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Policy and Procedure Name:
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FIFTEEN THOUSAND DOLLAR MEDICAL ONLY PROGRAM ($15K
PROGRAM)
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Policy #:
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CP-06-04
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Code/Rule Reference:
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R.C. 4123.29 (A) (6)
O.A.C. 4123-17-59
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Effective Date:
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08/13/2021
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy #
CP-06-04, effective 10/06/2020
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History:
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Previous versions of this policy are available upon
request
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Fifteen Thousand Dollar Medical Only Program ($15K
Program)
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Fifteen-thousand-dollar medical only
program ($15K Program)
Medical benefits
IV. POLICY
A. Participation
B. Medical Only Process
C. MCOs’ Role
D. Employer Requirements
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Determining if a Claim
is Enrolled in the $15K Program
C. Enrolling a Claim into
the $15K Program
D. Un-Enrolling a Claim in
the $15K Program
E. Employer Reimbursement
in $15K Program Claims
F. Application for
Determination or Increase of Percentage of Permanent Partial Disability (C-92)
in $15K Program Claims.
G. Treatment and Claim
Reactivation Requests in $15K Program Claims.
H. Travel Reimbursement in
$15K Program Claims
I. Statute of
Limitations in $15K Program Claims
J. Complaints in $15K
Program Claims
The purpose of this policy is to ensure the BWC administers
the fifteen thousand-dollar medical only program in accordance with the laws
and rules.
This policy applies to BWC claims services, BWC employer
program unit, and managed care organizations (MCO).
Fifteen-thousand-dollar
medical only program ($15K Program): An employer program which
allows state fund employers the opportunity to pay up to the first $15,000 in
medical and pharmacy bills for medical only claims with a date of injury on or
after September 10, 2007.
Medical
benefits: For purposes of this policy, medical benefits include
treatment, and when appropriate, travel to that treatment; services; supplies;
pharmacy benefits.
1. It is the policy
of BWC that covered state-fund employers may participate in the $15K Program,
which allows employers to choose to pay the first $15,000 of medical benefits
of a medical only claim, including reimbursement for a BWC physician file
review, independent medical examination, and travel reimbursement requests
related to the independent medical examination.
2. The $15K Program
shall not apply to claims in which an employer with knowledge of a claimed
compensable injury or occupational disease has paid salary continuation (wages
in lieu of temporary total compensation).
1. BWC shall follow
the standard process for making a medical only claim determination when an
employer is enrolled in the $15K Program.
2. BWC shall also
ensure that medical benefits are not reimbursed while a claim is enrolled in
the $15K program. Once the employer is enrolled, all medical only claims with a
date of injury on or after the enrollment date will be automatically included
in the $15K program. A claim that is changed to lost time is automatically
removed from the $15K program.
1. It is the policy
of BWC that medical only claims that are enrolled in the $15K program shall not
be fully medically managed by the managed care organizations (MCO). However,
the MCOs may offer limited assistance to employers who have elected to
participate in the $15K Program.
2. It is the policy
of BWC that when a claim is removed from the $15K program for any reason, the
MCO shall process the claim under standard protocols for claims management.
3. It is the policy
of BWC that the MCO shall not reconcile duplicative payments (i.e., employer
paid bills and BWC paid bills), and that the MCO shall refer the employer to
the provider for reconciliation of duplicate payments.
1. An employer
electing to participate in the $15K program must:
a. Keep a record of
the injury, and
b. Keep a copy of
all bills with proof and date of payment under the $15K program for five years
from the last date a bill has been paid by the employer.
c. This
information must be made available to BWC, the injured worker and/or their representative
upon request.
2. BWC may request
this information from the employer not more than twice a year.
1. BWC staff shall
refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Shall follow any
other specific instructions for claim notes and documentation included in this procedure.
1. To determine if
a claim is enrolled in the $15K Program, claims services staff shall go to Claim
Details > Occurrence tab > Profiles link.
2. If the $15K
group has checked the box stating that the employer is enrolled in the $15K
Program, the system will automatically designate an appropriate claim as
enrolled.
3. When an employer
is enrolled in the $15K Program, the assigned claims services staff can enroll
or terminate a claim from the program so long as the date of injury is after
the policy enrollment date and medical benefits have not yet been paid in the
claim.
4. If the $15K
Program checkbox is blank, the claim was never enrolled in the $15K Program.
