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OhioBWC - Basics: (Policy library) - File

Policy 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:

09/06/13

Approved:

Freddie Johnson, Chief of Medical Services (Signature on File)

Origin:

Claims Policy

Supersedes:

Medical Recovery/Medical Bill Adjustments policy effective 01/01/13

History:

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

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that 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.

 

III. DEFINITIONS

 

Outbound EDI 148:  Electronic transmission of data from BWC to a managed care organization (MCO)

 

 

IV. POLICY

  1. It is the policy of BWC to recapture 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 Industrial Commission of Ohio (IC) or Court;

2.    Treatment/services are unrelated to the claim allowance(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 request;

 

B.    It is the policy of BWC to recapture medical costs and adjust the amount of medical bills when a condition(s) is dismissed by the IC or Court at the injured worker’s request.

 

C.   When an employer or injured worker submits a request to 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.

 

D.   BWC may pay bills for a dismissed condition(s).

 

  1. When an employer submits a request to credit his/her risk, BWC may not advise the employer that the risk will be credited until after the request has been properly researched and approved.  

 

BWC staff may refer to the corresponding procedure for this policy entitled “Procedure for Medical Recovery/Medical Bill Adjustments” for further guidance.

 

 

 

Procedure Name:

Procedure for Medical Recovery/Medical Bill Adjustments

Procedure #:

CP-13-01.PR1

Policy # Reference:

CP-13-01

Effective Date:

11/14/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on File)

Supersedes:

Medical Recovery/Medical Bill Adjustments procedure effective 01/01/13,09/06/13

History:

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

 

 

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

A.    Specific Condition(s) Disallowed/Overturned by the IC or Court

1.    When a specific condition(s) in a claim is originally allowed, and then subsequently overturned by the IC or Court on appeal and disallowed, field staff shall:

a.    Update notes in the claim summarizing the IC Hearing Order or Court Order;

b.    Notify the managed care organization (MCO) of the decision; and

c.    Notify Medical Billing and Adjustments (MB&A). 

i.      The notification will contain the details of the IC Hearing Order or Court Order and what specific payments require adjustment.

ii.     The MB&A representative shall:

a)    Review the note entered in the claim and the notification received from field staff;

b)    Adjust all payments, as needed; and

c)    Make the appropriate charges to the Surplus Fund.

2.    The MCO shall receive an outbound EDI 148 when the ICD status is updated.

3.    All medical payments made in the claim for the identified disallowed condition(s) shall be adjusted.

4.    Once the adjustments are complete, MB&A shall respond to the requester that the request has been completed.

5.    The Employer Rate Adjustment Unit shall print and send the Notification of Adjustment (AC-7) to notify the employer’s representative of the adjustment.

 

B.    Entire Claim Disallowed/Overturned by the IC or Court

1.    When an entire claim is originally allowed, and then subsequently overturned by the IC or Court on appeal and disallowed, field staff shall:

a.    Update notes in the claim summarizing the IC Hearing Order or Court Order; and

b.    Notify the MCO of the decision.

2.    When the claim is disallowed in its entirety in the claims management system:

a.    The claims management system shall send the disallowed status to the employer rate-making system via nightly batch process. It is not necessary for field staff to send notification to the Employer Rate Adjustment Unit or MB&A.

b.    The employer’s experience shall be adjusted automatically within the rate making system. 

c.    The Employer Rate Adjustment Unit shall print and send the AC-7 to notify the employer’s representative of the adjustment.

3.    The MCO will receive an outbound EDI 148 when the claim status is updated.

4.    MB&A shall make adjustments to all medical payments made in the claim.

 

III.   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

A.    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, field staff shall:

1.    Update notes in the claim summarizing the IC Hearing Order or Court Order;

2.    Notify the MCO of the decision; and

3.    Notify MB&A.  The notification shall contain details regarding the IC Hearing Order or Court Order and what specific payments require adjustment.

a.    The MB&A representative shall:

i.      Review the note entered in the claim and the notification sent by field staff;

ii.     Adjust payments, as needed, in accordance with III.B. below; and

iii.    Make the appropriate charges to the Surplus Fund.

b.    Once the adjustments are complete, MB&A shall respond to the requester that the request has been completed.

4.    The Employer Rate Adjustment Unit shall print and send the AC-7 to notify the employer’s representative of the adjustment.

 

B.    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.

 

IV.  Claim or Condition(s) in a Claim Dismissed by the IC or Court at the Request of the Injured Worker (IW) and Paying Bills for a Dismissed Condition(s)

A.    When a claim is dismissed by the IC or Court at the request of the IW:

1.    Field staff shall enter a note in the claim to summarize the dismissal and notify the MCO.

2.    The MCO shall notify the necessary providers that the claim was dismissed at the IW’s request.

3.    The MCO shall adjust or recover payments to the IW’s medical service provider for the related service billing on the claim.

