual participants, every 6 months L&I’s pilot team assesses each surgeon’s aggregate performance on a set of 6 quality indicators.  Surgeons meeting or exceeding all performance thresholds are eligible for Tier 3 incentive pay (the highest level), while those who are unable to meet minimum thresholds risk losing incentive pay privileges.

To download a one page visual summary of enrollment, tier assignment, and incentive pay view the following flow chart in PDF.

Pilot Manual

For detailed information on the pilot, its background, and how it works, see the Orthopedic & Neurological Surgeon Quality Pilot: Participants Manual (version 7).

Pilot participants

Orthopedic, neurological, and hand surgeons were invited to join the pilot for participating in some or all of these cooperative quality improvement efforts:

• Development of this pilot; or
• Participation in the Centers for Occupational Health and Education (COHE); or
• Utilization Review Program Group A providers.

The pilot began on July 1, 2006, with 34 surgeons from 8 clinics across Washington participating.  As of October 2012, 269 surgeons from 43 clinics across the state are participating, and 75% of the surgeons are performing well enough to earn Tier 3 incentive pay.  Since the pilot began, participating surgeons have treated more than 101,542 workplace injuries insured by L&I.

List of providers enrolled in pilot (142 KB PDF).

Quality Indicators

Below are the best practices for the Ortho & Neuro Surgeon Quality pilot.

What is the reason, expectation, threshold, and method of measurement for the quality indicators listed below?

• Activity Prescription Form.

  Activity Prescription Form

  This form was developed for the Ortho & Neuro Surgeon Quality pilot and the COHE pilot and can be used by pilot providers without a request from a Claim Manager.

  • Activity Prescription Form (78 KB PDF).
   Get Help Downloading Files (files open in a new window).

   

  Reason

  Documentation is essential to prevent delayed recovery.

  • Clear rehabilitation planning,
  • Release for work and
  • Estimated abilities will enable:
    • Employers,
    • Claim managers and
    • Vocational counselors to better coordinate care and return to work planning.

  Providing information at initial and subsequent visits (when the worker's status changes) will reduce the need to complete at least 3 other forms (Time loss notification, Estimate of physical capacities and Supplemental medical report.)

  Expectation

  Bill for at least 1 Activity Prescription Form (APF) for each injured worker. If the injured worker has surgery, at least 1 additional form must be completed following surgery.

  Threshold

  APFs are completed and billed for 85% of the injured workers seen.

  Note: To accurately evaluate the APF, you must bill using procedure code 1069M each time the form is completed. Submit bills within 1 month of the date of service. This ensures that the data is available for analysis.

  Method of measurement

  L&I will analyze all claims seen during the 6 month time frame for the report* using our administrative data. L&I will round all findings to the nearest whole percent.

• Rehabilitation Plan.

  Rehabilitation Plan

  Reason

  Early development and ongoing review of physician-directed rehabilitation reduces disability, recurrent injury and the need for future health care use.

  Expectation

  Describe the rehab plan using the "Plans" section at the bottom of the APF. The following 2 fields must be addressed:

  • Worker progress, note whether the worker is:
    • Progressing better than expected,
    • Progressing as expected, or
    • Not progressing.
  • Current rehab, briefly describe the rehab activity (e.g. PT, OT, rest, home exercise, etc.)

  Threshold

  Note the worker's progress and describe the current rehab plan in the "Plans" section of 85% of the APFs reviewed.

  Note: To accurately evaluate the APF, you must bill using procedure code 1069M each time the form is completed. Submit bills within 1 month of the date of service. This ensures that the data is available for analysis.

  Method of measurement

  For each provider, L&I will review APFs submitted during the 6 month time frame for the report*. Depending on the number of forms submitted L&I will review either all forms or a random sampling.

• Dispense as Written (DAW).

  Dispense as Written (DAW)

  Reason

  Endorsing the WA state preferred drug list (PDL) reduces authorization requirements for providers. Minimizing dispense as written prescriptions enhances the use of cost-effective drugs within specific drug classes (therapeutic interchange program).

