WHEN AN INJURY OCCURS – WHO DOES WHAT AND WHEN????
BWC is responsible for:
Assignment of claim numbers
Determination of allowed conditions
Determine subsequent condition(s)
Issuing BWC orders
Paying compensation
Identification and pursuit subrogation opportunities
Negotiation of settlements
Conduct independent medical examinations (IME)
Second level of dispute resolution
Identification of fraud
Education of injured workers, employers and health-care providers
Travel reimbursement
MCOs are responsible for:
Medical Management
Utilization Review
First level of dispute resolution
Paying health-care providers for their services
Identification of fraud
Education of injured workers, employers and health-care providers
Vocation Rehabilitation
Answering questions regarding medical bills
Answering questions regarding medical treatment
Gathering medical reports and documentation
All claims and medical bills should be directed to the MCO representing the injured worker’s employer. The MCO will handle the reimbursement for these services.
Employers are responsible for:
Helping injured worker obtain medical services
Establishing a reporting procedure for employees to follow
Assisting injured workers in completing in-house accident/incident report
Communicating with BWC customer service teams, injured workers and health care providers to minimize the impact of the injury and resolve the claim
Certify or reject the claim
Staying in touch with the injured worker
Injured Workers are responsible for:
Reporting on-the-job accidents to their employers promptly
Completing an in-house accident/incident report at the request of the employer
Informing BWC of the injury, either through the employer, MCO or directly with BWC
Completing all claim-related paperwork promptly and thoroughly
Providing information to the designated claims specialist and MCO
Always using the claim number when calling or writing BWC
Keeping the employer and MCO informed of recovery process
Working safely to help prevent accidents, participating in safety training, being aware of emergency procedures.
Serving as an MCO, our services are often confused with those provided by your contracted Third Party Administrator (TPA).
The following lists some of the responsibilities of a TPA, however it is important that employers work directly with their TPA in understanding their specific TPA contracted services. Please note this portion of explanation is taken from information gathered from TPA employer information.
TPAs are responsible for:
Hearing Representation – TPAs are a party to the claim and available to attend hearings to represent the employer
Claims Administration – assistance in determining compensability and ensuring timely resolution
Actuarial Analysis – audit BWC rates and charges to the employer’s experience to ensure accuracy and to further assist with any BWC issues involving rates or premiums. Available to evaluate the impact of settlements, handicap reimbursements, or wage continuation can have on an employer’s experience.
Group Rating Programs – If eligible, employers in similar industries join together through a sponsoring organization, to be rated as a group for their BWC premium payment discounts.
Assistance with application to BWC for consideration of Self-Insured status