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Policy and Procedure Name:

FIFTEEN THOUSAND DOLLAR MEDICAL ONLY PROGRAM ($15K PROGRAM)

Policy #:

CP-06-04

Code/Rule Reference:

R.C. 4123.29 (A) (6)

O.A.C. 4123-17-59

Effective Date:

08/13/2021

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-06-04, effective 10/06/2020

History:

Previous versions of this policy are available upon request


 

Fifteen Thousand Dollar Medical Only Program ($15K Program)

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Fifteen-thousand-dollar medical only program ($15K Program)

Medical benefits

IV. POLICY

A.          Participation

B.          Medical Only Process

C.          MCOs’ Role

D.          Employer Requirements

V. PROCEDURE

A.          General Claim Note and Documentation Requirements

B.          Determining if a Claim is Enrolled in the $15K Program

C.          Enrolling a Claim into the $15K Program

D.          Un-Enrolling a Claim in the $15K Program

E.          Employer Reimbursement in $15K Program Claims

F.          Application for Determination or Increase of Percentage of Permanent Partial Disability (C-92) in $15K Program Claims.

G.         Treatment and Claim Reactivation Requests in $15K Program Claims.

H.          Travel Reimbursement in $15K Program Claims

I.            Statute of Limitations in $15K Program Claims

J.           Complaints in $15K Program Claims

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure the BWC administers the fifteen thousand-dollar medical only program in accordance with the laws and rules.

 

II. APPLICABILITY

 

This policy applies to BWC claims services, BWC employer program unit, and managed care organizations (MCO).

 

III. DEFINITIONS

 

Fifteen-thousand-dollar medical only program ($15K Program): An employer program which allows state fund employers the opportunity to pay up to the first $15,000 in medical and pharmacy bills for medical only claims with a date of injury on or after September 10, 2007.

 

Medical benefits: For purposes of this policy, medical benefits include treatment, and when appropriate, travel to that treatment; services; supplies; pharmacy benefits.

 

IV. POLICY

 

A.    Participation

1.    It is the policy of BWC that covered state-fund employers may participate in the $15K Program, which allows employers to choose to pay the first $15,000 of medical benefits of a medical only claim, including reimbursement for a BWC physician file review, independent medical examination, and travel reimbursement requests related to the independent medical examination. 

2.    The $15K Program shall not apply to claims in which an employer with knowledge of a claimed compensable injury or occupational disease has paid salary continuation (wages in lieu of temporary total compensation).

 

B.    Medical Only Process

1.    BWC shall follow the standard process for making a medical only claim determination when an employer is enrolled in the $15K Program. 

2.    BWC shall also ensure that medical benefits are not reimbursed while a claim is enrolled in the $15K program. Once the employer is enrolled, all medical only claims with a date of injury on or after the enrollment date will be automatically included in the $15K program. A claim that is changed to lost time is automatically removed from the $15K program.

 

C.   MCOs’ Role

1.    It is the policy of BWC that medical only claims that are enrolled in the $15K program shall not be fully medically managed by the managed care organizations (MCO). However, the MCOs may offer limited assistance to employers who have elected to participate in the $15K Program.

2.    It is the policy of BWC that when a claim is removed from the $15K program for any reason, the MCO shall process the claim under standard protocols for claims management.

3.    It is the policy of BWC that the MCO shall not reconcile duplicative payments (i.e., employer paid bills and BWC paid bills), and that the MCO shall refer the employer to the provider for reconciliation of duplicate payments.

 

D.   Employer Requirements

1.    An employer electing to participate in the $15K program must:

a.    Keep a record of the injury, and

b.    Keep a copy of all bills with proof and date of payment under the $15K program for five years from the last date a bill has been paid by the employer.

c.     This information must be made available to BWC, the injured worker and/or their representative upon request.

2.    BWC may request this information from the employer not more than twice a year. 

 

 

V. PROCEDURE

 

A.    General Claim Note and Documentation Requirements

1.    BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements; and

2.    Shall follow any other specific instructions for claim notes and documentation included in this procedure.

 

B.    Determining if a Claim is Enrolled in the $15K Program

1.    To determine if a claim is enrolled in the $15K Program, claims services staff shall go to Claim Details > Occurrence tab > Profiles link.

2.    If the $15K group has checked the box stating that the employer is enrolled in the $15K Program, the system will automatically designate an appropriate claim as enrolled.