5. If claims
services staff has questions about a claim in the $15K Program, staff may send
an email to the BWC Claims Policy Field Tech mailbox.
6. If claims
services staff has questions about an employer in the $15K Program, staff may
send an email to the Employer
Program Unit mailbox.
C.
Enrolling a Claim into the $15K Program
1. When a claim is
not systematically put into the $15K Program, claims services staff may put a
claim that is eligible for the program into the $15K Program when:
a. The claim is
changed from Lost Time to Medical Only;
b. There is a
change in the policy number; or
c. Two or
more claims are combined, and the surviving object claim is not systematically
placed into the $15K Program.
2. Claims services
staff shall investigate and ensure that the employer is enrolled in the $15K
Program, and if so, appropriately place the claim(s) into the $15K Program by:
a. Ensuring the
claim type is correct (e.g., Lost Time changed to Medical Only);
b. Ensuring no
medical benefits have yet been paid in the claim.
i. If
no medical benefits were yet paid, staff shall enroll the claim in the $15K
Program;
ii. If medical
benefits have been paid, claims services staff shall:
a) Refer to the Workflow
to recover money for claim costs paid; and
b) Send the
“Medical Only Program Employer” letter to recover payments and remove charges
from the employer’s experience.
3. Claims services staff
shall update the claims management system by updating Claim Details >
Occurrence tab > Profiles link to reflect that the claim is in the $15K
Program.
1. A claim can be
un-enrolled when:
a. It changes from Medical
Only to Lost Time. The claims management system will automatically enter a
termination date.
b. The employer
elects to have the claim removed. Claims services staff shall enter the
termination date in Claim Details > Occurrence tab > Profiles link.
2. Claims services
staff shall un-enroll a claim by:
a. Updating the
claim management system in Claim Details > Occurrence tab > Profiles link;
b. Checking one of
the following reasons in the drop-down box:
i. Employer
withdraws effective the date of injury. This is selected when the employer
does not wish to make any medical benefits payments in the claim at all and
wants the claim excluded from date of injury.
ii. Employer
pays bills through the end date. This is selected when the employer has
provided BWC with an end date because they no longer wish to be responsible for
the bills in a specific claim.
iii. Reached Limit.
This is selected when the employer has notified BWC that they have paid the $15K
Program maximum allowable.
E.
Employer Reimbursement in $15K Program Claims
1. To remove claim
costs due to file reviews and independent medical examinations in the $15K
Program claims:
a. All medical
benefit bills should be sent to the employer for payment, except for costs
related to a BWC physician file review, independent medical examination, and
travel reimbursement requests related to the independent medical examination.
b. Physician file
reviews, independent medical examinations, and travel reimbursement requests
related to the independent medical examination shall be paid by BWC as claim
costs and will be charged to the claim. This charge will appear as a charge to
the employer’s experience regardless if the claim is enrolled in the $15K
Program. Claims services staff shall remove these charges only at the request
of an employer and only after the employer reimburses BWC for the claim costs.
2.
Claims services staff shall follow the Medical Only Program Workflow for
file reviews and shall use the Nurse
Referral job aids on COR.
1. C-92
applications may be filed in a claim that is enrolled in the $15K Program.
2. Claims services
staff shall process the C-92 application in the normal manner. If the
determination of the C-92 application results in:
a. A 1% or greater
award – this will change the claim to lost time and the claims management
system will systematically remove the claim from the $15K Program.
b. A 0% award - the
claim shall remain in the $15K Program.
1. An MCO may
assist employers who have elected to participate in the $15K Program. Such
assistance is limited to:
a. Educating
employers on the benefits and requirements of the $15K Program;
b. Helping
employers to determine whether a claim should remain in
the $15K Program or whether the claim would benefit from medical
management;
c. Helping
employers to understand whether a claim in the $15K Program may require
treatments in excess of the maximum Medical Only program amounts;
d. Talking with the
medical provider treating the injured worker to understand the treatment plan
and prognosis for recovery for claims in the $15K Program;
e. Informing the
employer of the BWC fee schedule amounts for services to ensure that the
provider is reimbursed appropriately for claims in the $15K Program; and
f. Tracking
the medical payments made by an employer for a claim in the $15K Program and
assisting the employer with understanding when the employer is reaching the
maximum program expenditures.