  Expectation

  As a pilot provider, you must endorse the WA state PDL and are expected to prescribe preferred drugs or allow appropriate substitution within the therapeutic interchange program (TIP).

  Threshold

  Less than 10% of the prescriptions written for PDL drug classes in the TIP are for non-preferred drugs.

  Method of measurement

  L&I will analyze all prescriptions subject to TIP written during the 6 month time frame for the report* using our administrative data. L&I will round all findings to the nearest hundredth.

• Timely access to service.

  Timely access to service

  Reason

  Reducing delays in accessing care can enhance recovery, return-to-work and minimize or prevent disability.

  Expectation

  Visit occurs within 7 business days of the referral.

  Threshold

  70% or more first visits occur within 7 business days. Visits by PA-C and ARNP will count as long as an APF is completed and billed by the ortho-neuro pilot surgeon.

  Method of measurement

  You must provide the following information to L&I on a semi-annual basis:

  • Claimant name,
  • Claim number,
  • Date office received first referral for an appointment,
  • Date visit occurred,
  • Appointment rescheduled by worker and or provider? Y/N
• Timely surgery.

  Timely surgery

  Reason

  Reducing delays in accessing care can enhance recovery and return-to-work as well as minimize or prevent disability.

  Expectation

  Surgery is performed within 3 weeks (21 calendar days) of claim manager authorization.

  Threshold

  Surgery is performed within 3 weeks on 80% of the injured workers who have surgery.

  Method of measurement

  L&I will analyze all injured workers who have had surgery during the 6 month time frame for the report*. They will use their utilization review administrative data. L&I will also round all findings to the nearest whole percent.

  Note: Additional surgery data may be submitted by the provider in cases where the provider performs less than 10 surgeries that go through utilization review (Qualis).

• Occupational health continuing education.

  Occupational health continuing education

  Reason

  Helps physicians understand and recognize the specific medical and management needs that are associated with treating worker's compensation injuries. This knowledge can enhance recovery and reduce long-term disability.

  Expectation

  Receive annual occupational health training every two years. Requirements are met with any of the following:

  • Participate in pilot provider orientation training (1.5 hours one time only for new providers); or
  • Complete at least 1 of the following CMEs in L&I publications:
    • Attending Doctor's Handbook (F252-004-000),
    • Attending Doctor's Return-to-Work Desk Reference (F200-002-000),
    • Medical Examiners' Handbook (F252-001-000); or
  • Participate in Centers of Occupational Health and Education-sponsored course(s); or
  • Participate in L&I sponsored course(s) which can be found by visiting the Courses and Seminars website;
    or
  • Provide verification of continuing education in occupational health topics including, but not limited to:
    • Disability prevention.
    • Assessment tools for occupational health (e.g. pain diagrams, depression inventories, estimating physical capacities).
    • Return-to-work planning.
    • Job modification.
    • Chronic pain management.
  • Provide specific help to L&I in further developing and refining this pilot.

  Threshold

  When at least 6 continuing education hours are met every two years.

  Method of measurement

  Provide verification of attendance to L&I as follows:

  • Pilot provider training: L&I will maintain records of attendance.
  • L&I CME publications: L&I will confirm participation using CME self-assessments submitted to L&I's Office of the Medical Director.
  • L&I sponsored courses: L&I will confirm participation.
  • Other occupational health training: Provider submits a Occupational Health CME verification form, that includes:
    • Copy of attendance certificate with numbers of hours attended and
    • Course objectives.

Billing

Ortho-Neuro Surgeons participating in this pilot bill using the following codes and limits for services provided:

1071M - Quality indicator incentive payment

Fee: Effective July 1, 2012

• Tier 3 - $104.20
• Tier 2 - $78.15
• Tier 1 - $52.10

Limits:

• Billed and payable to Ortho-Neuro Pilot Surgeon when the activity prescription form is also paid and billed to the same provider for the same date of service.
• Payable during global surgery period.