3.    When an employer is enrolled in the $15K Program, the assigned claims services staff can enroll or terminate a claim from the program so long as the date of injury is after the policy enrollment date and medical benefits have not yet been paid in the claim.

4.    If the $15K Program checkbox is blank, the claim was never enrolled in the $15K Program.

5.    If claims services staff has questions about a claim in the $15K Program, staff may send an email to the BWC Claims Policy Field Tech mailbox.

6.    If claims services staff has questions about an employer in the $15K Program, staff may send an email to the Employer Program Unit mailbox.

 

C.   Enrolling a Claim into the $15K Program

1.    When a claim is not systematically put into the $15K Program, claims services staff may put a claim that is eligible for the program into the $15K Program when:

a.    The claim is changed from Lost Time to Medical Only;

b.    There is a change in the policy number; or

c.     Two or more claims are combined, and the surviving object claim is not systematically placed into the $15K Program.

2.    Claims services staff shall investigate and ensure that the employer is enrolled in the $15K Program, and if so, appropriately place the claim(s) into the $15K Program by:

a.    Ensuring the claim type is correct (e.g., Lost Time changed to Medical Only);

b.    Ensuring no medical benefits have yet been paid in the claim.

i.      If no medical benefits were yet paid, staff shall enroll the claim in the $15K Program;

ii.     If medical benefits have been paid, claims services staff shall:

a)    Refer to the Workflow to recover money for claim costs paid; and

b)    Send the “Medical Only Program Employer” letter to recover payments and remove charges from the employer’s experience.

3.    Claims services staff shall update the claims management system by updating Claim Details > Occurrence tab > Profiles link to reflect that the claim is in the $15K Program.

 

D.   Un-Enrolling a Claim in the $15K Program

1.    A claim can be un-enrolled when:

a.    It changes from Medical Only to Lost Time. The claims management system will automatically enter a termination date.

b.    The employer elects to have the claim removed.  Claims services staff shall enter the termination date in Claim Details > Occurrence tab > Profiles link.

2.    Claims services staff shall un-enroll a claim by:

a.    Updating the claim management system in Claim Details > Occurrence tab > Profiles link;

b.    Checking one of the following reasons in the drop-down box:

i.      Employer withdraws effective the date of injury.  This is selected when the employer does not wish to make any medical benefits payments in the claim at all and wants the claim excluded from date of injury.

ii.     Employer pays bills through the end date.  This is selected when the employer has provided BWC with an end date because they no longer wish to be responsible for the bills in a specific claim.

iii.    Reached Limit.  This is selected when the employer has notified BWC that they have paid the $15K Program maximum allowable.

 

E.    Employer Reimbursement in $15K Program Claims

1.    To remove claim costs due to file reviews and independent medical examinations in the $15K Program claims:

a.    All medical benefit bills should be sent to the employer for payment, except for costs related to a BWC physician file review, independent medical examination, and travel reimbursement requests related to the independent medical examination.

b.    Physician file reviews, independent medical examinations, and travel reimbursement requests related to the independent medical examination shall be paid by BWC as claim costs and will be charged to the claim.  This charge will appear as a charge to the employer’s experience regardless if the claim is enrolled in the $15K Program. Claims services staff shall remove these charges only at the request of an employer and only after the employer reimburses BWC for the claim costs.

2.    Claims services staff shall follow the Medical Only Program Workflow for file reviews and shall use the Nurse Referral job aids on COR.

 

F.    Application for Determination or Increase of Percentage of Permanent Partial Disability (C-92) in $15K Program Claims.

1.    C-92 applications may be filed in a claim that is enrolled in the $15K Program.

2.    Claims services staff shall process the C-92 application in the normal manner.  If the determination of the C-92 application results in:

a.    A 1% or greater award – this will change the claim to lost time and the claims management system will systematically remove the claim from the $15K Program.

b.    A 0% award - the claim shall remain in the $15K Program.

 

G.   Treatment and Claim Reactivation Requests in $15K Program Claims.

1.    An MCO may assist employers who have elected to participate in the $15K Program. Such assistance is limited to:

a.    Educating employers on the benefits and requirements of the $15K Program;

b.    Helping employers to determine whether a claim should remain in the $15K Program or whether the claim would benefit from medical management;

c.     Helping employers to understand whether a claim in the $15K Program may require treatments in excess of the maximum Medical Only program amounts;

d.    Talking with the medical provider treating the injured worker to understand the treatment plan and prognosis for recovery for claims in the $15K Program;

e.    Informing the employer of the BWC fee schedule amounts for services to ensure that the provider is reimbursed appropriately for claims in the $15K Program; and

f.      Tracking the medical payments made by an employer for a claim in the $15K Program and assisting the employer with understanding when the employer is reaching the maximum program expenditures.

