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Policy
and Procedure Name:
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Claim
Cost Adjustments (formerly called Medical Recovery/Medical Bill Adjustments)
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Policy
#:
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CP-03-14
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Code/Rule
Reference:
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R.C.
4123.34;
O.A.C. 4123-17-28
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Effective
Date:
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11/07/19
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Approved:
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Ann
M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims
Policy
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Supersedes:
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Policy
# CP-13-01, effective 11/09/18
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History:
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CP-13-01
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Rev.
09/06/13, 11/09/18; New 01/01/13
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CP-13-01.PR1
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Rev.
09/06/13, 11/14/16; New 01/01/13
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Claim Cost Adjustments (Medical Recovery/Medical Bill
Adjustments) Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Outbound EDI 148
IV. POLICY
A. It is the policy of BWC
to recover medical costs, adjust the amount of medical bills, and credit an employer’s
experience when:
B. Dismissed Conditions –
If BWC has paid bills for a dismissed condition(s), it is BWC’s policy to:
C. Employer Requests - When
an employer submits a request to:
V. PROCEDURE
A. Standard Claim File
Documentation and Other Instructions
B. Claim or Condition(s)
in Claim Disallowed/Overturned by the IC or Court
C. Treatment/Services
Unrelated to Claim Allowance(s)/No Longer Medically Necessary and Treatment
and/or Services Disallowed/Overturned by the IC or Court – Including BWC Errors
D. Claim or Condition(s) in
a Claim Dismissed by the IC or Court at the Request of the Injured Worker and
Paying Bills for a Dismissed Condition
E. Pharmacy Bill
Adjustments
F. Employer/IW Requests to
Move Medical Payments to a Different Claim (Does Not Include Pharmacy Bills)
G. Employer Request for
Adjustments
H. PES Claims Excluded from
Reimbursement from the Surplus Fund
The
purpose of this policy is to ensure that the Ohio Bureau of Workers’
Compensation (BWC) recoups payments made by BWC in error for medical services
rendered, modifies/adjusts medical bills, and credits an employer’s experience,
when appropriate.
This
policy applies to BWC staff and managed care organizations (MCO).
Outbound
EDI 148: Electronic transmission of data from BWC to an MCO.
A. It is the
policy of BWC to:
1.
Recover
medical costs, adjust the amount of medical bills, and credit an employer’s
experience as needed when:
a.
A
claim or condition(s) in a claim is disallowed/overturned by the Ohio
Industrial Commission (IC) or Court;
b. Treatment/services
are unrelated to the claim allowances(s)/no longer medically necessary;
c.
Treatment
and/or services are disallowed/overturned by the IC or Court (including BWC
errors); or
d. A claim is
dismissed by the IC or Court at the injured worker’s (IW’s) request.
2.
Notify
BWC’s Direct Billing Unit when an allowed claim assigned to a non-complying
employer is subsequently disallowed.
1.
Recover
medical costs; and
2.
Adjust
the amount of medical bills when a condition(s) is dismissed by the IC or Court
at the IW’s request.
1.
Credit
his/her policy number, BWC may not advise the employer that the policy number
will be credited until after the request has been properly researched and
approved.
2.
Move
medical payments to a different claim, it is BWC’s policy to research the
request to determine if the requested payment should be moved.
1.
BWC
staff shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note requirements; and
2.
Shall
follow any other specific instructions for claim notes included in this
procedure.
1.
Specific
Condition(s) Disallowed/Overturned by the IC or Court
a.
When
a specific condition in a claim is originally allowed, and then subsequently
overturned by the IC or Court on appeal and disallowed, claims services staff
shall:
i.
Enter
a claim note to summarize the IC Hearing Order or Court Order;
ii.
Notify
the MCO of the decision; and
iii. Notify BWC
Medical Billing and Adjustments (MB&A). E-mail
address is BWC CREDIT RISK ADJ and copy BWC MBA SUPV.
a) The
notification will contain the details of the IC Hearing Order or Court Order
and what specific payments require adjustment.
b) The MB&A
representative shall:
i)
Review
the note entered in the claim and the notification received from claims
services staff;
ii) Adjust all
payments, as needed; and
iii) Make the
appropriate charges to the Surplus Fund.
b. The MCO shall
receive an outbound EDI 148 when the ICD status is updated.
c.
