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Policy and Procedure Name:
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Transitional Work Performance Bonus
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Policy #:
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MP-20-02
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Code/Rule Reference:
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Ohio Administrative Code (OAC) 4123-17-55,
4123-6-01,
4123-6-02.2
BWC Employer Policy EP-20-02 (Transitional
Work Performance Bonus)
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Effective Date:
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08/25/2021
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Approved:
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Deborah Kroninger, Chief of Medical Operations
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Origin:
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Medical Policy
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Supersedes:
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All Medical policies, directives or memos regarding
Transitional Work Grant & Bonus Program that predate the effective date
of this policy.
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History:
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Available upon request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Eligible Claims
Eligible Employer
Non-Eligible Claims
Successful Claims
Transitional Work (TW)
Transitional Work Plan (TW Plan)
Transitional Work Performance Bonus
Program (Bonus Program)
IV. POLICY
A. Bonus Program
Eligibility
B. Bonus Program
Application- Submission and Evaluation
C. Appeals to Bonus Program
Decisions
V. PROCEDURE
A. Standard Claim File
Documentation
B. Bonus Program
Application: Submission and Assignment
C. Transitional Work Plan
Review and Verification
D. Monitoring of Claims in
the Bonus Program
E. Auditing of the TWB
Determination Report for Bonus Calculation
F. BWC Reporting to the
MCO
G. MCO Responsibilities
H. Complaints
Appendix: BWCWeb TW Plan Look-Up
Categories
The purpose of this policy is to ensure appropriate
monitoring of participating employer utilization of transitional work plans for
bonus payment calculation.
This policy and procedure complements BWC’s Transitional
Work Performance Bonus Employer Policy.
This policy applies to BWC staff, Transitional Work
Developers, Managed Care Organizations (MCOs) and employers taking part in the
Transitional Work Performance Bonus Program (Bonus Program).
Eligible Claims:
Allowed claims with a date of injury within the current program period with an
actual return to work date in modified duty.
Eligible
Employer: An employer that has met the BWC Employer Services
eligibility criteria for participation in the Bonus Program, as outlined in OAC
4123-17-55.
Non-Eligible
Claims: Non-eligible claims for the Bonus Program are claims not in
an allowed status, not returned to work, or returned to work full duty.
Program Period: The policy
year an employer participates in the Transitional Work Performance Bonus
program.
Successful
Claims: Claims in which the employer offers transitional work duties/
modified duty to the injured worker, and the injured worker accepts the transitional
work duties/modified duty tasks.
Transitional
Work (TW): Pursuant to OAC 4123-6-01,
a work-site program that provides an individualized interim step in the
recovery of an injured worker with job restrictions resulting from the allowed
conditions in a claim. Developed in conjunction with the employer and the
injured worker, or with others as needed, including, but not limited to the
collective bargaining agent (where applicable), the physician of record,
rehabilitation professionals, and the managed care organization, a transitional
work program assists the injured worker in progressively performing the duties
of a targeted job.
Transitional
Work Plan (TW Plan): A plan with the following components: corporate
analysis, employer-employee relations, policies and procedures, job analysis
and program evaluation.
Transitional
Work Performance Bonus Program (Bonus Program): Employers with a TW
plan may receive a financial incentive from BWC for using their TW plan to
return injured workers back to work. This incentive is provided to qualified
employers who return an injured worker to work quickly and safely after an
injury through utilization of the employer’s TW plan.
1. It is the
policy of BWC to provide employers who meet the criteria set forth by BWC with
a financial bonus for providing transitional work opportunities to injured
workers.
2. Eligibility
criteria are detailed in BWC’s Employer Services Transitional
Work Performance Bonus policy.
1. Employers
interested in the Bonus Program must make application to BWC.
a. Employers
may utilize BWC’s online
application, or submit an Application for
the Transitional Work Bonus Program (TWB-1).
b. Employers
must submit the application by the application deadline date, and supporting
documentation within 30 days of the application deadline for inclusion in the
current program period.
c. Employers
failing to timely submit documentation shall be denied participation in the
program and not be considered for the current bonus payment period.
d. Employers that
submit the TWB-1 online
must provide BWC with supporting documentation via:
i. E-mail
to TWSupport@bwc.state.oh.us
(the preferred method of submission);
ii. Fax
to: (614) 621-5758; or
iii. Mail to:
BWC Transitional Work Unit, 30 West Spring Street, L-20, Columbus, Ohio 43215.
2. BWC shall
process, review, and evaluate all applications.
