Managed Care

The Role of an MCO

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Published on May 15

The primary responsibility of a managed care organization (MCO) is to evaluate the current and future medical needs of injured workers by reviewing and approving treatments, paying medical bills, and providing rehabilitation referrals. However, the full scope of an MCO’s role often extends far beyond these basic tasks.

Below is a more complete picture of the role MCOs, like Sheakley UniComp, play in the management of your workers’ compensation claims.

What is an MCO?

MCOs perform a wide variety of functions that involve, to a large extent, the medical management of workers’ comp claims. Playing an active role in each step of the claims management process allows an MCO to look out for the best interests of its client companies and their injured workers.

Since the Ohio Bureau of Workers’ Compensation (BWC) requires all employers to select an MCO when they first apply for workers’ compensation insurance, service fees are paid out of the employer’s annual premium. Amongst their primary responsibilities, MCOs are tasked with obtaining the First Report of Injury (FROI), initial claim data, and medical records for the BWC; managing and paying all medical provider bills; and ensuring all fees are appropriate for the claim. Additionally, MCOs authorize and deny all medical treatment requests on behalf of their clients, coordinating with medical care providers to facilitate injured workers’ safe and timely return to work.

The BWC and MCOs work collaboratively to manage workers’ comp claims and coordinate appropriate and necessary medical services for injured employees. During the BWC’s biannual Open Enrollment period, employers have the opportunity to review their current MCO partner relationship and either continue it or select a new MCO with whom to work for the next two years. This year’s MCO Open Enrollment period runs from May 1 through May 26.

Reporting & Managing Workers’ Compensation Claims

One of the most important functions of an MCO is to report and manage all workers’ comp claims on behalf of its clients and their injured workers.

At Sheakley UniComp, we manage the medical portion of all of workers’ comp claims, ensuring injured workers receive the quality medical care they deserve so they can return to work safely. To make this process easier, we assign a team of skilled and experienced associates to each client, whose goals is to maintain proactive communication, supply comprehensive claim updates, suggest training and safety programs that may limit the number of future injuries, and facilitate the collaboration necessary to improve outcomes.

Reviewing & Approving Injured Worker Treatment

When an employee is injured on the job, a critical first step is ensuring that the worker receives timely, efficient, and effective treatment. Unnecessary or delayed procedures can lead to setbacks in the employee’s recovery and add excessive costs to the claim.

Sheakley’s MCO team works collaboratively with medical providers, occupational and physical therapists, and others involved in the injured worker’s treatment to ensure that the proper and necessary care is received. Our case managers review and confirm that all treatments are customary for the type of injury. Staying in constant contact with all interested parties throughout the recovery process enables our staff to facilitate timely treatment and safe returns to work.

Paying Injured Worker Medical Bills

The BWC places the responsibility of processing and paying all medical bills on the MCO. By maintaining active involvement in the claims process and reviewing all medical bills, MCOs can help their clients control the costs associated with each claim.

When processing payments for workers’ comp medical bills, our Sheakley UniComp billing team ensure that only those services, treatments, and medications actually provided are billed, and that the costs listed are customary for the injury and consistent with the BWC fee schedule. We also utilize our extensive medical provider network to access the greatest cost-saving opportunities.

Utilizing Proven Return-to-Work Strategies

Lost time claims can have a significant impact on a company’s workers’ compensation premiums. MCOs consistently strive to return injured workers to the job as soon as they are medically cleared. These efforts not only help businesses save time and decrease costs, but they also set injured employees up for more positive outcomes by keeping them engaged and reducing downtime.

At Sheakley UniComp, we approach every claim with the goal of returning the injured worker to active duty as soon as safely possible. Whether through modified-duty nonprofit, transitional work, or light-duty assignments, identifying the appropriate return-to-work opportunity is essential to reducing the lost-time cost of a claim and the likelihood that it will develop into total disability.

Providing a Network of Professional Care

When selecting an MCO, employers should ensure that their chosen partner will provide access to a large, high-quality professional care network that meet the needs of their employees.

When employers choose to work with Sheakley UniComp, they gain access to a large network of highly qualified, knowledgeable physicians that can provide the top-notch care and expertise their injured workers need to recover quickly and return to work safely. Additionally, we have negotiated network discounts up to 20% below the BWC fee schedule.

Choosing the Right MCO

Partnering with the right MCO is essential to reducing claim costs, improving injured worker outcomes, and managing all aspects of your workers’ comp claims. During this year’s open enrollment period, take the time to evaluate your current MCO partner and make sure that they’re fulfilling their promises of care, communication, and excellent service.

Learn more about Sheakley UniComp’s history as one of Ohio’s most tenured and trusted MCOs. To select Sheakley as your MCO partner, complete and submit our Open Enrollment form by May 26.

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