OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Medical Recovery/Medical Bill Adjustments

Policy #:

CP-13-01

Code/Rule Reference:

R.C. 4123.34; O.A.C. 4123-17-28

Effective Date:

11/09/18

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

Policy # CP-13-01, effective 09/06/13 and Procedure # CP-13-01.PR1, effective 11/14/16

History:

CP-13-01

Rev. 09/06/13; New 01/01/13

CP-13-01.PR1

Rev. 09/06/13, 11/14/16; New 01/01/13

 


 

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

 

 

 


 

I. POLICY PURPOSE

 

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. 

 

II. APPLICABILITY

 

This policy applies to BWC staff and managed care organizations (MCO).

 

III. DEFINITIONS

 

Outbound EDI 148: Electronic transmission of data from BWC to a MCO.

 

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:

1.    A claim or condition(s) in a claim is disallowed/overturned by the Ohio Industrial Commission (IC) or Court;

2.    Treatment/services are unrelated to the claim allowances(s)/no longer medically necessary;

3.    Treatment and/or services are disallowed/overturned by the IC or Court (including BWC errors); and

4.    A claim is dismissed by the IC or Court at the injured worker’s (IW’s) request. 

 

B.    Dismissed Conditions – If BWC has paid bills for a dismissed condition(s), it is BWC’s policy to:

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.

 

C.   Employer Requests - When an employer submits a request to:

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. 

 

V. PROCEDURE

 

A.    Standard Claim File Documentation and Other Instructions

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.

 

B.    Claim or Condition(s) in Claim Disallowed/Overturned by the IC or Court

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).

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. 

 

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

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.  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.

 

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

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.     Adjust or 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 payments from the providers.  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.    

 

E.    Pharmacy Bill Adjustments

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. 

 

F.    Employer/IW Requests to Move Medical Payments to a Different Claim (Does Not Include Pharmacy Bills)

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.

 

G.   Employer Request for Adjustments

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.  

 

H.   PES Claims Excluded from Reimbursement from the Surplus Fund

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.

 

Medical Recovery Quick Reference Guide – The Medical Recovery Quick Reference Guide, which summarizes these procedures, can be found on the Medical Bill Adjustments/Medical Recovery page on Claims Online Resources (COR) under Tips and Tools.