The Bureau of Workers’ Compensation (BWC) allows employers to self-insure the first $15,000 of medical expenses on any claim when they participate in the $15,000 Medical-Only Program ($15K Program). Participation in the $15K Program allows employers to contain their workers’ compensation premiums, but does require additional responsibility and reporting on the part of the employer. Here are five fast facts about the $15,000 Medical-Only Program that can help you decide if the program is the right cost-containment option for your company.
Cost-containment is always a top priority for employers and their TPAs. By limiting the amount that the BWC pays per claim, the $15K Program allows employers to do just that.
By participating in the $15K Program, employers agree to pay up to the first $15,000 in medical and pharmacy expenses directly to the medical provider for costs related to qualified claims. Only those claims with 7 or fewer days of lost time may be eligible for the $15K Program. Employers may choose which eligible claims they want to pay for directly. Since the BWC does not charge the employer’s experience for payments made to medical providers during the course of participation, the $15K Program may result in reduced premium costs. Check out Cost Containment Strategies for Ohio TPAs to learn more about how you can control your premiums.
When an employer elects to pay medical costs directly through the $15K Program, they must notify the employee, medical providers, the BWC, and their managed care organization (MCO). All medical bills should be sent directly to the employer for payment.
Since the MCO and BWC aren’t involved in the payment of these claims, the employer takes on additional responsibilities for claims paid under the $15K Program. According to the BWC, in order for employers to maintain eligibility in the Program and meet reporting requirements, they must:
- Maintain records of the injury and payments, keeping them for five years after the last paid bill.
- Supply bills paid and proof of payment to BWC within 30 days of a request.
- Not include paid wages as part of the $15,000 limit.
- Inform all employees and medical providers of the employer’s participation in the program so medical bills are sent directly to the employer.
- Pay the provider within 30 days of receipt of a bill.
- Pay in accordance with BWC’s fee schedule.
- Not process the Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) or deny bills if claim/condition is allowed.
- Report some claims to Medicare beginning July 2010.
Some workplace injuries require employees to be away from their jobs for longer than others. Injuries that result in an individual losing more than seven days of work will no longer be eligible for the $15K Program.
When an injury keeps an employee out of work for more than seven days, it will be automatically reclassified as a lost-time claim and removed from the $15K Program. Once the claim is changed to a lost-time claim, your MCO will be responsible for processing all future medical bills. Bills paid under the $15K Program are not eligible for reimbursement after the reclassification of the claim. Read Control Lost Time Claims for more tips to keep your lost-time claim costs under control.
Working with your MCO
When paying medical expenses for claims under the $15K Program, the employer must act independently of their MCO for those claims only. The MCO cannot authorize treatment or pay medical bills.
Once a claim reaches the $15,000 maximum, the employer must notify the BWC and MCO that they have reached the maximum payout on the claim. Additionally, the employer must give notice to the medical provider that future medical bills or the balance of existing bills exceeding the $15,000 maximum should be sent to the MCO. At this point, the employer should also send copies of all bills and payments processed under the $15K Program. The MCO will take responsibility for processing all future bills for the claim.
Just because an employer has opted to participate in the $15K Program does not mean that they must pay out of pocket for every qualifying claim. Employers may choose to remove a claim from the program or opt-out of the program entirely at any time.
Employers who opt to remove an individual claim from the program should do so as quickly as possible after the filing of the claim. Once removed, the MCO will begin processing all bills related to the claim regardless of the bill’s date of service.
Additionally, employers may choose to opt-out of the program entirely at any point. Employers should notify the BWC of their decision to opt-out by calling 1-800-644-6292 and notify their TPA and MCO of their decision. The MCO will then take over the processing of bills received after the program termination date for all medical-only claims.
Advocating for you
While the Ohio BWC may not require your business to use a TPA, the cost-savings and expertise of these groups can lead to reduced risk and lower costs for your company. Partnering with a TPA is an investment in your company’s future that can create a safer workplace for your employees and lead to lower premiums for your business.
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