What is the difference between an MCO and a TPA?
Under Ohio’s Health Partnership Program, the managed care organization (MCO) is responsible for the medical management of work-related injuries and illnesses. MCO responsibilities include handling first reports of injury, providing authorizations for medical procedures, processing providers’ bills for payment by the BWC, and facilitating the return-to-work process. MCO staff are medical professionals and their processes are clinically focused.
Under Ohio’s Health Partnership Program, the managed care organization (MCO) is responsible for the medical management of work-related injuries and illnesses. Its responsibilities include handling first reports of injury, providing authorizations for medical procedures, processing providers’ bills for payment by the state, and driving the return-to-work process. Its staff is clinically focused and includes medical professionals. On the other hand, a third-party administrator (TPA) covers the legal ramifications of a claim. Its responsibilities include providing legal and risk management advice to employers, litigating claims that the employer feels are unwarranted, and working with MCOs to facilitate return to work. Its staff typically consists of paralegals, claims adjusters, underwriters and statisticians. In many injury cases, both MCOs and TPAs become involved. Both groups need providers’ medical documentation to do their jobs.
