Claim management and the role of managed care organizations (MCOs)

By Krystal Smith, SAIF claims supervisor

Claims adjusters have many resources available to assist them in the management of workers' compensation claims. One of the most effective is the partnership SAIF has with managed care organizations, or MCOs.

What is an MCO?

It's an organization formed to provide medical services and that is certified in accordance with OAR 436-015. In other words, they are companies that medically manage treatment in workers' compensation claims through a contracted panel of providers.

Why does SAIF partner with MCOs?

Simply stated, claims adjusters are not allowed by statute to “direct medical care.” While the norm is that most claims require little direct medical management, there are those claims that, for a lot of reasons, simply require assistance to bring about an appropriate medical outcome. It is in those cases that our MCO partners are uniquely situated to assist in medical management.

Who are the MCOs SAIF works with?

Kaiser On-The-Job

• Located from Salem to southwest Washington
• Closed system—available only to injured workers who are Kaiser members
• Employ nurse case managers

Majoris Health Systems

• Located statewide in Oregon
• Proactive management model
• Opioid management program

CareMark Comp

• Located in Portland area and northern Oregon coast
• Employ nurse case managers
• Opioid Management Program

When are claims enrolled into an MCO?

A claim can be enrolled in an MCO at any time, but typically enrollment will occur at claim acceptance. The acceptance letter will state whether the claim is enrolled in an MCO or not.

Are all accepted claims enrolled in an MCO?

No. Claims adjusters have discretion to enroll a claim or not. We enroll roughly 67 percent of disabling claims into an MCO and about eight percent of nondisabling claims.

How does MCO enrollment impact the injured worker?

If the injured worker is already treating with a panel provider at MCO enrollment, the fact that their claim is enrolled in an MCO is essentially invisible to them.

If, however, the injured worker is treating with a nonpanel provider and their claim is enrolled, they would either need to change to a panel provider or seek to temporarily credential the nonpanel provider into the MCO.

Otherwise, the MCO's role is to work with the medical provider to ensure the injured worker obtains effective, appropriate, evidence-based medical treatment; that MCO oversight should not be overtly noticeable to the injured worker.

How does the MCO help?

MCOs provide precertification of requested treatment like inpatient hospitalization, outpatient surgery, physical medicine, and DME. Their role is to review the medical appropriateness, effectiveness, and use of the requested treatment.

In addition, they assist adjusters with medical advisory opinions, medical treatment reviews, opioid review and management, and a dispute resolution process. They also maintain a panel of providers. Providers sign contracts with the MCO to follow certain protocols and guidelines specific to workers' compensation. The MCOs, in turn, provide education and support to their panels of providers.