Provider Network and Expanding COHE

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About

New! Sign up for the network at www.JoinTheNetwork.Lni.wa.gov.

On March 14, 2011, Governor Gregoire signed SSB 5801, which directs L&I to create a statewide network for providers who treat injured workers. The legislation also calls for expanding access to the state's Centers of Occupational Health Education (COHE).

This legislation will return more workers to good health and help them get back on the job sooner after an injury. It is expected to save $218 million over the next four years.

This website will be updated with the latest information on:

Meetings and materials of the Provider Network Advisory Group.
Opportunities for public input.
Rules, policies and other documents.
Answers to common questions.

Provider network will serve all injured workers

The new statewide provider network will serve injured workers of both State Fund and self-insured employers. "State Fund" employers are those who pay premiums to L&I for their workers' compensation coverage. The legislation also directs L&I to develop a second tier within the network. Providers in the second tier will receive incentives for using occupational health best practices.

L&I has formed an advisory group representing the health care community, business and labor to provide input on standards and policies for the provider network. We will also provide opportunities for public input.

All injured workers will have access to COHEs

COHEs are community-based organizations that use occupational health best practices to treat injured workers. There are four COHEs in Washington state, in Renton, Spokane, Everett and Seattle. These COHEs treat about one-third of all State Fund workers' compensation claims. Research has shown that COHEs help injured workers return to work sooner and reduce claim costs. The new law directs L&I to expand access to COHEs statewide. Get more information about COHEs.

Important dates for implementing the provider network and COHE expansion

January 2012: Adopt requirements for the provider network.
January 2013: Launch the provider network.
December 2013: Expand access to COHEs to at least 50 percent of injured workers.
December 2015: Expand access to COHEs statewide.

How to submit written comments

Mail	Fax	Email
Joanne McDaniel, MA, OTR/L Office of the Medical Director PO Box 44321 Olympia, WA 98504-4321	Joanne McDaniel, MA, OTR/L 360-902-6315 (Comments submitted by fax must be 10 pages or less.)	Joanne.Mcdaniel@Lni.wa.gov

How will the new law affect injured workers?

When the provider network is launched:

Workers in all parts of the state will have access through the network to providers who meet minimum standards.
Workers will be able to choose from providers in the network.
For the first visit only, workers will be able to see a provider outside the network.

Medical Provider Network Q & A's

On this page:

Enrollment
Treating injured workers
Self-insured employers
Top Tier of the network

When will the medical provider network begin?

Injured workers can begin using the network in January 2013.
Who can be in the provider network? For example, will it include all provider types, such as pain clinics, physical therapists, and audiologists?
Yes, over time all provider specialties that treat injured workers will be invited to enroll in the network. Enrollment will be phased in and requirements will differ for different provider types.

During 2012, the following provider types that practice in Washington State are invited to join:
- Physicians
- Chiropractors
- Naturopathic physicians
- Podiatric physicians & surgeons
- Dentists
- Optometrists
- Advanced registered nurse practitioners
- Physician assistants
Out-of-state providers and other provider types not listed above can continue to treat injured workers in 2013 without joining the network.
Will there be a limit to the number of providers in the network?

No. It is an open network - we will accept all qualified providers who meet network requirements.
What are the standards for joining the network?

The standards for joining the network are described in new administrative rules, now in effect. (See new sections 296-20-01030 Minimum health care provider network standards and 296-20-01050 Health care provider network further review and denial.)
What are the standards for participation in the network?

After providers are admitted to the network, they will be required to meet standards to participate in the network. These standards are described in the network rules. (See new section 296-20-01040 Health care provider network continuing requirements.)
Who decided on the standards for enrollment and participation?

L&I developed the network standards based on the recommendations of the Provider Network Advisory Group as well as other research and input. The standards were adopted through a formal rulemaking process, with opportunities for public input.

The new rules describing standards for enrollment and ongoing participation in the network became effective on February 3, 2012.

The Provider Network Advisory Group includes members (or representatives) of the Workers' Compensation Advisory Committee, the Industrial Insurance Medical Advisory Committee, and the Industrial Insurance Chiropractic Advisory Committee. L&I also consulted with other provider groups.
How can providers give feedback about the network to L&I?

Providers can give feedback through their provider associations, or directly by emailing or phoning L&I staff. We will share feedback with the advisory group and with other stakeholders.

