Pilot Update: Is your clinic participating in L&I’s Orthopedic and Neurological Project (Ortho/Neuro)? If so, you qualify to become an early adopter of the Surgical Quality Care Program. Read on to learn more about this new program.
The Surgical Quality Care Program (SQC Program) is a pay-for-quality initiative. It rewards participating musculoskeletal surgeons for consistently implementing our administrative best practices. These best practices are designed to improve the outcomes of workers injured on the job.
What this means to the patient
Surgeon(s) is engaged in administrative best practices that address:
- Utilization of the department’s Medical Treatment Guidelines and Opioid Prescribing Guidelines
- A reduction or elimination of the risk of harm to the worker
- Avoidance of obstacles that inhibit the workers’ release to work
- Utilization of their Surgical Health Services Coordinator (SHSC) as a resource to answer questions and help navigate the workers’ care
What this means to the surgeon and their clinic
The SQC Program offers surgeons and their clinics both financial and non-financial rewards.
Financial rewards
- Monetary incentives proportional to best practice adoption (See the Provider Incentives tab to learn more).
Non-financial rewards
Participation in the SQC Program offers tools and resources that are not readily available. These may include:
- Performance reports to identify trends
- Access to an SHSC
- Special designation through L&I’s Find-A-Doctor application.
Benefits tied to the administrative best practices
How the SQC Program’s four administrative best practices (BP) are meaningful to the patient.
Best Practice (BP) | Significance | Expectation | Performance Threshold |
BP #1: Complete and submit an Activity Prescription Form (APF) before and after surgery. |
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BP #2: Perform surgeries within 21 days of authorization. |
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BP #3: Before surgery, establish release-to-work plans and goals with the patient. |
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BP #4: Review and integrate communications from ancillary provides into the rehab plan. |
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Strategic hint - many accomplishments in a single visit |
* Emergent surgery is defined as injury date followed by surgery within 11 calendar days.
Both the dollar amount and payment frequency of the financial incentives tied to the SQC Program will be announced shortly. Until notified otherwise, simply continue to bill L&I for the Ortho/Neuro project incentive (1071M) just as you have over the years.
Adoption levels
An adoption level will be assigned to each SQC Program participant as determined by how thoroughly the surgeon or their clinic has implemented the administrative best practices (BP).
- Low Adopter
- Assigned at the clinic level only.
- Reserved for clinics that fail to reach BP # 1 and BP # 2 performance thresholds.
- Medium Adopter
- Assigned at the clinic level only.
- Awarded to clinics that reach BP # 1 and BP # 2 performance thresholds.
- This is the highest level a clinic may reach.
- High Adopter
- Assigned at the surgeon level only.
- Awarded exclusively to those surgeons that reach all four BP performance thresholds.
- Cannot be achieved without the services of a Surgical Health Services Coordinator.
- High Adopter - Sustained
- Assigned at the surgeon level only.
- Other criteria under consideration.
The SQC Program is restricted to musculoskeletal surgeons that:
- Are participants in L&I’s Orthopedic and Neurological Surgeon Quality Project (Ortho/Neuro)
- Are credentialed as an L&I provider, with an active L&I provider ID number
- Regularly treat workers injured on the job, be it State Fund or Self-Insured
- Have completed the Surgical Quality Care Program's orientation
- Meet the program’s clinical entrance criteria for Medical Treatment Guidelines, Opioid Prescribing Guidelines utilization review, and reoperation rate criteria. (This program holds the surgeon accountable for their physician assistants’ (PA’s) prescribing practices.)
The Surgical Health Services Coordinators (SHSCs) help providers, workers, and employers in many ways.
Learn more about Health Services Coordination, qualifications, and standard work that is performed.
Benefits of having an SHSC
- Reduce transition times to and from surgical care.
- Assist workers, employers and health care providers navigate L&I processes.
- Identify and mitigate barriers to treatment, recovery and return to work.
- Improve release/return-to-work planning.
- Removes some of your administrative burden by responding to requests from claim managers, vocational counselors and employers.
SHSC options
A clinic’s relation to an SHSC may come as:
- The SHSC’s employer
- The SHSC’s client through a contract agreement
While SHSCs are not L&I employees, some community health care partners offer SHSCs. Reach out to us for more information.
SHSC billable services
SHSCs must first get an L&I Provider ID in order to bill services to state-fund claims.
Service Description | Code | Details | Rate |
Surgical Coordination Intake (SCI) | 1083M | Payable once in the life of the claim | $152.70 |
Surgical Health Services Coordinators’ Standard Services | 1088M | Billable in six-minute increments for activities that remove claim/treatment barriers or positively influence the recovery and/or release to work. | $9.40 |
Frequently Asked Questions
You will come in at the clinic level if it is currently participating in the program. If not affiliated to a currently enrolled clinic, you will be offered a one-year onboarding process to gain familiarity to the new best practices and working with an SHSC.