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OhioBWC - Basics: (Policy library) - File

 

Policy Name:

$15,000 Medical-Only Program ($15K Program)

Policy #:

EP-06-01

Code/Rule Reference:

Ohio Revised Code (ORC) 4123.29(A)(6); Ohio Administrative Code (OAC) 4123-17-59; 4123-17-74, Appendix C.

Effective Date:

March 7, 2014

Origin:

Employer Policy

Supersedes:

All EM policies and procedures regarding the $15K Program that predate the effective date of this policy.

History:

$15K Program Complaint Policy, effective September 21, 2011, revised July 1, 2012, superseded by this policy.

Review Date:

March 7, 2019

 

 

I.      Policy Purpose

 

The purpose of this policy is to ensure that BWC administers the $15K Program in accordance with the applicable laws and rules.

 

II.    Applicability

 

This policy applies to BWC Employer Services, employers, and employer agents/authorized representatives.

 

III.   Definitions

 

A.    Lost-time claim: A claim of eight (8) or more days of lost time due to a work related injury. Even though compensation or wages in lieu of compensation has not been paid, the claim is still categorized as lost time.

B.    Maximum: The maximum medical cost that an employer can pay on an individual medical-only claim has changed over the history of the program. The date of injury of the claim defines the maximum, as follows:

1.    For claims with a date of injury between July 1, 1995, and June 29, 2006, the maximum is $1,000.

2.    For claims with a date of injury between June 30, 2006, and September 9, 2007, the maximum is $5,000.

3.    For claims with a date of injury on or after September 10, 2007, the maximum is $15,000.

4.    While the policy references the program as the $15K Program, the date of injury in a claim establishes the maximum amount in the claim, as set forth in III(B)(1), (2), and (3) above.

C.   Medical-only claim: A claim of seven (7) or less days of lost time due to a work related injury, with no compensation paid to the IW.

IV.  Policy

A.    Eligibility Criteria: To begin participation in the $15K Program, an employer must:

1.    Be paying premiums to the state insurance fund.

2.    Have coverage that is in force.

B.    Election to participate.

1.    No formal application is required.

2.    An employer must elect to participate by calling or emailing BWC.

C.   Operation of program.

1.    Employer responsibilities:

a.    The employer is responsible for all medical and pharmacy bills in all medical-only claims with a date of injury on or after the date the employer elects to participate in the program, until the maximum is reached. The employer, or its agent, should pay the provider on behalf of the injured worker.

b.    The employer must notify the injured worker and medical provider in writing to:

i.      Acknowledge the medical-only claim and that the employer elects to pay bills as provided under ORC 4123.29, and;

ii.     Request that all bills be submitted to the employer and not the injured worker or BWC.

c.    The employer must pay bills within thirty (30) days of receipt.

i.      For claims with a date of injury prior to June 30, 2009, the employer must pay all bills as billed or reach an appropriate reimbursement amount with the provider.

ii.     For claims with a date of injury after June 30, 2009, the employer must pay medical bills in accordance with BWC’s fee schedule. (BWC fee schedule information is located on www.bwc.ohio.gov, under Medical Provider, Look-Ups)

d.    If both BWC and the employer pay the same medical bill, it is the employer’s responsibility to seek reimbursement from the provider for the duplicate payment.

e.    The employer may remove a medical-only claim from the $15K Program by notifying BWC in writing, or by phone:

i.      Within fourteen (14) days of the filing of the claim, if the employer does not wish to pay any bills in that particular claim.

ii.     The last date of service on which it will be responsible for the bills in a particular claim. The employer’s managed care organization (MCO) will begin processing bills, regardless of date of service, after the notification.

f.     If the maximum has been paid, the employer must:

i.      Notify BWC and the MCO that the maximum has been paid.

ii.     Provide the MCO proof of payment and copies of bills paid in the proper format.

g.    If the payment of a particular bill will exceed the maximum, the employer should pay the portion of the bill that will bring payment to the maximum and notify the provider to bill the MCO for the remainder of the bill.

h.    The employer must provide copies of the bills in a claim, in the proper billing format, to BWC, the injured worker, or the injured worker’s representative upon request.

i.      The employer must, upon written request from BWC, provide BWC documentation of all medical-only bills that the employer is paying directly.

i.      BWC may make such request no more than semiannually.

ii.     BWC may remove the employer from the program if the employer fails to provide the documentation to BWC within thirty (30) days of the receipt of the request.

j.      The employer must keep a record of the injury on file for five (5) years from the last date the employer paid a bill, or until the information has been received by BWC. The employer must provide the information to BWC, the injured worker, or the injured worker’s representative upon request. The employer must keep record of:

i.      Injured worker name, address and social security number.

ii.     Date and time of injury.

iii.    Type of injury.

iv.   Part(s) of body injured.

v.    Brief description of accident.

vi.   Copies of bills and proof of payment, including the payment date(s).

k.    The employer must meet federal Medicare requirements beginning July 2010. An employer can learn more through the Centers for Medicare and Medicaid Services web site, www.cms.gov.  

