Providence MCO - Frequently Asked Questions

• What is a managed care organization?
• How do I know if I am eligible to be enrolled in the MCO?
• If I wish to change physicians, may I do so within the MCO?
• Who can be an attending physician within the MCO?
• Will I be able to see my family physician for my work injury?
• Can I treat with a nurse practitioner?
• My primary care provider is a nurse practitioner who is not on the MCO panel. May I seek treat with this provider for my work injury?
• How will I know which MCO physicians I can see for my work injury?
• My personal physician, an internist, is treating me for a work injury. He/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?
• 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?
• I prefer to treat with a naturopath. May I go directly to one on your panel?
• 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 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?
• Does the MCO pay time loss and medical benefits?

The MCO is a group of medical care providers who have obtained certification from the Oregon Department of Consumer and Business Services to care for injured workers. These providers contract with insurance carriers and/or self-insured employers to provide medical care to injured workers.

The term MCO, or managed care organization, also is used frequently in a more generic sense to describe some health insurance offerings, or styles of medical treatment. A workers' compensation MCO, such as Providence MCO, is specialized to focus on the needs of injured workers.

Your employer must be located within the geographic service area of the MCO, and you must live within a 100-mile radius of the MCO's geographic service area. Any injured worker with a worker's compensation claim, whether the claim is open or closed, is eligible to be enrolled after the effective date of the contract between the insurer or self-insured employer and the MCO. If an injured worker is treating with a non-MCO physician, that injured worker may not be enrolled if the MCO determines that changing physicians would be medically detrimental to the worker. The worker may be enrolled when the worker becomes medically stationary or it would no longer be medically detrimental to change physicians.

Yes. You may change attending physicians twice after your initial choice, but you must choose physicians who are members of the MCO panel.

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.) or an oral/maxillofacial surgeon. Providence MCO chiropractors also qualify as attending physicians for the first 60 days of treatment in enrolled claims.

Yes, 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. However, if you need any specialty care, your family physician must refer you to medical providers who are members of the Providence MCO panel. If you are a member of a health plan and have designated primary care physician within the health plan, you may treat with this physician even if you have never received treatment from this physician before, as long as this physician was designated as your primary care physician before the date of your injury.

Yes, with some limitations. Under Oregon law, a nurse practitioner may provide treatment to injured workers only after he/she has completed the requirements set forth by the Department of Consumer and Business Services, and received an “Authorized Nurse Practitioner” number. “Authorized Nurse Practitioners” may provide treatment for a period of 90 days from the first visit, and may not authorize time loss for longer than 60 days.

You can treat with a non-panel nurse practitioner if all of the following apply:

• The nurse practitioner has been authorized by the Department of Business and Consumer Services to treat injured workers, and has received an “Authorized Nurse Practitioner” number.
• The Authorized Nurse Practitioner treated you before your date of injury and/or you selected this nurse practitioner as your designated primary care provider within your group health plan before the date of your injury.
• The Authorized Nurse Practitioner agrees to the terms and conditions of the MCO.

If you do not treat with your personal primary care physician or authorized nurse practitioner, you may select an attending physician or authorized nurse practitioner from the MCO panel. Providence MCO provides a list of participating physicians in the provider directory, which you can request from your workers' compensation insurer, self-insured employer, or directly from the MCO. If your primary care provider is not on the Providence MCO panel and needs to make a referral for specialty care, his/her office may 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 or employer.

Yes. By law, if your personal physician or authorized nurse practitioner agrees to treat your work injury, he/she must refer you into the MCO 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 is happy to assist your physician with referrals, if needed.

No. By law, a non-MCO physician must meet the legal definition of a primary care physician (M.D. or D.O. specializing in general practice, family practice, or internal medicine) in order to treat MCO-enrolled workers. If you wish to receive chiropractic care, you must choose a chiropractor from the MCO panel.

No. Providence MCO does not consider a naturopath to be an attending physician. You will first need to choose a qualified attending physician, who is a M.D., D.O., or MCO chiropractor. That physician can then refer you to a naturopath on the Providence MCO panel. By law, the attending physician in your claim is the only one who can authorize time loss or address permanent impairment.

If you do not comply with the program requirements after you have been informed that your claim has been enrolled, your employer and/or insurer have the right to suspend your benefits.

Contact your employer/insurer at the time you initially file your claim for direction in your initial choice of physicians. By law, you are not required to treat within the MCO until you have been notified that you have been enrolled. MCO providers may bill your group health carrier after your claim has been officially denied. Some services may be covered under “interim” medical benefits. Contact your employer/insurer for more information.

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.