The Difference Between MCOs and TPAs

iStock_000022673324_FullManaged Care Organizations

MCOs are the primary link between injured workers, medical providers, employers and the Ohio Bureau of Workers’ Compensation. MCOs manage claim filing and medical treatment as well as assist employers with the implementation of recovery and return-to-work programs.

The MCO is responsible for the medical management of any workplace injury that may occur. This includes gathering the initial injury data, gathering the medical documentation, reviewing any treatment request to approve or deny, paying bills related to the injury, coordinating care, and focusing on a safe and timely return to work for the injured employee.

Third Party Administrator iStock_000061432288_Full

Unlike MCOs, which are required for all Ohio employers to handle the medical management of their workers’ comp claims, TPAs are not required or regulated by the BWC but can be hired by employers at any time.

TPAs are private companies that contract directly with employers to assist with the administrative and financial components of their workers’ compensation programs. About 43 percent of employers in Ohio have a TPA representative.

TPAs are consultants that employers can hire to help manage and save money on workers’ comp claims. TPAs accomplish this by administering discount plans through programs such as a Group Rating and Group Retro.

TPAs are responsible for evaluating alternative rating programs and discount programs for employers including group rating, group retrospective rating, individual retrospective rating, self-insurance, and others.

The TPA also processes appeals and files motions on behalf of the employers, initiates claim settlements and pursues handicap reimbursements for pre-existing conditions.

“In short, the MCO is responsible for the care and treatment of the injured employee, while the TPA is responsible for ensuring the employer’s responsibilities are handled properly,” says Andrea Kiener, director of client programs for Sheakley.