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Pay health care providers for services that promote SAW/RTW

To ensure that health care providers are paid for their expertise and the time they devote to promoting functional restoration and SAW/RTW, the designated federal entity (see recommendation 2) should:

• Formally request the American Medical Association and CMS to collaborate with the American College of Occupational and Environmental Medicine and other relevant medical associations to develop Current Procedural Technology (CPT) codes, relative value units (RVUs), and fee schedules in the near future so that physicians can bill for a defined set of services that facilitate functional restoration, SAW/RTW, and/or a fuller participation in life

• Create an incentive or a mandate for employers and private sector payers to assign a dollar value to these codes and to pay for the related services when the billing criteria are met

Certain medical services shown to improve return-to-work outcomes are available only to a limited number of individuals. This is partly because there is no mechanism for requesting these services, documenting them, or guaranteeing that a provider will be paid for them. Two examples are:

• Educating patients about the implications of their health condition for work and then counseling them on both why they should try to stay at work and how they can cope with the disruption to their life

• Carefully considering and then providing explicit guidance to workers (and to their employers or insurers) on what they can still do safely—including advice on whether certain tasks are within a worker’s capability and suggestions for possible job modifications, whether temporary or permanent

Nearly all physicians and other health care providers are required to use CPT codes to describe the services they provided when billing for them. The current list of codes, however, includes neither the two services mentioned above, nor similar services offered by other health care providers such as mental health professionals, physical therapists, or occupational therapists.

Adding CPT codes for these types of services would be a significant breakthrough, but creating a way for providers to be paid for them requires three additional steps: (1) assigning RVUs to each code that estimate the intellectual work involved, (2) requiring payers to add new codes to their fee schedules and to assign a specific dollar value to them, and (3) requiring payers to set their own criteria for when they will pay for a service.

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Idea No. 3