With the change in the ADR Process,  does the rule still apply that if the MOC does not respond to a C-9 within 10 days the service is approved?

Answer:  NO.  Now the MCO Policy Reference Guide says:

A medical service request will be considered approved and the provider may initiate treatments when all of these criteria are met:

(1)   The MCO fails to communicate a decision to the physician within three business days of receipt of an original medical services request or five business days if the request was pended;
(2)   The physician has documented the medical services request completely and correctly on a C-9 or other acceptable document;
(3)   The physician has proof of submission to the appropriate MCO;
(4)   Medical services are for the allowed conditions;
(5)   The claim is in a payable status.

In instances when a C-9 is not responded to within three business days and the provider initiates treatment, the MCO will provide concurrent and retrospective review of that treatment. If it is found before, after or during delivery, that any treatment, approved or not approved within three business days, is not medically indicated or necessary, not producing the desired outcomes, or patient is not responding, the MCO will notify the parties of the decision to discontinue payment of said treatment. Only charges for treatments already rendered will be paid. If the provider, IW or employer wish to dispute the decision, they may do so via the ADR process. The MCO shall obtain beginning and estimated ending dates for inpatient services if not provided on the request for medical services.

Previously, if services were approved, they were not subject to change. Now, approvals can be rescinded at any time.

In this ‘new’ era of Ohio BWC Policy, you need an attorney to represent your interests more than ever !

© 2009, Gruhin & Gruhin Attorney's. All rights reserved.

• Alternative Dispute Resolution Changes (When the MCO denies your Medical Treatment Request)

The Ohio Bureau of Workers’ Compensation is changing its ADR process

In March of 2008 an internal audit of the ADR Process was performed.  The audit surmised that the timeframes for ADR’s are excessive; noting that appeal process could take between 73 and 261 days to reach a resolution.   Internal Audit Recommendations included:

• • Consider the feasibility of eliminating levels of appeal.
  • Ensure management reporting of pertinent ADR processes to assist with developing strategies to reduce appeals.
  • To Implement preventive controls to ensure services and treatment are addressed appropriately

 In response to these recommendations, a workgroup was formed to review the entire ADR processes and identify opportunities for continued improvement. This workgroup consisted of MCO and BWC members.   This group recommended:

• • Rule change eliminating BWC level of review
  • BWC to develop a robust program oversight and quality review program
  • Maintain ADR Goals

(1)   Facilitate resolution of medical treatment disputes—timely, effectively, and efficiently
(2)   Maintain fairness and due process
(3)   Ensure Quality Control of treatment decisions
(4)   Improve parties’ satisfaction

The reform proposal was presented to all stakeholders, OAJ, BWC Legal, the BWC Administrator and Senior Leaders, the BWC Board of Directors (02/18 & 03/18) and the Joint Committee on Agency Review (the legislative oversight for rule changes). 

ADR reform approved by BWC Board of Directors on 03/18/09 and the rule change went into affect 11/01/09;

What are the changes?

Copy of the updated ADR rule change (4123-6-16) is attached. 

• • MCO shall complete the ADR process and submit its recommended ADR decision to the bureau electronically (refer to paragraph (E) of the rule). BWC ADR Department will continue to serve as program oversight and quality assurance unit.
  •  (C)(2 allows MCOs to obtain a review from a more specialized area of medicine
  • Previously reviews conducted by a physician having a like practice as the physician requesting the treatment
  • (E) Allow the MCO time frame for completing the ADR process to be suspended during the time an independent medical examination is obtained
  • When an IME is indicated, the dispute timeframe is tolled until the MCO obtains a completed report—once the report is received an order will be published within 7 days.
  • In the case of a file review MCOs have 21 days to perform a file review and make a decision.

 Negotiations with providers can take place at any level in an attempt to resolve issues and get treatment approved. 

C-11 form updated:

• Instruction to withdraw appeal added
• Level 2 language removed
• A new withdraw appeal section added

Question:  Does the rule still apply that if the MOC does not respond to a C-9 within 10 days the service is approved?

Answer:  The MCO Policy Reference Guide says:

A medical service request will be considered approved and the provider may initiate treatments when all of these criteria are met:

(1)   The MCO fails to communicate a decision to the physician within three business days of receipt of an original medical services request or five business days if the request was pended;
(2)   The physician has documented the medical services request completely and correctly on a C-9 or other acceptable document;
(3)   The physician has proof of submission to the appropriate MCO;
(4)   Medical services are for the allowed conditions;
(5)   The claim is in a payable status.

