25
Fall 2014 Issue
Safety & Workers’ Compensation
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As an employer in the state of Ohio, being responsible for
your workers’ compensation program is a must. It is important
to have a fundamental understanding of the differing roles
provided by a Managed Care Organization (MCO) and a Third
Party Administrator (TPA). Both play unique roles in helping
employers control workers’ compensation costs.
What is an MCO?
Under Ohio’s Health Partnership Program, Managed Care
Organizations (MCOs) are responsible for the medical
management of Ohio employers’ work-related injuries and
illnesses. Every employer in Ohio must have a MCO, which is
paid for directly by the Ohio Bureau of Workers’ Compensation
(BWC) so there is no additional out-of-pocket expense for you
other than your workers’ compensation premium.
The core MCO functions include:
• Collecting initial injury reports and transmitting to BWC;
• Management and authorization of medical treatment to be
received by an injured worker;
• Medical review and bill payment processing;
• Maintaining a network of BWC-certified
healthcare providers;
• Return to work services;
• Utilization review;
• Providing Peer Reviews as necessary for treatment decisions;
• Processing treatment appeals through the Alternative
Dispute Resolution (ADR) process; and,
• Training and education.
Further, MCO associates are medical professionals and their
processes are clinically focused. They work diligently to help
employers avoid the most costly of claims – lost time claims –
when an injured worker is off work for eight or more consecutive
days. With clinicians managing the medical care and transitioning
injured workers back to gainful employment, employers are better
able to manage their long term insurance premiums.
What is a TPA?
A Third Party Administrator (TPA) assists employers in the
administrative and financial aspects of a claim.
The core TPA responsibilities include:
• Providing risk management consulting to employers;
• Administering compensation group rating savings programs
and other discount program consulting;
• Pertinent claims investigation;
• Claims administration;
• Industrial Commission hearing attendance;
• Evaluation of claims for workers’ compensation coverage; and,
• Assisting employers in the development of workers’
compensation cost control strategies.
TPA staff typically consists of claim representatives, account
representatives and other workers’ compensation professionals.
Understanding How TPAs and MCOs Differ
Employers can more effectively control workers’ comp
costs by recognizing the differences that exist
