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Medical Care Benefits Archives

Can I be compensated for sustaining an injury on my way to a medical exam ordered by the BWC?

A Court of Appeals has held that injuries sustained by the claimant while traveling to or from a Bureau medical examination are compensable "as being directly and proximately caued by circumstances that arose out of employment as the original injuries and obligations necessitated by those injuries in order to participate in the Workers' Compensation fund, directly resulted in the new injuries." 

Medical Exams Ordered by the BWC

Revised Code § 4123.53 permits the Administrator of the Bureau of Workers' Compensation or the Industrial Commission to compel any employee "claiming the right to receive compensation to submit to a medical examination, vocational evaluation, or vocational questionnaire at any time, and from time to time at a place reasonably convenient for the employee." The Administrator or the Commission may order such examinations to resolve issues of fact and credibility, and it is within their discretion to choose the physician. The statute authorizes the payment to the claimant of all necessary and actual expenses incurred in attending an examination. 

Outpatient medications paid for prior to a claim being allowed by the BWC takes effect February 1, 2015

The BWC's Board of Directors adopted O.A.C. 4123-6-21.6, which provides for first fill of outpatient medications.  This rule, expected to take effect on February 1, 2015, permits the BWC to approve payment for prescription medication for certain drugs (listed in an appendix to the rule) before the administrator makes the initial determination whether to allow the claim.  The rule also permits the BWC to provide first fill reimbursement for prescription medication not included in the appendix "in cases of medical necessity supported by clinical documentation and evidence of need." Under this plan, the BWC will pay for no more than ten days worth of prescription medication, with no refills permitted.

How can I get my medical bills paid?

Revised Code § 4123.54 provides that every employee who is injured or who contracts an occupational disease is entilted to receive such medical, nursing, and hospital services as are auhtorized under chapter 4123 of the Revised Code. Section 4123.66 authorizes the Administrator of the Bureau of Workers' Compensation to pay such amounts from the State Insurance Fund for such medical services, nursing services, hospital services, and medicine as the Administrator "deems proper." The Bureau and the Industrial Commission retain broad discretion in deciding whether to approve or disapprove payments for medical benefits. 

Medical Benefits Paid to Injured Workers

The Ohio Revised Code provides that every employee who is injured or who contracts an occupational disease is entitled to receive such medical, nursing, and hospital services as are authorized under Chapter 423 of the Revised Code. Section 4123.66 authorizes the Administrator of the BWC to pay such amounts from the State Insurance Fund for such medical services, nursing services, hospital services, and medicine as the Administrator "deems proper." 

What About My Medical Bills?

Revised Code § 4123.54 provides that every employee who is injured or who contracts an occupational disease is entitled to receive such medical, nursing, and hospital services as are authorized under Chapter 4123 of the Revised Code. Revised Code § 4123.66 authorizes the Administrator of the Bureau of Workers' Compensation to pay such amounts from the State Insurance Fund for such medical services, nursing services, hospital services, and medicine as the Administrator "deems proper." 

Managed Care Organization decisions

Managed Care Organizations, also known as MCOs, are required to look at three factors when determining whether or not medical suppliers and services should be covered. Payment of medical supplies and services are made only when those supplies and services are medically necessary in the diagnosis and treatment of any allowed conditions. MCOs must evaulate medical treatment and reimbursement requests by applying a three-part test, which requires that:

What is the difference between the BWC and MCOs?

The Bureau of Workers' Compensation is a state government agency that is responsible for Ohio's workers' compensation system. The BWC makes decisions regarding claim allowances and benefit payments. In opposition, Managed Care Organizations are private companies that are selected or assigned to each state-funded Ohio employer. The purpose of the MCO is to manage the employer's workers' compensation claims. The MCOs coordinate medical care and make treatment decisions.

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The Bainbridge Firm, LLC

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