CareWorks, a Managed Care Organization (MCO) that offers services such as bill review, utilization review, and “physician network services,” is in legal hot water with the State of Ohio for alleged manipulation of workers’ comp data to its financial benefit, according to an Ohio Inspector General investigation.

So why is CareWorks allowed to do business — including maintaining Medical Provider Networks (MPNs) — in California?

In California, MPNs restrict injured workers to seeking care only from doctors in the employer’s network; doctors are then cajoled into deleterious Preferred Provider Organization (PPO) discount contracts, under threat of exclusion from MPNs (a scheme we refer to as “Pay to Treat”).  

CareWorks is credibly alleged by law enforcement to have scammed the Ohio Board of Workers’ Compensation (OBWC), by finagling the numbers by which the OBWC awards incentive payments to MCOs. Yet California trusts CareWorks to help make determinations regarding where workers may seek care, and whether providers get reimbursed for that care.

Is it any surprise that an organization accused of hoodwinking workers’ comp authorities is in the MPN game? The state of Ohio stepped up, investigated, and seemingly took action. When will California step up and take action against the corrupted MPN system?

Read on for details of the case.

CareWorks: Juicing Workers’ Comp Stats for Profit?

The Ohio Inspector General’s Office acted on a complaint received in 2018, dispatching investigators to examine the “practices, job aids, training, and management guidance provided to CareWorks staff for the gathering, recording, and submitting of Return to Work data to OBWC.”

According to the Inspector General’s report, CareWorks took advantage of the OBWC’s system for awarding incentive payments to MCOs based on certain performance metrics, including Return to Work data. As the report states:

Investigators determined CareWorks had implemented processes for CareWorks staff to elicit questions in a manner to obtain a response of “no missed time”...This resulted in a zero-day scoring claim, which is the best score possible for the MoD [Measurement of Disability] Days Absent Score.

In other words, CareWorks (allegedly) systematically convinced injured workers and employers to give answers CareWorks could later use to misrepresent the MCO’s impact on patients’ returns to work — which allowed CareWorks to take a bigger slice of the incentive pie offered by the OBWC:

Investigators determined OBWC paid the MCOs a total of $132.3 million…for the MoD Days Absent metric of which CareWorks received $51.1 million, or 38.6% of the funds paid.

On top of that, CareWorks allegedly failed to update inaccurate data, except when the updates reflected positively on CareWorks, “...in furtherance of CareWorks’ overall goal to…receive a larger share of the incentive pool from OBWC.”

Yikes.

The fact that CareWorks still does business in California is a perfect example of the double standard to which doctors and payer-side vendors are held. An organization accused by state authorities of manipulating data on the health of injured workers, for profit, currently runs two active MPNs in its capacity as an “entity that provides physician network services.”

The good people of Ohio apparently got wise to the kind of “services” CareWorks offers as an MCO; we can only wonder how well CareWorks serves employers and insurers through its MPNs.  

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