You are on page 1of 3

UNDERSTANDING THE ROLES AND RESPONSIBILITIES OF YOUR

MANAGED CARE ORGANIZATION (MCO)


VANTAGE OCCUPATIONAL HEALTH PLAN (VOHP)

MCO Responsibilities:

As your MCO, VOHP is responsible for the medical case management of employees who file a claim against your Ohio
BWC Workers’ Compensation policy. MCO responsibilities include the following services:

• Receive, process, and file First Reports of Injury (FROI) with the Ohio BWC on behalf of the claimant and employer.
The FROI provides the information required to initiate a Workers’ Compensation claim in the State of Ohio.
• Initiate “Three Point Contact” communication with the: 1) Employer; 2) Injured Worker; and 3) treating Medical
Provider, to obtain and collaborate on information related to the claim.
• Provide objective medical case management that facilitates pro-active treatment, rehabilitation, and return-to-work.
• Review and authorize medical providers' treatment requests.
• Process and pay authorized medical treatment to treating medical providers on BWC allowed claims.
• Process Alternative Dispute Resolutions for disagreements over medical treatment requests.
• As your MCO we will provide claim information to the parties to the claim; the MCO cannot certify or deny a claim
on behalf of the employer.

VOHP’s objective is to facilitate an objective, safe, and productive return-to-work outcome. Our return to work team is
comprised of Nurse Case Managers and Claims Managers who develop individual plans to guide the return-to-work
process, even in the most difficult cases, and facilitate regular problem-solving contact with the health care provider,
employer, and injured worker.

Ohio BWC Responsibilities:

• The Ohio Bureau of Workers’ Compensation (BWC) is responsible for all claim determinations, certifications,
allowances, and paying lost wage compensation to injured workers.

Common Employer MCO Questions and Answers

How did VOHP become my MCO? governs the performance and services of the MCO, whereas, a
TPA is an optional third party claims management organization
Every employer that obtains workers’ compensation that is available to employers on a fee basis. TPAs work as the
insurance through the Ohio BWC is assigned or selects an authorized agent for the employer and have a broader risk
MCO. If an employer does not select an MCO within 90 days management scope than an MCO has in medical claims
of establishing workers’ compensation coverage or before management.
they have their first claim, an MCO is assigned to them.
TPAs will assist employers in certifying/rejecting claims, help
How does VOHP get paid to provide these services? determine the premium impact of a claim, enroll an employer in
a Group Rating program, attend hearings on the employer’s
VOHP is paid by the Ohio BWC a percentage of each behalf, and perform many other services that are not related to
assigned employers’ premiums to medically manage their medically managing claims.
claims. VOHP is not paid directly by the employer.

What is the difference between an MCO and a TPA (Third


Party Administrator)?

Every Ohio employer is required to have an MCO who is paid by


the BWC to medically manage claims. The BWC closely
UNDERSTANDING THE ROLES AND RESPONSIBILITIES OF YOUR MANAGED CARE ORGANIZATION (MCO)
VANTAGE OCCUPATIONAL HEALTH PLAN (VOHP) Page 2

Claim Allowance & Medical Treatment Corp will be the new PBM for the BWC. They can be reached
through the BWC number at 800.OHIO.BWC (644-6292).
The Employer is disputing a claim filed against their
Company; however, the employer received a letter stating My injured worker keeps receiving bills for his/her claim.
that VOHP has approved treatment on this disputed What do I do?
claim, why?
First, make sure that VOHP has received notification of the
The BWC has 21 days to allow or disallow a claim based on claim. Many times, especially if the FROI is initiated at the
the information that is received from the injured worker, the physician’s office/ER, we may not have received the FROI.
employer and medical providers. If treatment is requested It may have been sent to another MCO, etc. The first step is
within this decision period, VOHP is required to process making sure the claim has been filed.
that treatment request as if the claim was allowed. If
treatment is appropriate for the alleged diagnosis, it may be Only If the claim has been filed and allowed, please fax all bills
approved “with a disclaimer”. This disclaimer means that to VOHP at 800.946.7922. Please advise your injured worker to
if the claim is disallowed by the BWC, the injured worker is let their physician(s) know to fax all bills to us as well.
wholly responsible for the payment of services rendered. If the claim has been filed and disallowed, the injured worker is
responsible for the medical bills incurred.
How does VOHP determine whether treatment “is
appropriate” for a claim/diagnosis? Why is VOHP currently paying bills on a 3 year old claim
that has had no new treatment since the date of injury?
VOHP approves and denies all treatment requests in
accordance with Official Disability Guidelines (ODG). ODG In the BWC system, medical providers have two years to submit
are nationally recognized medical guidelines that provide the bills from the date of service (DOS). As long as they submit
most up to date evidence-based medical treatments and dis- them before this two year statute, the bills are eligible to be
ability durations for a particular medical diagnosis. Visit paid.
http://www.disabilitydurations.com/
Also, if VOHP receives a bill that has been improperly submit-
What if the employer disagrees with a VOHP Treatment ted (wrong diagnosis code, treatment was not preauthorized,
Decision? etc), we will deny payment and send an explanation of benefits
(EOB) stating what is wrong with the bill submission. VOHP will
Employers have the right to appeal a treatment decision continue to deny this bill based on BWC rules until the problem
within 14 days of receipt of the decision. The request for is corrected, which can also delay payment.
dispute resolution should be submitted to VOHP in writing.
Job Descriptions
What if a Treatment Request Does NOT Meet ODG?
Why does VOHP ask for an employee’s job description on
Lost Time or Restricted Duty claims?
When a treatment request does not meet ODG VOHP refers
the request to our Medical Director for review to approve or
VOHP wants to provide a clear, concise job description to the
deny treatment. In this case, all approvals or denials are
physician of record so there is no confusion as to the descrip-
issued by our Medical Director. Both the employer and their
tion of job duties. The goal is to facilitate the earliest and safest
TPA, if applicable, will receive a copy of any treatment
return to work outcome for you and your employee based upon
decisions the same day the decision is sent to the service
essential physical demands of their job.
provider and the employee.
Wages
Payments
I’m not sure if I should pay salary continuation or let the
The pharmacy will not fill my injured workers’ prescription BWC pay for my injured worker’s lost time.
under the BWC insurance even though the claim has been
certified. All advice on salary continuation or BWC compensation
should be directed to your TPA or BWC employer contact.
The BWC has 21 days to allow or disallow a claim based Wage issues are beyond the scope of an MCOs scope of
on the information that is received from the injured worker, medical management of claims and, therefore, are not
the employer and medical providers. If a prescription needs permitted to consult on salary continuation.
to be filled within that approval period, the injured worker will
have to pay for the medication out of pocket. Once the claim However, please be advised that a lost time claim will be
is allowed, the injured worker can be reimbursed for their assigned a reserve (future cost) which will increase your
expense. workers’ compensation losses should you decide to have the
BWC pay wages.
NOTE: VOHP is not authorized to administrate the
pharmaceutical aspect of the Ohio workers’ compensation
system. ACS is the Pharmacy Benefit Manager (PBM) for
the BWC. Effective November 1, 2009, SXC Health Solutions
UNDERSTANDING THE ROLES AND RESPONSIBILITIES OF YOUR MANAGED CARE ORGANIZATION (MCO)
VANTAGE OCCUPATIONAL HEALTH PLAN (VOHP) Page 3

