Medical treatment decision making for Ohio workers' compensation claims 
By Lance Watkins, VP, client services, Sedgwick MCO

One of the unique features of the Ohio workers’ compensation system is the involvement of managed care organizations (MCOs) in state-funded claims.  A primary role of the MCO is to address medical treatment requests submitted by an injured employee’s physician, which is closely related to the injury recovery and return-to-work process.  Following is a discussion of several aspects of the governance of a workers’ compensation claim and the handling of medical treatment.

How is the initial medical treatment after a work-related injury handled? 
Bureau of Workers’ Compensation (BWC) rules allow for an injured employee to receive the initial medical treatment after an injury from any physician or medical facility.  Subsequent medical treatment must be provided by a BWC-certified physician.  The specific treatment rendered during this initial visit is at the discretion of the treating physician with no MCO pre-approval required.  Payment for this initial service is guaranteed, provided that the claim is eventually allowed by BWC.  If the claim is denied, medical bills would typically be billed to private health insurance or directly to the employee.

How is the allowance of a claim and specific physical injuries/conditions determined?
The BWC is responsible for the claim allowance decision, as well as the specific physical conditions that comprise the scope of the claim.  The BWC relies heavily on the initial injury description (First Report of Injury), as well as the physician’s diagnoses and office notes from the initial medical evaluation and treatment.  The issue of “causality” is central to the BWC’s allowance decision, as they assess the correlation between the described injury and the nature of injury. 

Why must a physician involved in a workers’ compensation claim be certified by the BWC?
“BWC-certified provider” is the common terminology that refers to a physician’s eligibility to treat a workers’ compensation injury.  A physician willing to participate in the Ohio workers’ compensation system must contract directly with BWC and agree to maintain licensure requirements, accept fee-schedule payment for rendered treatment and comply with guidelines like MCO treatment requests and prompt submission of treatment notes. 

Why does the MCO have an oversight role in treatment?
As the insurance carrier, the BWC has a fiduciary responsibility to ensure that payments are made for medical treatment directly related to the allowed conditions in a claim.  Although state-funded employers select their MCO, MCOs are actually contracted by the BWC to provide this oversight.  MCOs are paid by BWC and incentivized by successful return-to-work and claim resolution.  At Sedgwick MCO, our view is that influencing efficient and effective treatment that leads to a safe and timely return-to-work is the best way take care of our client employers and their employees, while supporting the BWC’s stewardship of the state insurance fund.

Why would the MCO approve or deny requested treatment?
The Ohio workers’ compensation system grants a great deal of deference to BWC-certified physicians to pursue treatments for their patients that they believe will promote recovery.  Just as the BWC seeks a causal relationship between the injury description and diagnoses to determine claim allowance, the MCO seeks a close correlation between requested treatment and the allowed conditions in the claim.  There are a number of resources commonly referenced by the MCO to make sound treatment decisions (including Milliman, Official Disability Guidelines), but there is also consideration of factors like previous treatment, cost and available alternatives.   Our approach at Sedgwick MCO is to quickly facilitate meaningful treatment that makes sense for the claim and will lead to recovery and return-to-work.  It is not uncommon for the MCO to request additional commentary and rationale from the physician to support the treatment prescription.  A high priority is placed on clarity of treatment goals, results and recovery progress.

What recourse is available if anyone disagrees with the MCO’s treatment decision?
Alternative Dispute Resolution (ADR) is the arbitration process to resolve a disagreement in the MCO’s treatment decision.  The ADR process begins with an appeal of the MCO decision, and may involve a “Peer Review” (review of claim and treatment information by an independent physician reviewer) or an “ADR Independent Medical Exam” (physical evaluation of the injured worker to assess treatment recommendations), and often lead to an Industrial Commission hearing for a final call.  Our philosophy at Sedgwick MCO is to attempt to avoid delays inherent to the ADR process when possible through open and frequent dialogue with the physician and injured worker, collaborating for agreement on productive treatment.  The vast majority of ADR appeals are a result of an MCO’s denial of treatment, but any party to the claim can appeal.

We often say that no two claims are alike; every injury seems to follow a unique path of treatment and recovery that we must closely examine every step.  Ideally, you will find work-related injuries to be rare, and hopefully minor and simple when they do occur.  But if you do encounter a claim that involves significant medical treatment, we encourage you to remain in close contact with your injured employee and your MCO to facilitate open dialogue and a shared return-to-work objective.