What If I Disagree With An MCO Over My Treatment Of An Injured Worker?

You may be among those physicians who found the emergence of managed care organizations (“MCO’s”) unsettling. The idea of others judging and second-guessing your treatment decisions and fees did not appeal to you. Well, MCO’s appear to be here to stay. Oregon has extensive administrative rules governing the delivery of medical services through MCO’s (OAR 436-015-0001 through -0130, and others). This article looks at the rules governing disputes between MCO’s and doctors treating injured workers.

Disputes which arise between any party and a managed-care organization must first be processed through the dispute resolution process of the MCO. Within 60 days after you become aware you have a disagreement with the MCO, you must file your dispute in writing. When you do, be sure to request a summary of the MCO’s dispute resolution process. The MCO will then be required to promptly provide a written summary which includes:

• the name of the contact person responsible for the process and how to reach him or her;

• the types of the issues the MCO will consider in its dispute resolution process;

• the steps of the process and procedures at each level; and

• time frames for submitting disputes and for each step within the process.

It is important to understand that the MCO deals only with the physician. When they deny treatment, the patient and the patient’s attorney (if he/ she has an attorney) are not notified. So, if you do not contest the denial within the time stated in the letter, the denial can become final. This can result in the denial of needed medical services to your patient.

Upon receipt of your written dispute, the MCO will acknowledge it in writing and notify all affected parties of its process for resolution. The MCO must resolve the dispute and issue its decision within 60 days of receiving it.

If your dispute is not one of the types handled by its process, within 7 days of receiving your complaint the MCO must notify all parties in writing of their right to request review by the Director of the Department of Consumer and Business Services (“the Director”), as set forth in another rule (OAR 436-015-0008).

After the MCO resolves the dispute, it must notify all parties to the dispute in writing explaining the reasons for its decision. This notice must also inform you of the next step in the process.

What if you do not agree with the MCO’s decision and want to appeal? Within 60 days of the date the MCO issues its final decision, you (or your patient) – the “aggrieved party” – must request administrative review by the Director. Also, if the MCO internal dispute process has not been completed for reasons beyond your control, you may request review within 60 days of the failure of the MCO process. Your request must be made in the form and format prescribed by the Director. You must notify all other interested parties.

Your request must include the worker’s name, date of injury, insurer, and claim number. You must state the specific issue and exactly what you want. If treatment over a period of time is in dispute, specify the time period. Submit all medical documentation relating to the dispute. You may also include other relevant information such as written statements of facts, sworn affidavits and arguments. You need not be represented by counsel.

Since the objective is to resolve this dispute fairly and expeditiously, in a nonadversarial environment, you may request voluntary mediation.

What if you are not a member of an MCO? The rules also require MCO’s to provide a procedure for workers to receive compensable medical treatment from the primary care physician who is not a member of the MCO. Such primary care physicians must qualify under the law as an “attending physician” and must be a general practitioner, a family practitioner, or an internal medicine specialist; must maintain the worker’s medical records; must have a documented history of the worker’s treatment; and must agree to comply with all terms and conditions regarding services governed by the MCO.

There are also numerous rules MCO’s must follow to ensure that workers get prompt and appropriate medical treatment. If you think an MCO has violated any of the rules, you may submit a written complaint to the Compliance Section of the Division of Workers’ Compensation. If an MCO violates any of the rules or fails to meet any of the requirements of its “certified plan” (as required by the rules), it may be subject to sanctions including civil penalties up to $5,000.

You may not like following the rules of an MCO. But MCO’s have to follow rules, too. If you disagree with the MCO’s treatment or bill payment decisions, or think they are not following the rules, you, as treating doctor, have a right to be heard.

Please feel free to call Teresa Richey at our office (541) 776-2899 (x 210), if you have any questions or need further information. Teresa is a certified Workers’ Compensation Claims Examiner and can either answer your question or find the answer for you.

This article was prepared by Robert F. Webber.