5-Scope of Work.pdf

26P-116 Workers' Compensation Third-Party Administration Services

1.1. OBJECTIVE/JUSTIFICATION

The successful Contractor must provide all personnel, labor, materials, supervision, travel, facilities, software, and equipment to provide TPA services in compliance with the County's scope of work, which for all services required shall also include services requested and required by Marion County Board of County Commissioners (MCBOCC). Contractor must provide a toll-free or local area code (352) number for member services. The successful Contractor must prepare all deliverables in a manner that ensures they are accurate, coordinated, and adequate for the intended purposes, in conformance with all applicable laws and regulations, and, where appropriate, within our preferred provider, Florida Blue and our County Health Clinic My Health Onsite (MHO) or any subsequent Occupational Health Provider the County utilizes.

1.2. BACKGROUND

All Constitutional OƯicers of the County and certain county-funded court employees are included in the WC Program, except as otherwise set forth herein. All Constitutional OƯicers of the County currently participate in the WC Program including Tax Collector, Clerk of Court, Property Appraiser, and Supervisor of Elections. Marion County SheriƯ’s OƯice left MCBOCC in 2012 but there are a few legacy claims still open from that OƯice.

MBOCC has approximately 1900 employees at any one time, the Constitutional OƯices add another approximately 400.

The WC Program is Self-Insured. The County does carry an excess WC insurance policy to pay any claims that exceed $500,000. Currently, claims are managed by Davies, our current TPA. An actuary is engaged to advise on the current year operating fund for paying claims, as well as adequate amounts needed in the Reserve Fund for outstanding liabilities for open claims.

1.3. PREFERRED REQUIREMENTS

Contractor shall:

A. Provide a toll-free telephone call-in number for County employee inquiries. The telephone call-in number shall provide access for hearing-impaired employees.

B. Provide an Internet accessed, secure website for purposes of obtaining account information and account management by the County’s Risk Management staƯ and legal counsel.

C. Have an oƯice based in Florida, preferably in the North Central Florida region, that will service the account.

D. Meet the time requirements established by the Florida Division of Workers’ Compensation for benefits and a minimum payment accuracy of 95% for all medical and indemnity payments.

E. Meet the time requirements established by the Florida Division of Workers’ Compensation statute and established case law including responses to all requests from authorized medical providers, claimants or their attorneys for authorization of medical care.

1. Transition Duties –

a. The Contractor must provide the necessary support, including IT support, insight, guidance, and assistance to ensure a smooth conversion for all the County's WC claims, currently housed in our TPA’s database.

b. Transition duties require that the electronic data, including historical data, be transitioned to the Contractor and stored in a manner in which the contents are readily identifiable by type of document and date the document was created, not the date it was transitioned, in order to ensure proper and timely responses to requests for documentation by the County Attorney, participants in the County WC system, and WC claimants.

c. The Contractor must provide a mutually agreeable written transition schedule for both County and PSCO claims.

d. The Contractor must provide a work plan that lays out an eƯective strategy for service transition and the data conversion.

e. The Contractor must communicate the plan and provide timely progress updates. For reasons of time constraints and budgetary concerns, this process will need to be fast tracked to the extent possible, and all work must be completed by 10/1/26. Our existing contract expires on that date. Our current TPA is contractually obligated to continue servicing our account for an additional 30 days following termination. But it is the County’s intention to begin servicing new claims on 10/1/26. We will only utilize their service when necessary to complete data migration of legacy data.

1.4. Workers' Compensation Third-Party Administration Services: Scope of Work

A. SCOPE OF WORK:

The successful Contractor must provide all personnel, labor, materials, supervision, travel, facilities, software, and equipment to provide TPA services in compliance with the County's scope of work which for all services required shall also include services requested and required. The successful Contractor must prepare all deliverables in such a manner that they shall be accurate, coordinated, and adequate for the purposes intended and in conformance with all applicable laws and regulations.

a. The Contractor must ensure claim conversions are accurate with respect to data integrity, including but not limited to data mapping, historical financial transactions, and payment history and classification.

b. The Contractor must set up and train the County. The participants to be included in the County's team will be determined upon execution of a contractual agreement for services and for the term of the agreement.