In instances when a C-9 is not responded to within three business days and the provider initiates treatment, the MCO will provide concurrent and retrospective review of that treatment. If it is found before, after or during delivery, that any treatment, approved or not approved within three business days, is not medically indicated or necessary, not producing the desired outcomes, or patient is not responding, the MCO will notify the parties of the decision to discontinue payment of said treatment. Only charges for treatments already rendered will be paid. If the provider, IW or employer wish to dispute the decision, they may do so via the ADR process. The MCO shall obtain beginning and estimated ending dates for inpatient services if not provided on the request for medical services.

HAVING TROUBLE WITH YOUR OHIO WORKERS’ COMPENSATION CLAIM ?  CALL GRUHIN & GRUHIN

© 2009, Gruhin & Gruhin Attorney's. All rights reserved.

The current atmosphere at the OhioBWC is anti-injured worker. The MCO’s continue to deny requested medical treatment, the BWC is actively making settlements of claims more onerous.

It’s bad enough to get hurt on the job, but fighting the system that is supposed to protect injured workers is downright demoralizing.

The BWC is now forcing settlement allocations between compensation, future medical expense, and protection of Medicare interests. That would not be bad but when the BWC forces allocation in a settlement for an injured worker who will not be eligible for Medicare benefits until age 65 or 66, it becomes absurd.

As a result of an internal audit performed late in 2008, the BWC decided that, in order to clean house, it would reduce settlement offers to injured workers, utilize co-morbidity tables (taking a persons whole medical history into account in the settlement of a broken leg, for example), and use the current economic situation to ‘squeeze’ low settlement amounts for workers’ in economic distress (terminated due to economy, etc.)

So much for a system that makes a ‘Plegde’ of Service to injured workers.

Now, the Ohio Senate is considering bringing privatization to workers’ compensation in Ohio. Anyone who is injured in the service of a self-insured employer knows the extra nightmare of claim battles. Bringing privatization into the BWC arena will increase the battle between the injured worker and the benefits to which he/she is entitled.

Contact Governor Strickland and tell him that you want a change for the benefit of the injured worker.

Contact your state representative and tell him/her that you want a change for the benefit of the injured worker.

© 2009, Gruhin & Gruhin Attorney's. All rights reserved.

Yesterday I got a call from a client informing me that he was called by his MCO and was told that he is putting his company out of business because, through our office, the client was awarded his permanent partial compensation benefit (the money for his injury). Imagine my surprise at such a conversation which was initiated by an entity whose only job is to oversee medical treatment authorizations and payment for such treatment.

My client felt bad about the call from the MCO until I explained who/what the MCO is/does. And why such information from the MCO is inaccurate.

First of all, the MCO is the entity that authorizes/denies medical requests submitted by an injured worker’s doctor of record and pays the authorized medical bills (most of the time).

They are compensated, by the Ohio BWC, based on a percentage formula calculated by reviewing all of the denied medical treatments and monetary savings to the BWC from said denials. Without an attorney, an injured worker may believe that denied medical care request is correct and they don’t push the envelope to get the needed medical care.

As an FYI, most appealed medical denials, with supporting documentation from the treating physician,  are approved at the Industrial Commission Hearing Level. To that level, an appeal needed to be filed to the MCO medical treatment denial.

Hmmm, wonder what the actual percentage rate of medical treatment requests that are denied?  I review the orders that come in from the BWC and the denial letters from the MCO’s. It seems that most C9 requests for medical treatment authorization are denied. We are filing numerous appeals to treatment denials every week. Most of those appeals are determined in favor of our clients at the hearing level.

In any event, my client thought that the MCO handled his entire BWC claim. That is not the case. Here is how it works.

BWC CSS - every injured worker is assigned a BWC CSS – the case worker for the claim. They are not lawyers. They work for the BWC. Their allegiance is to their BWC boss. They are not supposed to give advice, legal or otherwise. Yet, they do just that. They are not lawyers.

My clients tell me what they are told by the CSS and, at times, I cannot believe the incorrect information/advice an injured worker is given. And injured workers think “isn’t the CSS in a better position to know what I should be doing in my claim”  The simple answer is NO, they are not.

As a Board Certified Workers’ Compensation Specialist with 32 years of experience, I know exactly what needs to be done in a claim and we do it. My role is to protect my client’s legal interest and obtain the maximum compensation benefits available in the claim. Most of the time, the CSS only has a high school education and is trained by the BWC to benefit the BWC system.

