10-Exhibit A - Claims Administration - FINAL.pdf

EXHIBIT A | CLAIMS ADMINISTRATION | RLI 25003JD

EXHIBIT A - CLAIMS ADMINISTRATION

This Exhibit is included as part of the Scope of Services document.

Claims Administration is comprised of the following components:

I. Claims adjusting and investigative services;

II. Data, filing and reports management;

III. Loss fund management services;

IV. Safety and loss control services;

Each of these components is described separately below.

I. CLAIMS ADJUSTING AND INVESTIGATION SERVICES

Upon receipt of notice regarding all workers’ compensation claims, the Proposer, on behalf of BSO will perform at a minimum the following services:

1. Assign a dedicated claims team of qualified, experienced, Florida-licensed adjusters exclusively assigned to BSO’s workers’ compensation claims. Adjusters will be assigned only to BSO workers’ compensation claims.

2. BSO expects that the maximum number of cases being handled per adjuster(s) will be one hundred fifty (150) and will be compliant with best practices or equivalent standards, subject to approval by BSO’s Director of Human Resources.

3. Develop a cost-effective staffing structure to include the number of adjusters, designated to appropriately handle the BSO’s claims. BSO reserves the right to negotiate and approve the staffing plan and any cost associated with any modifications to the plan. In addition, BSO will have the right to request removal of personnel assigned to the BSO’s Agreement. Removal will take effect within (30) calendar days of written request by BSO.

4. Provide a dedicated Claims Supervisor to be assigned exclusively to the BSO contract.

5. The adjuster will be responsible for obtaining recorded (audio) statements from the BSO employee (claimant) and any witnesses as required in determining compensability for all lost time claims.

6. Maintain contact with the BSO employee at all times, coordinating doctor’s and therapy appointments and facilitating return to work. Upon approval by BSO’s Workers’ Compensation Manager, the Nurse Case Manager may be asked to assist in this process depending on the seriousness of the injury, or deemed necessary by BSO.

7. File all appropriate State and Federal forms along with the EDI transmission of data (DWC1, etc.).

8. Prepare and send written correspondence requested by BSO to the injured worker or medical provider regarding entitlement of benefits along with providing the state-mandated booklets/forms for the employee’s information.

9. Accept/deny reported claims for employees’ injuries on behalf of BSO in accordance with the applicable Workers’ Compensation Florida Statutes. The decision to controvert a claim will be made by Proposer, consistent with Florida Statute language, case law, Proposer supervisory approval, and BSO Human Resources approval.

10. Lost time claimant’s checks will be issued by the Proposer on a bi-weekly basis in compliance with statute guidelines once an employee has separated from BSO.

11. Employ any outside vendors such as surveillance companies and case management experts to assist in the investigation and adjustment of claims upon the approval of BSO vendor of choice. Payment of the bills will be made by the Proposer from the loss fund as an allocated expense, but not without prior approval by BSO.

12. Assist the BSO with light duty cases and for those BSO employees who are losing time to include, but not necessarily be limited to, by providing a report indicating all employees that are not working in a full duty unrestricted capacity.

13. Dedicated adjusters or team from the Proposer will be expected to meet with the Director of Human Resources, Workers’ Compensation Manager or any other BSO management staff as necessary, on a monthly basis to discuss Summary Reports on any or all of the following:

a. Any new claim received for that month.

b. Any claim in which an employee is not working full duty.

c. Totals incurred value exceeding $25,000.

d. Potentially controverted cases.

e. Claims in which a settlement is recommended.

f. Changing Claim from Med only to Lost time.

The Director of Human Resources, Workers Compensation Manager or designee may ask the Proposer for reports in order to complete any settlement discussion. Furthermore, the Proposer will provide BSO with any and all reports requested by BSO.

14. Prepare and maintain files necessary for the legal defense of claims and/or other litigation (such as actions for subrogation) or other proceedings. All records related to the services provided by the Proposer shall be maintained in accordance with the Public Records law of the State of Florida.

15. Pay in a timely fashion, per Florida E.D.I. guidelines, all claims, and expenses from the loss fund account established by BSO, which will be maintained by the Proposer. Fees, interest, and civil penalties incurred due to late payments or adjuster mishandling shall be borne by Proposer, except where delays result from late reporting from BSO.