In addition, advisory group meetings are open to the public. For the meeting schedule, check the Advisory Group tab.
Could a provider be removed from the network? And, if so, why and how would L&I remove them?
L&I could remove a provider from the network if they:
- Put injured workers at risk of harm.
- Fail to maintain network credentialing standards.
- Do not follow other L&I requirements, such as administrative policies.
Detailed information is available in the network rules , effective February 3, 2012. (See new section 296-20-01040 Health care provider network continuing requirements and new section 296-20-01100 Risk of harm.)

If L&I has concerns about a provider, we will work with them whenever possible regarding compliance with requirements before removing them from the network. In the network rules, L&I has defined processes for providers to request reconsideration if they are removed from the network. (See new section 296-20-01030 Request for reconsideration of department decision.)
Why was it necessary to create a provider network?

High-quality medical care helps both injured workers and their employers, by supporting recovery which reduces unnecessary costs. Research shows that health-care providers using best practices for occupational medicine generally have better outcomes with injured workers. The network will encourage the use of the best practices.

Enrollment

Which providers will L&I enroll first?
L&I will enroll providers in the network in phases. During 2012, the following provider types that practice in Washington State are invited to join:
- Physicians
- Chiropractors
- Naturopathic physicians
- Podiatric physicians & surgeons
- Dentists
- Optometrists
- Advanced registered nurse practitioners
- Physician assistants
Out-of-state providers and other provider types not listed above can continue to treat injured workers in 2013 without joining the network.
Will L&I require providers to use OneHealthPort's ProviderSource system when applying to join the L&I network?

Through 2012, L&I will not require providers to use ProviderSource to submit credentials and other practice information. However, L&I will offer this as an option. In doing so, we will save work and time for providers who have already entered their data into ProviderSource. At a later date, L&I could require the use of ProviderSource for submitting information.
How will the enrollment process work?

All current providers for L&I must re-apply, including COHE providers.

Throughout 2012, we will be reaching out to current L&I providers to tell them how and when to apply. New providers (of the types listed above) may apply to the network at any time.

We encourage providers to apply as soon as invited. Applying early will help prevent any interruptions in your care for your patients. Later in the enrollment period, our processing could take longer.

Providers can apply through ProviderSource, using a paper application, or by delegation. Learn how to apply at www.JoinTheNetwork.Lni.wa.gov.
When will I hear back after I've submitted my application?

Unless we need additional information from you, you will hear back when we have taken action to approve or deny your application.

Applications from new providers (without a current L&I provider number to treat injured workers) will be handled as top priority. Other applications to join the new network will also be acted on as quickly as possible. The network takes effect January 1, 2013.

Treating injured workers

If I treat injured workers but I'm not the type of provider listed above or I practice out of state, will I be able to treat injured workers after the network begins in January 2013?

Yes, providers can continue treating injured workers with their existing L&I provider number until they are invited to enroll in the network.
If I am the type of provider listed above but I don't enroll in the network, will I be able to treat injured workers starting in January 2013?

If you are one of the provider types listed above and you don't become part of the network, starting in January 2013 you will be able to treat injured workers for an initial office or emergency room visit only. Any injured workers in your care will need to move to a network provider not later than January 1, 2013.

You can apply at any time at www.JoinTheNetwork.Lni.wa.gov. You can either complete the application online, or print it and then FAX or mail it to L&I. You do not need to wait for L&I to send you an invitation.
If a worker is initially treated for a work-related injury by non-network providers, for example if they are taken and admitted to a hospital, will L&I pay for the services?

Yes. For initial treatment, including hospital admission, an injured worker can see a non-network provider. For additional care, they must transfer to a network provider.
What if a worker wants to be treated by their regular doctor for a work-related injury, and the provider is not in the network?

A worker can see a non-network provider only for the initial visit. For additional care, they must transfer to a network provider. Workers are encouraged to ask their regular doctors to enroll in the network.
What is the definition of initial visit?

Under existing rules, "initial visit" is the first visit to a health-care provider during which the accident report is completed. This definition has not changed. While often the same, the initial visit isn't always the first date of treatment. Treatment before and after the initial visit (date associated with the completion of the accident report) can only be done by network providers after January 1, 2013.

Amendments to the Washington Administrative Code (83KB PDF) were adopted to further define what is included in the initial visit, worker and provider responsibilities, and who can provide medical support for reopening claims.

Self-insured employers

Will the employees of self-insured companies use the provider network?

Yes, employees of self-insured companies must be treated by network providers after the initial visit. Employees of both self-insured companies and those covered by L&I will use the same network.
Will network implementation require self-insured employers or their third-party administrators (TPAs) to change their processes or systems?