3. At the
conclusion of each bonus period, BWC shall audit all claims that are eligible
for bonus reimbursement.
4. Additional
application requirements are detailed in BWC’s Employer Services Transitional
Work Performance Bonus policy.
1. Pursuant
to Ohio Revised Code (R.C.) 4123.291
and OAC 4123-14-06,
BWC’s Adjudicating Committee shall hear employer appeals due to:
a. Denials of
applications for the Bonus Program; or
b. Disagreements
with BWC’s performance bonus determination.
2. BWC’s
Transitional Work (TW) Unit shall address employer appeals filed due to TW claim
issues (e.g., an employer believes appropriate credit was not awarded for a
return to work).
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.
Upon receipt of a paper application (received by mail or via fax) from
an employer for participation in the Bonus Program, BWC’s TW Unit Grant
Coordinator (Grant Coordinator) shall ensure that the paper application is:
a. Entered
online into BWC’s website for processing by BWC Employer Services; and
b. Scanned into
UDS to document the employer’s intent.
2. Applications
submitted online do not require action by BWC’s TW Unit prior to processing by
BWC Employer Services.
3.
When a TWB-1 application is entered online, the system automatically creates
a TW Plan Look-Up shell on BWCWeb.
a. The
created TW Plan Look-Up notes the following:
i. Policy
#: Employer policy number;
ii. TW
Plan Status: Will initially be “Expected”, which means that BWC is expecting
documentation confirming a TW plan from the Bonus Program applicant. The plan
status will be changed to “Approved” when BWC receives evidence the employer
has a TW plan;
iii. Plan
Status Effective Date: Date the document is reviewed and accepted;
iv. Plan Receipt
Date: Date the plan is received
v. Program
Type: Bonus;
vi. Application status:
a) Initial
Bonus Program application status is “Received”. The application status will not
change to “Approved” until Employer Services runs eligibility screening for the
assigned program period.
b) BWC will
automatically renew the employer for each subsequent program period provided
the employer meets all eligibility requirements.
vii. Application date: Date
application entered online;
viii. Program Year Begin Date: Program
period; and
ix. Assigned:
a) New
policies entered are automatically assigned to a Technical Medical Specialist (TMS)
from the Vocational Rehabilitation Unit.
b) The TW
Unit staff may reassign applications based on workload/vacation schedules to
another TMS.
c) Policies
entered prior to 2018 will retain the previously assigned Disability Management
Coordinator.
b.
Employers with multiple policy numbers must have separate TW Plan
Look-Up shells for each policy number.
c. See Appendix for detailed Plan Look-Up categories
and descriptions.
1.
As detailed in BWC’s Employer Services Transitional
Work Performance Bonus policy, employers applying to participate in the
Bonus Program shall submit documentation evidencing a developed and implemented
TW plan that includes, but is not limited to:
a. A
transitional work plan developed with a previous BWC grant, or
b. A
company-created transitional work plan, or
c. A
copy of the company’s transitional work policy from its human resource manual
or employee handbook, or
d. A signed
letter from a company officer stating the employer has a transitional work plan
or is in the process of developing a BWC Transitional Work Grant plan.
2. An
employer approved to participate in the Bonus Program is not required to submit
TW plan documentation with subsequent program period applications if there has
been no lapse in Bonus Program participation, and the employer continues to
meet BWC eligibility criteria.
3. The TMS
may contact the employer by e-mail, letter, or phone following review of
submitted documentation to offer BWC consultation services. Consultation
services include, but are not limited to:
i. Recommendations
for improving or enhancing the TW plan;
ii. Strategies
and suggestions for implementing transitional work and light duty successfully;
iii. Informational
assistance including:
a) BWC job
templates;
b) BWC
services to support transitional work such as job modifications, job analyses
and vocational rehabilitation; and
c) Explaining
the process for submitting the Transitional
Work Offer and Acceptance Form (TWB-2).
4. Once the
application has been received, the TW Unit will utilize the following programs
during the review process:
i. BWCWeb:
Location of TW Plan Look-Up
ii. Universal
Document System (UDS): Repository for TW plan documents, e-mails, and
correspondence received and sent out by the Grant Coordinator and TMS.
