CareMark Comp Workers' Comp MCO
CareMark Comp is a State
certified Managed Care Organization (MCO) sponsored by Managed HealthCare
Northwest, Inc. MHN is based in Portland, Oregon and is owned by Legacy Health and Adventist Medical Center. MHN was formed December l, l988 and is an
Oregon for-profit corporation.
CareMark Comp complements Workers’
Compensation plans by making sure the injured worker receives quality care
in the appropriate medical setting and in a cost efficient manner.
The most important management tool of the MCO
is the ability to require, by contractual agreement, physician cooperation for
early return-to-work and medical appropriateness of medical services.
- CareMark Comp operational since 1991
- Covered employees - 285,000
- Comprehensive Health Care System includes:
14 hospitals, 1900 professional providers in 64 medical specialties
- Managed by: Medical Director, a specialist in
Physical Medicine & Rehab, Registered Nurse Case Managers, Workers' Comp
specialists, 15 Physician-Member Joint Medical Committee.
- Provider Panel - Contracted Providers
- Utilization Management: Hospital Stay; Surgery;
- Hospital Stay Concurrent Review by RN Case
- Quality Management Analyses
- Complex / Catastrophic Case Management by RN Case
- Disability Prevention Consultant
- Dispute Resolution
- Peer Review
1. Precertification - verification of medical
2. Medical Case Management Performed by registered
nurses and physicians
3. Ensure consistency of care with treatment
standards and guidelines
4. Medical dispute resolution
5. Contractual enforcement of provider obligations
6. Facilitation of early return to work
7. Network of contracted providers and facilities
8. Mediation with medical providers and advocacy for insurer - employer
9. Education of medical providers as to their roles
and responsibilities within the Workers' Compensation System.
10. Discounts from fees.
/ QUALITY MANAGEMENT
Pre-certification - Verification of Medical Appropriateness
requires the doctor to submit a planned/proposed surgery or invasive treatment
to the MCO
for review of medical appropriateness with respect to the worker’s diagnosis.
The doctor agrees to abide
by the determination or to appeal to a group of physician peers for a decision.
Management - Medical Case Management
An MCO Nurse Case
Manager is assigned to each case to track appointments, facilitate communication
between the worker, doctor and employer, and to help keep a workers’ comp injury
recovery and return to function.
Consistency of Care with Treatment Standards and Guidelines
MCOs are required
to develop procedures which meet quality, continuity and other treatment
make certain all required medical and health care services are timely, effective
If any party
disagrees with a medical decision issued by an MCO, (generally when services
disapproved) the MCO is required to offer a process in which the decision can be
challenged and re-
evaluated, by other medical providers of like-specialty (peer review), before a
final determination is made.
Enforcement of Provider Obligations
providers agree to follow contract requirements for pre-certification and to
responses to job analyses and requests for information. They also agree to base
their medical decisions
upon objective medical findings, ensuring that any time loss or work
restrictions are necessary.
Facilitation of Early Return to Work
MCO providers are
contractually required to justify their decisions, to authorize time off work or
restrictions with objective medical reasons. Communication between employers,
and the doctor can be improved with the assistance of the MCO - removing
obstacles to the worker
returning to employment.
with Medical Providers and Advocacy for Insurer - Employer Issues
can be avoided and communication between medical providers, insurers and
employers can be improved when the MCO clarifies the concerns of each party to
enable negotiation to
proceed toward an acceptable outcome.
of Medical Providers as to Their Roles and Responsibilities within the Workers’
communication and updates respective to workers’ compensation laws,
administrative rules, changes in technology or procedures associated with
treatment of occupational injuries, are given to MCO providers.
FEES / SAVINGS
From OMFRVS Fees
Oregon law limits
doctor and hospital reimbursement to the respective workers’ compensation fee
schedules produced by the Department of Consumer and Business Services.
CareMark Comp MCO offers an additional discount from the Oregon Medical
Fee and Relative Value Schedule for services rendered by participating
physicians and professional providers.
Comp Administrative Fee
offers flexible administrative fee arrangements, including shared savings, per
worker enrollment fees, per service or per hour fees.
to comprehensive network of hospitals, urgent care and occupational medicine
centers, rehabilitation programs and physicians of every specialty
medical providers to follow standards and protocols for treatment and frequency
timely responses and reasonable time loss authorizations by network providers
treatment to ensure its medical necessity and appropriate setting
early return to work
injured worker’s care from injury to closure of case
proactive physician consultations in Disability Prevention process
dispute resolution process to minimize outside bureaucratic review and delay
treatment alternatives in catastrophic cases