Diane M Barnes, CDMS,CCM,CMC Barnes Consulting, LLC

1. Diane M Barnes, CDMS,CCM,CMCBarnes Consulting, LLC What Your Third Party Administrator Should Be Doing For You

2. Ohio Workers’ Compensation Act • Pre-1911 • An employee had to file a tort claim in court against the employer, alleging the employer was negligent. The injured worker then had the burden of proving this negligence was the actual cause of the injury.

3. Ohio Workers’ Compensation Act • most instances, injured workers received no wage replacement or coverage for medical expenses.  In rare instances when injured workers won their tort lawsuits, they received large punitive damages awards that sometimes bankrupted their employer.

4. Ohio Workers’ Compensation Act • The Workers’ Compensation Act passed in 1911.    The Act created a state insurance fund to compensate workers injured on the job.  The Industrial Commission of Ohio ran the system until 1955 when the Bureau of Workers’ Compensation was created.

5. Ohio Workers’ Compensation Act • In Ohio, workers’ compensation is a no-fault system.  Both employees and employers gave up certain rights.  Only after a workers’ compensation dispute has totally worked its way through the administrative system of BWC and the Industrial Commission of Ohio can a party appeal a disputed legal matter into Ohio’s court system.

6. Three Organizations Associated with the Claims Process • Ohio Bureau of Workers’ Compensation • Managed Care Organization • Industrial Commission of Ohio

7. Additional Assistance Utilized by Many Companies • Third Party Administrators • Attorney • Medical Case Manager Agencies

8. Ohio BWC • The Ohio Bureau of Workers’ Compensation determines the legal status of the claim. • Assigns a claim number • Obtains wage information from the employer

9. Ohio BWC • Sets the Average Weekly Wage and the Full Weekly Wage for the injured worker • Determines the Temporary Total Disability benefits rate for Lost Time Claims • Identifies the medical conditions that are ‘allowed’ in the claim • Pays the appropriate benefits to the injured worker • Determines eligibility for Vocational Rehabilitation

10. MCO • Provides the Medical Management for the injured workers medical treatment • Approves physical therapy • Approves diagnostic tests

11. MCO • Approves surgeries • Approves Vocational Rehabilitation in conjunction with the BWC • Assigns the Vocational Rehabilitation Case to a Qualified Rehabilitation Provider

12. TPA • An organization or person who serves as an advocate or representative for the employer in the BWC arena. • May include many services • Common services include assistance with claim certification, controlling claim cost, and assistance with Group Rating

13. COMMON GOAL OF ALL INVOLVED • Return the injured worker to work in an occupation that is consistent with his or her physical abilities, education, training, and work history. • SAME JOB / SAME EMPLOYER • DIFFERENT JOB / SAME EMPLOYER • SAME JOB / DIFFERENT EMPLOYER • DIFFERENT JOB / DIFFERENT EMPLOYER

14. TPA SERVICES • RISK MANAGEMENT • Group Rating Plan • Discount Programs • Drug Free Workplace • Risk Assessment • Claims reserves

15. TPA SERVICES • CLAIMS MANAGEMENT • Claim certification and investigation • Cost Control • Lump Sum Settlements • Handicap Reimbursement • Early Return To Work Programs

16. EMPLOYER’S RESPONSIBILITY • Maintain contact with a with the TPA representative • Do not relinquish control of the process • Maintain contact with the injured worker • Evaluate and review the strategies of the TPA • Maintain contact with the BWC • Arrange joint meeting with BWC and TPA