The Miller Criteria: A 3 Step Test For Reimbursement
November 20, 2018 | Karl R. Ulrich
If you deal with workers’ compensation in Ohio, you need to know about the “Miller Criteria.” The Ohio Bureau of Workers’ Compensation (“BWC”) takes into consideration these criteria when considering whether requests for medical services, treatment, and supplies are reimbursable by the state’s workers’ compensation insurance system.
Ohio is one of only a handful of states which operates a state-sponsored insurance fund. While larger Ohio employers may qualify for “self-insured” status, most Ohio employers pay premiums into a state-run insurance system. Ohio’s BWC also works with Managed Care Organizations (“MCOs”) to medically manage Ohio’s workers’ compensation claims. In the landmark 1994 decision, the Ohio Supreme Court laid out a three-step test to determine whether, and to what extent, medical treatment, services, and supplies are covered by the Ohio state workers’ compensation insurance fund. In State, ex rel. Miller v. Indus. Comm., 71 Ohio St. 3d 229 (1994), the Ohio Supreme Court laid out a three-step coverage test:
- Are the requested medical services reasonably related to the industrial injury / allowed condition(s)?
- Are the requested services reasonably necessary and appropriate for the treatment of the industrial injury / allowed condition(s)?
- Are the costs of the services medically reasonable?
The Miller case considered a unique situation involving an injured worker who had a severe weight problem prior to her industrial injury. That problem increased considerably after the accident. As a result, the injured worker’s doctor recommended that she enter a supervised weight-loss program even though the underlying weight problem was not an allowed condition. The Supreme Court ultimately determined that not only must weight loss be geared toward improving the allowed industrial condition, but the improvement must be curative and not merely palliative. It is not enough that weight loss decreases the pain associated with the allowed condition, but that weight loss must also actually improve the condition. In this case, even though the underlying condition (i.e. obesity) was not an allowed condition, the Court found that reimbursement was to be assessed under the three-part test. In these situations, the authorization of medical services, treatment, or supplies is permitted only until the symptoms or condition return to baseline or the temporary exacerbation has subsided.
All three questions must be answered in the affirmative for reimbursement to be appropriate. This Miller test is now embodied in Ohio Administrative Code §4123-6-16.2(B)(1)-(3).
The MCO’s role includes assessing whether a request for medical service, treatment, or supplies is effective and necessary. MCOs also rely on nationally recognized evidence-based treatment protocols in the Official Disability Guidelines (“ODG”). While the ODG guidelines do not supersede an MCO’s own medical judgment, the ODG’s web-based tool is an effective way for employers to conduct their own early assessment of the compensability of medical claims. An MCO will consider whether an alternative, lesser cost service, treatment or supply meets the injured workers’ needs, even though an MCO may not prevent an injured worker from choosing his or her own preferred provider.
MCO decisions on medical authorization are subject to appeal. As a general practice pointer, you should familiarize yourself with the Miller criteria, and its applicability, so that you are prepared should you receive an adverse decision from the MCO.