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Published on Jun 9
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Workers’ compensation can be a very difficult system to navigate. It is important for you to know the difference between the Ohio Bureau of Workers’ Compensation (BWC), your Managed Care Organization (MCO), and your Third Party Administrator (TPA). Below is a summary of which party handles what responsibilities:
[fusion_table]
| BWC Handles | MCO Handles | TPA Handles |
|---|---|---|
| Claim evaluation | Medical case management | Claim management |
| Compensation determination | Triage by RN for case management needs and case assignment | Hearing representation |
| Assignment of claim number | 3 pt. contact with injured employee, employer and medical provider | Claims award and reserve auditing |
| Wage calculation for compensation payments | Utilization review | Manual classification auditing |
| Assignment of customer service team | Peer review, quality assurance and alternative dispute resolution. | Payroll report auditing |
| Compensation/award payment | Bill processing | Experience rating and premium rate verification |
| Provider certification | Outcome measurements & statistical analysis | Alternative rate analysis |
| Identification & auditing employers | Education | Pursue lump sum settlement |
| Education | Filing motions, appeals and protests | |
| 90 day exams | Handicap reimbursement | |
| Fraud investigation | Schedule independent medical exams | |
| Approval of lump sum settlements | Education |
[/fusion_table]
[fusion_table]
| When to contact BWC | When to contact MCO | When to contact TPA |
|---|---|---|
| Initial determinations | Initial report of injury | Claim status |
| Allowance of additional conditions | Questions on medical bills | Questions on certification and compensation |
| Compensation benefit determination | Questions on treatment | Independent medical exams |
| Fraud | Change of physicians | Receipt of hearing notice |
| To request an exam or check status of an exam | Medical records/documentation | Lump sum settlement |
| Wage information | Treatment plans | Fraud |
| Living maintenance | MCO network of physicians | Safety programs |
| Monetary awards | Return-to-work questions | Violation of specific safety requirements |
| Rehabilitation | Excessive treatment | |
| Fraud | BWC/IC orders | |
| Utilization management | Rate questions & payrolls audits | |
| MCO procedures | Questions concerning WC coverage | |
| To request an exam or check status of an exam |
[/fusion_table]
It is important for the medical management of any workplace injury to communicate and collaborate. If you are ever unsure of who to contact, place your trust in your MCO, and they will lead you in the right direction.
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