16. Pursue all possibilities of subrogation and liens. The Director of Human Resources, Workers Compensation Manager and any other designee must be copied on all such correspondence relating to these issues.

17. BSO will select an attorney for the defense of claims. The Proposer must provide the defense attorney a complete copy of the file in question at the time of an assignment. The Proposer will provide a monthly report to BSO regarding all legal assignments and the costs associated with them.

18. All requests for settlement must be approved by the Director of Human Resources, WC Manager or General Counsel depending on the level of authority per Standard Operating Procedures.

19. Timely report all claims to the State and BSO’s excess carrier in accordance with Florida State Statues or as required by the carrier’s reporting criteria.

20. Provide all necessary status reports as required by the excess carrier, Director of Human Resources and Workers’ Compensation Manager or their designees.

21. Proposer will submit requests to the excess carrier for all payments above each claim’s SIR

(self-insured retention) to obtain the proper reimbursement for BSO. The reimbursement checks will be forwarded to BSO and the amount recovered will be entered into the claims information system.

22. Field Case Managers and/or registered nurses will be assigned to cases based upon criteria established by BSO and must be approved by the BSO Workers’ Compensation Department.

23. Provide BSO with a dedicated toll-free number for reporting claims that is available 24/7.

24. Communicate with BSO injured employees in a courteous, responsive and professional manner.

25. Establish reporting procedures which are compatible with the needs and organizational structure of BSO as determined by BSO Human Resources. Notice of injury report will be submitted by BSO to the Proposer in paperless format (i.e., internet or email).

26. Provide all necessary forms and instructions for use. Such forms shall include appropriate first reports of injury with a mailing address of the Proposer pre-printed thereon. These forms shall be provided electronically if requested. The cost of providing these forms shall be included within the proposed price.

27. Receive and examine on behalf of BSO all reports of employee injury claims.

28. Establish and maintain complete files on each claim.

29. Conduct the required investigations deemed necessary, as it relates to Workers Compensation, including scene investigations, and personal claimant contact on all lost time or light duty cases. Contact with the claimant must be attempted within twenty-four (24) hours of the Proposer’s receipt of the claim. Field investigations and claimant contact must be performed by employees of the Proposer. Independent adjusters shall not be used to provide this service.

30. Perform job site visits, to become familiar with exposures unique to BSO.

31. Provide a report to Workers’ Compensation, every thirty (30) calendar days, indicating all employees who are losing time or working in a light duty or restricted capacity.

32. Submit a full summary to Workers’ Compensation every ninety (90) calendar days, on all claims of the following types:

a. Any claim in which an employee is not working full duty.

b. Total incurred claim value exceeding $2,000.

c. Potentially controverted cases.

d. Cardiovascular claims.

e. Claims in which settlement (washout) is recommended.

33. Attend Workers Compensation mediations, and hearings involving work-related injuries, as requested by BSO.

34. Make written recommendations to Workers’ Compensation regarding any practices, procedures or conditions that should be examined to prevent future claims, which are revealed during the Proposer’s investigation of a claim.

35. Contact BSO Workers’ Compensation by telephone on all claims where the compensability or the relatedness of the medical expense on the claim is in question, and conduct all necessary investigations, as deemed necessary by BSO Workers’ Compensation.

36. Contact employees who experience loss time at least every two (2) weeks, for the duration of temporary total or temporary partial disability benefits payments. When an employee is represented, BSO Workers’ Compensation shall be contacted when appropriate.

37. Report all lost time and/or questionable cases to the Index Bureau. All lost time shall be re-indexed every six (6) months.

38. Establish initial reserves within ten (10) days of the first report of the claims being reported.

All files must be reserved adequately to extend through the expected life of the claim.

Although all the necessary facts may not be available at the onset of the claim, reserves should be adjusted when medical information or investigation indicates the existing reserve is inadequate or overstated. The following factors shall be considered when establishing reserve:

a. The injury.

b. The investigation.

c. Medical treatment and cost.

d. Projected temporary total or partial disability benefits to be paid.

e. Projected permanent partial disability and impairment benefits.

f. Potential use of outside experts (rehabilitation service providers, attorneys, etc.).

