4123-6-13 Payment to MCOs.

(A) The bureau shall determine fee payments to an MCO for providing medical management and cost containment services and administrative services.

(B) MCO fee payments may be subject to penalties based upon the failure of the MCO to meet predetermined performance criteria set forth in the MCO contract. The bureau may pay an MCO a performance payment and may pay an incentive payment.

(C) In establishing performance measures, the bureau may evaluate an MCO's performance based upon criteria including, but not limited to:

(1) Quality performance measures including, but not limited to, return to work rates and re-injury rates.

(2) Process performance measures including, but not limited to, first report of injury (FROI) timing. FROI accuracy and bill timing.

(3) Total cost measures including, but not limited to, average total paid cost, average incurred cost, and lost-time claims to total claims ratio.

(4) Change in cost measures including, but not limited to, change in average total paid cost, change in average incurred cost, and change in lost-time to total claims ratio.

(5) Customer satisfaction measures including, but not limited to, MCO network utilization rates and employee, employer, and provider satisfaction surveys.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.121 , 4121.30 , 4121.31 , 4123.05
Rule Amplifies: 4121.121 , 4121.44 , 4121.441 , 4123.66
Prior Effective Dates: 2/16/96, 1/1/99, 1/1/01