Yes. Self-insured employers or their TPAs will need to be able to distinguish between network providers and non-network providers to ensure that they only pay network providers for care after the initial visit.

Top Tier of the network

What is the Top Tier of the network?

The Top Tier will be a select group of network providers who agree to use certain occupational-health best practices and whose performance meets measures that are being developed. Providers qualifying for the Top Tier will be eligible to receive financial and non-financial incentives, which are also being developed.
When will the Top Tier of the network begin?

L&I plans to begin the Top Tier mid-year 2013.
Will providers get paid more if they qualify for the Top Tier?

Providers that qualify for the Top Tier will be eligible to receive financial and non-financial incentives, such as streamlined authorizations. The incentives are being developed.
What are the "best practices " for the Top Tier?

For the Top Tier, L&I plans to use best practices that are close to the ones currently used by providers participating in the Centers for Occupational Health Education (COHEs). Other best practices are being developed.

Expanding COHE - Q & A

Last fall, L&I hosted public meetings for providers around the state to explain how COHE works and encourage interest in sponsorship. We heard from many providers and used their questions to prepare this Q&A. If you don't find your question here, please contact Susan Campbell, COHE expansion coordinator, at 360-902-5413.

About COHE Benefits of COHE COHE Successes COHE Expansion and Request for Proposals (RFP) Information Technology COHE Services		COHE Providers The COHE Model Self-Insured Employers and COHE Health Services Coordinators Financing for COHE Best Practices Provider Network & COHE

About COHE

What is a COHE?
Centers of Occupational Health and Education (COHEs) are community-based organizations that work with medical providers to encourage the best ways to treat injured workers. With support from L&I, they:
- Provide resources to assist health-care providers.
- Coordinate care for injured workers.
- Promote occupational health best practices within their community.
How can a provider become part of a COHE?

Providers located within COHE communities can contact the COHE in their area to learn how and if they can enroll.
If I'm not in a COHE, can I be in the network?

Yes. Any provider who applies to L&I and meets network standards is eligible to join the network and treat injured workers.
What's the schedule for expanding the COHEs?
Currently, four COHE sites serve 2,000 providers and hundreds of employers, treating about one-third of State Fund claims in Washington. The four COHEs are:
- Renton COHE at Valley Medical Center.
- Eastern Washington COHE at St. Luke's Rehabilitation Institute, Spokane.
- The Everett Clinic.
- Harborview Medical Center.
Later in 2012 or early 2013, we will release a Request for Proposal (RFP) for organizations interested in sponsoring COHEs. We will select 6 COHEs in 2013.

Benefits of COHE

What are the benefits of COHE for a provider?
- Your patients often get back to work more quickly.
- Health Services Coordinators will assist you with the claim.
- Less "hassle factor" in working with L&I .
- Regular feedback from L&I on performance.
- Financial incentives for some best practices, for example, submitting timely Reports of Accident (ROA) and Activity Prescription Forms (APF).
- Consultations with a COHE advisor.
- Free occupational health training.
What are the benefits to institutions that sponsor a COHE?
- Gaining a reputation in your community as an expert in occupational health
- Becoming part of an integrated care system
- Increased revenue from providers following best practices.
How do employers and unions benefit from being involved with a COHE?
- Reducing long-term disability helps injured workers and employers.
- Injured workers receive care from providers with special training in occupational health and who understand their unique needs.
- COHE providers will call employers to coordinate return to work.

COHE successes

How successful are the COHEs in preventing long-term disability?

A newly released study of the COHEs shows that improving medical care for injured workers can dramatically reduce lost work time. The study was published in the December 2011 issue of the American Public Health Association journal, Medical Care. Dr. Gary Franklin, L&I medical director, was one of the researchers involved in the study; Dr Thomas Wickizer, Ohio State University, College of Public Health, was the lead investigator.

For more information about the study, see the L&I news release. To receive electronic copies of the research, contact Susan Campbell at 360-902-5053.
What are the aspects that have made the current COHEs successful?
Research on the effectiveness of the COHEs was unable to pinpoint which aspects of the COHEs contributed the most to their success. The following, however, are important COHE components:
- Institutional leadership.
- Connections with business and labor within the community.
- An environment of consistent quality improvement, provider education, and return-to-work resources.
- Health Services coordination.
- Clinical leadership.
- Adoption of evidence-based best practices.

COHE expansion and Request for Proposals

L&I must provide access to a COHE for 100% of injured workers by 2015 - What is the definition of access?

