Evaluating MCOs: Report cards help businesses learn how well claims are handled

Just as school report cards helps parents understand how well their child performs in school, the Ohio Bureau of Workers’ Compensation’s MCO Report Cards help companies understand how well managed care organizations perform on workers’ compensation claims.

Available since 1998, these report cards break each organization down by number of employers, number of claims, first report of injury timing, first report of injury turnaround time and optimal return to work, says Barbara Jacobs, director of the MCO Business and Reporting Unit at the Ohio BWC.

The Ohio BWC calculates the scores based on information it receives regularly from MCOs. Even though open enrollment happens every two years, the Ohio BWC updates the information yearly so new employers looking for an MCO in the off years will have access to updated information.

Described below are each of the report card categories and what businesses should know about each:

  • Number of employers — This includes the number of employers assigned to the MCO who are in active, reinstated or debtor in possession status.
  • Number of claims — This includes all claims, regardless of the date of injury, that have received medical case management or utilization review in a specified period. It excludes claims with a date of death populated, claims in disallowed, dismissed or settled status and out-of-statute claims.

Employers should pay special attention to number of claims and number of employers, as this gives an indication of the size of the MCO, Jacobs says. Some employers are more comfortable with a smaller MCO, while others prefer a larger one.

  • FROI timing — This includes both the time from date of injury to when the employer, injured worker or provider notifies the MCO and the time from when the MCO is notified to the time the claim was filed with the Ohio BWC. The Ohio BWC removes the 5 percent of claims with the average longest lag times per MCO.
  • FROI turnaround time — This measures an MCO’s efficiency in submitting claims. MCOs must gather and validate information before submitting a claim to the Ohio BWC. FROI turnaround is the average of the number of days between the date MCOs receive the FROI notice and the date they electronically file a claim with the Ohio BWC.

The thing to keep in mind with FROI timing and turnaround is the sooner a claim is filed, the sooner the injured worker can receive medical treatment and benefits and then ultimately return to work.

  • Quality Medical Management — This is the model BWC uses to evaluate the return-to-work services and quality of medical management provided by MCOs. This contains two metrics: days absent and recent medical, which both use the injured worker’s injury/injuries and occupation when calculating the MCOs’ scores.

The report card is just one tool employers can use, and the purpose of the report card is to inform the employers, Jacobs says. MCOs will also send marketing materials during open enrollment, although the Ohio BWC reminds employers these are created with the intent to influence your MCO selection.

“Because each employer has its own unique needs, one employer’s decision may be based on a set of factors different from another employer,” Jacobs says. “It is most important for employers to make an informed decision after taking inventory of their needs and researching each MCO.”

FOR SPECIFIC QUESTIONS regarding an MCO, view the Ohio Bureau of Workers’ Compensation’s MCO Selection Guide at http://bit.ly/HdlJgO. To view the Ohio BWC’s 2015 MCO Report Card, visit http://bit.ly/HhVEdM.