11-Exhibit B - MEDICAL MANAGEMENT CARE SERVICES - FINAL.pdf

EXHIBIT B | MEDICAL MANAGEMENT CARE SERVICES | RLI 25003JD

EXHIBIT B - MEDICAL MANAGEMENT CARE SERVICES

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

Proposer is expected to incorporate comprehensive, effective medical cost containment measures to ensure maximum control over, and delivery of, quality medical treatment, evaluation, and rehabilitative services at the lowest possible cost to the BSO.

Medical cost containment measures include, but are not limited to:

I. Preferred Provider Network

The Proposer will provide and maintain a network of authorized medical providers; including but not limited to, hospital care, physicians, therapy, surgical services, medical testing and diagnostic services and any other applicable authorized medical treatment in order to provide BSO employees with quality medical care at the best price possible.

The Proposer will aggressively pursue individual pricing agreements where there is substantial justification for utilization of non-participating providers.

BSO shall have the right to add additional medical providers to Proposer’s authorized medical providers.

II. Nurse Case Management (“NCM”) Services

The Proposer will provide Nurse Case Management Services to include, but not necessarily be limited to, the following:

1. Assist BSO in the development of criteria for cost-effective utilization of NCM services.

2. Nurses shall be Florida licensed registered nurses with at least 5 years of workers' compensation medical case management experience.

3. A licensed Certified Nurse Case Manager approved by BSO that is accessible year-round 24/7/365 for continuous, cost-effective support. (24 hours per day, 7 days per week, 365 days per year.)

4. The Proposer may provide nursing telephonic case management and field case management services. The Proposer may also provide on-site nurse case management service as required and as requested by BSO.

5. Serve as a liaison between the employee, employer, and medical provider in an effort to facilitate all communications between such parties.

6. Develop a rehabilitation treatment plan to provide rehabilitation services to employees requiring such services from out-of-network medical providers.

7. Monitor the treatment rendered and the medical progress of the employee.

8. Assess whether alternate medical care services are appropriate and delivered in a cost-effective manner based on acceptable medical standards.

9. Suggest treatment alternatives to surgical intervention, hospitalization, and elimination of treatments whose benefit to the client’s rehabilitation is not proven.

10. Ensure that the employee is following the prescribed treatment plan.

11. Formulate a plan for the employee’s safe and appropriate return to work.

12. Provide to BSO monthly reports which are titled and would reflect the following:

a. Cost Reports which shall reflect the total number of hours worked per file and itemized bills regarding the actual hours billed by Company’s Nurse Case Manager for purposes of this agreement.

b. Transactional Reports which shall reflect the number of all claims managed by Company on behalf of BSO. Such reports shall include all arising, pending, closed and high hazard liability (HHL) claims. BSO reserves the right to request additional reports that may be necessary on an “as needed” basis.

13. Assign an Account Representative that is fully qualified and responsible for the performance of Nurse Case Management Services as contemplated herein. The Account Representative’s responsibilities include, but are not limited to:

a. Assist with any medical related matters impacting the claim.

b. Act as a liaison between BSO, the provider network, and any other parties as deemed necessary by BSO; and

c. Assist BSO Workers’ Compensation with any performance reviews, as requested by Human Resources.

14. 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 by the Nurse Case Manager and/or Supervisor and documented in the file on 30, 60, 90, 120-day cycles.

15. The Supervisor(s) shall receive all First Report of Injury and outline investigate needs for the Nurse Case Manager to follow through. BSO Workers’ Compensation should assign the most difficult files to the most qualified Nurse Case Manager.

16. BSO reserves the right to the final prior approval of the hiring and/or assignment of the Nurse Case Manager, and Supervisor(s) to handle BSO’s claims.

17. Interact with BSO’s Pharmacy Network, presently ScriptAdvisor.

18. Telephonic Case Manager/Nurse Care Manager must be available twenty-four (24) hours, seven (7) days a week.

19. Telephonic Case Manager (TCM)/Nurse Case Manager (NCM) are subject to continuing education.

20. BSO shall have the right to add additional Nurse Case Managers to Proposer’s authorized list.

III. Utilization Review/Peer Review

Proposer will provide the following services:

1. Utilization review and peer (physician) review services to ensure that treatment requests from medical providers are appropriate for patient medical conditions, follow evidence-based guidelines, and follow all legal and statutory requirements and regulations.

2. The Utilization Review/Peer Review shall be performed by trained healthcare professionals (nurses and physicians) experienced in the evaluation of treatment plans and the validation of medical necessity for workers’ compensation claims utilizing industry guidelines.

3. There shall be comprehensive annual reporting on provider treatment patterns and a physician review scorecard.

4. BSO will be provided with any additional reports, as requested at no additional cost to

BSO.

5. Proposer must have Utilization Review Accreditation Commission (URAC) accreditation, as of the proposal due date, submitting proof with the proposal response.

IV. Bill Review and Audit Services.

Proposer will provide, at a minimum, the following services:

1. Review all medical bills and other services for which a claim is being made for reasonableness and conformity to appropriate medical and surgical fee schedules and network discounts and must be in compliance with Florida Statute fees.

2. Promptly review medical/surgical bills (in and out of network) for accuracy, including, but not limited to, as they relate to the following:

a. Duplicate billings;

b. Unbundling of charges;

c. Up-coding of charges; and

d. Approval and appropriate pre-certification.

3. Review all medical bills that:

a. Are not subject to fee schedule coding.

b. Are for services not specifically addressed in the fee schedule.

c. Need an in-depth medical interpretation of the rules and regulations.

d. In the exercise of professional judgment, specifically, warrant review.

4. Process, pay and mail payment within 20 days of receipt.

5. Reimburse BSO for any overpayments made in the bill review process, within 30 days of identification of overpayment. Reimburse BSO for any penalties and/or interest associated with inaccurate payments.

6. Audit-in network and out-network hospital/provider bills:

a. Exceeding $5,000.

b. Where a departmental charge exceeds 10% of the total bill, excluding room and board charges.

c. Others at the specific request by BSO for accuracy and appropriateness.

7. Develops and follow written policies addressing how late charges, no-show charges, and special arrangements shall be handled.

8. Develop and provide communication materials to explain the policies and procedures of the Medical Bill Review and Audit Services to BSO’s Medical Providers.

9. Develop and follow written grievance procedures for provider concerns.

10. BSO reserves the right to contract directly with specific providers or vendors to secure deductions below Florida Fee Schedule.

11. Aggressive pursuit of individual pricing agreements where there is substantial justification for utilization of non-participating providers.

12. BSO, at its sole discretion, retains the right to conduct its own audit and/or engage a third party to perform audits of all medical payments made on behalf of the BSO.

13. Proposer will pay fifty percent (50%) of the cost of an annual full audit to be performed in accordance with the specification determined by BSO. This should be considered when submitting your cost proposal.