OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Transitional Work Performance Bonus

Policy #:

MP-20-02

Code/Rule Reference:

Ohio Administrative Code (OAC) 4123-17-55, 4123-6-01, 4123-6-02.2

BWC Employer Policy EP-20-02 (Transitional Work Performance Bonus)

Effective Date:

01/14/2020

Approved:

Deborah Kroninger, Chief of Medical Operations

Origin:

Medical Policy

Supersedes:

All Medical policies, directives or memos regarding Transitional Work Grant & Bonus Program that predate the effective date of this policy.

History:

Available upon request

 


 

Transitional Performance Work Bonus 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

 

 


 

I. POLICY PURPOSE

 

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.

 

II. APPLICABILITY

 

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).

 

III. DEFINITIONS

 

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.

 

IV. POLICY

 

A.     Bonus Program Eligibility

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.

 

B.     Bonus Program Application- Submission and Evaluation

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.     Additional application requirements are detailed in BWC’s Employer Services Transitional Work Performance Bonus policy.

 

C.    Appeals to Bonus Program Decisions

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).

 

V. PROCEDURE

 

A.     Standard Claim File Documentation

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.

 

B.     Bonus Program Application: Submission and Assignment

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.

 

C.    Transitional Work Plan Review and Verification

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.

 

D.    Monitoring of Claims 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.

 

E.     Auditing of the TWB Determination Report for Bonus Calculation

1.     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.     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.

 

F.     BWC Reporting to the MCO

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.

 

G.    MCO Responsibilities

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.

 

H.    Complaints

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.