Public Service Clinics Topics
Provider Review and Education, Health Services Analysis, Washington State Dept. of Labor and Industries #2
Agency/Program Overview
The mission of the Department of Labor and Industries is to support the state's economic well-being by protecting the safety of Washington's workers, providing benefits to injured workers and ensuring fair wages and quality industry services.
These responsibilities include enforcing the Washington Industrial Safety and Health Act (WISHA); managing the state's workers' compensation system; providing safety and health consultations and information; enforcing wage-and-hour, child labor and family leave requirements; managing the state's crime victims' compensation program; registering contractors and apprentices; inspecting electrical work, elevators, boilers and factory-assembled structures; and issuing licenses for certain skilled trades.
Looking specifically at the health care received by injured workers, our department is the eighth largest insurance provider in the U.S. and is a national leader in workers’ compensation health care.
Specific Research Question
Given our team’s mission to insure injured workers receive quality medical care, are we achieving the best results and how can it be improved?
Additional Project Background
To provide the health care needed by injured workers, the department has over 60,000 health care providers delivering health care. L&I processes over 4,000,000 health care bills per year and pays these providers over $6,000,000 per year for their services.
The department has 1.5 occupational nurse consultant (ONC) FTE’s committed to reviewing the care and treatment licensed health care providers render to injured/ill workers. Health care providers are identified for review based primarily on complaints received within the unit. The sources of complaints
include department medical consultants, nurse consultants, claims managers, injured workers or their families, employers and/or third party administrators. A provider is selected for review based on the ONC’s assessment of the harm they have caused workers or the risk of harm injured workers face by continuing to receive treatment by them.
The department currently contracts with a peer review company, which has an extensive number of licensed health care professionals on contract, as well as five (5) other independent peer review physicians.
Once the ONC determines that a more in-depth review of a provider is indicated, the ONC selects cases for review and puts together the case files for the professional peer reviewers to review and render a report of findings. The ONC obtains and organizes the medical records within the selected claim files. Basic on-line claim information, summary of bills submitted by the provider and a pharmacy report are attached. These documents are mailed to the peer reviewers. It can take up to four (4) months to receive a report of findings. The ONC then reviews the findings and recommendations; generates a department report of findings; and meets with the unit manager and assistant attorney general (AAG) to finalize department actions based on that report.
Once a report with sanctions (i.e. revoking the provider’s eligibility to be paid for treating injured workers) is issued, the provider has up to sixty (60) days to either submit information supporting why the initial report and sanction is wrong (reconsideration) or file an appeal against the proposed
action with the Board of Industrial Insurance Appeals (BIIA). It can take up to 3 years to obtain a final disposition from the BIIA.
Key Steps
Student would interview audit staff and review current audit/screening and review process.
Conduct literature review and comparative analysis of other similar organizations.
Conduct analysis of current process, to include statistical analysis of available billing data to determine return on investment (ROI) and program effectiveness.
Provide recommendation on how to improve program’s processes and method to determine ongoing ROI.
Additional Research Resources
In addition to the key steps listed above, the student would have access to agency staff and department data bases, internet searches, professional peer review organizations and professional health care licensing bodies. Work space and computer support would be available as well.
If you have additional questions or would like more information, please email Gary Walker, Manager.