1069M - Completion of the Activity Prescription Form (APF)

Fee: Effective July 1, 2012

• $49.57

Billed and payable to Ortho-Neuro Pilot Surgeon when the activity prescription form is completed during an office visit and signed by the surgeon.

Bill promptly for pilot services

Billing promptly will ensure that we have received all the information we need to assign you to the appropriate payment tier.

Know the bill payment cutoff dates

Bills are processed every other Friday. See cutoff and payment dates.

Payments are mailed during the week of the payment date (beginning on Tuesday).

Resources

• 800-848-0811 - Provider Hotline, for all billing questions and to request L&I published forms and manuals.
• 800-831-5227 - To get claim or bill status information through an automated phone line.
• 360-902-6511 - Electronic Billing Unit, to get billing information on State Fund claims

Resources

Reduce Utilization Review Delays

Visit L&I’s Treatment Guidelines for information on how to reduce or avoid Utilization Review Delay’s.

Prescription Management

Why endorse the Washington State Preferred Drug List?

• Endorsement is required to participate in the Orthopedic and Neurological Surgeon Quality Pilot.
• Reduces your administrative burden. (See flow chart.)
• Authorization is not required to prescribe a non-preferred drug.

Why prescribe preferred drugs from the Outpatient Drug Formulary?

• Reduce your administrative burden.
• Do not require preauthorization.
• Patients can get their prescriptions faster.

Who do you call to obtain approval for non-preferred drugs?

• Preferred Drug List hotline at 1-888-443-6798 or 360-902-4321.

What are the preferred drugs in the therapeutic interchange program?

• You can go to our Preferred Drug List site.

For more information please visit Drugs and Prescriptions webpage.
Outpatient formulary (163 KB PDF).

Reduce Claim Delay

To reduce your claim delays, follow the suggestions below:

• Put the claim number in the top right corner of all documents.
• Do not use address stamps that are too large for the form.
• Send legible documentation.
• Fully complete the forms.
• Send reports and chart notes separately from bills.

Fax your documents to L&I, because faxed information goes directly to the claim file. You can fax your documents to: 360-902-4567

Self-Insured Employers Participating

L&I developed this pilot to help injured workers rehabilitate promptly by improving access to high quality surgical care. Because self-insured employers are responsible for the workers compensation benefits of one-third of Washington’s workforce, it’s important to have self-insurance participation. Participation in the pilot is voluntary. The pilot requirements and fee schedule are not in effect for self-insured injured workers unless the employer has registered to participate.

What are the benefits of participating?

• Improved access to orthopedic and neurological surgeons for your employees.
• More consistent information to manage claims (Activity Prescription Form).
• Improved coordination of care.
• Increased availability of work activity (restriction) information.

What are the costs?

• L&I estimates an additional $300, on average, of payment per injured worker receiving care from a pilot surgeon (including payment for APF and incentive pay).
  • NOTE: This additional cost may be offset by a decrease in time loss payments. The University of Washington will evaluate the pilot to find out the effects of the pilot.
• Participating providers may bill and be paid a quality indicator incentive payment each time they complete and bill for an APF:
• Amount of incentive pay depends on the provider’s tier assignment.
• Tier assignments are based on provider meeting thresholds for specific indicators of quality care.
• There is no fee to register as a participant.

Which self-insured employers are currently participating in the pilot?

City of Vancouver , WA Clark County Clark Public Utilities ESD 112 Fleetwood Homes of Oregon Georgia Pacific Corp. DOI on or after 12-19-05 is State Fund or DOI prior to 12-19-05 is self-insured Great Western Malting Company JH Kelly, LLC Legacy Health System	PeaceHealth RSG Forest Products, INC SDS Lumber Southwest Washington Medical Center UPS Vancouver Public Schools Waste Connections, Inc. Weyerhaeuser WinCo Holdings, Inc.
last updated 01/01/2013

 

If you would like to contact one of the self-insured employers please visit: http://Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

How do I participate as a Self-Insured Employer for the pilot or obtain more information?

