Definition of Managed Care Organization (MCO)

entity that offers a managed care plan for workers compensation benefits that joins a provider network with the following parts: case management personnel, medical bill review personnel, internal dispute resolution vehicle, written guidelines for treatment of cases, quality assurance program, and a utilization review committee. This mechanism executes in the following manner:

1. Case management personnel-monitors treatment of an injured employee to make sure the employee recovers from illness and returns to work in a timely fashion.
2. Guidelines for treatment of cases-written criteria for determining when an illness requires medical treatment, scope of the medical treatment, and acceptable disability time periods.
3. Internal dispute resolution vehicle-provides written instructions for procedures to resolve conflicts in issues between health providers and fee payers regarding the size of medical fees charged, type and scope of medical treatment, and overutilization of medical facilities.
4. Utilization review committee-provides guidelines for inpatient hospital care, outpatient care, and physician care.