4123-6-13 Payment to MCOs.

 

 

 

4123-6-13                    Payment to MCOs.

 

 

 

(A)  The bureau shall determine fee payments to an MCO which is selected by or assigned to employers with zero payroll, noncomplying employers, employers who are no longer in business, new employers, and other employer situations in which the employer's premium does not adequately account for an MCO's providing medical management and cost containment services and administrative services.

 

(B)   The bureau shall pay an MCO an administrative fee for its medical management and administrative services in a manner determined by the administrator. The administrative MCO fee payments may be subject to a disincentive penalty penalties based upon the failure of the MCO to meet predetermined performance criteria set forth in the MCO contract. The bureau may pay an MCO a performance payment and may pay an incentive payment.

 

(C)    In establishing performance measures, the bureau shall may evaluate an MCO's performance based upon criteria including, but not limited to:

 

(1)   Quality performance measures that may include including, but not limited to, return to work rates and reinjury re-injury rates.

 

(2)Process performance measures including, but not limited to, first report of injury (FROI) timing. FROI accuracy and bill timing.

 

(2)(3) Total cost measures that may include including, but not limited to, average total paid cost, average incurred cost, and lost-time claims to total claims ratio.

 

(3)(4) Change in cost measures that may include including, but not limited to, change in average total paid cost, change in average incurred cost, and change in lost-time to total claims ratio.

 

(4)(5) Customer satisfaction that may include in-network utilization rate and measures including, but not limited to, MCO network utilization rates and employee, employer, and provider satisfaction surveys.

 

 

 

 

 

 

 

 

 

 

 

 

 

4123-6-13                                                                                                                              2

Effective:                                                     02/01/2010

R.C. 119.032 review dates:                         11/17/2009 and 11/01/2014

CERTIFIED ELECTRONICALLY

Certification

01/22/2010

Date

Promulgated Under:                           119.03

Statutory Authority:                           4121.12, 4121.121, 4121.30, 4121.31, 4123.05

Rule Amplifies:                                  4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates:                         2/16/96, 1/1/99, 1/1/01