By Mark Powell, claims supervisor
Enrollment in a managed care organization (MCO) offers several advantages for the policyholder, as well as the injured worker. You may be more familiar with the cousin of the MCO, the health maintenance organization (HMO), which actually was modeled after the MCO. According to the Tufts Managed Care Institute, this model has been part of the American scene since the early 19th century and was originally formed to deliver health care to lumber, mining, and railroad workers.
Workers’ compensation insurance first ventured into the managed care arena in 1933, when Dr. Sidney Garfield and his associates contracted with Henry J. Kaiser to provide medical care for injured workers who were building the Grand Coulee Dam on the Columbia River. Although many view managed care organizations as a recent phenomenon, the use of this model to deliver quality medical care and control medical costs is a long standing tradition in the Northwest.
MCOs operate in the background and evaluate the need and effectiveness of medical care and treatment. For example, most MCOs have established programs to evaluate the need for highly addictive, opioid pain medications. MCOs also assist claims adjusters when there are concerns about a complex claim’s lack of resolution. MCO physicians review the medical records and talk to the treating physician about a new plan or may examine the injured worker to determine if something has been missed. In most instances, MCO intervention in a claim is viewed positively because it involves physicians brainstorming and supporting their colleagues on some of their most difficult cases. In the end, the MCO helps ensure better medical care delivery, faster recovery, and lower cost for the policyholder.
Each MCO is organized differently, but all of them offer a panel of physicians from which the injured worker is required to obtain medical care. Because of the large number of physicians on the MCO panels, an injured worker is often allowed to continue to treat with the doctor providing medical care at the time of enrollment. When an injured worker is treating with a primary care or internal medicine physician at the time of enrollment, the MCO offers temporary credentialing and allows the physician to continue to treat under the MCO’s protocols. This is a voluntary process and some physicians may decline to accept the MCO’s offer. As a last resort, the injured worker is asked to change doctors and seek medical care from an MCO panel member. SAIF’s claims adjusters work diligently to make this transition as smooth as possible by encouraging the injured worker to talk to his or her medical provider about choosing an MCO panel physician in the area and by forwarding the medical records to the new attending physician’s office so he or she is familiar with the patient at the first visit.
For a complete list of Comp Focus articles, see the State Agency news page.