MCO season: Monetizing workers’ compensation managed care services in Ohio

With open enrollment coming to a close this Friday, May 25, Ohio employers are nearing the end of their opportunity to select a managed care organization (MCO) to coordinate the medical aspects of workers’ compensation claims for the coming two years. During MCO Open Enrollment, materials are published that attempt to compare MCOs in terms of effectiveness and service. What factors should be considered when choosing an MCO? Ultimately, employers must select an MCO based on what is most important to them. The MCO’s responsiveness, level of engagement, ability to control expenses and lost workdays, and help injured employees recover and return to work should drive the decision.

What aspects of an MCO’s services help control costs?

It can be difficult to assess MCOs in terms of financial impact. When we think about controlling costs for Ohio workers’ compensation, we typically think of premium discount and rebate programs, administered by third party administrators that provide financial relief. We may also think of disputing a questionable claim to prevent unnecessary costs and preserve lower premium rates. These factors have clear implications for an employer’s premium, but the MCO’s ability to coordinate medical treatment, resolve workers’ compensation claims, and help employees get back to work can have a tremendous impact on your organization’s costs and should not be overlooked.

 What cost drivers may go unrecognized?

Qualifying for a premium discount or rebate depends on claim costs relative to an employer’s size. Claim costs are mainly driven by lost workdays. The MCO’s primary focus is to facilitate a prompt, safe return to work, limiting lost workdays and helping injured employees recover.

Of course, injuries can be severe at times and may result in substantial time off work. Lost time incurred on a claim drastically accelerates costs, and directly impacts the employer’s premium rates and options for discounts or rebates. In cases like these, the MCO’s role is crucial to the financial future of the employer.

Consistently engaging the injured employee and physicians to keep them focused on the return-to-work goal is critical. Every claim is different and there is no magical formula that guarantees painless results, but an employer should feel informed and confident that their injured employees are receiving appropriate medical treatment to help them recover and return to work.

 What are the signs of a high-performing MCO?

One sign that an MCO is performing at a high level is in its response to treatment requests. Most treatment requests are appropriate for the injury and approved by the MCO. Occasionally, a request will seek to treat issues unrelated to the claim and may be denied. But even with appropriate requests, there are often opportunities to coordinate with the treating provider to encourage more beneficial treatment and/or shorter durations to keep the recovery process moving as quickly as possible. This requires a thoughtful MCO that is closely scrutinizing every opportunity to shorten periods of disability and minimize the burden of the claim on both the employer and the injured employee.

 Most employers are aware of the value of offering modified duty to encourage an early return to work. MCOs can play a key role in matching a physician’s assessment of their patient’s physical ability with the employer’s flexibility to accommodate work restrictions. Throughout this process, there are therapy and rehabilitation resources available to help employers and employees continue to close the gap on working full duty, and the MCO is the access point for these services.

 Another sign of increasing importance is the MCO’s involvement in reviewing medications prescribed in claims. While the Ohio Bureau of Workers’ Compensation utilizes a pharmacy benefits manager to oversee the prescription drugs in claims, it also allows MCOs to refer cases to be reviewed for excessive or inappropriate medications. It is well known that the costs of prescription medications can be exorbitant and it is not uncommon for an individual to be unable to work solely because of the side effects of some of these drugs.  Examining medications for appropriateness and identifying alternatives have become crucial steps in medical management and important services employers should expect from their MCO.

This article was originally published in the May 2018 issue of Smart Business Magazine. 

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