What is the Difference Between an MCO and a TPA?

Date: July 24, 2019

The Ohio Bureau of Workers’ Compensation (BWC) will hold an MCO Open Enrollment in May 2020.
This gives Ohio employers the opportunity to select a new Managed Care Organization (MCO) or remain with their existing MCO for the medical management of their workplace injury claims for the next two years.

If you are responsible for managing Ohio workers’ compensation for your company, it is important to have a fundamental understanding of the roles and responsibilities of MCOs and Third Party Administrators (TPAs) in Ohio.  MCOs and TPAs play distinctive roles in helping Ohio employers manage their workplace injuries and control their workers’ compensation costs.

What is the Difference Between an MCO and a TPA?

What is an MCO?

  • Under Ohio’s Health Partnership Program, MCOs provide medical management services for Ohio employers’ work-related injuries and illnesses.
  • Every Ohio state-fund employer must select an MCO.  All MCO fees are included with an employer’s BWC premium.  If an employer does not select an MCO, BWC will randomly assign an MCO to an employer.

Core MCO Responsibilities Include:

  • Collecting initial workplace injury reports and transmitting to BWC;
  • Management and authorization of medical treatment to be provided by a BWC-certified provider to injured workers;
  • Medical review and bill payment processing;
  • Maintaining a network of BWC-certified healthcare providers;
  • Return to work services;
  • Utilization review;
  • Training and education for both employers and injured workers;
  • Providing peer reviews as necessary for treatment decisions; and,
  • Processing treatment appeals through the Alternative Dispute Resolution (ADR) process.

MCO associates are medical professionals and their processes are clinically focused.  MCOs should be working diligently to help employers avoid the most costly workplace injury claims – lost-time claims.

Lost-time claims occur when an injured worker is off work for eight or more calendar days. With clinicians managing the medical care and transitioning injured workers back to gainful employment, employers are better able to manage the health of their employees and control long term premium costs.

What is a TPA?

  • A TPA assists employers in the administrative and financial aspects of Ohio workers’ compensation claims.

Core TPA Responsibilities Include:

  • Providing risk management consulting to employers;
  • Administering group rating and other savings and discount programs to lower an employer’s Ohio BWC premium;
  • Pertinent claims investigation;
  • Claims administration;
  • Industrial Commission hearing attendance;
  • Providing workplace safety programs, and;
  • Assisting employers in the development of workers’ compensation cost control strategies.

TPAs typically consist of claims and account representatives and other workers’ compensation professionals. Unlike an MCO, TPA services do include a fee for their services which is billed directly to an employer.

For more information about the uniqueness of Ohio’s Workers’ Compensation system, please contact Jared Weiser, Member Benefits Program Manager at (614) 221-4107 or email [email protected].

The Ohio Bureau of Workers’ Compensation (BWC) will hold an MCO Open Enrollment in May 2016. This gives Ohio employers the opportunity to select a new Managed Care Organization (MCO) or remain with their existing MCO for the medical management of their workplace injury claims for the next two years.

If you are responsible for managing Ohio workers’ compensation for your company, it is important to have a fundamental understanding of the roles and responsibilities of MCOs and Third Party Administrators (TPAs) in Ohio.  MCOs and TPAs play distinctive roles in helping Ohio employers manage their workplace injuries and control their workers’ compensation costs.

What is the Difference Between an MCO and a TPA?

What is an MCO?

  • Under Ohio’s Health Partnership Program, MCOs provide medical management services for Ohio employers’ work-related injuries and illnesses.
  • Every Ohio state-fund employer must select an MCO.  All MCO fees are included with an employer’s BWC premium.  If an employer does not select an MCO, BWC will randomly assign an MCO to an employer.

Core MCO Responsibilities Include:

  • Collecting initial workplace injury reports and transmitting to BWC;
  • Management and authorization of medical treatment to be provided by a BWC-certified provider to injured workers;
  • Medical review and bill payment processing;
  • Maintaining a network of BWC-certified healthcare providers;
  • Return to work services;
  • Utilization review;
  • Training and education for both employers and injured workers;
  • Providing peer reviews as necessary for treatment decisions; and,
  • Processing treatment appeals through the Alternative Dispute Resolution (ADR) process.

MCO associates are medical professionals and their processes are clinically focused.  MCOs should be working diligently to help employers avoid the most costly workplace injury claims – lost time claims.

Lost time claims occur when an injured worker is off work for eight or more calendar days. With clinicians managing the medical care and transitioning injured workers back to gainful employment, employers are better able to manage the health of their employees and control long term premium costs.

What is a TPA?

  • A TPA assists employers in the administrative and financial aspects of Ohio workers’ compensation claims.

Core TPA Responsibilities Include:

  • Providing risk management consulting to employers;
  • Administering group rating and other savings and discount programs to lower an employer’s Ohio BWC premium;
  • Pertinent claims investigation;
  • Claims administration;
  • Industrial Commission hearing attendance;
  • Providing workplace safety programs, and;
  • Assisting employers in the development of workers’ compensation cost control strategies.

TPAs typically consist of claim and account representatives and other workers’ compensation professionals.  Unlike an MCO, TPA services do include a fee for their services which is billed directly to an employer.

For more information about the uniqueness of Ohio’s Workers’ Compensation system, please contact NFIB-Ohio’s Jared Weiser, Member Benefits Program Manager at (614) 221-4107 or email [email protected].

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