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Rules

Rules relating to the network have been proposed and adopted in 4 phases. The latest rules are listed first.

Adopted Rules

Phase 4: Medical Provider Network (effective May 10, 2013)

This rulemaking includes requirements that self-insurers make certain their workers receive the information necessary to access care within the health care provider network.

More information
- Adoption (Rule-Making Order CR-103) (PDF 98KB)
- Adopted Rule Language (PDF 33KB)

Emergency rule regarding enrollment process (effective March 1 - June 29, 2013)

An emergency rule went into effect Friday, March 1, 2013 and will be in effect for 120 days. It changes WAC 296-20-01020 to allow any provider who applied to join the network before January 1 to continue to treat, as long as a final decision hasn't been made on their application and it hasn't been withdrawn.

Also, until the Emergency Rule expires, there is no 60-day limit on provisional status.

More information
- Emergency Order Adoption (CR 103)
- Adopted Rule Language

Phase 3: Amendments to network rules (effective Dec. 14, 2012)

This third rulemaking phase amends certain L&I rules that conflict with the legislation to implement the network.

More information
- Concise Explanatory Statement (PDF 146KB): A summary of the proposed rules, comments that we recieved about the rules, and L&I responses to those comments.
- Adoption (Rule-Making Order CR-103) (PDF 98KB)
- Adopted Rule Language (PDF 33KB)

Phase 2: Rules concerning injured workers' first visit (effective Apr. 6, 2012)

The second phase rules allow injured and ill workers to see a provider of their choice for the initial visit to start their claims.

These rules also define what services may be provided by a non-network provider and when care must be transferred to a network provider.

More information
- Concise Explanatory Statement (PDF 118KB): A summary of written and oral comments on the draft rules, with L&I responses.
- Adoption (Rule-Making Order CR-103) (PDF 173KB)
- Adopted Rule Language (PDF 69KB)

Phase 1: Network rules (effective Feb. 3, 2012)

The first phase of rules established minimum standards for credentials of health care providers and other requirements for network participation.

These rules also clarify what constitutes patterns of risk of physical or psychiatric harm or death that determines when we may remove a provider from the network.

More information
- Concise Explanatory Statement (PDF 950KB): A lengthy summary of written and oral comments on the draft rules, with L&I responses.
- Adoption (Rule-Making Order CR-103) (PDF 316KB)
- Adopted Rule Language (PDF 67KB)

Legislation creating the network

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.

Provider Network

Will all providers in the new L&I Medical Provider Network have to be in a COHE?

No, there will be providers throughout the state who do not choose to join a COHE but will still be in the Network and able to see injured workers. In 2013, these providers may also choose to consider joining the L&I "Top Tier" program. Any provider wishing to enroll in COHE must first be fully approved in the L&I Medical Provider Network (MPN) and maintain that status throughout their COHE participation. Those in Provisional or In-process status must wait for MPN approval notification prior to submitting the supplemental COHE application.
Providers who practice exclusively in an emergency department are exempt from the MPN requirement. For more information, please see the Provider Network information at www.JointheNetwork.Lni.wa.gov.

Labor & Industries (L&I), Washington State

For Medical Providers