• 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.

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