OhioBWC - Common:  (Enhanced Care Program) - Participant details

Enhanced Care Program - Participant details

I am a claimant
BWC designed the Enhanced Care Program to provide higher-quality, better-coordinated care for when you're injured at work. In 2015, we introduced the program in 16 counties in northeastern Ohio for claimants who had only injured their knees at work. Now, we've expanded the program throughout the state.

You're eligible to participate if:

  • You live in Ohio.
  • You work for a state-fund employer.
  • You've injured your knee only.
  • You select an Enhanced Care Program physician of record (POR).

Find an Enhanced Care Program physician of record.

You have the right to choose any physician from our certified network. However, enhanced-care PORs offer additional value to you, including:

  • Better access - You will be able to see your enhanced-care physician within 48 hours.
  • Fewer delays - Enhanced-care PORs will be able to move care along more quickly, which means you get back to work - and to life - faster than before.
  • Superior coordination - You can rely on your enhanced-care POR to quarterback your care - including coordinating with specialists and other physicians where necessary to get you back to work.

It's simple to join.

  1. Confirm you meet the above requirements.
  2. Select an enhanced-care POR.
  3. Let your MCO know this physician is who you want to manage your claim.

I am an employer
How does the Enhanced Care Program work?
Claimants in Ohio who have an allowed claim for knee injuries only will be automatically eligible to participate. The enhanced-care physician of record (POR) will have 60 days to treat both the allowed conditions in the claim as well as medical issues causally related to those allowed conditions. The POR also will be expected to coordinate care where appropriate and document the treatment plan, which your managed care organization must decide whether to approve.

How will coordinating care and improving quality benefit me and my company?
It can help you maintain a stable, healthy work force while minimizing premium costs. Potential direct benefits include:

  • Minimizing lost productivity - more than 2 million days were lost during the July 1, 2013, policy year.
  • Shortening the average duration of a lost-time claim, which was approximately 45 days for the July 1, 2013, policy year.
  • Lessening costs for employers, since lost-time claimants should move more quickly through treatment and return to work.
  • Reducing opiate addictions, which afflict nearly 1 in 6 lost-time claimants today.

What impact will the Enhanced Care Program have on my experience?
BWC and its stakeholders are confident this program will lead to better outcomes for claimants at a lower cost for employers.

Will this affect my due-process rights?
No. You will still be able to appeal claims you believe either didn't happen in the course and scope of employment, or otherwise contest treatment you believe to be inappropriate. Those claims will fall out of this pilot program.

Will I be expected to pay for care related to co-morbid conditions or other general health matters?
No. BWC will incent its provider to coordinate care with the claimant's primary care physician or usual source of care. However, we will not pay for treatment that is not directly related to the workplace injury that arose out of the course and scope of normal employment.

Will BWC step in and pay for care in the event the claimant doesn't have health-care insurance?
No. BWC will only pay for costs related to the workplace injury that arose out of the course and scope of normal employment.

How do I operate as an enhanced care POR?
As the physician of record (POR) for a claimant participating in this program, you will have 60 days from the initial determination to treat both the allowed conditions in the claim as well as medical issues causally related to those allowed conditions. You'll also be expected to coordinate care where appropriate and document a comprehensive care plan, which the MCOs must still approve.

The program also separates the medical and legal components of the workers' comp process without affecting any party's due-process rights. For more complex claims, this approach can reduce delays by as much as five weeks - which means claimants will get back to work faster and healthier than before.

Why should I participate?

  1. Improved outcomes - PORs will be able to treat causally-related conditions without having an explicitly allowed condition with assurance of payment.
  2. Simplified process - PORs will be able to submit one comprehensive care plan and will be required to file the MEDCO-14 only if there's a change in the claimant's restrictions or the claimant's compensation period needs to be adjusted.
  3. Increased reimbursement - PORs will be eligible for a 15-percent incentive payment over and above what BWC pays for evaluation and management codes as part of its current fee schedule.

What's the catch?
There are additional expectations of PORs participating in the Enhanced Care Program. By signing an addendum, you agree to, among other things:

  • Provide timely access to claimants seeking care for workplace injuries.
  • Coordinate care for the claimant comprehensively.
  • Agree to be measured on performance.

The role of a specialty provider
Specialists play a crucial role in making the Enhanced Care Program successful. While the POR is expected to lead care management for participating claimants, many of them will need to use the services of surgeons, therapists, and other providers to help facilitate the claimant returning to work quickly and safely.

Getting paid as a specialist
The Enhanced Care Program allows for treatment of both allowed conditions and causally-related conditions as part of a workers' comp claim. Providers can proceed with treatment and will be paid for services without waiting for managed care organization approval. The only stipulation is that the care must be consistent with the "green" section of the Official Disability Guidelines (ODG) - or those evidence-based services for work-related conditions, which are indicated for automatic approval.

Succeeding as a specialist
Specialists do not need to enroll as a POR to participate in the Enhanced Care Program; a POR will coordinate where appropriate. However, because the program allows for treatment of both allowed conditions and causally-related conditions, specialists should be aware of the following:

  1. Not all conditions will be allowed - As part of the Enhanced Care Program, a claimant can be treated for both allowed conditions as well as causally-related conditions.
  2. PORs will use the ECP-TX, to document their care plans - This form will document the strategy the POR will use to provide care for the claimant for both allowed and causally-related conditions.
  3. Care can begin without waiting for MCO approval - A POR, along with other providers that are part of the initial care plan, can collectively begin treating both allowed and causally-related conditions without waiting for MCO approval so long as that care is consistent with the "green" section of ODG.
  4. Specialists can be paid for treating causally-related conditions - Specialists who are providing services for causally-related conditions can bill against the ECP-TX to receive reimbursement.

More information
For more information or to sign up for the program, email BWC medical services.

Where do I get current program information?
As a BWC-certified physician presently enrolled in the Enhanced Care Program, this information will support you in your work. Then, as the program evolves, this section will provide: