Frequently
asked managed care organization (MCO) questions
Q1:
"What
is a managed care organization (MCO)?"
A1:
MCOs
are organizations certified by the director that manage enrolled
workers' medical care and services (see What
is a managed care organization?).
Q2:
A
worker asks, "Can I be enrolled in an MCO?"
A2:
This
depends if you meet specific subjectivity and enrollment criteria
(see Subjectivity and enrollment of injured
workers). A worker may be enrolled in an MCO if he or she
has filed a claim and works for an employer who is located in
the MCO's authorized geographic service area (see MCO
geographical service areas) and that employer is covered
by an insurer who has a contract with the MCO. However, be aware
that "notice is the key." A worker
cannot be required to treat within an MCO unless provided proper
written notice by the insurer or self-insured employer.
Q3:
A
worker asks, "Who enrolls me into an MCO?"
A3:
Your
employer's workers' compensation insurance company (or, if your
employer is self-insured, your employer) determines if and when
to enroll you [see ORS
656.245(4)(a)] into its contracted MCO. The insurer or self-insured
employer must send you a written enrollment letter
and, at the same time, provide a copy of your enrollment letter
to your attorney (if you're represented), all your medical service
providers, and to the MCO.
Q4:
A
worker asks, "When am I subject to an MCO?"
A4:
You
are subject to the MCO when you receive your written enrollment
letter from the insurer, or upon the third day after the
insurer mails it to you, whichever first occurs [ORS656.245(4)(a)].
Q5:
The
insurer asks, "What information do we have to include in
a worker's enrollment notification?"
A5:
When
you enroll a worker into an MCO [see ORS
656.245(4)(a) and OAR
436-010-0275(4) - (7)],
you must simultaneously notify the worker, the worker's representative,
all health care providers, and the MCO of the enrollment. Your
enrollment notice must:
Include a list of the MCO's eligible attending physicians
within the MCO's relevant geographic service area;
Describe how the worker may get the names and addresses of
the complete panel of the MCO's medical providers;
Describe
how the worker may receive medical services within the MCO;
Describe how a worker may receive medical treatment from his
or her primary care physician or authorized nurse practitioner
who is not a member of the MCO;
Advise
the worker of his or her right to choose the MCO if you have
more than one MCO contract covering the worker's employer;
Provide
the title, address, and telephone number of the MCO's contact
person responsible for ensuring timely resolution of complaints
or disputes;
Advise
the worker of the time lines for appealing disputes beginning
with the MCO's internal dispute resolution process through administrative
review before the director, that disputes must be in writing
to the MCO and filed within 30 days of the disputed action,
with whom the dispute is to be filed, and that failure to request
review by the MCO precludes further appeal;
Notify
the MCO of any request by the worker for authorization to treat
with his or her primary care physician or authorized nurse practitioner.
If
you are enrolling a worker prior to claim acceptance [ORS
656.245(4)(b)(B)], you must inform the worker in writing
that you will pay [as provided in ORS
656.248] for all reasonable and necessary medical services
received by the worker that are not otherwise covered by health
insurance, even if you deny the worker's claim, until the
worker receives your denial or until three days after you've
mailed the denial (whichever first occurs).
When
you are enrolling a worker who is not yet medically stationary
and you are requiring the worker to change to an MCO provider,
you must inform the worker of his or her right to request
a review by the MCO if the worker believes changing providers
would be medically detrimental.
If, at the time you are enrolling the worker, his or her medical
service provider is not a member of the MCO and does not qualify
as a primary care physician or authorized nurse practitioner,
you must inform the worker and his or her medical provider(s)
regarding the provision of care under the MCO contract. This
includes the worker's right to continue to treat with the
non-qualified medical provider for at least seven days after
the mailing date of the written enrollment notice [OAR
436-015-0035(4)(e)(A)].
A worker is not subject to a managed care contract that expires
or terminates without renewal. No later than three days prior
to the contract's expiration or termination date, the insurer
must simultaneously provide written notice to the worker,
the worker's representative, all medical service providers,
and the MCO, that the worker is no longer subject to the MCO
contract. The insurer must also inform the worker of the manner
in which the worker may receive medical services after the
worker is no longer subject to the contract [OAR
436-010-0275(12)].
Q6:
A
worker asks: "Can I see my family doctor?" or "Can
I see my nurse practitioner?"
A6:
If
your physician or nurse practitioner is not an MCO member,
but meets certain conditions, the MCO must authorize him or
her to provide your medical treatment [ORS
656.260(4)(g), ORS
656.245(5) and OAR
436-015-0070].
Your doctor must qualify as an attending physician [ORS
656.005(12)(b)(A)], be a medical doctor or doctor of osteopathy,
and must be a general practitioner, a family practitioner,
or an internal medicine practitioner.
Your
nurse practitioner must be authorized by the director to provide
compensable medical services.
These
providers must also:
Maintain
your medical records;
Have
a documented history of treating you prior to your injury;
Agree
to comply with all the MCO's terms and conditions for medical
services. "Terms and conditions" means the MCO's treatment
standards, utilization review, peer review, dispute resolution,
billing and reporting procedures, and fees for services; and
Agree
to refer you to the MCO for any other specialized care that
you may require (such as physical therapy) to be furnished by
another provider.
If
you have any questions or a dispute about treating with a primary
care physician or authorized nurse practitioner who is not a
MCO member, you should first contact the MCO. (All disputes
must first be processed through the MCO's internal dispute resolution
process.)
Q7:
An
insurer or self-insured employer asks, " How can my company
contract with an MCO?"
A7:
Only
insurance companies and self-insured employers can contract
with Certified MCOs. The MCO must
be authorized to operate in your employer's geographic
service areas. location. If you wish to contract with a
specific MCO, you will need to contact that MCO directly to
discuss a contracting agreement. (To see a complete listing
of current MCO/insurer and self-insured employer contracts see
MCO/insurer contracts.)
Q8:
A
provider asks, "How do I become a panel provider?"
A8:
If you want to contract with an MCO to become panel member,
you will need to contact the Certified
MCO directly. If the MCO denies your request to participate,
they must provide you with a written explanation [ORS
656.260(4)(h)].
Q9:
A
worker asks, "Can my MCO doctor be my advocate for my medical
services and temporary disability benefits (timeloss)?"
A9:
Yes,
your attending physician may advocate for these benefits for
you if it is supported by your medical record [ORS
656.260(4)(i)].
Q10:
A
worker asks, "Can I appeal the MCO's medical decisions?"
A10:
Yes.
When an MCO disapproves a requested medical service, or you
do not agree with the MCO decision, you can appeal that decision.
The MCO must include dispute resolution information (OAR
436-015-0110) in its decision and must provide written notice
of its decision to all parties that can appeal the decision.
If the MCO receives a complaint or dispute that is not included
in its dispute resolution process, the MCO must, within seven
days of receiving the complaint, provide you with written notice
of your right to request review by the director.
If
a worker, medical provider, or insurer/self-insured employer
has questions or complaints about the MCO's medical management
services, they should first contact that MCO (see Certified
MCO listing). If additional help is needed regarding an
MCO issue, please contact the Medical Section's MCO Program
staff.
If you have questions about the information contained in this document, please contact
Sandra Savage, 503-947-7697.
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