For decades, studies of litigated workers’ compensation cases and the experience of claims handlers verified that employer care and concern for the employee immediately after an injury reduced ill will and litigation and facilitated rapid return to work.
Additionally, timely and appropriate medical care reduced the length and complication of the medical course and cost of treatment.
From May 3 to May 21, Ohio employers will be able to select a Managed Care Organization (MCO) to medically manage their workers’ compensation claims. Sanctioned by Bureau of Workers’ Compensation (BWC), Open Enrollment takes place every two years to allow Ohio employers to select an MCO that best suits their needs.
With the implementation of the BWC Health Partnership Program (HPP) and Qualified Health Plan (QHP, for self-insuring employers), a new era in health care for Ohio’s injured workers began. HPP brought together private MCOs and the BWC to provide comprehensive medical-management and claims-management services, respectively, to Ohio employers and employees.
The goal of the programs was to deliver high-quality, cost-effective health care for injured workers. BWC and MCOs work together to improve health care for employees and lower costs for businesses by focusing on an injured workers’ safe and early return to work.
Below are some frequently asked questions that will provide a better understanding of managed care and the role MCOs play in the workers’ compensation arena.
What is managed care?
Managed care is a system of health payment or delivery arrangements in which the plan coordinates the use of health services by its enrolled members in order to contain health expenditures and/or improve quality. The goal is to deliver appropriate health care services in a timely and cost-effective manner.
Must all employers have a workers’ compensation program in place?
Yes. Ohio employers can choose from different programs depending on how their organization is structured.
State fund employers can participate in a managed care program called the Health Partnership Program, in which employers choose an MCO. If one is not chosen, the BWC will assign the employer to an MCO.
Self-insured employers must set up their own QHP to deliver medical services to their employees or opt out, if they meet certain requirements.
What’s the difference between an MCO and a Third Party Administrator (TPA)?
An MCO delivers medical case management and coordinates vocational case management with effective and timely return-to-work. State fund employers are required to have an MCO in the HPP.
A TPA provides administrative claims management for employers and can be registered with the BWC as the employer’s administrative representative.
What are MCOs and what do they do?
MCOs are an integral part of the HPP. Certified by the BWC, MCOs handle the medical aspects of a claim by providing quality health care at an affordable cost. Their efforts in streamlining medical treatment, emphasizing health and wellness, and offering a wide spectrum of care within case management plans have revolutionized the health care industry. MCOs are leading the way in providing quality medical care for injured workers.
Do employers have to select a different MCO during open enrollment?
No. If the employer is satisfied with its current MCO, it will not need to do anything. Open enrollment enables employers to change MCOs if they are not satisfied with their current choice, if they need different services or if they just want to try someone different.
How does the MCO handle workers’ compensation medical claims?
Providers who treat injured workers send a bill for service to the MCO. When the bill is approved, the MCO sends it to the BWC for payment. The BWC then sends payment to the MCO, which, in turn, pays the provider.
What is the responsibility of an MCO?
* File first report of injury claim
* Ensure appropriate and timely medical care
* Coordinate return to work
* Offer a network of BWC certified health care providers
* Provide medical case management, including review of treatment requests and making treatment decisions
* Offer individualized transitional work programs
* Offer dispute resolution
* Initiate bill review and payment
* Educate and assist employers regarding safety and return-to-work initiatives
What should employers look for when choosing an MCO?
Look for an MCO that meets all the responsibilities outlined above and which has a high level of experience and success.
Today, only 3 percent of all work related injuries account for 50 percent of total medical expenses. MCOs strive to reduce workers’ compensation costs through early intervention, medical treatment plans and return to work programs while advocating care for injured employees.
George C. Smith III is Ohio District vice president of CorVel Corp. He oversees and directs the efforts of Ohio CorVel offices and staff. He has more than 30 years experience in the management of Workers’ Compensation systems and claims administration. CorVel is a BWC Managed Care Organization and national Workers’ Compensation cost containment company providing case management, utilization management, medical bill review, ADR, group health and integrated disability management programs to employers. Reach him at (800) 275-6463 or contact CorVel at [email protected]