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Medical Provider Network: Expansion Discussion Karen Jost, Health Services Analysis Program Manager January 2015.

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Presentation on theme: "Medical Provider Network: Expansion Discussion Karen Jost, Health Services Analysis Program Manager January 2015."— Presentation transcript:

1 Medical Provider Network: Expansion Discussion Karen Jost, Health Services Analysis Program Manager January 2015

2 2 Objectives  Review MPN purpose, criteria, previous expansion discussion  Introduce data regarding AP provider types, claimants, quality of care in border states (Oregon, Idaho)  Input from ACHIEV

3 3 MPN Eligible Providers Beginning January 1, 2013, the following Washington State providers can treat for the initial visit only unless they are in the network or submitted a complete application by December 31, 2012: Physicians (medical and osteopathic) Chiropractic Physicians Naturopathic Physicians Podiatric Physicians Advanced Registered Nurse Practitioners Physician Assistants Dentists Optometrists

4 4 Currently excluded providers  Pathologists  Consulting radiologists working within a hospital radiology department  Anesthesiologists or certified registered nurse anesthetists (CRNAs) except anesthesiologists and CRNAs with pain management practices in either hospital- based or ambulatory care settings  Emergency room providers  Hospitalists

5 5 Expansion  Department may expand to include –Additional providers not already listed (slide 3) –Those excluded (slide 4) –Out-of-state providers  Previous discussions –Out-of-state –PT/OT –Psychologists

6 6

7 7 Network criteria summary Minimum QualificationsFurther Review/Potential Denial Complete application, signed contract, no material misstatements or omission Pending licensure disciplinary action, informal license actions, noncompliance with restriction, history of licensure actions Professional liability coverageMalpractice claims history Current professional license without restrictions Termination or surrender privileges from a health plan, public program, clinic, or facility No exclusion from public program Medicare or Medicaid for quality care Material noncompliance with department rules, guidelines, and policies, risk of harm No felonyBilling fraud or significant billing irregularities No denial of hospital privileges for quality of care Criminal history, sexual misconduct, alcohol or chemical dependency, fraud Current Drug Enforcement Administration (DEA) registration without restrictions Invasive procedures without admitting privileges or use of unlicensed staff Pattern of material complaints or allegations Negligence, inadequate treatment, misconduct

8 8 Providers, Claimants, and Paid Amount 2012 # Providers (NPI) # Claimants Paid Amount Idaho 482 1,052 $ 854, Oregon 1,440 2,357 $ 2,329, Total * 1,921 3,405 $ 3,183, # Providers (NPI) # Claimants Paid Amount Idaho 465 1,022 $ 799, Oregon 1,450 2,474 $ 2,262, Total * 1,913 3,481 $ 3,061, # Providers (NPI) # Claimants Paid Amount Idaho 647 1,757 $ 1,653, Oregon 2,050 4,093 $ 4,592, Total * 2,694 5,827 $ 6,245, * (Across provider types, across states) See provider type detail in handout

9 9 Provider Distribution: Oregon ( )

10 10 Provider Distribution: Idaho ( )

11 11 Discussion / Input from ACHIEV  Meets purpose of MPN  Impact on access  Provider ease  Yield – balance work vs. actionable findings  Staff impact / resource needs / Cost  Coordination with related processes  Appropriate provider expectations / responsibility


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