About Workers’ Comp

The Workers’ Compensation System

The Ohio Workers’ Compensation system is made up of two branches – the Bureau of Workers’ Compensation (BWC), the administrative branch; and the Industrial Commission of Ohio (IC), the claims adjudicative branch. The BWC handles the daily processing of claims, and makes payments as appropriate. It monitors medical treatment, disability and return to work issues, and “medically manages” the claims with the help of outside companies called Managed Care Organizations (or “MCO’s” for short)

Workers’ Compensation Benefits

When a work-related injury or occupational disease causes an employee to lose time from work, the BWC provides benefits and services to help replace lost income, pay related medical expenses and return the injured employee to work. The Bureau pays benefits according to the laws in effect on the date of injury, or the date of disability or diagnosis for occupational diseases.

The BWC does not cover injuries that are purposely self-inflicted or primarily caused by the use of alcohol or drugs. If the work-related injury is fatal, BWC provides an allowance for funeral expenses and may provide compensation to the decedent’s legal dependents.

Medical Benefits

For a work-related injury resulting in the loss of seven or fewer calendar days of work, BWC pays related medical expenses. These are charges such as the emergency room fee, the x-rays taken there, and so forth. These are commonly called “no-lost-time-claims” or "medical only claims" because no monetary compensation is usually paid to the employee because they did not miss enough time away from work due to the injury.

If the BWC allows an injured worker’s claim, the BWC will pay the MCO, which in turn will reimburse the health-care provider for medical services related to the workplace injury. The MCO pays the health-care provider upon receipt of a properly completed and signed fee bill, and according to usual, customary and reasonable fees for the geographic area.

Remember, the entire Ohio workers' compensation system is "condition-sensitieve" which means that payments for treatment or disability are made ONLY when it is specifically shown that the payment requested is causally related to the original workinjury, OR the medical conditions for which the claim has been allowed. For example, if a person falls down the steps and injures his left knee, and the claim is allowed only for "left knee strain", any treatment to the shoulder (for example) will not be covered. This is easy, right? Right. However, suppose in that left knee injury, you also have been diagnosed wiht a "torn meniscus". If the claim is not specifically allowed for this condition, payment might not be made for treatment or disability. You are, however, allowed to amend or modify the list of allowed/approved conditions in your claim. But this is how the system is "condition-sensitive".

To be considered for payment, the injured worker must file his or her health-care bills with the MCO within two years of the date of treatment. MCO’s must pay medical bills within 30 days of submission. If an MCO questions a medical bill, it may request additional medical documentation from the attending physician. Once the MCO receives the additional information, it has another 30 days to pay or deny the medical bill.

Health-care services include, but are not limited to, routine physician care, doctor’s visits, hospitalization, surgery, tests, nursing home care, prescribed medicine costs, artificial limbs, hearing aids, eyeglasses, special or modified shoes, canes, and crutches. Except in cases of emergency, the MCO must approve certain medical services in advance. Medical services requiring advance approval include surgery, hospitalization or nursing home stays, special medical equipment, physical therapy, nursing services, dental work, elective amputations and weekly injections.

If the health-care provider treats an injured worker for a condition not recognized in the claim, payment is not the BWC’s responsibility. If, however, the injured worker believes the condition relates to the claim, they may apply to have it recognized by filing the form called the C-86 Motion. This form, once completed, can be used to request that the claim be amended to include the medical diagnosis in question. The BWC may approve the request, at which point all parties will be notified in writing. Alternatively, the BWC (or employer) may object to the amendment, at which time the matter will be referred to the Industrial Commission for a hearing on the issue. The parties will be notified in writing of this as well.

Pharmacy benefits

For medical prescriptions, the BWC contracts with a private company (like an inusrance company) to serve as the Bureau’s Pharmacy Benefit Manager (PBM). The PBM maintains an injured workers’ drug utilization history. Pharmacy providers connect to the PBM’s computer to compare prescription information to a claims’ allowed conditions, previously filed prescriptions and other criteria. The PBM notifies the pharmacist of the prescription approval before he or she dispenses it to the injured worker, or the reason the medication may be denied reimbursement. For approved medications, the PBM tells the pharmacist how much it will reimburse the pharmacy. This company may change from time to time so be sure to always know who the assigned PBM is on your case.