MCO Open Enrollment – The Vital Role of Your MCO

By Lance Watkins posted 11 days ago

Co-authored by Jennifer Oiler.

Open Enrollment for selecting a managed care organization (MCO) is May 3 through May 28, and Ohio employers have this opportunity to ensure they have the right MCO partner to help them navigate the workers’ compensation claim process. MCOs play a vital role in an employer’s ability to control claims costs, care for injured employees, and preserve options for premium savings in the long term. “Medical management” can be a rather vague description of the MCO function, but the impact can be substantial. Here are 5 key areas that make your MCO an extremely valuable resource for employers and their injured employees.

1. Post injury management
An employer’s initial reaction to their employee after an injury is a key moment. Following an organized game plan fosters trust and cooperation. A chaotic atmosphere can lead an injured employee elsewhere for direction. An MCO can help employers prepare to address these three things immediately after an injury:
  1. Initial medical treatment - Know the available options in the area. Have contact information to call ahead and make sure the employee has safe transportation.
  2. Quick and thorough documentation of the injury - Be prepared to assist in completing an injury report. Facilitate filing a clearly legitimate claim through your MCO. This will help prevent delays, keeping everyone focused on recovery and return-to-work.
  3. Discuss early return-to-work, Transitional Work options - Establish an expectation for everyone for a quick recovery and return-to-work. Be prepared to make adjustments to facilitate that return.

2. Negotiating for early return-to-work 
When an injured employee is off work for 8 or more days, lost-time costs accelerate quickly and can threaten future savings opportunities. A physician’s instinct may involve time off work, but this can be negotiated if employers can demonstrate a safe work environment that facilitates recovery. Working through the MCO to address Transitional Work options can promote cooperation with treating physicians and lessen exposure to costly lost-time claims. A formal transitional work policy is an asset because it will outline this process for all parties, and MCOs can help build that infrastructure.

3. Oversight of medical treatment
Medical treatment for a workers’ compensation injury must be approved through the MCO as appropriate and cost-effective. A claim’s duration of lost-time is related to the course of medical treatment. Engaging physicians on treatment decisions and advocating for quality treatment that facilitates early and safe return-to-work is an MCO role. It is sometimes appropriate to explore alternative approaches to treatment that may yield improved results in both cost and recovery time. Employers should be involved in this process with their MCO and should have an understanding of the necessity and value of treatment for their injured employees.

4. Review of prescription medications
Problems with prescription abuse are well documented. The cost of excessive medications certainly impacts the cost of a claim, but prescribed medications can also extend lost time simply due to their side-effects, rendering disabled an otherwise able body. MCOs can review medications prescribed through a claim and contest drugs that are not appropriate. Non-narcotic alternatives can be recommended that may eliminate side-effects that can extend lost-time and related costs.

5. Scrutiny of medical bills
The actual cost of medical treatment for workers’ compensation claims is usually far lower than the costs associated with lost workdays (compensation and reserves). But it should not be overlooked as a “given." Review of medical bills must be scrutinized to ensure accurate payment only for related treatment. There are often opportunities for significant reductions through the use of universal codes and “bundling” services for efficiency.

Sometimes the key to resolving a claim before it becomes extremely costly is found in the details. Leveraging resources like the MCO can help prepare employers to minimize costs and preserve premium savings options. It is important to remain tuned in to the work of the MCO through the claim management process. Sedgwick Managed Care Ohio is continuously seeking to be a dynamic problem-solving partner for our client employers and facilitate a return to productivity for injured employees.

Lance Watkins is Vice President at Sedgwick Managed Care Ohio (Formerly CompManagement Health Systems), an OASBO Strategic Partner
614-376-5524 |

Jennifer Oiler is an Account Executive at Sedgwick Managed Care Ohio (Formerly CompManagement Health Systems) an OASBO Strategic Partner
614-403-8978 |