c. The Contractor must provide one experienced lost time adjuster and a medical adjuster with at least five (5) years of experience is required for all cases for which a petition for benefits has been filed to both the County.

j. The electronic data, including historical data, be stored in a manner in which the contents are readily identifiable by kind and date to ensure proper and timely responses to requests for documentation by the County Attorney, participants in the County WC system, and WC claimants.

a. The Contractor must analyze, verify, and make payment of state fines and assessments, if/when appropriate. If the state fines and assessments are incurred based on the conduct of the Contractor, then the Contractor is responsible for payment of the state fines and assessments and shall not charge the same to the County. If the County's actions are the basis for the fines and assessments, then the Contractor may charge those amounts back to the County.

b. The Contractor must assist the County, including all reports and data necessary, for filing annual certification of the County’s Self-Insured WC Fund whenever FL DWC requires.

c. The Contractor must provide the County with annual documentation of the Contractor's State of Florida certification as a qualified servicing entity for self-insureds.

d. The Contractor must assist and coordinate with the County in filing the Annual Payroll Report to the state, including notifying the County that the report is due at least 60 days.

2. Administrative and Managerial –

a. The Contractor must provide WC claims data in the format requested by the County's actuary by October 15 of each year and provide any supplemental data as requested by the actuary.

b. The Contractor must coordinate and respond on the County's behalf to the state or federal government, including Occupational Safety Health Administration (OSHA) and the Center for Medicare Services (CMS) and any other audits or requests that may be required of or by the County, including investigating and responding to state's notification of late payments, related fines, and Inquiries on Special Disability Trust Fund and Permanent Total Disability cases.

c. The Contractor must provide responsive and professional account management, administrative services, information technology services, 1099 filing, subrogation and recovery services, Special Investigative Unit (SIU) services to investigate fraud, and any other professional services per industry standards and claims handling best practices.

d. The Contractor must provide prescription, bill review, and payment services in a manner that allows the County to realize optimum savings.

e. The Contractor must pay benefits on time per state requirements and file all information required by the Division of Workers Compensation (DWC) per Florida EDI guidelines for all WC claims benefits and WC claim related expenses and is solely responsible for any fines or fees including but not limited to attorney's fees imposed against the County or employee as a result of any failure to pay timely.

f. The successful Contractor must have and maintain a documented and successful Quality Assurance Program to ensure proper protocols are established and maintained for all claims processed.

g. The Contractor must provide an information management system for the County (Risk Management Information System or RMIS) with the following capabilities: i. Manage and store, in native format, all WC claims data, documents, and forms, including but not limited to medical records, payout sheets, referrals, reports, duty status including restrictions, and any other forms related to WC.

3. Technical and Reports –

a. transcripts, correspondence, notes, pleadings, orders, reports, voicemail messages when appropriate and any forms required by the State of Florida. The data must be identifiable by type of data and with the ability to be sorted chronologically or by type.

b. Create all automated reports required to be generated pursuant to this Agreement.

c. provides 24-hour telephonic and internet-based claim reporting and intake capabilities.

The Contractor must provide the County with the ability to report First Notice of Injuries electronically in real time, preferably with a telephonic 24-hour nurse hotline.

d. the Contractor must provide the County, including the County Attorney's OƯice, full access to the RMI System through an internet-accessed, secure website that is available 24 hours a day, 7 days a week for approximately 6-8 users. The website shall allow the County to view and obtain all data, payments, documents, and forms contained therein, to add notes to the adjuster or claim file that creates an automatic alert to the adjuster that such notes have been added, and to create automated and manual reports.

e. Within twenty-four (24) hours of the County sending a new loss report, Contractor must provide the County with a claim number in the format requested by the County.

f. The Contractor must provide check registers on a weekly basis as required by the County.

g. The Contractor must have in place a system to support electronic reporting for the FL DWC and any other regulatory entity requiring periodic filings.

h. The Contractor must have all technical services configured to meet ADA requirements.

i. The Contractor must provide professional WC claims administration, including:

telephonic and field investigation, statements, photos, settlement evaluation, medical care management referrals, scheduling· of appointments, tests and notifications of same, medical cost containment, medical bill review and payment in accordance with Florida WC fee schedule and any additional discounts existing provider networks provide.

j. the Contractor must determine and make payment of indemnity benefits due and owing, and provide electronic reporting of both indemnity and medical payments to the state.