All
medical payments made in the claim for the identified disallowed condition(s)
shall be adjusted.
d. Once the
adjustments are complete, MB&A shall respond to the requester that the
request has been completed.
2.
Entire
Claim Disallowed/Overturned by the IC/Court
a.
When
an entire claim is originally allowed, and then subsequently overturned by the
IC or Court on appeal and disallowed, claims services staff shall:
i.
Enter
a claim note to summarize the IC Hearing Order or Court Order; and
ii.
Notify
the MCO of the decision.
b. When the claim
is disallowed in its entirety in the claims management system:
i.
The
claims management system shall send the disallowed status to the employer
ratemaking system via nightly batch process. It is not necessary for claims
services staff to send notification to the Employer Rate Adjustment Unit or
MB&A.
ii.
The
employer’s experience shall be adjusted automatically within the ratemaking
system.
c.
The
MCO will receive an outbound EDI 148 when the claim status is updated.
d. MB&A shall adjust
all medical payments made in the claim.
e.
When
an allowed claim assigned to a non-complying employer is subsequently
disallowed and the decision is final (appeal periods have expired), claims
services staff shall:
i.
Send
an e-mail to the BWC Direct Billing Unit e-mailbox (BWC ARDB Requests) and copy
the Cash Control and Direct Billing Supervisor; and
ii.
In
the body of the e-mail, include the claim number and notification that the
claim has been disallowed.
1.
When
medical treatment/services are unrelated to the claim allowance(s)/no longer
medically necessary, payment(s) is made after denial/termination due to BWC
error, or medical treatment and/or services are disputed through the
Alternative Dispute Resolution (ADR) process and ultimately appealed to the IC
or Court and disallowed, claims services staff shall:
a.
Enter
a claim note to summarize the IC Hearing Order or Court Order;
b. Notify the MCO
of the decision; and
c.
Notify
MB&A. E-mail address is BWC CREDIT RISK ADJ and copy BWC MBA SUPV. The
notification shall contain details regarding the IC Hearing Order or Court
Order and what specific payments require adjustment.
i.
The
MB&A representative shall:
a) Review the note
entered in the claim and the notification sent by claims services staff;
b) Adjust
payments, as needed, in accordance with V.C.2. below; and
c)
Make
the appropriate charges to the Surplus Fund.
ii.
Once
the adjustments are complete, MB&A shall respond to the requester that the
request has been completed.
2.
When
treatment and/or services are disallowed or determined to be unrelated/no
longer medically necessary, only medical payments made for dates of service
after the date the treatment/services were disallowed or determined to be
unrelated/no longer medically necessary shall be adjusted, unless otherwise
ordered by the IC.
1.
When
a claim is dismissed by the IC or Court at the request of the IW, claims
services staff shall:
a.
Enter
a claim note to summarize the dismissal; and
b. Notify the
MCO. The MCO shall:
i.
Notify
the necessary providers that the claim was dismissed at the IW’s request;
ii.
Recover
payment(s) to the IW’s medical service provider(s) for the related service
billing on the claim; and
iii. Notify MB&A
that the MCO has recovered payment(s) from the provider(s).
a) MB&A shall
adjust all payments made and deduct payment from the MCO.
b) The IW shall be
responsible for bills related to the claim.
c.
Payments
for file review or independent medical exams performed in relation to the
dismissed claim shall be charged to the Surplus Fund.
d. If compensation
has been paid in the claim prior to the IC or Court dismissal, claims services
staff shall:
i.
Void
the previously paid payments;
ii.
Seek
an overpayment (See the Overpayment
of Compensation policy and procedure); and
iii. Send a BWC
Subsequent Order to the IW/claimant.
e.
If
medical bills only have been paid in the claim prior to the IC or Court
dismissal, claims services staff shall update the claims management system to
dismissed status.
f.
The
MCO shall receive an outbound EDI 148 when the claim status is updated.
2.
When
a claim is dismissed in its entirety, the claims management system shall send
the dismissed status to the employer rate making system via nightly batch
process and the employer’s experience shall be adjusted automatically within
the rate making system.
3.
When
a condition(s) in a claim is dismissed by the IC or Court at the request of the
IW:
a.
Claims
services staff shall send a notification to MB&A. The notification shall
include the following:
i.
Specifics
regarding the IC Hearing Order or Court Order;
ii.
Condition(s)
dismissed; and
iii. Payments that
require adjustment.
b. Claims services
staff shall:
i.
