Q&A: About the new Medical Provider Network
and COHE Expansion (SB 5801)

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Medical provider network

When will the medical provider network begin?

L&I has already started initial planning for development of the network and we will update stakeholders and providers as we proceed. Ultimately, our goal is to launch the network by January 2013. If needed, we will phase the launch to ensure injured workers have broad access to care and choice of providers in their geographic region. By mid-2013, we hope to begin the second-tier network for providers who adopt best practices.

L&I will be working closely with a new advisory group and provider groups as we develop the network. We will reach out to current providers to keep them informed and help with the transition into the network. (For more about the advisory committee, see question 6.)

Who can be in the provider network?

Any provider can be in the network if they meet certain standards which are still to be determined.

To treat a worker for a first visit to an emergency room or clinic after an injury, providers will not need to be part of the network. After the first visit, a provider will need to be in the network to get paid for treating an injured worker. This will apply to workers insured by L&I as well as to workers employed by self-insured companies.

Why was it necessary to create a provider network?

High-quality medical care helps both injured workers and their employers, by supporting recovery while at the same time controlling workers' compensation costs. Research shows that health-care providers using best practices for occupational medicine generally have better outcomes with injured workers.

A provider network gives us the ability to insure that injured workers receive high-quality medical care.

Will there be a limit to the number of providers in the network?

No. Any provider who meets L&I's minimum standards will be allowed to join the network.

What minimum standards will be required in order to participate in the network?

L&I will propose minimum standards for network providers based on the recommendations of the advisory group as well as other research and input. Advisory group meetings will be open to the public. Then L&I will adopt the standards through a formal rulemaking process, with opportunities for public feedback.

Standards for joining the network

According to the new law, to be admitted to the network, providers must meet certain minimum standards, such as:

  • Current malpractice insurance;
  • Previous malpractice judgments or settlements not in excess of criteria to be determined;
  • No licensing or disciplinary action, or loss of privileges in any jurisdiction;
  • For some specialties such as surgeons, have privileges in at least one hospital; and
  • Credentialing by another health plan;
  • Alternative criteria for providers who are not credentialed by another plan, or who serve a region where there are concerns about access to care.

Standards for participating in the network

After providers are admitted to the network, they will be required to follow L&I's coverage decisions and treatment guidelines, as well as other national treatment guidelines that may be appropriate for individual patients. Network providers will also be required to follow L&I's administrative policies.

Who will decide on the minimum standards?

L&I will adopt the standards for network participation. To develop recommendations on the standards, L&I will form an advisory committee that will include members (or representatives) of the Workers' Compensation Advisory Committee, the Industrial Insurance Medical Advisory Committee, and the Industrial Insurance Chiropractic Advisory Committee. L&I will also consult with other provider groups.

Advisory group meetings will be open to the public.

Will providers who do not join the network still be able to treat injured workers?

Non-network providers will only be able to treat injured workers for an initial office or emergency-room visit. Follow-up care must be provided by a network provider.

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).

If L&I has concerns about a provider, we will work with them whenever possible regarding compliance with requirements before removing them. In its rules, L&I will define processes for providers to request reconsideration if they are removed from the network

What is the second tier of the network?

The second tier will be a sub-group of network providers who agree to follow certain occupational health best practices, in addition to the minimum requirements, and who meet performance-based measures that will be developed. Providers qualifying for the second tier will be eligible to receive financial and non-financial incentives, which also need to be developed.

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

Yes, employees of self-insured companies must also be treated by network providers after the initial visit.

Will the new network include all provider types, such as pain clinics, physical therapists, and audiologists?

All provider specialties that treat injured workers will need to be in the network, but requirements may be phased in or differ for different provider types. For example, some standards will probably apply only to those provider types that can be the "attending providers" who coordinate care for injured workers – physicians, chiropractors, naturopathic physicians, podiatrists, dentists, optometrists, and advanced registered nurse practitioners.

COHE expansion

What is a COHE?

Centers of Occupational Health and Education (COHEs) are operated by health care organizations such as hospitals and clinics. With support from L&I, they:

  • Provide resources to assist health care providers,
  • Coordinate care for injured workers, and
  • 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 office to learn about how to enroll.

If I'm not in a COHE, can I be in the network?

Yes. Any provider who applies to L&I and meets minimum standards is eligible to join the network and treat injured workers.

What's the schedule for expanding the COHEs?

Currently there are four COHEs in the state and L&I expects to add two more in 2013. Additional COHEs will be added by the end of 2015 so that all providers and injured workers have access to a COHE.

The four existing COHEs are:

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