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 AttorneyHired 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.

You Need Gruhin & Gruhin