Monetizing managed care in Ohio workers’ compensation

Ohio employers will soon have the opportunity to select a managed care organization (MCO) for the medical management of workers’ compensation claims. Open Enrollment will be held this month, and there will be an abundance of material published that attempts to compare MCOs in terms of effectiveness and service. Ultimately, employers must select an MCO based on what is most important to them. Service is an obvious factor, but the financial impact of the MCO should drive the decision.

Smart Business spoke with Quinn Guist, president of CompManagement Health Systems, to learn more about factors to consider when choosing an MCO.

What might employers miss when choosing an MCO?

It can be difficult to assess medical management and MCOs in terms of financial impact. When we think about money in Ohio workers’ compensation, we typically think of discount and rebate programs, administered by third-party administrators, that provide financial relief. We may also think of fighting a questionable claim to prevent unnecessary costs and preserve lower premium rates. These factors have clear implications for an employer’s premium, but the MCO’s function in managing the medical aspect of a claim cannot be overlooked.

What could be driving up costs that may go unrecognized?

Qualifying for a premium discount or rebate depends on claim costs relative to an employer’s size. Claim costs are mainly driven by lost workdays. The MCO’s primary focus is to facilitate a prompt, safe return to work, limiting lost workdays and helping injured employees recover and get back to work. Of course, injuries can be severe at times and may result in substantial time off work. Lost-time incurred on the claim drastically accelerates costs, and directly impacts the employer’s premium rates and options for discounts or rebates.

It is in cases like these where the MCO’s role is crucial to the financial future of the employer. Consistently engaging the injured employee and physicians to keep them focused on the return-to-work goal is critical. Every claim is different and there is no magical formula that guarantees painless results, but an employer should feel informed and confident that their injured employees are receiving appropriate medical treatment to help them recover and return to work.

What are the signs of a high-performing MCO?

One sign that an MCO is performing at a high level is in its response to treatment requests. Most treatment requests are appropriate for the injury and approved by the MCO. Occasionally, a treatment request will seek to treat issues unrelated to the claim and may be denied. But even with appropriate medical treatment requests, there are often opportunities to coordinate with the treating provider to encourage more beneficial treatment and/or shorter durations to keep the recovery process moving as quickly as possible. This requires a thoughtful MCO that is closely scrutinizing every opportunity to shorten periods of disability and minimize the burden of the claim on both the employer and the injured employee.

Most employers are aware of the value of offering modified duty to encourage an early return to work. MCOs can play a key role in matching a physician’s assessment of their patient’s physical ability with the employer’s flexibility to accommodate work restrictions. Throughout this process, there are therapy and rehabilitation resources available to help employers and employees continue to close the gap on working full duty, and the MCO is the access point for these services.

Another sign of a high-performing MCO is in their review of drugs prescribed in claims. While the Ohio Bureau of Workers’ Compensation utilizes a pharmacy benefits manager to oversee the prescription medications in workers’ compensation claims, it now allows MCOs to refer cases to be reviewed for excessive or inappropriate medications. It is well-known that the costs of prescription medications can be exorbitant, but it is not uncommon for an individual to be unable to work solely because of the side effects of prescribed medication.

Insights Workers’ Compensation is brought to you by CompManagement Health Systems