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Is bigger better when choosing your MCO?
One of the most important jobs for an MCO is to approve or disapprove treatment requests, which are submitted on a C-9 form. When treatment requests are authorized, the provider treats and then bills for its services. Authorizing treatment therefore authorizes expenditure, which results in higher premiums for employers.
How does your MCO handle treatment requests? Large MCOs want to be efficient in handling the many C-9 forms. Some MCOs use staff members who are not registered nurses to rubberstamp all requests, as long as the treatment can be considered reasonably related to the allowed conditions in the claim. They don’t look at how many of the requested services have already been provided, so they will authorize all physical therapy, chiropractic, consultations, MRIs, CT scans, etc. Your MCO may not tell you when it has authorized treatments; you just get a big surprise when you see the claims costs that caused the increase in your new premiums rates. The MCO may only tell you when they don’t authorize treatment.
Another “efficient” MCO practice is to authorize any and every treatment described in the Official Disability Guidelines (ODG). The chiropractor can ask for the maximum of 12 treatments and get them approved, without demonstrating “functional improvement” after the first 2 or 3 sessions as recommended in the Guidelines. If there are additional conditions later allowed for the same body part, more treatment will be authorized, even though that body part has already been treated. For example, the ODG recommends up to 9 visits over 8 weeks for an elbow sprain/strain. The ODG recommends 9 visits over 8 weeks for olecranon bursitis. Should the provider be paid for 18 visits over 16 weeks, when the same body part is being treated? Is the therapy for sprain/strain really so different from treatment for inflammation of the bursa?
MCOs are paid a percentage of your premiums, so it’s in their financial best interest to approve lots of treatments to increase the claims costs and increase your premiums. The BWC will say that it has “incentives” in place to make sure that doesn’t happen, but it does happen.
Your two best defenses against rubber-stamping are 1) choose an MCO that has nurse case managers review all C-9 requests, and 2) choose a TPA that will be a watchdog over your MCO.

Here’s an example of the BWC pushing its work onto its customers.
The claim had not yet been allowed. The IW needed physical therapy. The provider wouldn’t provide the therapy unless it got a letter from the employer stating that it wouldn’t appeal the claim. To be a certified provider for workers’ comp claims, the provider has to agree to treat the IW as needed for a quick and safe return to work. Obviously, the provider in this example was more concerned about getting paid than providing treatment.
The BWC says that the MCO is required to train the provider.
Here are the problems with this procedure:
The BWC sets the rules for a provider to be part of the Health Partnership Program (HPP) and accepts the provider into the program. The MCO has no ability to discipline the provider if it does not comply. Also, the MCO would have no way of knowing about any other “training” the provider has received from other MCOs. The MCO has to decide whether to spend time & resources on “training” a provider.
The BWC will only step in after the MCO shows what it has done to train the provider and that the provider has continued the inappropriate behavior.
So in this example, the IW is delayed from returning to her full duties, and employer is denied the full value of its employee while waiting for PT to be completed. The provider gets away with its behavior, because it hasn’t refused to treat anyone else that our MCO knows of. The BWC does nothing to demonstrate its commitment to the rules it sets for providers.
Self-insured employers do not use MCOs, so what does the BWC do when they complain about non-compliant providers? The BWC should monitor the practices of all providers that it accepts into the HPP, and investigate when complaints are filed. The BWC should eliminate the providers who refuse to comply with the requirements of the program.