Vohp Q&a 8-09

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? Every employer that obtains workers’ compensation insurance through the Ohio BWC is assigned or selects an MCO. If an employer does not select an MCO within 90 days of establishing workers’ compensation coverage or before they have their first claim, an MCO is assigned to them. How does VOHP get paid to provide these services? VOHP is paid by the Ohio BWC a percentage of each assigned employers’ premiums to medically manage their 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

governs the performance and services of the MCO, whereas, a TPA is an optional third party claims management organization that is available to employers on a fee basis. TPAs work as the authorized agent for the employer and have a broader risk management scope than an MCO has in medical claims management. TPAs will assist employers in certifying/rejecting claims, help determine the premium impact of a claim, enroll an employer in a Group Rating program, attend hearings on the employer’s behalf, and perform many other services that are not related to medically managing claims.

UNDERSTANDING THE ROLES AND RESPONSIBILITIES OF YOUR MANAGED CARE ORGANIZATION (MCO) VANTAGE OCCUPATIONAL HEALTH PLAN (VOHP)

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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 that VOHP has approved treatment on this disputed claim, why?

My injured worker keeps receiving bills for his/her claim. What do I do?

The BWC has 21 days to allow or disallow a claim based on the information that is received from the injured worker, the employer and medical providers. If treatment is requested within this decision period, VOHP is required to process that treatment request as if the claim was allowed. If treatment is appropriate for the alleged diagnosis, it may be approved “with a disclaimer”. This disclaimer means that if the claim is disallowed by the BWC, the injured worker is wholly responsible for the payment of services rendered. How does VOHP determine whether treatment “is appropriate” for a claim/diagnosis? VOHP approves and denies all treatment requests in accordance with Official Disability Guidelines (ODG). ODG are nationally recognized medical guidelines that provide the most up to date evidence-based medical treatments and disability durations for a particular medical diagnosis. Visit http://www.disabilitydurations.com/ What if the employer disagrees with a VOHP Treatment Decision? Employers have the right to appeal a treatment decision within 14 days of receipt of the decision. The request for dispute resolution should be submitted to VOHP in writing.

First, make sure that VOHP has received notification of the claim. Many times, especially if the FROI is initiated at the physician’s office/ER, we may not have received the FROI. It may have been sent to another MCO, etc. The first step is making sure the claim has been filed. Only If the claim has been filed and allowed, please fax all bills to VOHP at 800.946.7922. Please advise your injured worker to let their physician(s) know to fax all bills to us as well. If the claim has been filed and disallowed, the injured worker is responsible for the medical bills incurred. Why is VOHP currently paying bills on a 3 year old claim that has had no new treatment since the date of injury? In the BWC system, medical providers have two years to submit bills from the date of service (DOS). As long as they submit them before this two year statute, the bills are eligible to be paid. Also, if VOHP receives a bill that has been improperly submitted (wrong diagnosis code, treatment was not preauthorized, etc), we will deny payment and send an explanation of benefits (EOB) stating what is wrong with the bill submission. VOHP will continue to deny this bill based on BWC rules until the problem is corrected, which can also delay payment.

Job Descriptions What if a Treatment Request Does NOT Meet ODG? When a treatment request does not meet ODG VOHP refers the request to our Medical Director for review to approve or deny treatment. In this case, all approvals or denials are issued by our Medical Director. Both the employer and their TPA, if applicable, will receive a copy of any treatment decisions the same day the decision is sent to the service provider and the employee.

Payments The pharmacy will not fill my injured workers’ prescription under the BWC insurance even though the claim has been certified. The BWC has 21 days to allow or disallow a claim based on the information that is received from the injured worker, the employer and medical providers. If a prescription needs to be filled within that approval period, the injured worker will have to pay for the medication out of pocket. Once the claim is allowed, the injured worker can be reimbursed for their expense. 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

Why does VOHP ask for an employee’s job description on Lost Time or Restricted Duty claims? VOHP wants to provide a clear, concise job description to the physician of record so there is no confusion as to the description of job duties. The goal is to facilitate the earliest and safest return to work outcome for you and your employee based upon essential physical demands of their job.

