In Ohio, your employer’s Managed Care Organization (MCO) manages all medical parts of your workers’ compensation claim, such as treatment approval and medical bill payments. They also may provide rehabilitation referrals, if applicable. They play an important role in evaluating your medical needs based on your injury.
It is important to understand that your employer’s MCO is not the same as your health insurance provider. The MCO only deals with your workers’ compensation claim and any medical bills that may be part of your claim. You should also know that the MCO is not the same as your treatment provider.
How do I appeal a medical treatment decision made by an MCO?
The process to appeal a medical treatment decision in your workers’ compensation claim differs from the regular appeal process. If you disagree with any portion of the MCO’s decision, you can complete an alternative dispute resolution (ADR) appeal form. You as the injured worker, your employer and your medical provider will need to provide an explanation of what is being appealed and why.
The MCO will work with medical professionals to review your medical history and reports to make a determination on your appeal. They will review the cost of treatment, the necessity of treatment and check if the services are related to your injury. Sometimes, the MCO will recommend that you schedule an examination with an independent medical practitioner before providing an appeal decision.
What if my appeal is denied?
If your appeal is denied, you can file another appeal within 14 days with the Ohio Industrial Commission (IC). You will then attend an administrative hearing to make a determination.
This process may seem confusing or daunting, but know you do not have to go it alone when appealing treatment decisions. Experienced legal guidance can help.