The Surgical Quality Care Program (SQC Program) is a quality improvement initiative. It rewards participating musculoskeletal surgeons for consistently implementing our occupational health 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) that are engaged in administrative best practices address:
- Utilization of the department’s Medical Treatment Guidelines and Opioid Prescribing Guidelines
- Remove 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
Benefits tied to the occupational health best practices
How the SQC Program’s six occupational health best practices (BPs) are meaningful to the patient.
Best Practice (BP) | Significance | Expectation | Performance Threshold |
Best Practice 1: Appropriate Opioid Prescribing (mandatory for any incentive) |
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Best Practice 2: Utilization Review (mandatory for medium adoption level incentive and above). |
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Best Practice 3: Complete and submit an Activity Prescription Form (APF) before and after surgery. |
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Best Practice 4: Perform surgeries within 21 days of authorization. |
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Best Practice 5: Before surgery, establish release-to-work plans and goals with the patient. |
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Best Practice 6: Review and integrate communications from ancillary providers into the rehab plan. |
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Important things to know:
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* Emergent surgery is defined as injury date followed by surgery within 11 calendar days.
SQCP participating surgeons should use the following codes once the informational reporting is complete and their updated adoption levels are determined:
Billing Code: 1086M
Service: Best Practice Incentive - Surgical
Description: Billed and payable at initial visit/consultation with worker.
Maximum Fee: Payable once in the life of the claim per surgeon for the first two surgeons. Payment level based on assigned adoption level for each individual surgeon. Fees effective August 1, 2023. The first two providers will be assessed through dates of service on billing, so the first bills to be received will be those which are included in this calculation. Refer to MARFS (August 2023 update) for more information.
- Sustaining Adopter: $525
- High Adopter: $305
- Medium Adopter: $230
- Low Adopter: $155
- No Adoption: $0
Comments:
- Not payable to ARNPs or PA-Cs.
- Still payable during the Global Surgical Period.
- Not tied to the Activity Prescription Form (APF).
- Payment based on adoption level from the last scheduled reporting.
Adoption levels
An adoption level will be assigned to each SQC Program participant as determined by how thoroughly the surgeon has implemented the occupational health best practices over the six-month review period.
- No Adoption:
- Fails to meet best practice 1 (appropriate opioid prescribing), AND
- Does not meet Low Adopter requirements.
- Low Adopter:
- Must meet best practice 1 (appropriate opioid prescribing), AND
- One other best practice (best practice 2 - 6).
- Medium Adopter:
- Must meet best practice 1 (appropriate opioid prescribing) and best practice 2 (80% utilization review), AND
- Two other best practices (best practice 3 -6).
- High Adopter:
- Awarded exclusively to surgeons that achieve a Utilization Review of 100%, AND
- Meet or exceed the threshold for all the remaining best practices (best practice 1, 3, 4, 5, and 6).
- Cannot be achieved without the services of a Surgical Health Services Coordinator (SHSC).
- Sustaining Adopter:
- Meets High Adopter requirements for three consecutive reporting periods (18 months).
The SQC Program is restricted to musculoskeletal surgeons who:
- Regularly perform surgeries as Hand, Orthopedic, or Neuro surgeons*.
- Are credentialed within the L&I MPN with an active L&I provider ID.
- Provide treatment for state-fund or self-insured workers.
- Have a completed, signed, and accepted SQC Program Supplemental Application.
* Podiatrists within a surgical clinic are also eligible to participate.
Providing Timely Reporting:
The department would like to provide timely and actionable provider reporting. For this to occur, SQC Program requests that all Activity Prescription Forms (APFs) be submitted electronically (through either Health Information Exchange or through direct entry on My L&I).
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 may either be the SHSC's employer or 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 | $157.28 |
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. | $9.68 |
Frequently Asked Questions
- January - June 2022
- July - December 2022
- January - June 2023
- July - December 2023
You will receive three informational reports based on your individual adoption of SQC Program best practices:
You will then receive another report that will determine your updated adoption level:
As a new provider, you will start out as a Low Adopter. After your first full reporting period, your adoption level will be based on your individual adoption of SQC Program best practices.