The department considers access to mean that a COHE provider is within a reasonable distance for the worker, generally within the same county.
What is L&I looking for in proposals to start new COHEs?
The Request for Proposal will be explicit about what is required. We will look for:
- Evidence of business and labor support within the community.
- A projected number of injured workers for the COHE to be financially viable (we estimate COHEs will need at least 3,000 claims initiated per year to meet expenses).
- Creative and new projects that will meet the needs of the COHE's community.
- Sponsoring institution with upper management support.
Will L&I accept more than one COHE in a region?

L&I will evaluate each application on its merits. We will consider if there is added value to having a second COHE in a region; however we are encouraging groups in an area to work together to provide integrated care for workers.
Will L&I take more than six COHEs if they meet the requirements?

The expansion is not limited to six COHEs if there are more than six excellent proposals. We will, however, need to consider impacts on our limited resources.
I am a doctor not currently in a COHE geographic area, and my practice's claim volume may not be enough to support a COHE. If I want to be a COHE provider, what do I do?

You can work with other providers in your community to start a community COHE. Please see the "COHE Model" section below for an explanation of community and institutional COHEs. You will need an organizational sponsor for the COHE as well as business and labor support.

How does L&I provide updates on the RFP process?

We will send updates and release a Request for Proposal (RFP) to interested parties though WEBS (Washington's Electronic Business Solutions). You and/or your organization must be registered in WEBS to be notified about the RFP. Please follow these instructions:


How to get notified about the COHE RFP
If you are:	You should:
Not yet registered in WEBS	Go to www.ga.wa.gov/business/3start.htm and follow the instructions to register. During the registration process, select Commodity Code 948-74 (Professional Medical Services). If you would like to partner with others on a bid, share contact information (name and email) in Step 1 as you register.
Already registered in WEBS	Commodity Codes have changed. Log in to WEBS and verify registration in Commodity Code 948-74 (Professional Medical Services). If you would like to partner with others on a bid, use the “Manage Profile” tab to share contact information.

How do ancillary care providers get connected to the COHE process?

COHEs currently focus on attending providers. But we encourage you to work with others in your community to develop a COHE proposal that is innovative, provides integrated care, and involves all aspects of an injured worker's care.
What is the best mix of providers in a proposed COHE?

L&I requires a COHE to have a mix of providers, including all those that are initiating and acting as attending providers on a workers' compensation claim. Provider types that are commonly attending providers are MDs, DOs, DCs, ARNPs, and PAs.

Where can I find claim volume information to consider in a proposal for a new COHE?

The table below shows the number of claims filed in 2011 for each county.

Number of claims filed in 2011 by county
County	Number of claims
Adams	532
Asotin	215
Benton	2,638
Chelan	2,038
Clallam	1,055
Clark	3,411
Columbia	57
Cowlitz	1,079
Douglas	460
Ferry	65
Franklin	1,549
Garfield	56
Grant	1,514
Grays Harbor	916
Island	465
Jefferson	299
King	29,183
Kitsap	2,871
Kittitas	729
Klickitat	262
Lewis	1,204
Lincoln	143
Mason	802
Okanogan	899
Pacific	367
Pend Oreille	92
Pierce	10,361
San Juan	322
Skagit	2,300
Skamania	88
Snohomish	8,252
Spokane	7,580
Stevens	338
Thurston	3,627
Wahkiakum	51
Walla Walla	940
Whatcom	2,856
Whitman	436
Yakima	3,608

Information Technology

What kind of information technology system will the COHEs need?

L&I is developing a case-management tracking system to be ready for the start of the COHEs in July 2013. All COHEs will be required to use this system once it is available.

COHE Services

What role do the COHEs have in primary prevention?

The COHEs are asked to track employer and industry injury trends and to alert the employer (and/or L&I) about any trends. Current COHE providers have worked with employers to identify and prevent recurring injuries.
What is the timeframe for COHE involvement in a claim?

Health Services Coordinators are involved for the first 12 weeks of a claim. COHE providers continue to see injured workers throughout the life of the claim and there are some incentives paid to providers who follow best practices throughout the life of the claim.
How do the COHEs work with Third Party Administrators (TPAs)?

The COHEs work closely with TPAs to alert them when an injury has occurred and a claim has been filed. They can assist TPA staff with provider questions and clarifications and contact employers regarding claims with time-loss.

COHE Providers

Can you be part of both a COHE and the Ortho-Neuro Pilot at the same time?

Yes. See Orthopedic and Neurological Surgeon Quality Pilot for more information.
Can a provider be a member of more than one COHE?

This has not yet been decided. The Request for Proposals will have further details on this question.