4.    The MCO shall notify MB&A that the MCO has recovered payments from the providers. 

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.

5.    Payments for file review or independent medical exams performed in relation to the dismissed claim shall be charged to the Surplus Fund.

6.    If compensation has been paid in the claim prior to the IC or Court dismissal, field staff shall:

a.    Void the previously paid payments;

b.    Seek an overpayment (See the Overpayment of Compensation policy and procedure);

c.    Send a BWC Subsequent Order to the IW/claimant.

7.    If medical bills only have been paid in the claim prior to the IC or Court dismissal, field staff shall update the claims management system to dismissed status.

8.    The MCO shall receive an outbound EDI 148 when the claim status is updated.

 

B.    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.

 

C.   When a condition(s) in a claim is dismissed by the IC or Court at the request of the IW:

1.    Field staff shall send a notification MB&A.  The notification shall include the following:

a.    specifics regarding the IC Hearing Order or Court Order;

b.    condition(s) dismissed; and

c.    payments that require adjustment.

2.    Field staff shall enter a note in the claim to summarize the dismissal and notify the MCO.

3.    The MCO shall:

a.    notify the necessary providers that the condition was dismissed at the IW’s request; and

b.    notify MB&A that the MCO has recovered payments from the providers.  MB&A shall adjust all payments made and deduct payment from the MCO.

4.    Providers shall 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 VI. D. below.

5.    Payments for file review or independent medical exams performed in relation to the dismissed condition(s) shall be charged to the Surplus Fund.

6.     The MCO shall receive an outbound EDI 148 when the injury status is updated.

 

D.   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 submitted for treatment of osteoarthrosis of the right knee, localized, not specified whether primary or secondary may be paid if it is medically necessary.

 

V.    Pharmacy Bill Adjustments

A.    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.

1.    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 and the Employer Rate Adjustment Unit.

2.    The Employer Rate Adjustment Unit shall print and send the AC-7 to notify the employer’s representative of the adjustment.

 

B.    When a request to move pharmacy payments from one claim to another with the same or different policy (risk) number is received:

1.    Field staff must refer the issue to the pharmacy department via the BWC Pharmacy Benefits email box.

2.    The pharmacy department shall coordinate any necessary adjustments with MB&A and the Employer Rate Adjustment Unit.

 

VI.          Employer/IW Request to Move Medical Payments To a Different Claim (Does Not Include Pharmacy Bills)

A.    The employer, including Public Employer State Agency (PES) employers, or IW may request to move medical payments (does not include pharmacy bills) from one claim to another with the same or different policy (risk) number.  The request shall be researched by field staff, in coordination with MB&A, the Employer Rate Adjustment Unit and the MCO to determine where the payments should be appropriately placed.

 

B.    Field staff shall review pertinent claim information (including, but not limited to allowed condition(s) and date of injury) to make the determination.  Field staff shall enter a note in both claims to document the results of the investigation.

 

C.   Once field 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.

 

D.   The MB&A employee assigned to move or credit bills shall notify field staff when the adjustments are complete. 

1.    Field staff shall notify the MCO and/or the provider of the correction via phone or email for future billing purposes.

2.    The Employer Rate Adjustment Unit shall print and send the AC-7 to notify the employer’s representative of the adjustment.

 

VII. Employer Request for Adjustments

A.    When an inquiry or Motion (C-86) is received from an employer asking BWC to credit the employer’s risk, field staff shall not advise the employer that the risk will be credited until the matter is properly researched.

1.    If the request received is regarding bills for drugs, field staff shall refer the issue to the pharmacy department.

2.    Field staff shall not send a due process letter when a C-86 is filed to request a credit to the risk.

 

B.    If field staff determines that the request is valid, field staff shall research the request and follow the appropriate guidelines. 

1.    If the investigation involves proper payment of medical bills, field staff shall include the MCO in the investigation. 

2.    Depending on the outcome of the research, field staff shall notify the employer of the decision with the Employer Risk Adjustment Letter.  

a.    Field staff shall choose one of the three inserts for the letter;

b.    Or, field staff may insert text to adequately describe the decision reached.

 

VIII.        PES Claims Excluded from Reimbursement from Surplus Fund

A.    PES claims shall be excluded from the medical recovery process because PES employers do not contribute to the surplus fund. 

1.    PES employers must fund all costs through direct premiums.

2.    Field staff shall deny requests from PES employers to credit the employer’s risk via charges to the surplus fund.

 

B.    When an inquiry or C-86 is received from a PES employer asking BWC to credit the employer’s risk, field 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, field staff shall instruct the employer to contact BWC’s Actuarial section.

 

IX.          Medical Recovery Quick Reference Guide - The Medical Quick Reference Guide can be found on the Medical Bill Adjustments\Medical Recovery page on COR under Tips and Tools.  The guide summarizes the information in these procedures.  

 

 

 


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