CareMark Comp Workers' Comp MCO

OVERVIEW

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 System 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.  

SERVICES

1.  Precertification - verification of medical appropriateness

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 issues

9.  Education of medical providers as to their roles and responsibilities within the Workers'   Compensation System.

10.  Discounts from fees.

MEDICAL / QUALITY MANAGEMENT

·         Pre-certification - Verification of Medical Appropriateness
The contract 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.

·         Disability 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 moving toward
recovery and return to function.

·         Ensured Consistency of Care with Treatment Standards and Guidelines
MCOs are required to develop procedures which meet quality, continuity and other treatment standards to
make certain all required medical and health care services are timely, effective and convenient.

·         Medical Dispute Resolution
If any party disagrees with a medical decision issued by an MCO, (generally when services have been
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.

NETWORK / PROVIDER MANAGEMENT

·         Contractual Enforcement of Provider Obligations
MCO participating providers agree to follow contract requirements for pre-certification and to give timely
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 activity
restrictions with objective medical reasons.  Communication between employers, workers
and the doctor can be improved with the assistance of the MCO - removing obstacles to the worker
returning to employment. 

·         Mediation with Medical Providers and Advocacy for Insurer - Employer Issues
Misunderstandings 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. 

·         Education of Medical Providers as to Their Roles and Responsibilities within the Workers’ Compensation System
Regular 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

·         Discounts 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. 

 ·       CareMark Comp Administrative Fee 
CareMark Comp offers flexible administrative fee arrangements, including shared savings, per worker enrollment fees, per service or per hour fees.

CareMark Comp MCO: 

·         Offers access to comprehensive network of hospitals, urgent care and occupational medicine centers, rehabilitation programs and physicians of every specialty

·         Requires medical providers to follow standards and protocols for treatment and frequency of care 

·         Enforces timely responses and reasonable time loss authorizations by network providers 

·         Reviews treatment to ensure its medical necessity and appropriate setting 

·         Focuses on early return to work  

·         Monitors injured worker’s care from injury to closure of case 

·         Conducts proactive physician consultations in Disability Prevention process  

·         Provides dispute resolution process to minimize outside bureaucratic review and delay  

·         Recommends treatment alternatives in catastrophic cases