Managed Care

Making the Case for Workers’ Comp Case Management

Ella Baker
Making the Case for Workers’ Comp Case Management
Reading time 5 Mins
Published on Jul 25
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Ensuring employees get the help they need and helping you manage premiums.

Ohio BWC and case management

A Managed Care Organization is a private company that employers select to medically manage their workers’ compensation claims for injured employees. The Ohio Bureau of Worker’s Comp requires all employers that pay into the state fund to have an MCO to manage their claims, and the cost is already built into your premiums. A strong partnership with your MCO is important to ensure your injured workers receive the treatment they need to get back to work as safely and quickly as possible.

Core case management functions

Providing medical case management for the duration of the claim, the MCO obtains the initial claim date, works with the medical provider to obtain medical records and physical restrictions, and assists with getting injured workers back to work safely. The MCO monitors all claims and approves medical payments throughout the process. The core case management functions of an MCO include:

  • Collecting initial injury reports and transmitting to the BWC;
  • Management and authorization of medical treatment to be received by an injured worker;
  • Medical review and bill payment processing;
  • Maintaining a network of BWC-certified healthcare providers;
  • Return to work (RTW) services;
  • Utilization review;
  • Providing Peer Reviews as necessary for treatment decisions;
  • Processing treatment appeals through the Alternative Dispute Resolution (ADR) process;
  • Training and education

By working to reduce the length of time an employee is out of work due to an injury, MCOs are also able to help employers manage their long-term workers’ compensation insurance premiums. This is primarily achieved through avoiding or reducing the length of lost time claims, which occur when an injured employee is off work eight or more days, through modified duty off-site work programs and other return to work services.

Benefits of case management for your company

• Communication- With so many stakeholders involved in Worker’s Compensation Case Management, every Case Manager must be highly skilled in communication and collaboration. Since your Case Manager is the central repository of information obtained from your employee, their attorney, and all providers of care for your employee, they are able to provide you with a whole picture of the claim. This wealth of information allows your Case Manager and you to make the best decisions for your company quickly and efficiently.

• Decrease Cost of the Claim- Our Case Managers work closely with Utilization Review team to ensure that medical costs are contained. Utilization Review assesses the medical care provided to an injured worker for factors including: medical necessity, appropriateness of the place of care, level of care and duration, and frequency and quality of services. While we want to provide the right treatment for the employee, we also want the treatment to end with the common goal of returning your employee to work with the lowest cost.

• Active Participation with the Employee- By speaking early and often with your Case Manager, you have a direct line of communication with the employee. The Case Manager can assist with facilitating communication between you and the employee to ensure a safe and timely return to work. This facilitation helps the employee to feel connected to their workplace and provides you with the information you need to maintain production.

Benefits of case management for your employees

• Promote Wellness, Not Illness- The Case Manager will work with your injured employee to set “self-care” goals and assist them to meet those goals and return to work. Research shows that a speedy return to work helps the employee feel more useful.

• Effective Early Treatment- The BWC provides a “presumptive” period of 60 days from the date of injury during which most diagnostic testing and treatments are approved without the MCO making a treatment decision. This period of time facilitates early treatment, which has been shown to facilitate optimal outcomes for the injured worker. Your Case Manager takes advantage of this period of time to ensure that all needed testing and treatment is completed early. This ensures that the correct diagnoses are added to the claim and treated appropriately from the onset of treatment. Delivering the right treatment at the right time by the right provider can significantly lessen the length of disability of your employee – allowing them to return to work sooner.

• Reinforcement of the “Going to Work” Habit- The best way to get the injured employee to return to work is to talk about it and set goals with specific end dates that leads them on the road back to the work place. The Case Manager will also identify RTW services that best meet the needs of your injured employee, including modified duty off site and light duty options.

Helping you manage the claims process

When an employee is injured in the workplace, it can often be a stressful and confusing time for your company. In addition to lost production, you are also worrying about the health and safety of your injured employee. With an MCO partner like Sheakley UniComp, you and your injured worker will have the support of a case manager to work with you through the workers’ compensation case management system to achieve the common goal of returning your employee to work quickly and safely.

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