Karen Conger on MCOs Featured

7:00pm EDT January 26, 2010

Navigating a workers’ compensation claim can be quite confusing. You may question if the claim is valid or if the treatment is necessary, or you may not understand much of the medical terminology. By working closely with a Managed Care Organization (MCO), you should be able to answer all these questions.

Your MCO should be able to help you understand if the injury and allowed condition(s) “make sense,” based on the injured worker’s job description and description of the injury. Your MCO should take care of all medical management and assist in returning your injured workers to work as soon as possible, and keep you informed regarding progress in the claim. Since all state-funded employers in Ohio are mandated by law to use an MCO, you should make sure that the one you choose provides you with all these services.

“It gives employers the medical experts and expertise at their fingertips,” says Karen Conger, CEO of Ohio Employee Health Partnership. “The MCO helps the employer through all of the medical components of a workers’ compensation claim, and works with the providers returning injured employees to work.”

Smart Business spoke with Conger about the role an MCO plays in a workers’ compensation claim and how to choose a good MCO.

What are the benefits of using MCOs?

You have access to medical experts who are involved in every aspect of the claim, from the date of injury to date of closure. A good MCO will contact and educate you to explain what’s going on medically with the injured worker, and will work to be sure that appropriate medical care is provided in order to help injured workers recover and return to work as soon as possible.

Over time, you should see a reduction in your premium to the Bureau of Workers’ Compensation (BWC), as well as fewer days that injured employees are out of work.

What kind of interaction takes place between the MCO, employer and injured worker?

MCOs are neutral parties, and work with employers, providers and injured workers to improve medical care and return employees to work. A good MCO coordinates all medical aspects of a workers’ compensation claim, and is responsible for reviewing every treatment authorization for reimbursement. A case manager is assigned to each claim to help everyone navigate through what can sometimes be a confusing medico-legal system. MCOs provide identification cards to injured workers, to be presented when visiting their treating physicians. You need to make sure your employees know whom to contact at your MCO, and encourage any injured worker to talk with the MCO case manager about any questions because it is important that the injured worker takes an active role in his or her recovery.

What are some key things employers need to understand about using MCOs?

You should understand the MCO’s role regarding medical management and payment of providers. Your MCO should be communicating with you on these aspects. Work with your MCO long before an injury happens to make sure everything goes smoothly when needed. In this regard, workers’ compensation is a lot like health insurance. You may not know what’s on your health plan until you need it, but you know it’s there. With your MCO, it’s better to know ahead of time whom to contact if an injury happens.

What kind of information needs to be laid out for the relationship between the MCO and employer to be successful?

Be aware that MCOs can also help you create a safer environment to prevent injuries. MCOs can educate your supervisors and employees. MCOs can review injury records and track trends in your work environment. For example, if one department tends to have a lot of specific injuries on a certain day, you can work with the MCO to investigate possible causes and solutions.

You can also work with the MCO to set up an aggressive but safe return-to-work program. With workers’ compensation you have both medical and indemnity (lost wage replacement) expenses. Working with your MCO to make sure the injured worker is back with modified duty will impact your indemnity expense. It’s also medically better for the injured worker to be at work instead of at home, worrying about paying bills and wondering about whether he or she still has a job. Develop your return-to-work program with your MCO’s help prior to a claim occurring.

You can also work with your MCO to find a quality health provider to suggest to injured workers. An employee is able to go to any physician who is BWC certified, but many times your employee will not know where to go right after an injury has occurred. Working together with the MCO on this can make a big difference in the quality of care your injured workers receive.

Make sure that your MCO is one of your first touch points once an injury happens. The sooner you let the MCO know that the injury has occurred, and get on top of it, the better it is for everyone.

What should you look for in a good MCO?

You should ask yourself four questions when choosing an MCO:

  • Does the MCO understand my company and what I do?
  • Does the MCO give me timely information when an employee is injured? You should choose an MCO that will communicate with you in whatever format is best for you, whether that be through the Internet, on paper, or by phone.
  • Can the MCO case manager meet with you in person and come out to your site to see exactly what your employees do?
  • Does the MCO put an emphasis on safe and timely return to work for the injured worker?

Karen Conger is the CEO of Ohio Employee Health Partnership.