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OhioBWC - Basics: (Policy library) - File

Policy Name:

FIFTEEN THOUSAND DOLLAR MEDICAL ONLY PROGRAM ($15,000 MEDICAL ONLY PROGRAM)

Policy #:

CP-06-04

Code/Rule Reference:

R.C. 4123.29 (A) (6)

O.A.C. 4123-17-59

Effective Date:

 03/30/17

Approved:

Rick Percy, Chief of Operational Policy, Analytics and Compliance (Signature on file)

Origin:

Claims Policy (CP)

Supersedes:

08/12/13; 08/24/12; All policies and procedures regarding the $15,000 medical only program that predate the effective date of this policy.

History:

New 08/24/12; Rev. 08/12/13; 03/30/17

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure the BWC administers the fifteen thousand dollar medical only program in accordance with the laws and rules.

 

II. APPLICABILITY

 

This policy applies to BWC field operations, BWC employer program unit, and managed care organizations (MCO).

 

III. DEFINITIONS

 

Fifteen thousand dollar medical only program ($15,000 Medical Only Program):  An employer program which allows state fund employers the opportunity to pay up to the first $15,000 in medical and pharmacy bills for medical only claims with a date of injury on or after September 10, 2007.

 

Five thousand dollar medical only program ($5,000 Medical Only Program):  An employer program which allows state fund employers the opportunity to pay up to the first $5,000 in medical and pharmacy bills for medical only claims with a date of injury on June 30, 2006 to September 9, 2007.

 

Medical benefits:  For purposes of this policy, medical benefits include: treatment, and when appropriate, travel to that treatment; services; supplies; pharmacy benefits.

 

One thousand dollar medical only program ($1,000 Medical Only Program):  An employer program which allows state fund employers the opportunity to pay up to the first $1,000 in medical and pharmacy bills for medical only claims with a date of injury on July 1, 1995 to June 29, 2006.

 

 

IV. POLICY

A.    It is the policy of BWC to ensure that state-fund employers may participate in the medical only program that allows the covered state fund employers to choose to pay the first $15,000 of medical benefits of a medical only claim, including reimbursement for a BWC physician file review and/or independent medical examination (IME) and travel reimbursement requests related to the IME.  The medical only program shall not apply to claims in which an employer with knowledge of a claimed compensable injury or occupational disease has paid salary continuation (wages in lieu of temporary total compensation).

 

B.    BWC shall follow the standard process for making a medical only claim determination when an employer is enrolled in the medical only program.  BWC shall also ensure that medical benefits are not reimbursed while a particular claim is enrolled in the medical only program.  Once the employer is enrolled, all medical only claims with a date of injury on or after the enrollment date will be automatically included in the appropriate medical only program.  A claim that is changed to lost time is automatically removed from the medical only program.

 

C.   It is the policy of BWC that medical only claims that are enrolled in the medical only program shall not be medically managed by the managed care organizations (MCO).

 

D.   It is the policy of BWC that when a claim is removed from the medical only program for any reason, the MCO shall process the claim under standard protocols for claims management.

 

E.    It is the policy of BWC that the MCO shall not reconcile duplicative payments (i.e., employer paid bills and BWC paid bills), and that the MCO shall refer the employer to the provider for reconciliation of duplicate payments.

 

F.    An employer electing to participate in the medical only program must keep a record of the injury and shall keep a copy of all bills with proof and date of payment under the medical only program for six years from the last date a bill has been paid by the employer.  This information must be made available to BWC, the injured worker and/or his/her representative upon request.  BWC may request this information from the employer not more than twice a year.  When an employer is enrolled in the medical only program payment of medical benefit bills in the claim extends the statute of limitations based on the last medical paid date by the employer.

 

 

BWC staff may refer to the corresponding procedure for this policy entitled “Procedure for $15,000 Medical Only Program” for further guidance.

