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Frequently Asked Questions


What it the difference between a MCO, TPA, and the BWC?
What to do if an employee is injured?
What are my responsibilities for claims in the $15K program?
How do I report a fraudulent claim?


What it the difference between a MCO, TPA, and the BWC?

The Ohio Bureau of Workers' Compensation (BWC) is the state agency responsible for Ohio's workers' compensation system. The BWC is responsible for claim determinations and allowances (i.e. if the claim is allowed and what it is allowed for) and paying lost time compensation.

A Managed Care Organization (MCO) is a private company that an employer contracts with to medically manage the workers compensation claims for injured employees. An MCO will work with the employer, injured worker and provider to ensure a safe and quick return to work and to minimize costs. All state-funded Ohio employers are required to select an MCO. MCOs are paid by the BWC and will not bill employers for the service.

A Third-Party Administrator (TPA) is a private company that an employer hires to represent its interests with the Bureau of Workers' Compensation. The TPA can contest claims and attend hearings on your behalf as well as recommend and implement premium saving programs like group rating. The TPA is paid by the employer for their services.

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What to do if an employee is injured?

Early reporting is essential to reducing workers' compensation costs. An injured worker needs early, effective treatment before the injury becomes more serious or before more damage is done.

When an employee is injured:

  • Report injuries to SMAI as soon as possible. For help in filing a claim, please read this.
  • Once the claim has been filed, your Claims Analyst will be following up with you to verify the injured worker's return to work status.
  • Depending on the severity of the injury, the claim might be transferred to Case Management with a Nurse Case Manager who will help get your employee back to work.
  • During the life of the claim, your Claims Analyst or Nurse Case Manager will be in contact with you to discuss claim activity, answer any questions you may have and ensure that the injured worker has returned to work successfully.
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What are my responsibilities for claims in the $15K program?

While a claim is enrolled in the $15K program, SMAI as a MCO cannot medically manage the claim, authorize treatment or pay medical bills. While in the program, the employer is responsible for the following:

  • Paying all medical bills within 30 days of receipt. If you participate in the program, you inherently approve the first $15,000 of medical costs.
  • Notifying the BWC and SMAI when the $15,000 limit is reached and supply proof of such payment to SMAI. By supplying proof of bills already paid, it will ensure that a bill is not paid twice and will lower the cost of the claim.
  • Keeping a record of all work-related injuries for 6 years from the last date of bill payment
  • Reporting claims to Medicare that are federally required to be reported.

You have the ability to opt out of the $15K program for a specific claim or entirely at any time by notifying the BWC - if the claim because a Lost Time claim, it will automatically be opted out. Once a claim has been opted out, SMAI will start to medically manage the claim and pay the medical bills.

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How do I report a fraudulent claim?

Fraud is a hidden cost of workers' compensation insurance, with an impact on both employers and injured workers. National industry studies estimate 5 percent to 20 percent of all workers' compensation benefits paid are fraudulent. Some examples of workers' compensation fraud occur when:

  • Injured workers go back to work, but still collect benefits
  • Doctors bill for services they never provided

If you suspect workers' compensation fraud you may submit an on-line Fraud Allegation Form on the BWC website or call the BWC at 1-800-OHIOBWC and follow the options. Whether you submit the Fraud Allegation Form or call the fraud hotline, you will be asked to confidentially provide all of the information you have pertaining to the suspected fraud, including the following:

  • Name and address of the person you suspect is committing fraud
  • Details about the improper or fraudulent activity you suspect
  • Other general information pertaining to the suspected fraudulent activity
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Spooner Medical Administrators, Inc. | 28301 Ranney Parkway | Westlake, Oh 44145 | Main: 440.899.2400 | Toll-Free: 800.542.9479 | Fax: 440.899.2411