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OhioBWC - Basics:  How 15K works

How the $15,000 Medical-Only Program ($15K Program) works

Employers who choose to participate in the $15K Program pay up to $15,000 in medical and pharmacy bills. They inherently approve the treatment in the normal course of the injury. They cannot authorize or deny treatment, or additional conditions. That means they cannot process a Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9). In addition, their managed care organizations (MCOs) cannot authorize treatment or pay medical bills.

If you want to enroll in the $15K Program, call 1-800-644-6292 and listen to the options. Once you enroll, you are responsible for the bills in all medical-only claims (claims with seven or fewer lost days from work) with injury dates after the enrollment effective date.

Program requirements

  • Notify your injured workers and their health-care providers that you, not the MCO, are paying the medical bills for an injury
  • Pay all bills within 30 days of receipt or risk disqualification from the program
  • For claims with dates of injury before July 1, 2009, pay as billed or in accordance with the pre-negotiated payment agreement with providers
  • For claims with dates of injury after July 1, 2009, pay in accordance with BWC's fee schedule.
    Note: BWC’s professional (practitioner) fee schedule is available in the Medical Providers section under Look-ups. Facility reimbursement policies are in Chapter 3 of the Provider Billing and Reimbursement Manual in the Medical Providers section under Services.
  • Notify BWC and the MCO if/when the $15,000 maximum is reached and supply proof of such payment to the MCO
  • Report some claims to Medicare beginning July 2010. You can learn more about this through the Centers for Medicare and Medicaid Services Web site.
    REMINDER: This is a federal requirement.
  • Keep a record* of all work-related injuries, including:
    • Injured worker’s name, address and Social Security number;
    • Date and time of injury;
    • Type of injury;
    • Part of the body injured;
    • A brief description of the accident that led to the injury;
    • Copies of all bills with proof and date of payment under this program;
    • Proof of payments made within 30 days of request from BWC;
    • Documentation for excluding any wages paid to the employee while off work in the $15,000 limit;
    • Documentation showing no denial of any bills. If you participate in the program, you inherently approve the first $15,000 of medical and pharmacy costs.
*You must maintain these records for six years from the last date of bill payment.

EXCEPTIONS to program requirements

  • You notify us within 14 days of learning that a claim has been filed that you do not want to pay for the bills in that claim.
  • You notify us that you've reached the $15,000 maximum in a claim.
  • You notify us that you do not want to pay for any additional medical bills, and you provide the last date you will be responsible for a particular claim.
    Note: The last date can be the date of injury or after a payment of any amount up to $15,000.

Once you tell us to remove a claim from the $15K Program your MCO will begin processing the bills in that claim regardless of the date of service on a bill.

Reaching the $15,000 maximum
If the payment of a particular bill will exceed the $15,000 maximum, pay that portion of the bill that brings the total paid to $15,000, and then tell the provider to bill the MCO for the balance. Remember, you must notify BWC and the MCO that you've reached the $15,000 maximum. Also, send copies of all bills with proof of the dates of payment to the MCO. At that point, it becomes the MCO’s responsibility to process all future bills received. We will not reimburse you for any bills you've paid.

Lost-time claims
If the injured worker loses more than seven days of work, the injury is no longer eligible for this program. The process to change the claim to lost time will automatically remove the claim from the $15K Program. The MCO will be responsible for processing subsequent medical bills. We do not reimburse you for bills paid under this program prior to the change over from medical only to lost time.

Injured worker and employer rights

  • Payment of medical bills under this program in no way supersedes the right of the injured worker to file a workers’ compensation claim.
  • Payment of medical bills under this program does not waive BWC’s right to hear and decide a claim if filed.
  • Payment of medical bills under this program does not waive the employer’s right to contest a claim if filed.

Opting out of the program
You can opt out of the $15K Program by calling 1-800-644-6292 and listening to the options. Once you notify us that you want to opt out, we will send written confirmation of this decision. The MCO will then be responsible for processing bills received after the program termination date for all medical-only claims. To opt a specific claim out of the program, you must notify the BWC-assigned claims service specialist for that claim.

NOTICE!
We will not mediate disputes between you and any medical provider(s) pertaining to bill payment. If you fail to meet any of the requirements for this program, including responding timely to bill payment requests, no denial of treatment and maintaining active workers' compensation coverage, you are subject to program removal.



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