• Contact the Ortho/Neuro Pilot Team at: ONSQualityPilot@Lni.wa.gov or 360-902-6060.

Collaborative engagement with providers increasing

One of L&I’s aims with this quality initiative is to engage in a more collaborative working relationship with orthopedic and neurological surgeons that have participated with L&I in other cooperative quality improvement efforts. An Interim Evaluation Report and Survey Report published independently in 2010 by the University of Washington (UW), as well as administrative data gathered by L&I’s pilot team, show that:

• Engagement among qualified surgeons has increased during the pilot period.
  When the pilot began in July 2006, 34 surgeons from 8 clinics in the state of Washington enrolled. In the following years, enrollment increased gradually and, as of October 2012, 268 surgeons, from 42 clinics across Washington and 1 clinic in Oregon, are participating in the pilot. The UW Survey Report finds that most clinics in the pilot continued to treat the same number of workers’ compensation patients as before the pilot, and some clinics increased the number.
• L&I attracted surgeons to the pilot who had lower costs and disability rates to begin with.
  Data from the UW Interim Evaluation Report shows that before the pilot began, when compared to other orthopedic and neurological surgeons treating similar injuries, pilot participants had a per claim average of $704 less in medical costs and 12 fewer days of timeloss.
• Pilot participants want to continue working with L&I.
  In addition to maintaining or increasing the number of workers’ compensation patients they treat, the UW Survey Report reveals that 83% of providers said that improving their relationship with L&I was an important reason for continuing to participate in the pilot.

Success in implementing the quality indicators

Before we can find out if the pilot actually improves injured worker outcomes, it is critical that participating providers successfully implement the quality indicators in their day-to-day clinic practices.  A good indication of successful implementation is that a surgeon has demonstrated 80-100% of the quality indicators on a consistent basis.

• Most pilot surgeons are high performers.
  When the pilot began, L&I Management set a benchmark goal of at least 75% of participating surgeons implementing the quality indicators. During the first few years of the pilot, many providers struggled to do so. L&I’s pilot team worked closely with those providers to clarify expectations, and as of October 2012, 94% of participating surgeons have implemented the quality indicators successfully.
• Most providers understand what they need to do to implement the quality indicators.
  The UW researchers reveal in the Survey Report that a clear majority of participating surgeons and their office staff reported that they consider the quality indicator and incentive tier system requirements of the pilot are clear, reasonable, and important for injured worker outcomes.
• Room for improvement.
  Though almost all of the pilot surgeons have implemented the quality indicators, a few are still struggling to do so. The UW Survey Report reveals that L&I’s pilot team still has some work to do in terms of clarifying expectations about the quality indicators:
  • "...comments, especially the complaints about the time to surgery requirements, indicate that many of the respondents don’t know about available exceptions to the requirements."
  • "There were a number of comments about the APFs [Activity Prescription Forms] and confusion about when APFs are expected to be used, indicating more opportunities for training."

L&I’s pilot team continues to work closely with participating providers to make sure that expectations are as clear as possible.

Future goals

In the current phase of the pilot, we are focusing on:

• Expanding the scope of the pilot by incorporating these four additional best practices:
  • Timely transition to surgical care at primary care provider’s request.
  • Pre-operatively documented return to work plans and goals.
  • Intervention of an integrated post-operative team when return to work goals aren’t met.
  • Timely transfer to next step in appropriate care at surgeon’s request.
• Creating a new position of a Surgical Health Services Coordinator to help surgeons effectively use the four new best practices.
• Working with providers to find more ways to reduce administrative burden.
• Measuring and reporting on indicators of L&I’s quality and efficiency as a health insurer.
• Continuing with a formal objective evaluation to answer (among other things):
  • What impact do the quality indicators have on clinical outcomes and timeloss?
  • What are the appropriate thresholds for incentives?
  • How much do generic drugs affect cost savings?
• Communicating our best-practice findings to a broader health care community.