Orientation of the COHE Program and WA States L&I Occupational Health Best Practices__________________________________________________________Prepared by COHE Community of Eastern Washington

Agenda• What is COHE

• Why do providers join COHE

• What is the role of an HSC

Background of the Centers of Occupational Health &

Education

• Types of workers’ compensation claims

Introduction to Workers’ Compensation

• What are the best practices

• How to apply them

Overview of L&I Occupational Health Best Practices

• Program resources

• Final step for enrollment

Next Steps to Complete Enrollment

• Provide reliable resources to all stakeholders and reduce obstacles within the first year of opening a Washington State Labor & Industry (L&I) Worker Compensation claim.Goal

• Educate providers about the Washington State Occupational Health Best Practices.

Focus

• Deliver care coordination for improved return to work outcomes.

Foundation

Why do providers join COHE?

Incentives• COHE enrolled facilities receive up to 50%

more compensation when initiating an L&I state fund claim.

Best Practice Training

• Receive education in Occupational Health best practices.

• Preferred provider on L&I Find-A-Doc.

Health Service Coordinator

(HSC)

• Access to HSCs for care coordination for up to the first year of a claim to resolve barriers and help to prevent prolonged disability.

COHE Medical Advisors

• Access to expert consultations related to occupational health and assessment of claim barriers.

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

Care Coordination

To provide care coordination in the 1st year of a claim.

To resolve barriers and reduce prolonged disability for improved claim outcomes.

Stakeholder Consultation

To assist Workers, Employers and Providers in navigating worker compensation systems and resources.

Continuous Education

To educate Providers and staff regarding Occupational Health Best Practices.

Call an HSC when:

Assistance is needed with a challenging claim

Have questions related to the Employer or Worker

Have questions regarding L&I Paperwork or Process

L&I State Fund Claims

U.S. Government Federal Claims

Self-Insured Claims

Types of Worker Compensation Claims

L&I State Fund Claims

COHE currently supports State Fund worker compensation

claims ONLY.

Employers and employees pay into a fund for Washington

State to manage the employees’ worker

compensation benefits.

Facility is reimbursed for services by Washington State

Department of Labor & Industries (L&I).

Several thousand employers are covered under the

centralized L&I state fund system.

Self-Insured Claims

Employers can choose to manage their own claims or

have them managed by a third-party administrator

(TPA).

When an employer partners with a Third-Party insurance company, they pay workers’

compensation benefits directly to the worker and

provider.

The claim processes are similar to State Fund

coverage.

The Office of the Ombuds serves as an independent

agent and advocate for self-insured workers.

http://ombuds.selfinsured.wa.gov/

U.S. Government Federal Claims(OWCP, Longshore, Maritime, Rail)

Employees who work for the U.S. Government or for a

Federally regulated Employer fall into this worker

compensation group.

Forms and processes are different than that of L&I State Fund or Self-Insured

patients.

Best Practices

Complete & Timely Report of Accident (ROA)

Complete & Timely Activity Prescription Form (APF)

Provider-to-Employer Phone Call

Barriers to Recovery:Functional Recovery Questionnaire (FRQ)

*Coming Soon

Best Practice 5: Prescribing

#1

Best Practices for Emergency

Department Providers

#2

#3

#4

**

*

Urgent Care providers and all non-ED providers complete 4 Best Practices.

#5

Best Practice #1 Report of Accident (ROA)

• The ROA is the 1st official notice L&I receives of an injury or illness.

• The ROA can be filed online via FileFast. ($10 additional reimbursement for online filing)

• When completing the ROA via FileFast the completed original ROA must still be faxed to L&I.

• Process the ROA as a HOT CLAIM If the injured worker is admitted into hospital or transferred to another; if a catastrophic injury occurred; or if injury resulted in death of worker.

• Fax completed ROA and APF within 2 business days to L&I: 855.222.4652 or 360.902.5126.

• Fax HOT CLAIM to 360.902.4980

Completion of each box on the ROA is not only required but is essential for claim adjudication.

Box 1: List work-related medical diagnosis. e.g., contusion, strain/sprain, abrasion.

Diagnoses such as “pain” and “tenderness” are considered subjective and will not be

allowed by L&I and will result in revision and delay of claim acceptance.

Box 2: Can be completed by support staff, ICD Codes are not required at ED.

Box 3 : Indicate the date you first saw patient for this condition.

Completion of ROA

Pain, Tenderness

Box 4 : Indicate if this condition is due to a specific incident.

Box 5 : Objective Diagnosis/Findings. Be specific and detailed in your objective findings.

Objective Medical Findings (OMFs) are described as a ‘finding’ that can be seen, felt, heard,

measured, or reproduced (by provider) through examination or testing.

