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Policy and Procedure Name:
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Claim Cost Adjustments (formerly called Medical
Recovery/Medical Bill Adjustments)
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Policy #:
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CP-03-14
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Code/Rule Reference:
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R.C. 4123.34; O.A.C. 4123-17-28
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Effective Date:
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11/07/19
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-13-01, effective 11/09/18
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History:
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CP-13-01
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Rev. 09/06/13, 11/09/18; New 01/01/13
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CP-13-01.PR1
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Rev. 09/06/13, 11/14/16; New 01/01/13
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Claim Cost Adjustments (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
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.
This policy applies to BWC staff and managed care
organizations (MCO).
Outbound EDI 148:
Electronic transmission of data from BWC to a MCO.
A. It
is the policy of BWC to:
1.
Recover medical costs, adjust the amount of medical bills, and credit an
employer’s experience as needed when:
a. A claim or
condition(s) in a claim is disallowed/overturned by the Ohio Industrial
Commission (IC) or Court;
b. Treatment/services
are unrelated to the claim allowances(s)/no longer medically necessary;
c. Treatment
and/or services are disallowed/overturned by the IC or Court (including BWC
errors); or
d. A claim is
dismissed by the IC or Court at the injured worker’s (IW’s) request.
2.
Notify BWC’s Direct Billing Unit when an allowed claim assigned to a
non-complying employer is subsequently disallowed.
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.
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.
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.
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). E-mail
address is BWC CREDIT RISK ADJ and copy BWC MBA SUPV.
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.
e. When an
allowed claim assigned to a non-complying employer is subsequently disallowed
and the decision is final (appeal periods have expired), claims services staff
shall:
i. Send
an e-mail to the BWC Direct Billing Unit e-mailbox (BWC ARDB Requests) and copy
the Cash Control and Direct Billing Supervisor; and
ii. In
the body of the e-mail, include the claim number and notification that the
claim has been disallowed.
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. E-mail address is BWC CREDIT RISK ADJ and copy BWC MBA SUPV. 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.
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. 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 payment(s) from the provider(s). 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.
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.
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.
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.
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 Claim
Cost Adjustments page on Claims Online Resources (COR) under Tips and Tools.