Alphabet Soup: The parties in a workers’ comp case

by Kara Dolan-West | Dec 20, 2012 | Workers' Compensation Benefits

In a workers’ compensation claim, there are various parties that a claimant will come into contact with.  These parties, often shortened into various abbreviations, all serve different roles within the system. Here are just a few of the various parties and organizations that play roles in these claims.

MCO

The managed care organization operates as a “gatekeeper” for medical requests. When a physician of record or other treating provider makes a request for treatment, the MCO in most cases will review the treatment request and approve or deny the request.  Although the MCO employee does not work for the BWC, he or she does make the first decision on whether treatment is related to the claim.  Of course, the MCO’s determination is not final.  A claimant has the right to challenge the determination through a series of appeals and hearings before the Industrial Commission.

TPA

Many employers in Ohio utilize “third party administrators” to handle the management of workers’ compensation claims on their behalf.  While the CSS handles the claim for the BWC, the TPA represents the employer.  TPAs will provided clams management services and also represent employers at hearings before the Industrial Commission.  Because of its interest in representing the employer, an injured worker should consider the TPA an “adverse party.”

DHO

The staff hearing officer or SHO is the second-level hearing officer in the Commission’s hierarchy.  Like the DHO, the SHO is a lawyer who listens to appeals that are filed from the DHO level.  The SHO is also responsible for hearing requests for permanent total disability compensation.

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Tags: CSS district hearing officer MCO SHO TPA