2. While a claim is
enrolled in the $15K Program, an MCO shall not:
a. Authorize or
deny treatment or require the submission of a Physician's Request for
Medical Service or Recommendation for Additional Conditions for Industrial
Injury or Occupational Disease (C-9) for prior
authorization of services;
b. If a medical
bill is received the MCO will add appropriate EOB code so that the bill is
not paid by the MCO, and then the bill should be sent to the employer to
pay;
c. Apply
discounted rates based on the MCO’s negotiated panel or negotiate on behalf of
the employer any fee lower than the BWC fee schedule amount;
d. Mediate billing
disputes between the employer and the medical provider;
e. Notify BWC on
behalf of the employer:
i. To opt
in or out of the $15K Program; or
ii. To remove a
claim from the $15K Program; or
iii. That the claim
has reached the maximum $15K Program expenditures.
f.
Charge employers participating in the medical only program for any of
the services listed in Paragraph V.G.1.above.
3. When an MCO
receives a Physician's Request for Medical Service or Recommendation for
Additional Conditions for Industrial Injury or Occupational Disease (C-9), and the
claim is enrolled in the $15K Program, the MCO staff shall:
a. Dismiss the C-9
request;
b. Not include
appeal language on the dismissal; and
c. Notify the
employer and provider.
4. When a claim is
removed from the $15K Program for any reason, the MCO shall be responsible for
the:
a. Full medical
management of the claim; and
b. Processing of
all bills, regardless of the date of service.
5.
The MCO shall not reconcile duplicative payments (i.e., employer paid
bills and MCO/BWC paid bills) in the claim. The MCO shall refer the employer to
the provider for reconciliation of duplicate payments.
6. When claims
services staff receives a request for claim reactivation, staff shall verify
whether the claim is enrolled in the $15K Program.
a. If the claim is
enrolled, claims services staff shall notify the MCO that the claim is enrolled
in the $15K Program and the claim reactivation request will not be processed.
b. If the claim is
not enrolled, claims services staff shall process the claim reactivation
request.
1. When claims
services staff receives a travel reimbursement request, staff shall verify if
the claim is enrolled in the program or not.
a. If the claim is
enrolled and:
i. If
travel reimbursement is related to medical treatment, notify the injured worker
that the claim is enrolled in the $15K Program and the travel reimbursement
request must be sent to the employer for processing. BWC shall not process the
request.
ii. If travel
reimbursement is related to an IME, BWC shall process the request for travel
reimbursement, and, if appropriate, pay.
b. If the claim is
not enrolled, claims services staff shall process the travel reimbursement
request, and if appropriate, pay in accordance with the Travel
Reimbursement policy and procedure.
2. For claims in
the $15K Program, an employer may request removal of claim costs due to a file
review, independent medical examination, or travel reimbursement requests
related to the independent medical examination, pursuant to section V.C. and V.E. of this procedure.
1. If there is a
question as to whether the statute of limitations has expired in a claim, claims
services staff shall request written documentation from the employer of the
last date of service for medical treatment, as well as the last medical benefit
paid date for claims with a date of injury prior to July 1, 2020. Once the
employer submits the information, claims services staff shall calculate the new
statute expiration date and enter a new statute of limitations override date in
Claim Details > Details > Claim Dates > Other Dates in the claims
management system.
2. If a conflict
exists in determining the new statute expiration date or the employer fails to
submit requested written documentation, claims services staff shall refer the
issue to the Industrial Commission on a Notice of Referral.
3. Staff may refer
to the Jurisdiction
policy and procedure for more information.
1. BWC may receive
complaints from an injured worker, the injured worker representative, and/or
providers regarding non-payment of medical benefit bills by the employer.
2. Claims services
staff shall create a work item and refer all complaints regarding the $15K
Program to the employer program unit.
3. The employer
program unit shall investigate the complaint with the employer and notify the
assigned claims services staff of the outcome via email.
a. If the employer
is to be removed entirely from the $15K Program, the employer program unit will
remove the employer and notify the assigned claims services staff. When the
employer is removed from the program, all claims for the employer are removed.
b. If the claim is
to be removed from the $15K Program, the employer program unit shall notify the
assigned claims services staff, and the claims services staff shall remove the
claim from the $15K Program.
c. If the
claim is to remain in the $15K Program, the employer program unit shall notify
the assigned claims services staff.