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BWC $15K Medical Only Program
When an employer chooses to participate in the $15K Program, the employer becomes the manager of the claim. The company's managed care organization (MCO) can not authorize treatment or pay medical bills. The employer can register for the program by calling 1-800-OHIOBWC and listening to the options. Once an employer enrolls in the $15K Program, the employer is responsible for the bills in all medical-only claims (claims with seven or fewer lost days from work) with injury dates after the enrollment effective date unless:
Major Benefits
- The employer notifies BWC within 14 days of learning that a claim has been filed, that it does not wish to pay for the bills in that claim;
- The employer notifies BWC that the $15,000 maximum has been reached in a claim;
- The employer notifies BWC that the company does not wish to pay any additional amount and informs BWC of the last date it will be responsible for a particular claim. This could be the date of injury or after payment of any amount up to $15,000
Once the employer notifies BWC to remove a claim from the 15K Program the MCO will begin processing the bills in that claim.
Employers participating in the program must do the following:
- Notify their injured workers and their health-care providers that they, not the MCO, are paying the medical bills for an injury.
- Pay all bills within 30 days of receipt as billed or according to prior agreement with the medical provider.
- For claims with dates of injury before July 1, 2009, pay as billed or in accordance with the pre-negotiated payment agreement with providers.
- For claims with dates of injury after July 1, 2009, pay in accordance with BWC's fee schedule.
- Notify BWC and the MCO if/when the $15,000 maximum is reached and supply proof of such payment to the MCO.
- Report some claims to Medicare beginning July 2010. This is a federal requirement.
- Keep a record* of all work related injuries including:
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• Injured worker’s name, address and Social Security number; |
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• Date and time of injury; |
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• Type of injury; |
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• Part of the body injured; |
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• A brief description of the accident that led to the injury; |
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• Copies of all bills with proof and date of payment under this program; |
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• Proof of payments made within 30 days of request from BWC; |
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• Documentation for excluding any wages paid to the employee while off work in the $15,000 limit; |
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• Documentation showing no denial of any bills. If you participate in the program, you inherently approve the first $15,000 of medical costs. |
*These records must be maintained for six years from the last date of bill payment.
Reaching the $15,000 maximum
If the payment of a particular bill will exceed the $15,000 maximum, employers should pay that portion of the bill that brings the total paid to $15,000, and then inform the provider to bill the MCO for the balance. Employers must then notify BWC and the MCO that they've reached the $15,000 maximum. Copies of all bills with proof and the dates of payment should be sent to the MCO. It then becomes the MCO’s responsibility to process all future bills. BWC will not reimburse the employer for any bills paid by the employer.
Lost Time Claims
If the injured worker loses more than seven days of work, the injury is no longer eligible for this program and a claim must be filed with BWC. If a claim has already been filed with BWC, the process to change the claim to lost time will automatically remove the claim from the $15K Program. The MCO will be responsible for processing subsequent medical bills. BWC does not reimburse the employer for bills paid under this program prior to the change over from medical only to lost time.
Injured Worker and Employer Rights
- Payment of medical bills under this program in no way supersedes the right of the injured worker to file a workers' compensation claim.
- Payment of medical bills under this program does not waive BWC's right ot hear and decide a claim if filed.
- Payment of medical bills under this program does not waive the employer's right to contest a claim if filed.
Opting Out of the Program
Employers can opt out of the $15K Program by calling 1-800-OHIOBWC and listening to the options. Once the employer notifies BWC of the desire to opt out of the program, BWC will send written confirmation of this decision. The MCO will then be responsible for processing bills for all medical-only claims after the program termination date.
Notice
BWC will not mediate disputes between the employer and medical provider(s) pertaining to bill payment. Employers, who fail to meet the requirements of this program, including responding timely to bill payment requests, will be subject to program removal.
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