2.    While a claim is enrolled in the $15K Program, an MCO shall not:

a.    Authorize or deny treatment or require the submission of a Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) for prior authorization of services;

b.    If a medical bill is received the MCO will add appropriate EOB code so that the bill is not paid by the MCO, and then the bill should be sent to the employer to pay;

c.     Apply discounted rates based on the MCO’s negotiated panel or negotiate on behalf of the employer any fee lower than the BWC fee schedule amount;

d.    Mediate billing disputes between the employer and the medical provider;

e.    Notify BWC on behalf of the employer:

i.      To opt in or out of the $15K Program; or

ii.     To remove a claim from the $15K Program; or

iii.    That the claim has reached the maximum $15K Program expenditures.

f.      Charge employers participating in the medical only program for any of the services listed in Paragraph V.G.1.above.

3.    When an MCO receives a Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9), and the claim is enrolled in the $15K Program, the MCO staff shall:

a.    Dismiss the C-9 request;

b.    Not include appeal language on the dismissal; and

c.     Notify the employer and provider.

4.    When a claim is removed from the $15K Program for any reason, the MCO shall be responsible for the:

a.    Full medical management of the claim; and

b.    Processing of all bills, regardless of the date of service.

5.    The MCO shall not reconcile duplicative payments (i.e., employer paid bills and MCO/BWC paid bills) in the claim. The MCO shall refer the employer to the provider for reconciliation of duplicate payments.

6.    When claims services staff receives a request for claim reactivation, staff shall verify whether the claim is enrolled in the $15K Program.

a.    If the claim is enrolled, claims services staff shall notify the MCO that the claim is enrolled in the $15K Program and the claim reactivation request will not be processed.

b.    If the claim is not enrolled, claims services staff shall process the claim reactivation request.

 

H.   Travel Reimbursement in $15K Program Claims

1.    When claims services staff receives a travel reimbursement request, staff shall verify if the claim is enrolled in the program or not.

a.    If the claim is enrolled and:

i.      If travel reimbursement is related to medical treatment, notify the injured worker that the claim is enrolled in the $15K Program and the travel reimbursement request must be sent to the employer for processing.  BWC shall not process the request.

ii.     If travel reimbursement is related to an IME, BWC shall process the request for travel reimbursement, and, if appropriate, pay.

b.    If the claim is not enrolled, claims services staff shall process the travel reimbursement request, and if appropriate, pay in accordance with the Travel Reimbursement policy and procedure.

2.    For claims in the $15K Program, an employer may request removal of claim costs due to a file review, independent medical examination, or travel reimbursement requests related to the independent medical examination, pursuant to section V.C. and V.E. of this procedure.

 

I.      Statute of Limitations in $15K Program Claims

1.    If there is a question as to whether the statute of limitations has expired in a claim, claims services staff shall request written documentation from the employer of the last date of service for medical treatment, as well as the last medical benefit paid date for claims with a date of injury prior to July 1, 2020.  Once the employer submits the information, claims services staff shall calculate the new statute expiration date and enter a new statute of limitations override date in Claim Details > Details > Claim Dates > Other Dates in the claims management system.

2.    If a conflict exists in determining the new statute expiration date or the employer fails to submit requested written documentation, claims services staff shall refer the issue to the Industrial Commission on a Notice of Referral.

3.    Staff may refer to the Jurisdiction policy and procedure for more information.

 

J.     Complaints in $15K Program Claims

1.    BWC may receive complaints from an injured worker, the injured worker representative, and/or providers regarding non-payment of medical benefit bills by the employer.

2.    Claims services staff shall create a work item and refer all complaints regarding the $15K Program to the employer program unit.

3.    The employer program unit shall investigate the complaint with the employer and notify the assigned claims services staff of the outcome via email.

a.    If the employer is to be removed entirely from the $15K Program, the employer program unit will remove the employer and notify the assigned claims services staff.  When the employer is removed from the program, all claims for the employer are removed.

b.    If the claim is to be removed from the $15K Program, the employer program unit shall notify the assigned claims services staff, and the claims services staff shall remove the claim from the $15K Program.

c.     If the claim is to remain in the $15K Program, the employer program unit shall notify the assigned claims services staff.