Wages I’m not sure if I should pay salary continuation or let the BWC pay for my injured worker’s lost time. All advice on salary continuation or BWC compensation should be directed to your TPA or BWC employer contact. Wage issues are beyond the scope of an MCOs scope of medical management of claims and, therefore, are not permitted to consult on salary continuation. However, please be advised that a lost time claim will be assigned a reserve (future cost) which will increase your workers’ compensation losses should you decide to have the BWC pay wages.

UNDERSTANDING THE ROLES AND RESPONSIBILITIES OF YOUR MANAGED CARE ORGANIZATION (MCO) VANTAGE OCCUPATIONAL HEALTH PLAN (VOHP)

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Notice to Change Physician of Record (C-23)

proactive and efficient process.

Why is VOHP allowing a change of physician of record just because the injured worker has requested this change, especially when it appears that there has been a treatment plateau?

When is a 15K claim “eliminated” and referred back to VOHP for management?

The BWC rules provide that an injured worker has the right to be treated by the doctor of their choice so long as the doctor is a BWC certified provider. The injured worker may change their physician of record by completing a Notice to Change Physician of Record form and submitting it to VOHP. The injured worker is asked to identify the reason for change and VOHP is required to process this notice within 24 hours of receipt. A Notice to Change Physician of Record will usually be honored by the BWC unless the new physician is not BWC certified. What does it mean for a physician to be “BWC Certified”? A physician that is certified by the BWC has agreed to:

• • • •

Comply with all compensation laws and rules Maintain acceptable malpractice coverage Practice in a managed care environment Bill only for services provided, that are medically necessary, cost effective, and related to the claim/allowed condition. • Inform injured workers of their liability of payment of non-covered services prior to delivery • Charge no more than usual fees billed to non-workers’ comp patients for the same service • Accept BWC fee schedule and not balance bill the injured worker NOTE: Please be advised that VOHP promotes the utilization of a Preferred Provider (PP) in your company policy. Establishing a relationship with a local occupational health provider proves to have a positive effect on claims cost and on the objective progression of injured workers back to their full duty position.

The 15K Medical Only Deductible Program and the MCO The BWC offers this program which allows employers to selfpay medical only claims up to $15,000 directly to the provider at the BWC fee schedule. These claims are not processed by the MCO or BWC. NOTE: The MCO is prohibited from advising on any part of a 15K claim. Why do I have to notify VOHP of a new claim that is in my 15K Program when VOHP cannot authorize treatment or pay medical bills on these claims?

• As the employer you may opt out of this program at any time by notifying the BWC. At that time VOHP will assume the management of the claim including the authorization of treatment and payment of medical bills.

• If the injured worker loses more than seven days of work, thus becoming a Lost Time claim, the injury is no longer eligible for the 15K program and VOHP will assume the management of the claim including the authorization of treatment and payment of medical bills.

• If treatment is disputed by the employer/TPA, the claim is automatically terminated from the 15K program and is referred back to VOHP for management.

VOHP Quarterly Reports I have received a report from VOHP called a “Loss Run”, what does this report mean? This report shows your company’s total (open and closed) 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 report allows you to view and identify payments, track trends in your claims history, etc. I have received a report from VOHP called a “Fee Bill Listing by Employee”, what does this report mean? This report is an itemized claim detail of the costs paid thus far in the current calendar year. This information will help identify current claim activity that may require more proactive management. NOTE: If you have claims in the 5 year period queried, but have had no payments made on any of those claims in the current calendar year, you will only receive the “Loss Run” report. You will continue receiving these reports every quarter as long as you have claims in that 5 year period. I see something on the report(s) that I do not understand or necessarily agree with, who should I contact? You may contact the VOHP Account Representative, Brandy Jordan at 614.602.8273, Monday through Friday, 7:30am 4:30pm. For more information about Vantage visit our website at 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

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