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MCO Grievance Conference with Providers

In accordance with (OAC 4123-6-044); “The MCO shall review all bills submitted to it for payment by a provider for appropriateness consistent with the MCO’s utilization standards and certification requirements.  The MCO shall have in place and operating a grievance hearing procedure allowing a provider, employer, or employee to grieve a disputed bill payment.”


The BWC rule uses the term “grievance hearings” or “grievance conference” to describe the appeal procedure the MCO must have in place. The MCO’s grievance hearing procedures are limited to 1) appeals regarding the recovery of overpayments   and 2) bill payment disputes such as denial of payment or reduced payment.  Grievance hearings shall not address fee schedule grievances or ADR issues.  The grievance hearing gives the disputing party the opportunity to present evidence to support the disagreement and affords due process.


Recovery of an Overpayment

Effective March 1, 2000, MCOs implemented a recovery grievance conference that provided due process for the provider and adjudicated disputes regarding recovery of reimbursements in the following manner:

o   Provider is notified by MCO an overpayment has been identified and adjustment will be processed to recover the funds.

o   The provider may appeal the MCO’s decision in writing within 14 days.

o   The MCO’s recovery grievance conference will allow a provider to grieve the disputed bill payment.  The MCO will schedule a recovery grievance conference within 14 days upon receipt of the provider’s written appeal.  The MCO must notify the provider of the date, time, location of the conference, the issue and a statement of fact.  The conference will be limited to the stated issue in the letter.

o   Upon conclusion of the recovery grievance conference, the MCO will issue a decision, in writing, to the provider within 7 days.

o   The provider may appeal the MCO’s recovery grievance conference decision to BWC’s Administrator’s designee. The provider may appeal the MCO’s recovery grievance conference decision to BWC Medical Bill Payment Recovery, within 14 days after receiving the decision of the MCO, via email to: Sharon.Kaeppner@bwc.state.oh.us

o   The Administrator’s designee will review and make the final determination within 14 days.


If an MCO determines an overpayment should be recovered because the service did not meet Miller criteria (medically necessary and appropriate, related to the treatment of the industrial injury and the costs medically reasonable), then the MCO may initiate recovery.  However, if the provider appeals that recovery, then the recovery process shall stop and the appeal submitted by the provider should be considered as an ADR appeal.  The receipt date of the provider’s appeal by the MCO will be day one of the ADR process.  The MCO must follow the criteria for appeals received in ADR, for example, the appeal must be signed


Medical Billing Dispute

A medical billing dispute exists when a provider is not satisfied with the amount of payment and explanation of benefits received from an MCO, but does not include dispute of BWC’s fee schedule rates.  The provider should submit a request for reconsideration to the MCO to begin the bill grievance dispute. The MCO shall review the bill, and determine if the provider is correct and an adjustment is appropriate or if the MCO’s initial payment was correct.  If the MCO’s review determines that the issue is still not resolved, they should proceed to the bill grievance conference process.   The MCO must provide the reason and the rationale for the initial medical bill payment decision.  Examples of the rationale may include BWC’s coverage provisions or coding conventions. The MCO’s procedure may be a review by a nurse or supervisor.  Once the review is completed, the decision on the review is communicated to the provider in writing.


Procedures for Handling Billing Disputes


When a provider disagrees with the denial of payment or a reduced payment a medical billing dispute exists and the following steps shall be taken:


The Provider contacts the MCO to inquire about the reimbursed amount or denial of a medical bill via; e-mail, fax, phone, mail.  It may be necessary to submit the inquiry, along with supporting documentation, in writing to the MCO.  The provider and the MCO should keep detailed notes for his/her records, including the name and phone number of the person to whom he/she spoke, fax confirmations, etc.


It may be necessary for the provider to request to speak to an MCO supervisor to resolve the issue or to escalate the issue to a grievance conference.  Most provider billing inquiries can be handled by the MCO on the phone.


The MCO shall acknowledge the inquiry (e-mail, fax, phone, mail) within four (4) calendar days of receipt, and shall resolve or initiate resolution of the inquiry within seven (7) calendar days of receipt per the MCO contract.


If the issue is not resolved with the MCO, the provider should be instructed on how to initiate a medical bill grievance conference with the MCO.  The conference may occur in person or via telephone, and shall occur within seven (7) calendar days from the request for the conference.  MCO’s must document details of all grievances conferences and the outcome.  


The MCO shall issue a decision, in writing, within seven (7) calendar days from the date of the conference.  The MCO’s determination letter shall be imaged into the injured workers claim.  Imaging documents in the claim will make it possible for BWC to research any subsequent provider complaint that may come into the Provider Contact Center and will provide documentation that the medical bill grievance was addressed.


Required Elements for “Bill Dispute Grievance Conference Decision.” letter.

·         Identification of the specific documentation reviewed at the conference such as the office notes or other documentation;

·         Date, time, place and persons who participated in the conference (MCO and Provider) and the method used for the conference (phone, face to face or email).


If the provider does not agree with the MCO’s decision, the provider may contact BWC’s Provider Contact Center at 1-800-ohiobwc, option 3-0 or via email at feedback.medical@bwc.state.oh.us to ask for BWC’s assistance in resolving the billing dispute.  It is the MCO’s responsibility to inform and provide this information to the provider.  The BWC Provider Contact Center will ask the provider to document the complaint, which will be researched and tracked.    It may be necessary for the BWC Provider Contact Center to consult other BWC departments such as, (but not limited to) Medical Policy, Voc Rehab Policy, Medical Director or Legal or for input in making a determination.


BWC’s provider contact center will refer the provider back to the MCO if the grievance conference has not been held.  If the MCO did not conduct a medical bill grievance conference or the documentation has not been imaged into the claim,  the provider’s request for a medical bill dispute shall be referred by BWC back to the MCO.  BWC will educate the provider on the process and the steps that are established to handle such inquires/requests/grievances.


BWC’s Provider Contact Center will coordinate a written response to the provider and the MCO and send the response to the IW’s claim file.  After BWC’s determination is rendered, no additional levels of review will be considered.


If at any point during the inquiry/dispute process the MCO or BWC determines that a payment correction is needed, the MCO shall correct or submit an adjustment to BWC within fourteen (14) calendar days of determination. If BWC has reviewed and made a determination to instruct the MCO to pay the provider, the MCO will notify the Provider Contact Center when the payment is released.