2.    Employer limitations.

a.    The employer cannot:

i.      Pay bills on claims in which it has paid wages in lieu of compensation.

ii.     Authorize or deny treatment.

iii.    Agree to additional conditions and cannot process a Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupation Disease (C-9).

iv.   Utilize its MCO to authorize treatment or pay medical bills.

v.    Include paid wages while the employee was off work as part of the maximum.

vi.   Utilize the $15K Program for a medical-only claim that occurs during a period of lapsed coverage.

b.    The employer may participate in other compatible BWC employer programs during its participation in the $15K Program. Employer compatibility is outlined in OAC 4123-17-74, Appendix C. Programs that may be compatible with the $15K Program are:

i.      Destination: Excellence.

ii.     Drug-Free Safety Program (DFSP).

iii.    Early Payment Discount.

iv.   EM Cap.

v.    Grow Ohio Incentive.

vi.   One Claim Program (OCP).

vii.  Safety Council.

viii.Group Experience Rating Program.

ix.   Retrospective Rating Program.

x.    Go Green.

3.    BWC responsibilities. BWC will:

a.    Notify providers that send bills to BWC that the employer is responsible for the bills in the claim.

b.    Not charge the employer’s experience for payments made under this program. If the employer complied with the program rule, and BWC made payments in contravention of the rule, BWC will adjust the employer’s experience.

c.    Investigate allegations that the employer has not paid medical bills in accordance with the program requirements. Actions that BWC may take if it is determined the employer failed to pay medical bills according to program requirements include, but are not limited to:

i.      Remove the specific claim from the $15K Program.

ii.     Remove the employer from the $15K Program. In this case, all of the employer’s medical-only claims are removed from the program.

d.    Process bills on a medical-only claim if an employer removes the claim from the program.

e.    Not automatically remove an employer from the $15K Program if the employer’s coverage lapses. However, a medical-only claim that occurs during a period of lapsed coverage will not be part of the $15K Program.

D.   Stipulations:

1.    Payment of a bill by the employer does not waive BWC’s right to adjudicate the claim or the employer’s right to contest the claim should a claim be filed.

2.    The program does not supersede the injured worker’s right to file a claim with BWC.

3.    BWC will not pay interest on bills that were not paid within thirty (30) days if the bills are the responsibility of the employer.

4.    BWC will not mediate fee disputes between the employer and provider.

5.    The injured worker is not liable for a bill that an employer participating in the $15K Program fails to pay.

6.    Once an employer pays a bill under the program, BWC will not reimburse the employer.

7.    A claim is removed from the program immediately if the claim changes to a lost-time claim. See Claim Policy.

8.    The employer’s failure to pay bills timely will not affect the employer’s coverage status.

9.    All bills must be submitted to the employer in the proper billing format and received by the employer within one (1) year of the date of service of the bill.

E.    Exit from program. An employer may cancel its participation in the $15K Program at any time by calling or emailing BWC. The employer’s MCO will process all bills in all medical-only claims for the employer after the date of removal.

F.    Resolution of complaints.

1.    The employer may appeal BWC’s decision to remove the employer, or a specific claim, from the program to the BWC Adjudicating Committee, per OAC 4123-14-06.

2.    Employer complaints should be processed under the General Employer Complaint Policy. BWC has not identified any program-specific extenuating circumstances that apply to the $15K Program.

G.   Combinations and transfers.

1.    Predecessor: Enrolled in $15K Program.

Successor: Not enrolled in $15K Program.

Action: Predecessor’s enrollment in the $15K Program terminates as of the effective date of combination.

 

2.    Predecessor: Enrolled in $15K Program.

Successor: Enrolled in $15K Program.

Action: Predecessor remains enrolled in the $15K Program. Successor must comply with all program requirements for predecessor’s medical-only claims.


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