MCO - as described above, they authorize/deny medical treatment requests. Many times they do not timely pay authorized medical treatment.

TPA - Third Party Administrator - Hired by the Employer to represent its interests. That interest is to fight the claim to keep the payments down so that risk premiums are as low as possible.

Employer Attorney – Hired by the Employer to represent its interests. That interest is to fight the claim to keep the payments down so that risk premiums are as low as possible.

Injured Worker Attorney – represents the injured worker’s interest in the BWC process. Makes sure the claim is filed for the correct medical/injury conditions. Makes sure all denied medical treatment requests are appealed. Attends all Industrial Commission hearings to represent the injured worker’s legal interests. Files requests for compensation on behalf of injured worker. Remember, the BWC has its lawyers to represent it. The Employer has its lawyers to represent it. An Injured Worker needs to have legal representation to protect his/her own legal interest and right to obtain necessary medical care, prescription medication, and monetary benefits. Gives counsel and advice to the client.

After a long conversation, my client expressed understanding of the process and what the MCO process is all about.

© 2009, Gruhin & Gruhin Attorney's. All rights reserved.

I was called by a prospective client about her BWC claim and the fact that she could not get authorized for treatment. After talking to her for a few minutes it became obvious that I needed to speak with her doctor. So, I call the doctor and ask about the treatment that he requested on the C9 authorization form.  I was dumbfounded by his comments during the conversation! Here is the skinny on our discussion.

First I ask him what he filled out on the form. He told me that  he asked for permission to provide therapy modalities over a multi week period. It was apparent to me, during the conversation with the prospective client and the doctor, that the claim was medically inactive. The request should have asked for claim reactivation.

If you are an injured worker, you must be informed and know that if you have an allowed BWC claim and you do not obtain medical treatment for a period of 14 months, your claim becomes inactive. Once that happens, you may have to prove – all over again - that your needed treatment is related to the original work injury. The doctor’s mistake was not requesting reactivation of the claim.

But now for the clincher to the conversation . . . . Then I ask the doctor when he sent the C9 Form to the MCO (Medical Care Organization). His reply, on the 5th (today is the 13th).  I ask if he has a fax transmittal sheet to prove that he sent it on the 5th and that the MCO received the C9 on the 5th.  He seemed surprised by the question. Well, if he was surprised by the question, I was dumbfounded that a medical provider – an OhioBWC Certified Medical Provider at that – would not be aware of the simple rules governing the time limits pertaining to authorization of treatment requested via the C9 Form.

I explain that there are rules and that the rules are printed right on the form. A state funded employer’s MCO has 3 days to respond to a C9. If there is no response, guess what – the requested treatment is authorized. For a self insured employer, there is a 10 day response time. I can’t tell y0u how many times MCO’s blow the response time.  A C9 Form is attached to this article via hyperlink below so you can see it for yourselves.

In this instance, the doctor could not prove that he sent the C9 form to the MCO over 7 days before, without response.

Who suffers? The injured worker because here she is waiting for necessary treatment that could have started days before.

I then explained to the doctor that there is a rule regarding the submission of medical bills. A medical bill must be submitted to the MCO or OhioBWC within 2 years of the date of service. If the bill isn’t filed within the 2 year period, the BWC doesn’t have to pay the bill, even if the treatment was rendered for allowed claim conditions,  because the bill is time barred. Who suffers in such situation? Both the doctor and the injured worker. But then I suppose the doctor eventually would sue the injured worker for payment of the bill even though the doctor failed to file his bill in a timely fashion.

Bottom Line – The Importance of a Fax Transmittal Sheet - I explained that the doctor needed to set his fax machine to spit out a transmittal sheet so he can prove when and to whom he sent the C9 for treatment approval and also to prove when and to whom he submitted his medical bills for payment.

Hopefully, the doctor learned what needs to be done.

Please check with your doctor to make sure that he/she can prove when documents, office notes, C9 authorization requests, and bills were filed with the BWC.

Check out the C9 Form and see the rule for yourselves. Why don’t the doctors read the forms they use every day?

If you have any questions about your Ohio Workers’ Compensation claim, please give us a call. We would like to help you receive all of the benefits to which you are entitled.

To make sure your claim is being handled correctly, call Mike Gruhin Board Certified Ohio Workers’ Compensation Specialist at 216-861-5555.  Get the protection you need and all of the compensation benefits and money you deserve.

© 2009, Gruhin & Gruhin Attorney's. All rights reserved.