Roles & Responsibilities
Frank Gates Managed Care Services works to medically manage your workers’ compensation claims, coordinating the return-to-work process with the employer, injured worker and health care providers. Our team is comprised of Nurse Case Managers and Claims Managers who develop individual plans to guide the process, even in the most difficult cases, and facilitate regular problem-solving contact with all involved parties.
MCO Responsibilities
As your Managed Care Organization (MCO), Frank Gates Managed Care Services is responsible for the medical case management of employees who file a claim against your workers’ compensation policy with the Ohio Bureau of Workers’ Compensation (BWC). In Ohio, MCO responsibilities include:
- Receiving, processing and filing First Reports of Injury (FROI) with the BWC on behalf of the claimant and employer. The FROI provides the information required to initiate an Ohio workers’ compensation claim.
- Initiating three point contact with the: 1) employer, 2) injured worker, and 3) treating medical provider to obtain and collaborate on information related to the claim.
- Providing objective medical case management that facilitates proactive treatment, rehabilitation and return-to-work.
- Reviewing and authorizing medical providers’ treatment requests.
- Processing and paying authorized medical treatment on BWC-allowed claims.
- Processing Alternative Dispute Resolutions for disagreements over medical treatment requests.
As your MCO, we will provide claim information to the parties involved with the claim; the MCO cannot certify or deny a claim on behalf of the employer.
Ohio BWC Responsibilities
The BWC is responsible for all claim determinations, certifications, allowances and paying lost wage compensation to injured workers.
How did Frank Gates Managed Care Services become my MCO?
Every employer that obtains workers’ compensation insurance through the BWC is assigned or selects an MCO. If an employer does not select an MCO within 90 days of establishing workers’ compensation coverage or before they have their first claim, an MCO is assigned to them.
How does Frank Gates Managed Care Services get paid to provide these services?
A percentage of each assigned employer’s premiums is paid – by the BWC – to Frank Gates Managed Care Services for medical management of their claims. We are not paid directly by the employer.
What is the difference between an MCO and a TPA (Third Party Administrator)?
Every Ohio employer is required to have an MCO who is paid by the BWC to medically manage claims. The BWC closely governs the performance and services of the MCO, whereas a TPA is an optional third party claims management organization that is available to employers on a fee basis. TPAs work as the authorized agent for the employer and have a broader risk management scope than an MCO has in medical claims management.
TPAs will assist employers in certifying/rejecting claims, help determine the premium impact of a claim, enroll an employer in a group rating program, attend hearings on the employer’s behalf, and perform many other services that are not related to medically managing claims.