 


 

Procedure Name:

PROCEDURE FOR $15,000 MEDICAL-ONLY PROGRAM

Procedure #:

CP-06-04.PR1

Policy # Reference:

CP-06-04

Effective Date:

03/30/17

Approved:

Rick Percy, Chief of Operational Policy, Analytics and Compliance (Signature on file)

Supersedes:

11/14/16; 03/14/14; CP-06-04.PR1 effective 08/12/13; New 08/24/12

History:

New 8/24/12; Rev. 08/12/13; 03/14/14; 11/14/16; 03/30/17

 

 

I.      BWC staff shall refer to the Standard Claim File Documentation policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure.

 

II.    Determining if a Claim is Enrolled in the $15,000 Medical Only Program (15K Program)

A.    To determine if a claim is enrolled in the 15K Program, field staff shall go to the Insured Policy Page in the Employer Profile statement and click on the Questions tab.

 

B.    If the 15K group has checked the box stating that the employer is enrolled in the 15K Program, the system will automatically designate an appropriate claim as enrolled.

 

C.   When an employer is enrolled in the 15K Program, the assigned field staff can enroll or terminate a claim from the program so long as the date of injury (DOI) is after the policy enrollment date and medical benefits have not yet been paid in the claim.

 

D.   If the 15K Program checkbox is blank, the claim was never enrolled in the 15K Program.

 

E.    If field staff has questions about a claim in the 15K Program, staff may send an email to the BWC Claims Policy Field Techs mailbox.

 

F.    If field staff has questions about an employer in the 15K Program, staff may send an email to the BWC Employer Programs Unit mailbox.

 

III.   Enrolling a claim into the 15K Program

A.    When a claim is not systematically put into the 15K Program, staff may put a claim that is eligible for the program into the 15K Program when:

1.    The claim is changed from Lost Time (LT) to Medical Only (MO);

2.    There is a change in the policy number;

3.    Two or more claims are combined and the surviving object claim is not systematically placed into the 15K Program.

 

B.    Field staff shall investigate and ensure that the employer is enrolled in the 15K Program, and if so, appropriately place the particular claim(s) into the 15K Program by:

1.    Ensuring the claim type is correct (e.g., LT changed to MO);

2.    Ensuring no medical benefits have yet been paid in the claim

a.    If no medical benefits were yet paid, staff shall enroll the claim in the 15K Program;

b.    If medical benefits have been paid, staff shall:

i.      Refer to the Medical Only Program workflow, and

ii.     Send the “Medical Only Program Employer” letter to recover payments and remove charges from the employer’s experience.

 

C.   Field Staff shall update the claims management system by updating Claim Maintenance, Profile tab to reflect that the claim is in the 15K Program.

 

IV.  Un-enrolling a claim in the 15K Program

A.    A claim can be un-enrolled when:

1.    It changes from MO to LT the claims management system will automatically enter a termination date.

2.    The employer elects to have the claim removed and field staff shall enter the termination date in the claim management screen under the Profile tab.

 

B.    Staff shall un-enroll a claim by:

1.    Update the claim management screen under the Profile tab;

2.    Checking one of the following reasons in the drop-down box:

a.    Employer pays bills through the end date.  This is selected when the employer has provided BWC with an end date because they no longer wish to be responsible for the bills in a specific claim.

b.    Employer withdraws effective DOI.  This is selected when the employer does not wish to make any medical benefits payments in the claim at all and wants the claim excluded from date of injury.

c.    Reached Limit.  This is selected when the employer has notified BWC that they have paid the medical only program maximum allowable.

 

V.    Employer reimbursement to remove claim costs due to file reviews and independent medical examinations (IME) in the 15K Program claims

A.    All medical benefit bills should be sent to the employer for payment, except when BWC is processing the claim, or when a file review and/or independent medical examination (IME) and travel reimbursement requests related to the IME are necessary.

 

B.    Physician file reviews and/or IMEs and travel reimbursement requests related to the IME shall be paid by BWC as claim costs and will be charged to the claim.  This charge will appear as a charge to the employer’s experience regardless if the claim is enrolled in the 15K Program. Field staff shall remove these charges only at the request of an employer if the employer reimburses BWC for the claim costs.

