If you are responsible for your workers’ compensation program, it is important to have a fundamental understanding of the roles of a MCO and a Workers’ Compensation Third Party Administrator (TPA). MCOs and TPAs play unique roles in helping employers control workers’ compensation costs.
What is a MCO?
Under Ohio's Health Partnership Program, 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 Bureau of Worker's Compensation.
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, i.e. 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.
ERC is proud to endorse CareWorks as the preferred workers’ compensation Managed Care Organization (MCO) for members. For more information, click here.