medical provider network: provider re-credentialing
DESCRIPTION
Medical Provider Network: Provider Re-credentialing. Karen Jost Health Services Analysis Program Manager October 23, 2014. Medical Provider Network (MPN) Status. Over 21,000 approved providers. - PowerPoint PPT PresentationTRANSCRIPT
Medical Provider Network: Provider Re-credentialing
Karen Jost
Health Services Analysis Program Manager
October 23, 2014
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Medical Provider Network (MPN) Status
Over 21,000 approved providers. Access goal: ensure that the percent of
injured workers within 15 miles of at least 5 attending provider types is within 5% of the January 2012 (pre-network baseline) for their county of residence.
Goal continues to be met: 99% statewide, and stable by county
Initial 3-year credentials up for re-credentialing January 2016
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Distribution of Quality of Care
Clinical Efficiency
PoorGood
Com
mun
ity
Phy
sici
ans
Zone 1 Zone 2 Zone 3 Zone 4
Excellent Health and Disability Outcomes
Low to ModerateMedical and Disability
Costs
Average Health and Disability
Outcomes
Average Medical and Disability
Costs
Poor Health and Disability Outcomes
Average to High Medical and
Disability Costs
Very Poor Health andDisability Outcomes
High Medical and Disability
Costs
(Quality & Value)
RECOGNIZE
COHE High Adopters, Top Tier,Financial and Non-financial Incentives, Recognition, Mentors
RECOGNIZE
COHE High Adopters, Top Tier,Financial and Non-financial Incentives, Recognition, Mentors
IMPROVECOHE Participation, Education, Mentoring, Evidence-based best practice guidelines, Top Tier, Financial and Non-Financial Incentives, Care Coordination
IMPROVECOHE Participation, Education, Mentoring, Evidence-based best practice guidelines, Top Tier, Financial and Non-Financial Incentives, Care Coordination
REMOVE
Network Minimum Standards
Risk of Harm
Audit, Education and other interventions
REMOVE
Network Minimum Standards
Risk of Harm
Audit, Education and other interventions
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Complementary processes
Risk of harm – opioid death reviews and re-operations
Department of Health (DOH) feed – licensure actions
Audit and fraud actions One-year credentialing Provider complaints National Practitioner Data Bank (NPDB)
updates
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Requirements For Provider Monitoring or Reapproval
RCW 51.36.010(2)(d) WAC 296-20-01030 Minimum health care
provider network standards WAC 296-20-01040 Health care provider
network continuing requirements
Purpose: Ensure approved network providers remain in compliance with minimum standards and continuing requirements. – Secondary: Update demographics and credentials
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Re-credentialing process considerations
Risk to injured workers Meets purpose of MPN Potential for Error Impact on access Provider ease Yield – balance work vs. actionable findings Technology / capacity Staff impact / resource needs / Cost Industry standard Defensible process and standards Coordination with related processes Appropriate provider expectations / responsibility
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Options for Re-credentialing Standard process
– Cyclical update of documentation (usually 3 years)– Requires provider submittal of forms (usually
attestation, insurance, release of information)– Request staff input, review and verification
Continuous monitoring– Uses continuous updates from reporting sources– Provider submits information only when issue or
concern identified– Staff review data feeds and respond to issues as
they arise
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Recommendation
Continuous monitoring–Over 99% of providers met network standards
• Yield of re-review of approved providers is even lower
–Data (changes) drive focused reviews and action taken, rather than cycle review of all –Lower provider and staff burden
Feedback from ACHIEV–Potential for error–Industry standard