OMCA is one of the few MCOs certified by the Department of Workers Claims in each of the 120 counties in Kentucky.

Workers' compensation medical provider networks should be significantly different than group medical insurance networks. In group medical, the MCO looks for a panel as large as possible recruiting as many providers willing to participate for the agreed upon reimbursement. In workers' compensation, however, we look for a much smaller panel; one that includes the right doctors with the clinical, philosophical and communication skills required to be a good workers' compensation provider. OMCA providers are recruited through a variety of methods. Frequently we take the suggestion of another physician, employer, adjuster or attorney. Once identified, our Provider Relations staff visits the physician to determine if the physician and his/her staff will help us treat injured employees in a manner most conducive to returning them to work safely and promptly.

OMCA customizes education programs to meet the specific needs of the employer. The objective of this program is to communicate the rights and obligations of both the employee and employer as it relates to on the job injuries. This employee education includes the risk of the denial of medical bills if the injured worker treats outside the provider network.

Employees and employers are given ample opportunity to answer questions, and follow up is available in the form of a telephone hotline as well as periodic on site follow up.

Insured's are instructed to promptly call OMCA injury reporting line at 1-800-KYCOMP1 (1-800-592-6671), toll free, 24-hours a day, 7-days a week when an employee is injured and needs to see a doctor. OMCA is available to assist employees in reporting injuries through a variety of portals. These include phone, fax or web based. In situations where an employer already is utilizing the first reporting service, OMCA's follow-up services can be obtained simultaneously. OMCA is a trading partner with the Kentucky Department of Workers Claims for I A-1 and all subsequent reports.

If the injured worker needs information about what to do, where to go, or a Gatekeeper listing, call 1-800-KYCOMP1 (1-800-592-6671), toll free, 24 hours a day, 7 days a week. Louisville area employees can call 499-6000.

OMCA provides four-point telephonic case management serving as the liaison among the injured worker, employer, claims adjuster and medical provider. Our primary goals are to:

• obtain appropriate medical care for the injured worker in a cost effective manner,
• coordinate return to work, and
• bring the file to closure.

Nurse case managers make four-point contact within 24 hrs of the referral. Reports to the adjusters are sent to the adjuster via fax, email, mail or electronic transfer per the needs of the client.

The nurse works closely with the adjuster to identify issues of non-compliance by the injured worker. She/he helps the employer to identify modified duty work within the injured workers medical restriction. The nurse assists the injured worker through the medical maze of the workers' compensation system.

Prolonged medical treatment, excessive lost time or catastrophic injury are just some of the flags for field case management. OMCA's Field Case Management involves four point telephonic contacts within 24 hours of assignment - employee, provider, employer, and adjuster. Nurse case managers provide verbal reports to adjusters within 24 hours of an on-site visit and provide a written report within 48 hours of visits or monthly reports on long term assignments.

OMCA provides a review of proposed or delivered medical services to determine the medical necessity and appropriateness. Our registered nurses, licensed practical nurses and medical records technicians issue approvals based on nationally approved criteria. The physician advisors use their medical judgment and criteria to either approve or deny procedures.

OMCA performs pre-authorization, pre-admission, readmission, continued stay authorization, treatment plan reviews and retrospective reviews per the Kentucky Department of Workers' Claim statutes.

OMCA maintains a Physician Peer Review Panel to have available the services of sufficient numbers of Kentucky-licensed and board certified physicians in appropriate specialty areas to assure adequate review of medical, surgical specialty and subspecialty cases.

All bills from system providers come to OMCA for review. All bills are audited by the OMCA medical audit staff to determine if the service is reasonably related to a work-related injury/illness and whether it conforms to usual coding procedures and the state fee schedule (or other agreement with the provider). Necessary corrections are made to the billings and letters of explanation are generated. Verification of the provider's status as an approval system provider is noted and the bill is forwarded to the insurance carrier / third party administrator for processing and payment.

Most problems or disputes arise from lack of communication, miscommunication or injured workers having unreasonable or misguided understanding of what the workers' compensation statute covers. OMCA's grievance program tracks all grievances to facilitate speedy response to employee's concerns and takes prompt corrective action whenever it is warranted.

Annual MCO reports are compiled and submitted to the Kentucky Department of Workers Claims as required by statute.

OMCA will design and obtain approval of a Managed Care Plan specifically for needs of the self-insured employer, fund or carrier.