39. Review the adequacy of reserves at least every three (3) months and document the file accordingly.

40. Present in writing all settlements to BSO Workers’ Compensation for approval regardless of the amount.

41. Follow all Division of Workers Compensation (DWC) rules when compensation, medical, or other benefits are being controverted. The case must be discussed with and approved by BSO Workers’ Compensation before the claim is denied.

42. Report all claims involving a fatality to BSO Workers’ Compensation and the BSO General Counsel Office immediately. Payments on these and all other Workers Compensation matters shall be made in accordance with the Florida Workers’ Compensation Law and or governing contractual agreements. Periodic activity/status checks shall be performed to ensure that dependents who receive survivor’s benefits are still eligible to receive them and notify BSO Workers’ Compensation regarding those activity checks.

43. Adhere to all applicable federal, state, and local reporting and record-keeping requirements relative to workers compensation on behalf of BSO.

44. Prepare, maintain and file all records and reports as may be required by legal authorities

(State, local and Federal). Attach copies of reports.

45. Prepare, maintain and file statistical information required by Workers’ Compensation Rating Bureaus, including all required data necessary for the promulgation of experience modifications.

46. Review for accuracy and approve the appropriateness of State assessments, prior to the due date of the assessment.

47. Establish an interest-bearing bank account to make claims, indemnity, expense and legal payments on checks drawn from this account. It is understood that all funds in this account are BSO funds and shall be returned upon BSO’s request or the termination of the Agreement. Regarding this account, the Proposer shall:

a. Provide all monthly bank statements to BSO in a timely manner along with both a simple and detailed bank reconciliation.

b. Any interest earned on the account shall belong to BSO.

48. Ensure that all adjusters handling BSO cases are kept abreast of the Workers Compensation Statutes, DWC rules, and applicable laws.

49. Ensure all DWC filings, including compromise settlements agreement payments, are made in a correct and timely manner.

50. Provide notification of suit being filed against BSO for any reason, to BSO Workers’ Compensation with twenty-four (24) hours of suit being filed.

51. Aggressively pursue recoveries to the satisfaction of BSO, including recoveries based on subrogation and special disability trust fund (SDTF). As regards to subrogation recoveries involving injuries to the claimant caused by third parties, the Proposer acknowledges that such recoveries may include reduction in future workers’ compensation benefits as provided by Florida Workers’ Compensation Law based on formulas provided in Chapter 440 and case law interpreting such law, and shall be responsible for documenting and collecting such recoveries from health care providers and the claimant as mutually agreed upon by the claimant and BSO upon the claimant’s recovery from the third party(ies).

52. Proposer will report such activities in the time, manner, and method, as deemed necessary by BSO. Document and provide BSO Workers’ Compensation written notice of any and all recovery, subrogation, contribution, and/or coordination of benefits recovery potential, as they develop. If the Proposer decides not to pursue any such recovery, the Proposer must give written notice to BSO Workers’ Compensation of its decision within fourteen (14) days of claim receipt.

53. Pursue, track, and provide quarterly reports on all SDTF, as well as subrogation recoveries in such manner as deemed necessary by BSO.

54. Ensure data integrity. This includes properly inputting all cause codes, location codes, loss description, and other claims information. If a data conversion is involved, the Proposer must attest to the integrity of the combined data.

55. Provide training for BSO supervisory personnel responsible for Workers Compensation activities.

56. Comply with all applicable laws, rules and regulations regarding the administration of Workers Compensation benefits.

57. Provide and integrate successfully, an online claims management system that interfaces with all other existing systems to be utilized in the performance of this scope of work.

58. Work closely with BSO to enhance the BSO Safety Program in order to reduce claims on an annual basis.

59. Assist and support BSO’s Return to Work Program.

60. Document all new claim information received from BSO employees, which should be available to BSO Workers Compensation Unit within one (1) hour of receipt, if received during normal business hours, or within the first business hour of the next business day, if received less than one (1) hour before the close of a business day. File shall include First Report of injury form.