5. The Grant
Coordinator shall:
a. Review the
TWSupport@bwc.state.oh.us e-mail
box at least twice daily;
b. Scan all e-mails
and documents received and sent out by the TW Unit into UDS;
c. Monitor
employer application status using the TW Plan Look-Up on BWCWeb.
i. If
an assigned employer’s Bonus application is in “Received” status and is missing
supporting documentation (is in “Expected” plan status), the Grant Coordinator may
contact the employer and request that the employer submit the missing documentation
prior to BWC Employer Services’ cutoff date for inclusion in the current program
period.
ii. If
supporting documentation is:
a) Submitted
timely, the Grant Coordinator shall update:
i) The
TW Plan Status from “Expected” to “Approved”; and
ii) The
Plan Status Effective Date and Plan Status Receipt Date to the date the
supporting documentation was received.
b) Not
submitted timely, the Grant Coordinator may either:
i) Update
the TW Plan Status from “Expected” to “Denied”; or
ii) Leave
the status in “Expected”. When BWC Employer Services runs a final eligibility
screening for the assigned program period, the application status will
automatically change to “Denied”.
iii. BWC Employer
Services shall notify the employer by e-mail letter of their approval or denial
to participate in the Bonus Program.
1. As
detailed in the BWC Employer Services Transitional
Work Performance Bonus policy, employers participating in the Bonus Program
must submit a TWB-2, signed by the employer and the employee.
a. The TWB-2
completed online by the employer will interface with the claims management
system and update the Begin Date and Signature Date in the Profiles screen of
the injured worker’s (IW) claim.
b. TWB-2
forms printed and electronically sent to the employer’s MCO or to BWC will be
imaged and indexed into the IW’s claim as a TWB-2.
i. The
imaged TWB-2 will generate a work item to the Claims Service Specialist (CSS).
ii. The
CSS shall:
a) Review the
TWB-2 form information; and
b) Enter the
details in the claims management system, on the Profiles screen under, “Has the
employer made a Transitional Work Program Offer to the claimant?”
c. If
any information on the TWB-2 is missing:
i. The
CSS may either:
a) Contact the
employer for the missing information; or
b) Review the
claim notes and MEDCO-14 to obtain and verify the missing information.
ii. The
CSS shall then:
a) Update the
Profiles and select “BWC Confirmed” from the Method of Confirmation drop-down;
and
b) Document the
TWB-2 update in claim notes.
d. The CSS
may enter up to three TWB-2 episodes in the Profiles screen.
2. TW Unit Responsibilities
a. TW Unit staff
shall utilize the 62- Transitional Work Bonus Report, a systematic-generated
COGNOS report which is sent to the TW Unit weekly and contains all TW Bonus
data for all active program periods.
i. This
report is used to monitor the:
a) Submission
of TWB-2s submitted by employers; and
b) Input of
TWB-2 data by the CSS in the claim.
ii. If,
upon review of the report, TW Unit staff finds that elements of the Profiles
screen are incomplete, TW Unit staff shall contact the claim owner to remind
them to complete the Profiles for transitional work in the claims management
system.
iii. If a TWB-2
is not imaged in a claim, TW Unit staff shall contact the employer by e-mail or
telephone to discuss the Bonus Program requirements and completion and
submission of the TWB-2 form.
b. The TW Unit
manager shall only enter the data from the TWB-2 form into the Profiles screen
of the claims management system in emergent situations. For example, when the
snapshot report is scheduled to run by BWC Rates and Payments (R&P) for the
program period and the data is not entered, the employer will not receive
appropriate credit for a successful claim and an incorrect bonus calculation
will be factored, affecting the employer’s bonus rebate.
1. After the
snapshot date for each bonus period, R&P shall send the TW Unit the TWB
Determination Report that contains policies that are eligible for bonus
reimbursement.
2. The TW
Unit Management Analyst shall use R&P’s report of eligible policies to create
the TW Unit’s TWB Determination Report, which identifies eligible and
successful claims, by policy, in order to:
a. Look for
duplicate claims. When there are two rows for the same claim number, one
full-duty and one restricted duty, remove the full-duty line from the report;
b. Filter out
non-eligible claims; and
c. Divide
the report among TW Unit staff for auditing.
3. Prior to
all final bonus determinations, TW Unit staff shall ensure final TW bonus
calculations are correct by auditing all eligible and successful claims that
will be used to calculate an employer’s TW bonus. TW Unit staff shall utilize
the following resources in their audit:
a. The claims
management system;
b. Document
Management; and
c. The TWB
Determination Report.
