RTW Strategies: Washington’s COHE Model

Reimburse providers for communication, expertise and time

As the Medical Director of one of the 6 Washington State COHE's and as an occupational medicine clinician, I can state that in order for other states or the Federal government to implement a COHE-type model, there must be practicing physician leadership or involvement at every stage of development and implementation. By "practicing" I mean physicians who have at least 5 years of experience in serving as the attending provider for workers' compensation patients and who earn(ed) 50% or more of their living doing so (and, ideally, continue to do so during development and implementation).


Another essential is a commitment by the state/Fed to reimburse workers' comp clinicians for their professional time and expertise for "non-clinical" services. By non-clinical I mean services that are not accurately captured by a CPT code, that add value to a CPT-coded encounter, or that occur outside of a provider-patient encounter. For example, all communications between a provider and any other person who is officially related to a claim, whether by phone conversation, secure voicemail, secure email, videoconference, or face-to-face, should be reimbursed according to time. The other party in this communication could be a supervisor or employer HR representative, a PT or OT, another provider, a VRC, a claim adjuster, or a nurse case manager, or any number of professionals who are tasked with assisting patients and reducing permanent disability. Now, there are CPT codes for some of this communication, but CMS criteria must be modified such as eliminating a minimum time length of a billable phone call. The state/Fed would also need to create a mechanism for reimbursing a provider's time for form completion (the generic 99080 CPT code will not suffice for vast array of forms of varying complexity that are part of workers' comp). The State of WA, for example, has created an entire system of local codes specific to workers' comp. Without reimbursing providers for their valuable time outside of the exam room, any COHE-type program will fail.


Finally, there must be a set of evidence-based best practices that constitute the core of the program, ideally based upon research done on the prospective patient population of the jurisdiction. In WA we have a small number focusing on rapid transmission of the claim, communication between the provider and the employer to arrange modified duty, a written activity prescription, and avoiding the unnecessary use of deadly medications (opioids). Following all best practices generates the highest provider reimbursement while following none results in exclusion from seeing workers' comp patients. There must be such incentives and disincentives in any COHE-type system.

Last Edited by Moderator Linda


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