Notice to Change Physician of Record (C-23) proactive and efficient process.

Why is VOHP allowing a change of physician of record When is a 15K claim “eliminated” and referred back to
just because the injured worker has requested this VOHP for management?
change, especially when it appears that there has been
a treatment plateau? • As the employer you may opt out of this program at any
time by notifying the BWC. At that time VOHP will assume
The BWC rules provide that an injured worker has the right to the management of the claim including the authorization of
be treated by the doctor of their choice so long as the doctor treatment and payment of medical bills.
is a BWC certified provider. The injured worker may change
their physician of record by completing a Notice to Change • If the injured worker loses more than seven days of work,
Physician of Record form and submitting it to VOHP. The thus becoming a Lost Time claim, the injury is no longer
injured worker is asked to identify the reason for change and eligible for the 15K program and VOHP will assume the
VOHP is required to process this notice within 24 hours of management of the claim including the authorization of
receipt. A Notice to Change Physician of Record will usually treatment and payment of medical bills.
be honored by the BWC unless the new physician is not BWC
certified. • If treatment is disputed by the employer/TPA, the claim is
automatically terminated from the 15K program and is
What does it mean for a physician to be “BWC Certified”? referred back to VOHP for management.
A physician that is certified by the BWC has agreed to: VOHP Quarterly Reports
• Comply with all compensation laws and rules
• Maintain acceptable malpractice coverage I have received a report from VOHP called a “Loss Run”, what
• Practice in a managed care environment does this report mean?
• Bill only for services provided, that are medically
necessary, cost effective, and related to the This report shows your company’s total (open and closed)
claim/allowed condition. claims and their total medical cost per year by month, year to
date, and total life of the claim for a period of five years. This
• Inform injured workers of their liability of payment of report allows you to view and identify payments, track trends in
non-covered services prior to delivery your claims history, etc.
• Charge no more than usual fees billed to non-workers’
comp patients for the same service I have received a report from VOHP called a “Fee Bill
• Accept BWC fee schedule and not balance bill the Listing by Employee”, what does this report mean?
injured worker
This report is an itemized claim detail of the costs paid thus
NOTE: Please be advised that VOHP promotes the utilization far in the current calendar year. This information will help
of a Preferred Provider (PP) in your company policy. identify current claim activity that may require more proactive
Establishing a relationship with a local occupational health management.
provider proves to have a positive effect on claims cost and
on the objective progression of injured workers back to their NOTE: If you have claims in the 5 year period queried, but have
full duty position. had no payments made on any of those claims in the current
calendar year, you will only receive the “Loss Run” report. You
The 15K Medical Only Deductible Program and the will continue receiving these reports every quarter as long as
MCO you have claims in that 5 year period.

The BWC offers this program which allows employers to self- I see something on the report(s) that I do not understand or
pay medical only claims up to $15,000 directly to the provider necessarily agree with, who should I contact?
at the BWC fee schedule. These claims are not processed by
the MCO or BWC. NOTE: The MCO is prohibited from You may contact the VOHP Account Representative, Brandy
advising on any part of a 15K claim. Jordan at 614.602.8273, Monday through Friday, 7:30am -
4:30pm.
Why do I have to notify VOHP of a new claim that is in my
15K Program when VOHP cannot authorize treatment or For more information about Vantage visit our website at
pay medical bills on these claims? www.ohpinc.com.

VOHP is responsible for immediate notification to the BWC


(First Report of Injury) of ALL claims. Should a 15K claim
become a BWC claim, VOHP is responsible to continue to
manage the claim from that point forward.. Obtaining all of the
claim information from the beginning allows for a more

End

You might also like