Enter
a claim note to summarize the dismissal; and
ii.
Notify
the MCO. The MCO shall notify:
a) The necessary
provider(s) that the condition was dismissed at the IW’s request; and
b) MB&A that
the MCO has recovered payment(s) from the provider(s). MB&A shall:
i)
Adjust
all payments made; and
ii) Deduct payment
from the MCO.
c.
Providers
must bill the IW, who is responsible for the bills related to the dismissed
condition(s), unless the bills meet criteria for payment as outlined in section
V.D.4. below.
d. Payments for
file review or independent medical exams performed in relation to the dismissed
condition(s) shall be charged to the Surplus Fund.
e.
The
MCO shall receive an outbound EDI 148 when the injury status is updated.
4.
When
the principal diagnosis on a bill is a diagnosis that is documented in the
claims management system notes as having been dismissed and the
diagnosis is medically necessary and related to the allowed conditions in the
claim, the bill may be paid. The MCO may submit an adjustment to MB&A for
each affected bill.
Example: Principal
diagnosis billed is osteoarthrosis of right knee, localized, not specified
whether primary or secondary, which is in a dismissed status in the claim.
However, the allowed condition in the claim is osteoarthrosis of the right
knee, unspecified whether generalized or localized. A bill is submitted for
treatment of osteoarthrosis of the right knee, localized, not specified whether
primary or secondary may be paid if it is medically necessary.
1.
When
medications are denied/terminated by BWC Order based on a physician review and
the order is appealed to the IC by the IW, the Pharmacy Department shall make
the necessary updates based on the IC Order. If the IC denies
treatment/medications with an effective date on or before the original denial
date and any bills are paid during the appeal period, the Pharmacy Department
shall coordinate the adjustments with MB&A.
2.
When
a request to move pharmacy payments from one claim to another with the same or
different policy number is received:
a.
Claims
services staff must refer the issue to the Pharmacy Department via the BWC
Pharmacy Benefits email box.
b. The Pharmacy
Department shall coordinate any necessary adjustments with MB&A.
1.
The
employer, including Public Employer State Agency (PES) employers, or IW may
request to move a medical payment(s) (does not include pharmacy bills) from one
claim to another with the same or different policy number. The request shall
be researched by claims services staff, in coordination with MB&A and the
MCO to determine where the payments should be appropriately placed.
2.
Claims
services staff shall:
a.
Review
pertinent claim information (including, but not limited to, allowed
condition(s) and date of injury) to make the determination; and
b. Enter a note in
both claims to document the results of the investigation.
3.
Once
claims services staff has identified the appropriate claim, he/she shall send a
notification to MB&A of the decision and the details of what adjustments
shall be made in the claim.
4.
The
MB&A employee assigned to move or credit bills shall notify claims services
staff when the adjustments are complete. Claims services staff shall notify
the MCO and/or the provider of the correction via phone or email for future
billing purposes.
1.
When
an inquiry or Motion (C-86) is received from an employer asking BWC to
credit the employer’s risk, claims services staff shall not advise the employer
that the risk will be credited until the matter is properly researched.
a.
If
the request received is regarding bills for drugs, claims services staff shall
refer the issue to the Pharmacy Department.
b. Claims services
staff shall not send a due process letter when a C-86 is filed to request a
credit to the risk.
2.
If
claims services staff determines that the request is valid, claims services
staff shall research the request and follow the appropriate guidelines.
a.
If
the investigation involves proper payment of medical bills, claims services
staff shall include the MCO in the investigation.
b. Depending on
the outcome of the research, claims services staff shall notify the employer of
the decision with the “Employer Risk Adjustment Letter.” Claims services
staff:
i.
Shall
choose one of the three inserts for the letter; or
ii.
May
insert text to adequately describe the decision reached.
1.
PES
claims shall be excluded from the medical recovery process because PE employers
do not contribute to the Surplus Fund.
a.
PES
employers must fund all costs through direct premiums.
b. Claims services
staff shall deny requests from PES employers to credit the employer’s risk via
charges to the Surplus Fund.
2.
When
an inquiry or C-86 is received from a PES employer asking BWC to credit the
employer’s risk, claims services staff shall notify the PES employer that the
request cannot be granted by sending the “State Agency Public Employer Risk
Adjust Letter.” If the PES employer disagrees with the decision, claims
services staff shall instruct the employer to contact BWC’s Actuarial section.