*L&I reviews boxes 1 & 5 against ED chart notes when making the determination for claim allowance or

rejection.

Box 6: Indicate if more treatment is needed.

Completion of ROA

Pain, Tenderness

Box 7 : Work-relatedness/Causation. CHECK 1 BOX ONLY.

Checking “YES” or "PROBABLY” means in your opinion, the condition is “more likely than not”

(≥ 51%) work-related. Checking “POSSIBLY” or “NO” means, the condition is (< 50%) work-

related, the claim will likely be rejected.

*If selecting something other than yes, indicate reason in chart note.

Box 8: Miss work. If patient is medically unable to perform any work due to the injury, estimate

how many days the patient will miss work.

*If releasing to modified duty select No and indicate restrictions on APF. Time loss begins if off

work 4 or more days.

Completion of ROA

Box 14*, & Box 15a: Shaded areas may be completed by support staff. All other fields must be

completed by health care provider.

*Box 14: For proper claim attribution and enhanced reimbursement, use your L&I Provider

Number and not your NPI. If you work at multiple locations, provider attribution maybe delayed

or made to the wrong clinic.

Box 16: Signature. Medical provider must sign & date ROA to initiate claim. If there is no

Provider signature the claim will be rejected.

Completion of ROA

L&I # is specific to practicing location and preferred

General Hospital 123 456-7890

1234 ABC Lane Port Charles WA 98123

Complete Provider Report of Accident

R Knee Sprain 1 25 20

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1234567

01 25 20

01 25 20AP Signature

Dr. COHE

X-ray negative, Decreased ROM, Swelling

RICE, NSAIDS, Ace Wrap, crutches

2

Reimbursement amount is based on the date the health care provider includes in box

15b of the ROA (this exam date).

If that box is blank, the payment system will use box 3 (Date you first saw patient for this

condition). If both boxes are blank, payment will automatically revert to lowest

reimbursement amount because there must be dates in order for the payment system to

calculate any incentives.

S83.91XA

Completeness of ROA includes required worker sections

• Claim ID (top box)

• Language preference (top box)

• Worker name (First-Middle-Last) (box 1)

• Worker gender (box 2)

• Worker home phone (box 4)

• Worker birth date (box 5)

• Worker address (box 6)

• Date of injury (box 14)

• Description of injury/exposure (19b)

• Job title and job duties (box 35)

• Employer Name (box 30)

• Worker signatures (box 42 and 43)

Providers verify all required worker fields are complete:

Best Practice #2Activity Prescription Form (APF)

• Communicates an injured worker's physical restrictions and ability to work as well as the provider's treatment plan.

• Completed during injured worker’s visit and a photocopy is given to worker at discharge.

• Emphasis on early return to work opportunities and discussion of physical restrictions.

• Certifies time-loss for injured worker.

• APFs can be submitted electronically using Direct Date Entry or Health Information Exchange (HIE).

• Fax to L&I: 360.902.4567

General Info: Please complete all areas under General Info and list work-related

medical diagnosis. Support Staff can complete all sections except diagnosis.

*Diagnosis must be added by provider.

Work Status: If patient is medically able to return to the job of injury (JOI) without

restrictions (related to work injury), mark patient as released to JOI and note date,

then skip to “Plans” section on APF.

Completion of APF

*

Work Status: If patient is able to return to work and requires modified duty, indicate

with start and end date. If patient is medically unable to perform any work due to

the injury, estimate how many days the patient will miss work.

Make sure there are no time gaps or overlaps in any of the date ranges indicated in

the Work Status and Plans sections.

*This is an estimated date and should cover patient until follow up appointment,

which generally occurs in 3 to 7 business days from ED visit or 3 to 14 days from

Urgent Care visit.

Completion of APF

2 04 20 2 07 20*

2 01 20 2 03 20*

Measurable Objective Finding(s): Be specific and detailed in your objective

findings. Remember, pain and tenderness are not considered objective findings.

Examples of findings L&I CANNOT accept: Pain, Tenderness, See chart notes.

Completion of APF

02 04 20 02 07 20

02 01 20 02 03 20

✓ Decreased ROM

✓ X-ray positive for fracture

✓ Swelling

✓ Muscle atrophy

See Chart Notes

Pain, Tenderness (More is needed)

Physical Restrictions/Capacities: Complete applicable parts of the grid as it relates

to patient’s injury and *indicate any additional patient restrictions in “Other restrictions/

instructions” box.

*All providers are required to complete the grid for workers current capacities and/or

restrictions. A blank space = not restricted.

Complete 24/7 restrictions, even when not released to any work, patients have

restrictions that apply at home.

