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Guide
to Ohio Workers' Compensation Medical Benefits
The following is an explanation of the provision of
medical benefits in the Workers' Compensation system. Included is
information on the Bureau's managed care system. You can scroll through
the information, or go directly to the area you want by selecting a
link from the list below. Additionally, on a separate page, we have a
chart setting out the "MCO
Decision Process".
Overview
There are three different Workers' Compensation medical
programs:
- State Fund Employers participate in a managed care
program, called a "Health Partnership Program" (HPP). The rules for HPP
are spelled out in O.A.C. 4123-6;
- Self-Insured Employers can choose to set up a managed
care program if they want to. If they choose to do so, the program is
referred to as a "Qualified Health Plan" (QHP). Self-Insured Employers
also can choose to join the BWC's HPP;
- Self-Insurers who do not set up a QHP, or join the
BWC HPP, will operate under the former system. For those Self-Insurers,
the rules spelled out in O.A.C. 4123-7 still apply.
A statewide list of BWC certified providers is available
on the BWC web site.
Types of Plans -- State Fund Employers
Each employer chooses an MCO. If an
employer does not chose an MCO, the BWC will assign the employer to an
MCO. If an employer is not satisfied with an MCO, there are enrollment
periods where an employer can switch MCOs. If the employer is satisfied
with the MCO, it will not need to do anything.
The list of which MCO serves which
employer is available on the BWC web site.
The injured worker has the choice of which doctor to use
in the Managed Care Organization (MCO) panel, but must use a BWC
certified doctor. If the injured worker is not happy with the doctor
chosen, s/he can switch to any BWC certified provider.
The HPP program for State Fund employers started March
1, 1997. For all injuries which occur on or after October 20, 1993, the
injured worker must be treated by a BWC certified provider. For
injuries which occurred on October 19, 1993 or before, an injured
worker can continue to be treated by a non-BWC certified provider.
However, if the injured worker switches providers, s/he has to go to a
BWC certified provider.
Types of Plans -- Self Insured
Employers
Self-Insurers have three options. A
self-insurer may either:
- set up a QHP (a self-administered
MCO),
- join in the BWC Health Partnership
(MCO) Program; or
- maintain the status quo as it existed
before Managed Care was provided for by law.
Any new employers being granted
Self-Insurer status must set up a QHP.
O.A.C. 4123-7 applies where the
Self-Insurer does not set up a QHP or join the BWC's HPP. If the
self-insurer does nothing, the injured worker has the same freedom to
chose a doctor that he has had in Ohio since 1959. The employer cannot
restrict injured worker's choice of doctor.
If the Self-Insurer sets up a QHP it has
an obligation to inform the employees as to who the medical providers
are in the QHP. If the Self-Insurer chooses to set up a QHP all its
providers must be chosen from the list of BWC certified providers.
If the injured worker has gone to the
QHP doctor once and is not satisfied, he may transfer to another doctor
on the QHP panel or elect to request treatment by any BWC certified
provider. The injured worker will need to make the request in writing.
If the Self-Insurer joins the BWC HPP
program, the injured worker will be going to a BWC certified medical
provider by using a doctor on the panel set up by the MCO. However,
here also, the injured worker may elect not to use a panel doctor and
instead can chose to go to any BWC certified provider.
The MCO -- What the MCO does
The MCO will manage the medical
aspects of the claim.
The MCO will also enter into
contracts with the various providers. The MCO and employer will be
responsible for informing employees of the panel of providers.
Each MCO will provide a dispute
resolution mechanism. [see "MCO Decision Process".]
The MCO -- Providers
Any provider may apply to be
certified. Once certified a provider may contract with many MCOs. The
provider sends his/her bill for service to the MCO which, if it
approves the bill, sends it to the BWC for payment. The BWC sends
payments for the bill to the MCOs who then pay the providers.
Providers will be certified for a two
year period and will then have to reapply for certification.
Providers who are not certified
initially will have an opportunity to correct the problem and become
certified.
Providers will enter into contracts
with MCOs. The contract will address the utilization of services.
The MCO adjudicates the doctor bill
in accord with its own negotiated rate with the doctor or the use of
the BWC regional processing fee schedule.
The MCO -- Appeals
In the event a provider's request for
authorization to do a specific procedure is rejected, the injured
worker or the provider may appeal within the MCO. If the MCO rejects,
an appeal is available to the BWC.
The BWC will issue a tentative order
which can be appealed (by either party but not by the provider) to the
Industrial Commission. [see "MCO Decision Process".]
The BWC's Role -- BWC
Compensability determinations
The BWC will still be responsible for
making compensabiltiy determinations (i.e., causal relationship,
work-relatedness, additional allowances.)
Under O.A.C. 4123-6-045, when the BWC
gets notice of a State Fund claim it will determine the allowance and
the conditions allowed. It will then notify the parties and the MCO.
The BWC Order may be appealed under O.A.C. 4123-6-16 and R.C. 4123.511
by the employer or the injured worker. The BWC will not pay medical for
disallowed claims or for conditions not allowed. Payment will be made
as provided under R.C. 4123.511 in allowed claims. In a contested claim
(under the present law) that means no payment until an SHO order
favorable to the injured worker issues. The provider can continue to
treat and the MCO to manage the claim while it is being contested, but
the MCO shall notify the injured worker that continued treatment may be
at the injured worker's expense. See also O.A.C. 4123-6-09.
Special Situations -- Emergency
If an emergency occurs the injured
worker may go to any doctor, whether certified by the BWC or not.
However, if the injured worker continues to go to a non-certified
doctor, s/he will be responsible for payment of the bill. O.A.C.
4123-6- 12.
Special Situations -- Injured
Workers Living Outside Ohio
Where the injured worker lives in
states surrounding Ohio, it is expected there will be certified
providers there, or that a doctor will apply to be certified.
Special Situations --
Pharmaceutical Benefits
Pharmaceutical benefits will be
managed through a pharmaceutical manager (PBM). The PBM is
administrative; it will not dispense medicine.
Prescriptions will still be filled
through local pharmacies.
ACS State Healthcare is the
pharmaceutical manager. ACS State Healthcare's address
is Northridge Center One, 365 Northridge Rd., Suite 400, Atlanta,
GA 30350.
Special Situations -- Non-Certified
Provider
Under O.A.C. 4123-6-062, if the injured
worker goes to a non-certified provider, the MCO is to pay for the
first visit if the claim is allowed and inform the provider that no
further treatment will be authorized. Under these circumstances, the
provider may apply for emergency credentialling from the MCO for care
and services unavailable through MCO panel providers, or the injured
worker or may continue to treat at his/her own expense. See also O.A.C.
4123-6-12.
Special Situations --
Confidentiality of Records
O.A.C. 4123-6-15 provides for
confidentiality of some records as provided by R.C. 149.43.
What legal challenges have been
made to the MCO system?
The Ohio Supreme Court has decided that the MCO process
is constitutional in two cases.
In State, ex rel. Haylett v.
Ohio BWC, decided on December 29, 1999, the Supreme Court held
that the MCO process is constitutional. To read about the Supreme
Court's decision, click here.
In Northwest Ohio Bldg. and Construction Trades
Council v. Conrad, decided on July 18, 2001, the Ohio Supreme
Court held that the method used to fund the MCO system is
constitutional. To read about the Supreme Court's decision, click here.
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