61. Within fourteen (14) days of receipt of the claim, the claim adjuster shall perform a three point contact, send appropriate notification packages to the claimant, as required by Chapter 440, review the claimant’s pre-employment physical, and document the Proposer’s analysis of the compensability of the claim.

62. Set initial reserves within seventy-two (72) hours of claim receipt. Thereafter, reserves will be reviewed on an on-going basis, as follows:

a. 30 days from 72-hour review.

b. 30 days from 30-day review.

c. 60 days from last 60-day review.

d. Every 6 months thereafter.

63. An increase or decrease of reserves by $10,000 or more requires notification to BSO Workers’ Compensation. Subsequent to the notification, BSO Workers’ Compensation reserves the right to discuss the case and request a reconsideration of the reserve of the Proposer.

64. The Proposer shall inform BSO of any litigation within two (2) days of receipt of litigation notification, or less than two (2) days as requested by BSO Workers’ Compensation if a shorter deadline is deemed legally necessary.

65. Settlement evaluation shall be provided to the BSO Human Resource Director and Workers’ Compensation thirty (30) calendar days prior to mediation. The Proposer shall evaluate, or cause, a third party expert, as deemed necessary, to evaluate the need for a Medicare Set Aside (MSA), and this shall be determined and documented in all settlement evaluations.

66. File/System documentation shall include documentation of return phone calls to injured worker and BSO, and should notify BSO Workers’ Compensation Unit within twenty-four (24) hours or the next business day.

67. File/System documentation shall include documentation that referral appointment was made for a claimant to a network provider specialist (i.e.; Diagnostic testing, Neurologist, Orthopedic) so that claimant was seen by specialist within two (2) weeks of the date of receipt of the referral from the primary treating physician, unless it is clearly documented that, despite the Proposer’s best efforts, no specialist was available to see claimant within the requisite two (2) weeks period.

68. BSO reserves the right to assign outside counsel of their choosing in the handling of any workers compensation litigation claim.

69. The Proposer’s files must reflect evidence of supervisory direction and involvement at every level. All files must be kept current. File review should be performed on 30, 60, 90, or 120 days cycles, as appropriate. Periodic review by the handling adjuster and all supervisors should be reflected in the file. The Proposer’s Supervisors shall receive all First Reports of Injury and outline investigative needs for the adjuster to follow through. Supervisors should assign the most difficult files to the most qualified adjusters.

II. DATA, FILING AND REPORTS MANAGEMENT

1. BSO’s current Claims Administrator (USIS), utilizes an on-line claims processing system where all data is maintained, updated, and payments are issued. The adjudication of Workers’ Compensation medical bills and payments to BSO providers are performed through this system. On a monthly/weekly/daily basis, USIS provides BSO with a bank reconciliation report to interface with BSO’s financial system.

The Proposer shall be responsible for the provision of an on-line claim processing system and the conversion of any data necessary for successful integration with any and all other systems, including following the termination of the Contract. Any procedures, equipment, and/or costs necessary to connect with USIS’s hardware and software, shall be the sole responsibility of the Proposer.

The Proposer must be able to manage the claims with a comprehensive database system which will allow computer access to adjuster notes, adjuster correspondence and other pertinent information needed by BSO to generate analytical data reports upon demand;

which will allow secure web-based communication between BSO and Proposer’s Adjusters.

This program should also allow BSO to add information to the adjuster notes section of the Proposer computer system and have the ability to interface with BSO’s current Luminos system unless Proposer is approved by BSO to utilize a system other than Luminos.

It is BSO’s desire to move towards a more paperless system for this process. Therefore, Proposer should submit any suggestions or systems that would further this desire.

2. All claims data on the Proposer’s claims database must be downloaded daily or overnight as part of the ongoing claims handling program which will include all claim notes, medical notes, and nurse case manager information as well as lost time payments and medical payments (i.e. hospitals, pharmacies, therapy, legal fees, etc.)

3. The Proposer must prepare, maintain, and file statistical data, records, and reports as required or requested by BSO, BSO’s excess insurers, BSO or Broward County actuaries, and the State of Florida and any other governmental or regulatory agency. Required forms and reports shall be completed by the Proposer and sent to BSO for review and appropriate signatures. Any self-insurance reports that must be filed shall be provided to BSO on a timely basis so that BSO has sufficient time to review and execute the documents before the due date.

