Policy
Name:
|
$15,000
Medical-Only Program ($15K Program)
|
Policy #:
|
EP-06-01
|
Code/Rule
Reference
|
ORC 4123.29(A)(6); OAC 4123-17-59; and OAC 4123-17-74, Appendix C.
|
Effective
Date:
|
July 1,
2014
|
Approved:
|
Winnie
Warren, Interim Chief of Employer Services
|
Origin:
|
Employer
Policy
|
Supersedes:
|
All EM
policies and procedures regarding the $15K Program that predate the effective
date of this policy.
|
History:
|
Revised April
29, 2021; July 17, 2018. New policy issued March 7, 2014.
|
Review
Date:
|
July 1, 2025
|
I. Policy Purpose
The
Ohio Bureau of Workers’ Compensation makes available to
state fund employers a program whereby the employer pays the first $15,000 of a
compensable medical-only claim, pursuant to ORC 4123.29.
II. Applicability
This
policy applies to BWC Employer Services, employers, their agents, and authorized
representatives.
III. Definitions
A.
Lost time claim:
1.
Any claim with eight
or more days of lost time from work directly caused by a work-related injury,
even if compensation or wages in lieu of compensation have not been paid to the
injured worker (IW); or
2.
Any claim in which
BWC awards compensation.
B.
Maximum: The maximum medical cost that an
employer can pay on an individual medical-only claim. For claims with a date of
injury on or after September 10, 2007, the maximum is $15,000.
C.
Medical-only
claim:
1.
A claim of seven or
fewer days of lost time from work directly caused by a work-related injury; and
2.
The claim has no
compensation awarded.
IV. Policy
A.
Eligibility
criteria: To begin participation in the $15K Program, an employer must:
1.
Pay premiums to the
state insurance fund; and
2.
Be in an active
policy status. Active policy status does not include a policy in a no coverage
or lapsed policy status.
B.
Election to
participate.
1.
No formal
application is required.
2.
An employer must
elect to participate by calling, writing, 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 IW.
b.
The employer must
notify the IW and medical provider in writing to:
i.
Acknowledge the
medical-only claim;
ii.
The employer elects
to pay bills as provided under ORC 4123.29; and
iii. Request that all bills be submitted to
the employer and not the IW 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 on or after June 30, 2009, the employer must pay medical bills
in accordance with BWC’s fee schedule. BWC fee schedule information is located
on BWC’s website on the Fee schedules webpage.
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 calling, writing, or
emailing BWC:
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; or
ii.
The last date of
service on which the employer will be responsible for the bills in a particular
claim. The employer’s managed care organization (MCO) will begin processing
bills, regardless of the 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; and
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 IW, or the IW’s authorized representative upon request.
i.
The employer must,
upon written request from BWC, provide documentation of all medical-only bills
the employer is paying directly.
i.
BWC may make this
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 years from the last date the
employer paid a bill, or until the information has been received by BWC,
whichever is later. The employer must provide the information to BWC, the IW,
or the IW’s representative upon request. The employer must keep record of:
i.
IW 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; and
vi.
Copies of bills and
proof of payment, including the payment date(s).
k.
The employer must
meet federal Medicare requirements. An employer can learn more through the
Centers for Medicare and Medicaid Services web site, www.cms.gov.
l.
The employer must
reimburse the IW for reasonable and necessary travel expenses related to an
employer-requested independent medical examination (IME) upon the filing of a
proper request. IW travel expenses are set forth in OAC 4123-6-40.
m.
The employer may
refer to the claim policy and procedure Fifteen Thousand Dollar Medical Only
Program ($15,000 Medical Only Program) for additional information.
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;
iv.
Process a Request
for Medical Service Reimbursement or Recommendation for Additional Conditions
for Industrial Injury or Occupation Disease (C-9);
v.
Utilize its MCO to
authorize treatment or pay medical bills;
vi.
Include paid wages
while the employee was off work as part of the maximum; or
vii. 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 set forth in OAC 4123-17-74, Appendix C.
3.
BWC responsibilities.
BWC will:
a.
Notify providers who
send bills to BWC 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
entirely from the $15K Program, resulting in removal of all of the employer’s
medical-only claims 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 IW’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 IW is not liable
for a bill the employer 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.
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 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, writing, 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, pursuant to 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.