Common questions workers ask
What is a managed care organization?
A managed care organization (MCO) is a health care provider or group of medical service providers contracted with insurers and self-insured employers to provide a wide variety of managed health care services to enrolled workers through participating panel providers. The Director of the Department of Consumer and Business Services (DCBS) must certify these organizations. The director cannot certify an organization that is formed, owned, or operated by a non-qualifying employer, such as a workers' compensation insurer or third-party administrator.
How do I know if I’m eligible to be enrolled in the MCO?
You may be enrolled in the MCO if you have filed a workers' compensation claim and your employer is located within the MCO's authorized geographic service area (GSA), and is covered by an insurer that has a contract with the MCO. If your employer is self-insured, the employer will have a direct contract with the MCO. You may be enrolled at any time after the effective date of the contract, whether your claim is open or closed. If you live more than 100 miles outside the MCO's certified GSA, you are not eligible to be enrolled.
Your employer or your employer's insurer must notify you in writing of your enrollment. At the same time, they must provide a copy of your enrollment to all medical providers currently treating you for your work-related injury, and to your attorney, if you are represented. Please note that the only time your employer or insurer is obligated to notify your medical providers of your enrollment is at the time you are enrolled in the MCO. You should provide any subsequent providers with a copy of your enrollment letter, so they may notify the MCO of any services that might need pre-certification for medical necessity. Services that require precertification, or services provided by non-MCO providers, may not be paid by the employer or insurer if no precertification is obtained from the MCO. You could be liable for payment of these services.
If I wish to change physicians, may I do so within the MCO?
Yes. You may change attending physicians twice after your initial choice, but you must choose physicians who are members of the MCO panel. If you are required to change physicians to an MCO provider at the time of enrollment, this change does not count as one of the two changes allowed.
Who can be an attending physician within the MCO?
Under Oregon law, an attending physician is a physician who is primarily responsible for the treatment of a work injury and who is a medical doctor (M.D.), a doctor of osteopathy (D.O.), a doctor of podiatry (D.P.M.), or an oral/maxillofacial surgeon. Other categories of providers may also act as your attending physician for limited time periods.
Providence MCO chiropractors are also qualified attending physicians. Treatment after 20 visits or 60 days, whichever comes first, must be approved by the MCO. A Providence MCO naturopathic physician (ND) or physician assistant (PA) may act as your attending physician for 20 visits or 60 days from the first visit to any ND or PA on the initial claim. They may address work status for not more than 30 days. Review the Providence MCO medical provider limitations for more information on the time limits for other provider types to treat work-related illnesses and injuries.
Will I be able to see my family physician for my work injury?
Yes, under certain conditions. If your family physician is a M.D. or D.O. and is a general or family practitioner or internal medicine specialist, and you have treated with that physician before the date of your work injury, this physician qualifies as an attending physician within the MCO as long as s/he agrees to the terms and conditions of the MCO. An "authorized" nurse practitioner may treat and address work status for 180 days from the date of the first nurse practitioner on the initial claim, if you have a history of treatment with this nurse practitioner before your date of injury . The nurse practitioner must be "authorized" by the Director of the Department of Business and Consumer Services (DCBS) in order to provide care to injured workers in Oregon.
If you are a member of a health plan and have designated a primary care physician or authorized nurse practitioner within the health plan, you may treat with this provider even if you have never received treatment from this provider before, as long as this provider was designated as your primary care provider before the date of your injury. Your non-MCO chiropractic physician must have a documented history of treating you before the injury, and also must be "authorized" by the Director of DCBS to treat injured workers in the state of Oregon. Non-MCO authorized chiropractors may act as attending physicians for 60 days or 18 visits from the first chiropractic visit on the initial claim. Thereafter, if you still need treatment, you will need to transfer to a Providence MCO attending physician.
How will I know which MCO physicians I can see for my work injury?
Providence MCO provides a directory of participating physicians and other medical providers located at www.providence.org/php/mco, or you may request a printed copy from your workers’ compensation insurer or self-insured employer, or directly from the MCO. You may select a qualified Providence MCO attending physician or authorized nurse practitioner from this directory. If you treat with your primary care provider who is not on the Providence MCO provider panel, and this provider needs to make a referral for specialty care, s/he may refer to the online directory or call the MCO for assistance. You will not be required to treat within the Providence MCO panel until you receive a MCO enrollment letter from your insurer, employer, or directly from Providence MCO. However, if you are injured you may wish to initially treat within the MCO so you will not need to change physicians later. The MCO enrollment is normally effective when you receive it or three days after it was mailed, whichever comes first. (See OAR 436-010-0275(a)-(c) for exceptions or call your insurer.)
My personal physician, an internist, is treating me for a work injury. He or she is not a member of the Providence MCO panel and is not affiliated with Providence Health & Services. Do I have to be referred to specialists within Providence MCO even if my doctor does not know any of the specialty physicians?
Yes. Under Oregon law, if your personal physician or authorized nurse practitioner agrees to treat your work injury, s/he must refer you to an MCO provider for any specialty services. These services may include specialist consultation, surgery, physical therapy, lab work, and diagnostic tests. Providence MCO has a large network of providers and we are happy to assist your physician with referrals, if needed.
My personal physician is a chiropractor who isn't on the Providence MCO panel. If I am injured on the job and enrolled in Providence MCO, will I be able to treat with this chiropractor?
Yes, if you have a documented history with this chiropractic physician prior to the date of your injury, and the chiropractic physician agrees to the terms and conditions of the MCO. Non-MCO chiropractic physicians may treat enrolled workers for 18 visits or 60 days, whichever comes first, during the open period of the initial claim. Further treatment must be obtained from an MCO attending physician.
If I refuse to go to any physician on the MCO panel and choose not to participate in the program, what will happen to my claim?
If you do not comply with the program requirements after you have been informed that your claim has been enrolled, your insurer or self-insured employer has the right to suspend your benefits.
If my claim is denied, who will pay my medical bills if I go to MCO providers who do not participate in my group health insurance plan?
Under Oregon law, you are not required to treat within the MCO until you have been notified that you have been enrolled in the MCO. If you are enrolled before your claim is accepted, your insurer or self-insured employer is required to pay for any reasonable and necessary medical services obtained within the MCO that are not otherwise covered by health insurance up to the date of denial, if your claim is denied. If your claim is denied within 14 days of the employer's "date of knowledge" of the claim, services may not be covered. Contact your claims examiner for additional information.
Does the MCO pay time loss and medical benefits?
No. Providence MCO manages your medical care. We do not make administrative decisions regarding your claim. Your employer’s insurance carrier or administrator is responsible for processing your claim and paying time loss and medical benefits.
What if I still have questions?
The MCO has customer service representatives available to answer any questions at 503-574-7640 or 1-800-947-4707.