Completion of APF

(e.g. Keep wound clean & dry, Wear right arm in sling)* If listing other restrictions here use terms: “Never, Seldom, Occasional, Frequent, Constant”

Weight Reference Sheet

Produced by L&I 4/16/2007 in collaboration withHome Depot & Fred Meyer

Employer Notified: Make notation on APF when contacting the employer on first visit

or any subsequent communication; documentation must be made in SOAP-ER notes.

*The ER in SOAP-ER notes stands for E – Employment issues and R – Restrictions to

recovery.

Note to Claim Manager: Indicate any notes to claim manager, such as “I am the new

AP.”

Completion of APF

02 01 20

Examples: “I am the new Attending Provider (AP)” “Pending surgical authorization.”

Complete Plans section of APF: Please check all that apply in both columns.

Sign: Sign and date document.

Provide a copy of APF to patient at discharge. Fax a copy of all APFs to L&I.

Completion of APF

*Providers who only see patients in the ED skip to slide 27

APF Best Practice Measures: Measure 1: 80% of all claims have an APF with the ROA (1st visit).Measure 2: 80% of all time-loss claims have a second APF within 4 weeks of claim established date.Measure 3: 80% of all APFs received in 2 business days, excluding weekends and state holidays.(L&I received date subtracted from the APF visit date.)

Best Practice #3Provider-to-Employer Phone Call

Use -32 modifier for all calls or conversations to employers

99441-32Physician Brief Conversation

(1-10 min)

99442-32

Intermediate discussing/resolving RTW issues

(11-20 min)

99443-32

Complexity and/or Duration

(21-30 min)

98966-32Non-physician brief conversation

(1-10 min)

98967-32

Non-physician intermediate conversation

(11-20 min)

98968-32

Non-physician complex conversation

(21-30 min)

9918M

Physician and Non-Physician

Online Communication

(limited to once per day per claim)

Communication by the provider with the employer about restrictions, modified

work, and treatment plan is a billable service.

Make notation on APF when contacting the employer on first visit or any subsequent

communication; documentation must be made in SOAP-ER notes.

What is the FRQ? It’s six questions asked to injured workers to gauge their

chances of returning to work.

The questionnaire is delivered by HSC between 11 days and 6 weeks after

claim initiation.

Questions 1-3: Cover time loss and pain, which determines the overall FRQ

score, positive or negative.

Questions 4-6: Cover work accommodation, recovery expectation,

and fear-avoidance, which helps identify specific worker psychosocial

issues.

If a positive FRQ is determined the HSC will review results with the Attending

Provider (AP) or designated clinic contact to help identify Functional

Recovery Interventions.

Some intervention examples are increasing activity, tracking functional improvement goals and progress, or considering referrals such as Physical

Therapy, Occupational Therapy, Vocational Services, and/or Activity

Coaching (PGAP).

Best Practice #4Barriers to Recovery: Functional Recovery Questionnaire (FRQ)

Future Measures:

Measure 1a: ≥90% of workers have an initial opioid prescription of ≤ 3 days (non-surgicalcomparison groups).

Measure 1b: ≥90% of workers have an initial opioid prescription of ≤ 7 days (surgicalcomparison groups).

Measure 2: ≥90% of workers on chronic opioid therapy are dosed at <50mg/day MED.

Measure 3: <5% of workers taking opioids are transitioned to chronic1 opioid therapy.

*Chronic, as it pertains to these opioid measures, is defined as number of days filled ≥60 (non-consecutive) days in a 90-day period.

*Includes all prescribed opioids – not just what L&I authorized and/or paid for.

Since prescribing is done by each individual medical provider, Health Service Coordinators will only provide Best Practice prescribing measures.

The HSC will not have additional information on these reports. If a provider has questions about an opioid prescribing report sent from the L&I or has questions concerning the prescribing best practice, please email the Pharmacy team at (PharmacyManager@LNI.WA.GOV).

*Only L&I’s Pharmacy Program has access to prescribing data.

**COMING SOON**

Best Practice #5 Prescribing

Questions?

Contact usCOHEMgmt@providence.org

866-247-2643

Program Resources

An important service of the COHE office and staff is to provide up-to-date versions of forms, job-aids, fee schedules and other resources.

You can obtain resources from your partnered HSC or by visiting the COHE website.

https://www.gocohe.com/Program-Resources/

Next Steps For Enrollment

To complete enrollment in the COHE program, complete the quiz.

ED provider: Quiz Link Here

orUrgent Care and all Other providers:

Quiz Link Here

Once your quiz is received, your HSC will send a follow up email with contact information and confirmation of enrollment.

Once enrolled you will be required by contract to complete an annual refresher training. Your HSC will send you or your clinic contact a reminder every year.

Thank you!

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www.gocohe.com/survey