4123-6-16 Alternative dispute resolution for HPP medical issues.

 

 

NOTICE OF PUBLIC HEARING

 

 

The Ohio Bureau of Workers' Compensation will hold a public hearing on Friday, May 13, 2005, at 1:00 p.m., in Room D, 3rd Floor, 30 West Spring Street, Columbus, Ohio 43215, to consider the following:

 

Rescission of the following rule for the purpose as shown below: 4123-6-16      Dispute resolution for HPP medical issues.

This rule is to be replaced by new rule 4123-6-16 of the Administrative Code to modify the process for the resolution of medical disputes prior to an appeal to the Industrial Commission under Ohio Revised Code 4123.511.

 

Adoption of the following new rules for the purpose as shown below: 4123-6-16     Dispute resolution for HPP medical issues.

This rule eliminates the Managed Care Organization (MCO) level of Alternative Dispute Resolution (ADR), providing that, within fourteen days of receipt of written notice of an MCO determination giving rise to a medical dispute, an injured worker, employer, or provider may request that the MCO refer the dispute to BWC to initiate the ADR process. BWC, in consultation with the MCO, shall then complete the ADR process and enter a final order within thirty days of BWC's receipt of written notice of the medical dispute from the MCO. This rule reaffirms that an injured worker or employer must exhaust the ADR process prior to filing an appeal on an issue relating to the delivery of medical services under Ohio Revised Code 4123.511, and that neither the provider nor the MCO is a party entitled to file an appeal under Ohio Revised Code 4123.511.

 

4123-6-16.2    Medical treatment reimbursement requests.

 

This rule provides that medical treatment reimbursement requests must be submitted by the physician of record (POR) or treating provider to the Managed Care Organization (MCO) responsible for medical management of the claim prior to the POR or treating provider's initiating any non-emergency treatment. The rule also provides that the MCO may dismiss, without prejudice, medical treatment reimbursement requests upon certain conditions. Further, this rule states that if the MCO determines that any approved medical treatment reimbursement request is not medically indicated or necessary, is not producing the desired outcomes, or the injured worker is not responding, the MCO may notify the parties of its decision to discontinue payment of approved treatment that has not already been rendered. Finally, the rule provides that medical treatment reimbursement requests submitted retroactively (after treatment has been rendered) by the POR or treating provider without just cause shall, if approved, be reimbursed at fifty percent (50 %) of the applicable fee schedule amount, and the POR or treating provider may not balance bill the injured worker for the difference.

 

 

 

 

 

 

The full and complete text of the proposed rules is available at the Register of Ohio (http://www.registerofohio.state.oh.us) and is on file in the office of the Secretary of State (180 East Broad Street, 15th Floor, Columbus, Ohio), the Legislative  Service Commission (77 South High Street, 9th Floor, Columbus, Ohio), the office of the Joint Committee on Agency Rule Review (77 South High Street, Concourse Level, Columbus, Ohio), the Bureau of Workers' Compensation, Legal Operations (30 West Spring Street, 26th Floor, Columbus, Ohio), the Bureau of Workers' Compensation (30 West Spring Street, Columbus, Ohio, 1st Floor, Hearing Rooms), and all service offices of the Bureau.

All interested parties will be given an opportunity to be heard. Any interested party unable to attend the public hearing may submit written comments to the undersigned prior to the public hearing.

Tom Sico

Director, Legal Operations

Bureau of Workers' Compensation 30 West Spring Street, L-26 Columbus, Ohio 43215-2256

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