MCO and TPA
The MCO Is the Managed Care Organization, and is Responsible For The Care And Treatment Of The Injured Employee.
The TPA Is the Third party administrator, and is Responsible For Ensuring The Employer’s Responsibilities Are Handled Properly.
Managed Care Organization (MCO)
Managed Care Organizations, (MCOs) are the primary link between injured workers, medical providers, employers and the Ohio Bureau of Workers’ Compensation. MCOs manage claim filing and medical treatment as well as assist employers with the implementation of recovery and return-to-work programs.
The MCO is responsible for the medical management of any workplace injury that may occur. This includes gathering the initial injury data, gathering the medical documentation, reviewing any treatment request to approve or deny, paying bills related to the injury, coordinating care, and focusing on a safe and timely return to work for the injured employee:
> Collecting Initial Injury Reports And Transmitting To BWC
> Management And Authorization 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
> Processing Treatment Appeals
> Providing An Alternative Dispute Resolution (ADR) Process
> Training And Education
MCOs can make the greatest impact by helping employers achieve successful return to work and providing aggressive medical cost savings. Return to work helps employers avoid the most costly of claims - lost time claims - when an injured worker is off work for eight or more consecutive days. Having a provider network that offers savings beyond BWC's established fee schedule can help control medical costs.
Note: Every employer in Ohio must have an MCO, which is paid for directly by the BWC.
Third Party Administrator (TPA)
Unlike MCOs, which are required for all Ohio employers to handle the medical management of their workers’ comp claims, Third Party Administrators (TPAs) are not required or regulated by the BWC but can be hired by employers at any time.
-TPAs are private companies that contract directly with employers to assist with the administrative and financial components of their workers’ compensation programs. About 43 percent of employers in Ohio have a TPA representative.
-TPAs are consultants that employers can hire to help manage and save money on workers’ comp claims. TPAs accomplish this by administering discount plans through programs such as a Group Rating and Group Retro.
-TPAs are responsible for evaluating alternative rating programs and discount programs for employers including group rating, group retrospective rating, individual retrospective rating, self-insurance, and others.
-The TPA also processes appeals and files motions on behalf of the employers, initiates claim settlements and pursues handicap reimbursements for pre-existing conditions.
Questions about TPA or MCO?
Contact your Sedgwick Program Manager: