Page 11 - Ohio RA 2011 Winter FlipBook

www.ohiorestaurant.org 9 Winter 2012 Issue

Recognizing the Differences Between a MCO and a TPA

Through careful review, you can fnd the right ft for your needs

Selecting the proper managed care organization (MCO) and third party administrator (TPA) can help you control work-related injury and illness claims and their related costs. Prior to making the decision on which company to choose, there are some important guidelines that you should know.

First off – what exactly is a MCO?

According to Ohio’s Health Partnership Program, MCOs are responsible for the medical management of Ohio employers’ work-related injuries and illnesses.

Every state-funded Ohio employer can choose a MCO to medically manage their claims. Those employers who not to select their own MCO will have one randomly assigned to them by the Ohio Bureau of Workers’ Compensation (BWC). Additionally, employers are limited in their ability to change MCOs. In fact, in most circumstances, employers can only do so during a MCO Open Enrollment period. The periods are customarily held only one month every other year.

A MCO is responsible for handling all matters related to medical treatment for approved Ohio workers’ compensation claims. The organizations provide a number of services, all to assist Ohio employers and their injured employees in successfully recovering from a workplace injury and returning to work.

So, now that you know their function, what exactly do MCOs do?

• Collect initial injury reports and transmit them to BWC;

• Manage and authorize the medical treatment an injured worker receives;

• Handle the medical review and process bill payment;

• Maintain a network of BWC-certifed healthcare providers;

• Implement return to work services;

• Manage utilization review;

• Process treatment appeals;

• Provide an Alternative Dispute Resolution (ADR) process; and

• Train and educate.

Further, they provide a number of customer service and communication functions essential to delivering the timely and appropriate medical care necessary to achieve healthy and successful claims outcome. MCO staff members are medical professionals and their processes are clinically focused.

MCOs can make the greatest impact by helping employers achieve successful return to work programs and by providing aggressive medical cost savings. Return to work helps employers avoid the most costly of claims – lost-time claims – when an injured worker is off

work for eight or more consecutive days. Having a provider network that offers savings beyond BWC’s established fee schedule can help control medical costs. Thus, this assists employers in managing their long-term insurance premium. Every employer in Ohio must have a MCO, which is paid for directly by the BWC.

So, now that you know what a MCO is, what exactly is a TPA?

A TPA serves as an advocate for employers on workers’ compensation matters. Many Ohio employers, both state-funded and self-insured, hire TPAs to administer their workers’ compensation programs. While employers must have a MCO, there is no requirement to have a TPA. TPAs provide claims management services at the onset of a claim. TPAs must work closely with the employer’s MCO on all claim medical matters, and TPAs must consult with the employer on the best course of action for each claim, keeping in mind cost control for the employer.

Additionally, TPAs serve as plan administrators for association and chamber-sponsored group rating programs. The TPA manages the group program, ensuring the integrity and stability of the group.

So, now that you know their function, what exactly do TPAs do?

• Claims Administration

• Claims investigation

• Certifcation/rejection advice

• Outcome management

• Cost control strategies

• Salary Continuation

• Transitional Work

• Lump Sum Settlement

• Handicap Reimbursement

• Risk Management

• Financial reports

• Premium projections

• Experience forecasting

• Assessment of alternative rating program options

• Group Rating

• Retrospective Rating

• Premium Discount Program Plus

• Drug Free Workplace

• Safety Council

• Payroll Segregation

• Self Insurance

• Hearing Representation

Having a TPA is an effective way to control costs through claims management, risk management and cost-control initiatives.