How does the BWC decide if my medical expenses will be reimbursed?

Some people—and, unfortunately, many employers—believe that workers’ comp recipients are gaming the system and not doing the things they need to do to get better and return to work.

Coverage for medical costs per the Miller CriteriaHowever, I've found over many years of practicing workers’ comp law that my clients want nothing more than to recover and get back to the work that made them feel like contributing members of society. My clients often push for newer, better, or alternative treatments to help them heal more quickly.

The problem isn't about getting better. The problem is often gaining approval for the treatment that will help them do just that.

MCOs Must Apply the Miller Criteria to Requested Treatments

As with everything related to Ohio workers' comp, getting approval for a medical procedure, service, or treatment is a process. When you or your doctor request approval from your Managed Care Organization (MCO) for a new treatment, the state Bureau of Workers’ Compensation (BWC) requires that a three-pronged test, referred to as the Miller Criteria, be applied.

The medical service you're requesting has to meet all three of these criteria:

  • It must be reasonably related to the industrial injury.
  • It must be reasonably necessary and appropriate to treat the industrial injury or allowed condition.
  • The costs of the services must be medically reasonable.

The MCO may consult the Official Disability Guidelines when deciding, but ultimately, the choice is up to its judgment.

Miller v. Industrial Commission Ruling

The Miller Criteria arose from a 1994 Ohio Supreme Court ruling on a case involving an injured woman who was obese. Even though her weight wasn't a factor in her workplace injury, her doctor believed it was preventing her from recovering, so he recommended that she enter a supervised weight-loss program.

Her employer’s MCO denied coverage of the program, and she appealed to the Supreme Court. The Supreme Court drafted these criteria and ruled that they must be applied to her request for medical service. Her weight loss treatment was approved, with the requirement that the weight loss would help her overcome her injury and not just ease her discomfort—standards now routinely applied to weight-loss programs paid for by workers’ comp.

The Miller Criteria were later embedded in Ohio workers’ comp law and are now applied to every treatment request, not just weight loss.

Do the Miller Criteria Sound Vague and Subjective to You?

That’s because they are. If you're facing a denial of treatment, an experienced workers’ comp attorney might have to argue for the validity of the treatment your doctor says you need.

Learn more by requesting my free guide, Worker’s Guide to Injury Compensation in Ohio. Then call my office to schedule a meeting to discuss your specific situation.  

 

James Monast
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Fighting for Ohio’s Injured Workers and their Families