Eligibility for MCO certification

Any healthcare provider or group of medical service providers may apply to the director of the Department of Consumer and Business Services (DCBS) to become a certified MCO. Oregon law prohibits an organization that is formed, owned, or operated by an insurer or employer other than a healthcare provider to be certified as an MCO. This ensures an arm’s length relationship between the providers of medical services and insurers to avoid the company doctor syndrome, thereby striking a balance between quality care and cost effective care.

Certification - a three-part process

Notice of Intent to form a managed care organization
The Notice of Intent is designed to protect interested parties from committing antitrust violations when they’re meeting to discuss formation.

Proposed plan of operation
The plan shows how the potential MCO intends to comply with the certification requirements in OAR 436-015-0030, including access to medical providers within a reasonable distance from workers’ place of employment; how workers will be informed of such providers; how attending physicians will be identified; how workers will receive specialized medical services that the MCO does not provide; and how the MCO will obtain, develop, and update treatment standards so workers will receive timely, effective, and convenient care. The plan must also prove financial ability and provide procedures for utilization review, peer review, and dispute resolution.

Final MCO certification application
The final application for certification must be submitted with a non-refundable fee of $1,500 to the department within 120 days of filing the Notice of Intent. The application includes the names and addresses of the medical providers contracting with the MCO. This information is used to ensure that workers have adequate access to medical providers of different specialties. The application identifies the geographical service area (GSA) in which the MCO proposes to operate. Applicants provide evidence of the MCO’s corporation status and bylaws and the name of the communications liaison for the department and the insurers.

Within 45 days of receipt of all required information, the director of DCBS will notify the applicant of the effective date of certification and authorized GSAs. If denied, the applicant is given the reason(s) for denial. Any changes to the certified application must be filed with DCBS within 30 days.