4. The Proposer must prepare, maintain, and file statistical information required by the workers’ compensation rating bureaus, including all data required for the promulgation of BSO’s experience modification and state assessments.

5. The Proposer must prepare and file any other reports as required by BSO and the state relating to claims experience, payments, etc.

6. All reports currently provided to BSO by USIS are required from the Proposer, including but not limited to specialty reports, ad hoc reports.

7. Specialty reports beyond those identified in the Scope of Services should be available to BSO by the Proposer, at no additional cost.

8. Claims data is the property of BSO and any data and media will be provided to BSO upon request and upon termination of the Contract. All information or data contained in the database is subject to Public Records Disclosure (per Florida Statute) upon closure of the claim file and must be retained in accordance with the Florida Public Records Retention Law.

9. The Proposer shall make an immediate report to the Director of Human Resources or designee on:

a. Fatalities.

b. Catastrophic occurrences with potential exposure $50,000 for more.

10. The Proposer must submit “full captioned reports” to BSO within thirty (30) days of setting reserves at or above $25,000. The content of the “full captioned reports” shall include, but not be limited to, the following;

a. Coverage items.

b. Employee’s background.

c. Dependents.

d. Employee’s Job Description.

e. Occurrence.

f. Injury.

g. Medical Management.

h. Wage and Compensation Rates.

i. Dates and Periods of Disability.

j. Rehabilitation.

k. Other employee benefits.

l. Litigation.

m. Index/State Filings.

n. Subrogation.

o. Remarks and/or recommended actions.

p. Strategy for resolution.

11. The Proposer will ensure that follow-up reports are received within ninety (90) days of the “full captioned report”.

12. The Proposer must become familiar with existing labor agreements and report all activities pursuant to those Agreements to the Director of Human Resources or designee as requested, at least on a monthly basis, or as otherwise required by BSO.

13. The Proposer’s system shall have the ability to run queries.

14. Proposer shall allow BSO auditors access to all or part of any claim handling by the Proposer.

15. Proposer must be able to provide compliance with Electronic Data Interchange (EDI) for both State of Florida and Federal Government as necessary or required.

III. LOSS FUND MANAGEMENT SERVICES

1. Proposer, at its expense, will ensure all claims and payment data is included in their loss runs. Historical data from our current TPA’s database cannot be purged. Claims data for all open and closed claims must be transferred.

2. Loss runs are to be provided on a monthly basis sorted separately by policy year and department/location. Loss runs should list each claim separately. Specific summary reports also must be provided as needed or requested by BSO. At a minimum, the following reports are required:

a. Claims listing by Department.

b. Check register.

c. Cumulative report by line of coverage by year.

d. Annual summary reports Location report.

e. Large loss or severity report.

f. Safety report.

g. Excess insurance report.

h. Litigation report.

i. Legal payments report.

3. Claims, expenses, and legal payments will be made by the Proposer on checks drawn on an account set up by the Proposer and funded as agreed upon by BSO. It is understood that all funds in this account are BSO funds and are to be returned to BSO upon request or at termination of this contract.

4. Proposer must notify BSO of any reserve changes greater than $10,000 depending on level of experience.

5. Proposer will submit a list of all payments made on a monthly basis. A wire for funds will be initiated as agreed to or required by BSO Finance Division.

6. Monthly reconciliation statement submitted by the Proposer to BSO will include the following:

a. All claims paid during the monthly period to include all payments i.e. medical, wages, legal or others as requested or required by BSO.

b. Balance at inception of statement period.

c. List of disbursements which cleared, by date and claimant/payee.

d. List of deposits, credits, and refunds.

e. List of outstanding checks.

f. Balance at close of statement period.

IV. SAFETY AND LOSS CONTROL SERVICES

BSO would be highly interested in the Proposer’s qualifications or consulting services for loss control pertaining to accident reduction and prevention. BSO is interested in support by Proposer via media, posters, general information to enhance its efforts in prevention and mitigating losses (including but not limited to ergonomics, exposure prevention, hazardous material handling, slip, trip, fall hazards, etc.)

Proposer should provide information (i.e. Loss Control Services) offered by your firm.