COHE Model

Are the staff who manage the COHE (project director, etc.) employees of the COHE or L&I employees?

They are employees of the COHE and its sponsoring organization.
What are the staffing requirements for current COHEs?
The staffing requirements below are for the current COHEs. There may be changes to these requirements in the Request for Proposals. Each COHE will have staff to fulfill the following roles. These roles may not require a full-time equivalent staff person; COHE staff may fulfill multiple roles.
- Medical Director: Health care provider with an active Washington State license who is focused on medical leadership and management.
- Project Director: Operational leader with project management experience who manages all of the core COHE functions and staff.
- Health Services Coordinator: Facilitator and coordinator between provider, employer, patient, union (when applicable), and claim manager.
- Community Outreach Facilitator: Staff who encourages employers, unions, and community organizations to partner with COHE and implement best practices.
- Provider Trainer: Trainer of providers and provider staff on COHE procedures and occupational health best practices.
What kind of claim volume have the current COHEs experienced?

The current COHEs range in size from over 1,000 providers and 18,000 claims per year to 240 providers and 3,000 claims a year. The existing COHEs treat about 30% of all state fund claims. (State fund claims are those managed by L&I.)
What is the difference between a community and an institutional COHE?
- Community COHE: A COHE where a sponsoring healthcare organization pulls together resources to support providers (including providers outside their organization), workers, and employers in a geographically defined area.
- Institutional COHE: A COHE where a single healthcare organization offers resources to support its providers, the injured workers seeking care, and the workers' employers. Institutional COHEs do not enroll providers outside their organization.
Do all providers in an institutional COHE need to be COHE providers?

All providers in the institution who have initiated one or more L&I claim in the last year must participate as a COHE provider.
If a worker chooses a COHE provider over a provider not in a COHE that is geographically closer, how will their travel be reimbursed?

We do not currently anticipate expanding L&I's travel reimbursement policies to assist an injured workers use of COHE providers. Workers will retain their right to choose their provider, ultimately from within L&I's provider network.

Self-insured employers and COHE

Are self-insured employers involved with the COHEs?

There are no self-insured employers currently involved in the COHEs. L&I is considering the feasibility of a pilot with interested self-insured employers. At this point, when a COHE provider sees injured workers from a self-insured employer, they treat them the same as workers with state-fund claims but do not always get reimbursed for the increased services encouraged by the COHEs.

Health Services Coordinators

What is the role of the Health Services Coordinator (HSC)?

The HSC works closely with all parties (L&I, the provider, injured worker, and employer) to aid communications to ensure injured workers are back to work as soon as medically appropriate. They work for the COHEs and are readily available to assist all parties in the claim.
How many HSCs are COHEs required to have?

The contract currently requires one HSC full-time equivalent for every 3,000 claims initiated per year. This could change, and will be clearly specified in the Request for Proposals.
How do the HSCs work with L&I regional staff?

The HSCs and the regional staff sometimes work on the same claims, especially those in the Early Return to Work program.

COHE financing

How are the COHEs reimbursed?

The COHEs receive an administrative payment for each Report of Accident completed by a COHE provider. Currently, the payment is $37 per claim for community COHEs and $34 per claim for institutional COHEs.

Health Services Coordinators and COHE providers also receive payment for their claim-specific services (see questions below).
How do Health Services Coordinators receive payment for their services?

Health Services Coordinators are considered L&I providers and can bill L&I directly for any claim-specific work. An estimate of their non claim-specific work is also included as part of the COHE administrative payment.
What financial incentives are available for providers?

Providers enrolled in the COHE are paid an additional amount if the Report of Accident comes into L&I within two business days, and they can self-generate the Activity Prescription Form.
Will there be start-up funds available for new COHEs?

Yes, there may be funds available for financial support of new COHEs during their initial start-up phase. These funds will be tied to specific activities identified in the proposal.

Best Practices

How is L&I developing new best practices?

Researchers at the University of Washington conducted a literature search of best practices for the treatment of back conditions. They compiled about 20 best practices. Then, in late September 2011, L&I hosted a focus group of providers from around the state, as well as an expert from Johns Hopkins University, to review the best practices. They have proposed 14 best practices, which L&I is working to develop and implement.
What are some of the best practices being tested at this time?

Some of the COHEs are now testing a questionnaire that, when administered around two weeks into a claim, can help identify injured workers who are at risk of long-term disability. The interventions designed for this group include addressing fear avoidance and other psycho-social issues.

They do, however, stress active modalities and activation. They also include activity coaching which helps to get people gradually moving and eventually back to work.