OhioBWC - Employer:  (Self-insuring) - Medical management guidelines

Self-insuring medical management guidelines

A self-insuring employer must be able to furnish or make arrangements for reasonable medical services for injured employees during all work hours and the management of any medical claims. The employer must provide BWC a medical services plan that includes:

  1. A list of health-care providers or networks which it has arrangements with for the purpose of providing medical treatment and services to its injured workers;
  2. A plan for overall medical management of all claims. The plan should focus on providing quality medical services to safely and quickly return injured workers back to work as soon as medically possible;
  3. The process for handling the authorization and denial of medical treatment;
  4. The procedure for providing BWC with a timely and accurate report of information regarding medical and health-care services, supply costs, quality and utilization;
  5. Documentation of how injured employees will be notified of their right of freedom to choose providers.

All self-insuring employers must administer either a Qualified Health Plan (QHP) or a Medical Management Plan. A Medical Management Plan must incorporate the five elements listed above. A QHP must incorporate the five elements listed above, and it must meet additional nationally recognized standards as outlined in Ohio Revised Code 4121.442.

Qualified Health Plan
Once BWC certifies a QHP, the employer will educate its employees about the QHP's services and benefits as well as the employee's rights and responsibilities. The QHP may be:

  • Self-administered - The self-insuring employer has all of the resources/tools accessible to administer the QHP in-house;
  • Vendor-administered - The self-insuring employer contracts with a medical-management vendor to provide all of the required services to administer the QHP;
  • Partial vendor-administered - The self-insuring employer has some of the resources/tools and will administer some of the QHP and contract the remainder.

All self-insuring employers with a QHP are required to have an alternative dispute resolution (ADR) process. Employers who do not participate in an approved QHP may not use the ADR process. ADR is intended to handle medical disputes regarding quality assurance, utilization review, medical necessity, and other treatment and provider issues. ADR provides due process regarding conflicts in medical treatment issues. However, this does not include fee schedule grievances. Disputed issues may include:

  • Quality assurance;
  • Utilization review;
  • Determining whether or not a service is covered;
  • Treatment/service necessity;
  • Issues involving health-care providers

There are at least two levels of peer review by the QHP administrator. BWC is not involved in this process. If the injured worker does not agree with the self-insuring employer's decision on a treatment issue, the injured worker must follow the ADR process as outlined by the employer's QHP. If there continues to be a dispute after the ADR process has been completed, the injured worker may file a motion requesting an Industrial Commission of Ohio hearing.

Employers with an active QHP must be recertified every three years pursuant to Ohio Administrative Code 4123-6-52. Current employers who have a QHP may opt out during their renewal period. The self-insuring employer must notify BWC in writing at least 30 days prior to the date of opting out. Upon opting out, the self-insuring employer must provide its active Medical Management Plan to BWC.

If you have questions regarding the medical services requirements for a self-insuring employer, please email BWC's self-insured department.