4. To perform
claim audits, TW Unit staff shall:
a. Open the TWB
Determination Report for the time period being verified;
b. Filter the
columns to generate a variety of scenarios to audit.
i. TW
Unit staff shall audit every claim that falls under one of the following
scenarios:
a) “Actual
Return to Work (ARTW) Full Duty (FD)”, “Offer made”, “Not eligible”, “Not
successful”;
b) “ARTW with
restrictions”, “No offer made”, “Eligible”, “Not successful”; and
c) “ARTW with
restrictions”, “Offer Made”, “Eligible”, “Not successful”.
ii. TW
Unit staff shall audit a statistically significant percentage of claims that
fall under the scenario, “ARTW with restrictions”, “Offer made”, “Eligible”,
and “Successful”.
iii. TW Unit
staff are not required to audit claims that fall under the scenario, “ARTW FD”,
“No offer made”, “Not eligible”, and “Not successful”.
c. When
a claim requires further research, TW Unit staff shall:
i. Open
the claim in the claims management system.
a) To verify
ARTW FD and modified duty episodes, look in Disability Tracking;
b) To verify
whether an offer was made and accepted, and the signature dates, look in Claim
Details > Profiles in the TW section; and
c) For
additional information or clarification, look in claim notes.
ii. Open
the claim in Document Management and look at the:
a) TWB-2, or
equivalent, and verify that it is complete and that the IW and employer signed
the form;
b) MEDCO-14
to verify that the IW was released back to work with restrictions; and
c) Medical
documentation to verify that the IW is working or was released back to work
with restrictions.
5. At the
conclusion of each claim audit, TW Unit staff shall enter a note in the
“Comments” column of the TWB Determination Report, indicating what claim
information was verified as part of the review.
6. If, based
on the audit findings, the scores on the TWB Determination Report
require change, TW Unit staff shall:
a. Change the
score from “0” to “1” or “1” to “0” in the “Eligible” and/or “Successful”
columns;
b. Document the
information used to support the change in the “Comments” column; and
c. Highlight
the row to indicate that a change was made and the claim requires additional
review by the TW Unit manager.
7. If a claim
eligibility or success cannot be determined using claims documents, TW Unit
staff shall:
a. Highlight
the row to indicate to the TW Unit manager that the claim requires additional
review; and
b. Document
the issue in the “Comments” column.
8. Upon
completion of all assigned audits, TW Unit staff shall save their section of
the report in SharePoint: TW Grants>TW Bonus Program>Reports to the
appropriate folder for the program period being audited; and
9. The TW
Unit manager shall then review all claims in the report that are highlighted.
The TW Unit manager shall:
a. Document
all findings of their review. Findings may include:
i. Whether
the TW Unit manager agrees or disagrees with the change(s) made by the original
TW Unit staff auditor; and
ii. Whether
the manager made any new changes as a result.
b. Initial
each claim the manager reviews.
c. Upon
completion of their review, the TW Unit manager shall notify the TW Unit Management
Analyst that the reports are ready to compile.
10. The Management analyst shall
then:
a. Compile
all audited claims into a final report, which will automatically calculate the
percentage of bonus for each policy;
b. Save a
copy of the newly compiled report; and
c. Send
the report to BWC R&P.
1. The TW
Unit Management Analyst shall provide to each MCO a report containing their
assigned employers who are participating in the Bonus Program at specific times
during the program period:
a. TWB Eligibility
Report: Provided at the start of each program period;
b. Claims
Participation Report: Provided weekly; and
c. TWB
Determination Report: Provided at the end of each program period.
2. The TW
Unit Management Analyst shall:
a. Divide
each report by MCO; and
b. Upload
each MCO-specific report into the appropriate MCO’s TW folder on the MCO
Portal.
1. As part of
the medical management of a claim, the MCO must:
a. Follow the
Return
to Work Data policy;
b. Send the
RTW indicator to BWC via a 148 file for all claims where the employer is
participating in the Bonus Program;
c. Obtain
from the provider, or work with the employer to obtain, work restrictions and
releases to work;
d. Inform
providers about opportunities for transitional work at the employer’s location.
2. The MCO
shall also:
a. Work with
employers participating in the Bonus Program to obtain a completed TWB-2;
and
b. Verify
data entry accuracy for each claim on the 62- Transitional Work Bonus Report
posted weekly on the MCO portal by the TW Unit until the snapshot date, and, if
necessary:
i. Provide
missing information to the TW Unit; and
ii. Clarify
any conflicting information on the report.