 

C.   Field staff shall follow the Medical Only Program Workflow for File Reviews & IMEs and use the “Medical Only Program Employer” Letter for File Reviews and IMEs.

 

VI.  Application for Determination of Percentage of Permanent Partial Disability (%PP) or Increase of Permanent Partial Disability(C-92) in 15K Program claims.

A.    C-92 applications may be filed in a claim that is enrolled in the medical only program.

 

B.    Field staff shall process the C-92 application in its normal manner.  If the determination of the C-92 application results in:

1.    A 1% or greater award – this will change the claim to LT and the claims management system will systematically remove the claim from the medical only program.

2.    A 0% award - the claim shall remain in the 15K Program.

 

VII. Treatment and claim reactivation requests in 15K Program claims.

A.    When an MCO receives a Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9), and the claim is enrolled in the 15K Program, the MCO staff shall:

1.    Dismiss the C-9 request;

2.    Not include appeal language on the dismissal; and

3.    Notify the employer and provider.

 

B.    When a claim is removed from the 15K Program for any reason, the MCO shall be responsible for the:

1.    Medical management of the claim; and

2.    Processing of all bills, regardless of the date of service.

 

C.   When field staff receives a request for claim reactivation, staff shall verify whether the claim is enrolled in the 15K Program.

1.    If the claim is enrolled, field staff shall notify the MCO that the claim is enrolled in the medical only program and the claim reactivation request will not be processed.

2.    If the claim is not enrolled, field staff shall process the claim reactivation request.

 

VIII.        Travel Reimbursement in 15K Program claims

A.    When field staff receives a travel reimbursement request, staff shall verify if the claim is enrolled in the program or not.

1.     If the claim is enrolled and:

a.    If travel reimbursement is related to medical treatment, notify the injured worker that the claim is enrolled in the 15K program and the travel reimbursement request must be sent to the employer for processing.  BWC shall not process the request.

b.    If travel reimbursement is related to an IME, BWC shall process the request for travel reimbursement, and, if appropriate, pay.

2.    If the claim is not enrolled, field staff shall process the travel reimbursement request, and if appropriate, pay in accordance with the Travel Reimbursement policy.

B.    An employer may request to have claim costs due to a file review and/or IME and travel reimbursement requests related to the IME removed, for claims in the 15K Program claims, pursuant to section V. of this procedure, above.

 

IX.  Statute of limitations in 15K Program claims

A.    If there is a question as to whether the statute of limitations has expired in a claim, field staff shall request written documentation of the last medical benefit paid date from the employer.  Once the employer submits the information, field staff shall calculate the new statute expiration date based upon the last medical benefit paid date and enters a new statute of limitations override date in other claims dates in the claims management system.

 

B.    If a conflict exists in determining the date last medical paid date or the employer fails to submit written documentation of the last medical paid date, field staff shall refer the issue to the Industrial Commission on a Notice of Referral.

 

C.   Staff may refer to the Jurisdiction policy and procedure for more information.

 

X.    Complaints in the 15K Program claims

A.    BWC may receive complaints from an injured worker, the IW representative, and/or providers regarding non-payment of medical benefit bills by the employer.

 

B.    Field staff shall create a task and refer all complaints regarding the 15K Program to the employer program unit.

 

C.   The employer program unit shall investigate the complaint with the employer and notify the assigned field staff of the outcome via email.

1.    If the employer is to be removed entirely from the 15K Program, the employer program unit will remove the employer and notify the assigned field staff.  When the employer is removed from the program, all claims for the employer are removed.

2.    If the claim is to be removed from the 15K Program, the employer program unit shall notify the assigned field staff, and the field staff shall remove the particular claim from the 15K Program.

3.    If the claim is to remain in the 15K Program, the employer program unit shall notify the assigned field staff.

 


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