Grievance Conference with Providers
accordance with (OAC 4123-6-044); “The MCO shall review all bills submitted to
it for payment by a provider for appropriateness consistent with the MCO’s
utilization standards and certification requirements. The MCO shall have in
place and operating a grievance hearing procedure allowing a provider,
employer, or employee to grieve a disputed bill payment.”
rule uses the term “grievance hearings” or “grievance conference” to describe
the appeal procedure the MCO must have in place. The MCO’s grievance hearing
procedures are limited to 1) appeals regarding the recovery of overpayments
and 2) bill payment disputes such as denial of payment or reduced payment.
Grievance hearings shall not address fee schedule grievances or ADR issues.
The grievance hearing gives the disputing party the opportunity to present
evidence to support the disagreement and affords due process.
of an Overpayment
March 1, 2000, MCOs implemented a recovery grievance conference that provided
due process for the provider and adjudicated disputes regarding recovery of
reimbursements in the following manner:
notified by MCO an overpayment has been identified and adjustment will be
processed to recover the funds.
may appeal the MCO’s decision in writing within 14 days.
recovery grievance conference will allow a provider to grieve the disputed bill
payment. The MCO will schedule a recovery grievance conference within 14 days
upon receipt of the provider’s written appeal. The MCO must notify the
provider of the date, time, location of the conference, the issue and a
statement of fact. The conference will be limited to the stated issue in the
conclusion of the recovery grievance conference, the MCO will issue a decision,
in writing, to the provider within 7 days.
may appeal the MCO’s recovery grievance conference decision to BWC’s
Administrator’s designee. The provider may appeal the MCO’s recovery grievance
conference decision to BWC Medical Bill Payment Recovery, within 14 days after
receiving the decision of the MCO, via email to: Sharon.Kaeppner@bwc.state.oh.us
Administrator’s designee will review and make the final determination within 14
MCO determines an overpayment should be recovered because the service did not
meet Miller criteria (medically necessary and appropriate, related to
the treatment of the industrial injury and the costs medically reasonable),
then the MCO may initiate recovery. However, if the provider appeals that
recovery, then the recovery process shall stop and the appeal submitted by the
provider should be considered as an ADR appeal. The receipt date of the
provider’s appeal by the MCO will be day one of the ADR process. The MCO must
follow the criteria for appeals received in ADR, for example, the appeal must be
medical billing dispute exists when a provider is not satisfied with the amount
of payment and explanation of benefits received from an MCO, but does not
include dispute of BWC’s fee schedule rates. The provider should submit a
request for reconsideration to the MCO to begin the bill grievance dispute. The
MCO shall review the bill, and determine if the provider is correct and an
adjustment is appropriate or if the MCO’s initial payment was correct. If the
MCO’s review determines that the issue is still not resolved, they should
proceed to the bill grievance conference process. The MCO must provide the
reason and the rationale for the initial medical bill payment decision.
Examples of the rationale may include BWC’s coverage provisions or coding
conventions. The MCO’s procedure may be a review by a nurse or
supervisor. Once the review is completed, the decision on the review is
communicated to the provider in writing.
for Handling Billing Disputes
provider disagrees with the denial of payment or a reduced payment a medical
billing dispute exists and the following steps shall be taken:
Provider contacts the MCO to inquire about the reimbursed amount or denial of a
medical bill via; e-mail, fax, phone, mail. It may be necessary to submit the
inquiry, along with supporting documentation, in writing to the MCO. The
provider and the MCO should keep detailed notes for his/her records, including
the name and phone number of the person to whom he/she spoke, fax
be necessary for the provider to request to speak to an MCO supervisor to
resolve the issue or to escalate the issue to a grievance conference. Most
provider billing inquiries can be handled by the MCO on the phone.
shall acknowledge the inquiry (e-mail, fax, phone, mail) within four (4)
calendar days of receipt, and shall resolve or initiate resolution of the
inquiry within seven (7) calendar days of receipt per the MCO contract.
issue is not resolved with the MCO, the provider should be instructed on how to
initiate a medical bill grievance conference with the MCO. The conference may
occur in person or via telephone, and shall occur within seven (7) calendar
days from the request for the conference. MCO’s must document details of all
grievances conferences and the outcome.
shall issue a decision, in writing, within seven (7) calendar days from the
date of the conference. The MCO’s determination letter shall be imaged into
the injured workers claim. Imaging documents in the claim will make it
possible for BWC to research any subsequent provider complaint that may come
into the Provider Contact Center and will provide documentation that the
medical bill grievance was addressed.
Elements for “Bill Dispute Grievance Conference Decision.” letter.
of the specific documentation reviewed at the conference such as the office
notes or other documentation;
place and persons who participated in the conference (MCO and Provider) and the
method used for the conference (phone, face to face or email).
provider does not agree with the MCO’s decision, the provider may contact BWC’s
Provider Contact Center at 1-800-ohiobwc, option 3-0 or via email at
email@example.com to ask for BWC’s assistance in resolving the
billing dispute. It is the MCO’s responsibility to inform and provide this
information to the provider. The BWC Provider Contact Center will ask the
provider to document the complaint, which will be researched and tracked. It
may be necessary for the BWC Provider Contact Center to consult other BWC
departments such as,
(but not limited to ) Medical Policy, Voc
Rehab Policy, Medical Director or Legal or for input in making a determination.
provider contact center will refer the provider back to the MCO if the
grievance conference has not been held. If the MCO did not conduct a medical
bill grievance conference or the documentation has not been imaged into the
claim, the provider’s request for a medical bill dispute shall be referred by
BWC back to the MCO. BWC will educate the provider on the process and the
steps that are established to handle such inquires/requests/grievances.
BWC’s Provider Contact Center will coordinate a written response to the provider and the MCO and
send the response to the IW’s claim file. After BWC’s determination is
rendered, no additional levels of review will be considered.
any point during the inquiry/dispute process the MCO or BWC determines that a
payment correction is needed, the MCO shall correct or submit an adjustment to
BWC within fourteen (14) calendar days of determination. If BWC has reviewed
and made a determination to instruct the MCO to pay the provider, the MCO will
notify the Provider Contact Center when the payment is released.