1. Receipt of
Complaint
a. Upon
receipt of a complaint to the TW Unit, the TW Unit manager shall enter the
complaint into BWC Employer Services Complaint Tracking Version 2 Tracker
(tracker). Complaints received directly to BWC Employer Services are also
entered into the tracker.
b. When a
complaint is received that perains to transitional work claims issues (e.g., an
employer believes appropriate credit was not awarded for a return to work), the
tracker systematically assigns the complaint to the TW Unit manager and
generates an e-mail to the TW Unit manager.
c. If
the TW Unit receives a complaint that relates to program enrollment or
participation eligibility, the TW Unit manager shall e-mail the complaint to BWC
Employer Services. BWC Employer Services shall process complaints in the manner
outlined BWC’s Employer Services Transitional
Work Performance Bonus policy.
2. Investigation
a. The TW Unit
manager shall:
i. Review
all claims assigned to the complaining employer’s policy for the bonus program
period in question; and
ii. Document
the following information on the Claims Review Form:
a) Actual
Return to Work (ARTW);
b) ARTW type;
c) Whether
the TWB-2 is present;
d) TWB-2 signature
dates;
e) Eligible
claims;
f) Successful
claims;
g) An
investigative summary; and
h) The TW
Unit manager’s decision.
iii. Complete the
Bonus Adjustment Request Form, supplying the reason for the adjustment,
if any, and details of the adjustment or lack thereof, including:
a) The original
bonus percentage;
b) The new
percentage; and
c) An estimate
of the adjusted bonus amount.
iv. Review the Claim
Review and Bonus Adjustment Request forms with the Chief of Medical
Operations.
b. The
following parties shall sign and date the forms:
i. The
TW Unit manager;
ii. The
Chief of Medical Operations, if the financial impact is greater than $5,000;
and
iii. The Chief
Medical and Health Officer, if the adjusted bonus amount exceeds $50,000.
3. Complaint Resolution
a. The TW
Unit Manager shall:
i. E-mail
a complaint response letter to the employer outlining the complaint decision
and containing the following information:
a) Total
number of BWC-allowed claims during the program period;
b) Total number
of claims eligible for transitional work;
c) Total
number of claims returned to work using transitional work;
d) TW bonus
percent (c divided by b); and
e) TW bonus
premium rebate percent (d times 10 percent).
ii. Upload
the complaint response letter and the Claim Review and Bonus
Adjustment Request forms to the tracker;
iii. Update the
tracker with the complaint status and TW Unit manager’s decision; and
iv. E-mail R&P
informing them of the decision’s financial impact, if any.
a) The Employer
Services manager shall then review the complaint and all resulting documents.
b) R&P
shall calculate a new bonus amount based on the new bonus percentage and issue
a rebate check to the employer, if a financial adjustment is needed. Any money
owed to BWC by the employer is subtracted from the rebate prior to mailing the
check.
b. All decisions
regarding the Bonus Program made by the TW Unit or BWC Employer Services may be
appealed to BWC’s Adjudicating Committee, pursuant to R.C. 4123.291
and OAC 4123-14-06.
Appendix: BWCWeb TW
Plan Look-Up Categories
BWC Web TW Plan Look-up contains the following categories:
·
Policy Number: Employer’s risk/policy number
·
Plan Status: Status of transitional work plan. Plan status
categories include:
o
Expected: BWC is expecting a transitional work plan;
o
In Process: TMS has received a plan and initiated review;
o
Pended: TMS has reviewed transitional work plan, items are
missing, and the plan is on hold awaiting additional information;
o
Approved: TMS has approved transitional work plan;
o
Denied: TWG 1 application is denied;
o
Not Needed: Employer notified BWC that they wish to opt-out of
the Grant or Bonus program;
o
Remediatin [sic]: No longer utilized. Prior to 9/1/2018 it
was a placeholder category created because Grant and Bonus shells were linked. Utilized
when an employer submits both a Grant Program and Bonus Program application
that pass BWC Employer Services’ initial screening criteria and the Grant
Program TW plan review has not yet been completed.
·
Plan Status Effective Date: Date any plan status above is
changed;
·
Plan Receipt Date: Date transitional work plan was
received by BWC;
·
Program Type: Grant or Bonus based on online application
type *;
·
Application Status: Status of Bonus or Grant Application
from BWC Employer Services *;
·
Application Date: Receipt date of Bonus or Grant
application from employer*;
·
Program Year Begin Date: Only applies to Bonus Program. Updated
by Employer Services with Bonus Program begin date after R&P runs policy
eligibility *.
·
TW Unit Assigned: As of 9/21/2018, auto-assigned to the
TMS when online application is submitted. Can be reassigned to other TW Unit
staff as needed.
·
Action: Tool to input actions into BWCWeb.
(*) TW Unit staff cannot update
these fields.