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What does it mean to certify a claim for medical only? Nothing good – if you are an employer.

Once a claim is allowed, the claimant can request compensation by filing an application with the BWC. The BWC will issue an order granting the compensation, and pay it unless the employer files an appeal within 14 days. If the employer objects, there will be a hearing and a hearing officer will decide how much, if any, compensation will be paid.

When does the BWC or a hearing officer consider whether the employer certified the claim for medical expenses only? NEVER.

Your MCO will ask you to certify the claim for medical-only expenses just to get you to say yes, so it can check the box.

Currently, the BWC codes the status of every new claim with employer certification as ALLOW.

When a claim is coded ALLOW, prescription drugs can be paid, and the BWC policy is not to credit for drug bills (unless the claim is completely denied).

Without certification, the BWC has up to 30 days to issue an order allowing or disallowing a claim. During that time, the employer can find out what treatments have been recommended or completed, and if any additional diagnoses are contemplated. Any medical care is authorized with a disclaimer. Bills will not be paid until the appeal period is over or the claim is allowed by a hearing officer.

When should an employer certify a claim? NEVER.

Has the BWC or your MCO ever asked you if you will certify the new claim? Have they asked if you agree that “something happened” at work? If so, here’s the right response: “We don’t have enough information to make a decision.”

What does it mean to certify a claim? There is no legal definition of “certify” regarding a workers’ compensation claim.

Here’s a little history: back in the 1980’s, employers were expected to type the long pink form (C-3) and file a workers’ compensation claim against themselves. There was a box on the back where the employer provided its contact information. The employer was expected to sign that everything was correct and asked to certify or not certify the claim. If the employer checked the certification box, then the BWC considered the claim accepted by the employer and started paying bills. If the employer checked not certified, then the BWC sent the claim for a hearing officer to decide whether to allow the claim. Nowhere on the form was it clear that the employer was accepting the claim by certifying; it could be interpreted as certifying that all information about the employer was correct.

Then, the BWC realized that employers don’t know whether a claim meets the legal requirements to be compensable, and began to request the medical records which would provide a description of the medical condition of the claimant and a diagnosis.

Now, the employer’s MCO obtains medical records and talks to the claimant, the medical provider and the employer. The MCO will ask if the employer will certify the claim.

So, what does it mean to certify a claim? Nothing that is good for an employer.

Will the claim be processed faster? It might, before you or your representative have enough time to get all the information necessary to make an informed decision whether to contest the claim.

As the employer, do you know what the claimant told the doctor about his work or his complaints? Have you seen all the medical records? Do you know how many other workers’ compensation claims your employee has ever filed, and for what conditions? Do you know whether the claimant has used attorneys in any prior claims and gotten compensation?

If you can’t say yes to all the above questions, you don’t have enough information to make an informed decision, and that’s exactly what you should tell the BWC or MCO when they ask.

Under the guise of “rate equity”, the BWC is implementing another way to increase Ohio workers’ compensation premiums.

Starting 7/1/2010, the BWC will use MIRA to calculate reserves for claims in which only medical bills have been paid. These reserves will be included in the premium rates that will be effective 7/1/2011.

Currently, reserves are calculated only for claims in which compensation has been paid directly to the claimant, and the reserves are eliminated once the claim has been inactive for 180 days.

According to my contact at the BWC, the medical only reserves will also be eliminated once the claim has been inactive for 180 days.

An inactive claim is one in which there haven’t been any costs with dates of service within the past 180 days. As long as the claimant goes to the doctor, has therapy or gets prescriptions filled, the claim is active and reserves will be calculated.

If the claim has been active since July 1, the reserves will be included in the premium rates that take effect the following July 1.

Here’s an example: An employee gets hurt in September, and all bills are paid within 60 days. The following August, the claimant fills a prescription that is charged to the claim. (Even if the prescribing doctor is not the doctor for the claim – see previous post) The claim is now active, and reserves will be calculated and included in the claims costs when the BWC surveys all claims on December 31.

Timing is crucial when it comes to the calculation of your premium rates.