k. the Contractor must maintain and administer one or more bank accounts for the payment of claims. Contractor must send monthly reconciliations and an outstanding checks list to the County by the 15th day of the following month. Annually, Contractor will review outstanding checks and identify stale-dated checks outstanding greater than 90 days from the check date. The Contractor is responsible for compliance and remittances due under escheatment laws of any jurisdiction as they apply to claims paid under this agreement.

l. County will remit payment to the Contractor via ACH or wire transfer monthly for claims paid. The Contractor must provide a monthly payment report Microsoft Excel or similar accessible format as determined by the County including all payments made and reductions and fees associated with those payments. Similarly, weekly, on Monday mornings, Contractor will provide a report indicating all claimants on a light duty or no duty status and any WC claims that have changed in the past 2 weeks from light duty or no duty to full duty. Report must include detailed information on the last 2 indemnity payments, with type of benefit paid, payee information, time period covered, date of check, payee, amount paid, temporary total disability rate (TTD), average weekly wage (AWN), temporary partial rate (TPR), customary work week, check number, date of loss, claimant name, current work status, date of current work status, claim number, and department.

4. Claims Management, Adjusting, Investigation, & Reporting -

a. The Contractor must provide an experienced litigation adjuster with a minimum of 5 years' experience who can respond to a Petition for Benefits and ongoing communication with the County Attorney's OƯice or outside counsel, if any, attending mediations, depositions, and trials when requested by the County, handling of subrogation, third-party recovery, other adjuster claim services, and maintaining files for all the County's WC claims .

b. The Contractor must pay outside counsel and other contractual fees in accordance with the time frames set forth in the Florida Local Government Prompt Payment Act, Fla. Stat.

§218.70, et seq., as may be amended.

c. The Contractor must manage an open, re-opened, and new WC claims for the duration of the Agreement. The Contractor must perform live and well checks on all PTD claims.

d. The Contractor will receive the notice of claim from either an electronic telephonic reporting service or the County department and create claim files in the Contractor's RMI System for each claim and maintain the file for the duration of the Agreement. Files reporting period shall be established per the County's fiscal year and shall contain the County's hierarchy as provided and updated by the County. Files are the property of the County and information in the same should be maintained and safeguarded per industry standards, state and federal requirements and as described herein.

e. The Contractor must provide an adequate number of experienced licensed lost time adjusters dedicated to the County's WC claims to handle all matters in a timely manner.

Additionally, the adjuster must be located on-site in the County's WC oƯice Monday through Friday for 8 hours a day, the time to be established by the County and the Contractor. The Contractor's adjuster will also act as the liaison for the County's WC administration oƯice and be available to handle WC claim situations needing immediate attention.

f. The Contractor must investigate WC claims for compensability, validity and liability for subrogation purposes and provide field adjusters/investigations when necessary.

g. The Contractor must document the claim file clearly as it relates to all phone conversations, discussions or meetings.

h. The Contractor must ensure compliance with the County's drug-free workplace program and if any drug testing is necessary, ensure proper protocols are followed to enable valid defense of WC claims.

i. The Contractor must determine compensability including securing the injured employee's recorded statement on lost time and on subrogation files and ultimately for investigating liability for subrogation potential. Contractor must secure recorded statements on WC claims involving ongoing lost time to confirm and limit injuries and secure information on prior accidents and injuries. Any subrogation recovery will be paid 100% to the County.

j. The Contractor must provide courteous and responsive service to the injured employee and others involved in the claim process, including responding to the claimant within one

(1) business day and to the physician's oƯice within two (2) business days for all lost time cases. The Contractor must respond to the County Attorney's OƯice or outside counsel, if any, within one (1) business day or same day if needed on WC claims with an active petition for benefits. The County Attorney's OƯice or an outside counsel of the County's choice will respond within the same time frame, to the extent reasonably practicable.

k. The Contractor must contact the injured employee's supervisor or the County's specified liaison when warranted to investigate WC claims as well as advise of claim status and ensure proper work status.

l. The Contractor must coordinate any return of injured employees to light duty with the employee's supervisor and contact the County for assistance as needed.

m. The Contractor must advise the County on any claim that may require loss control or safety investigation to aid in the prevention of similar losses in the future.

n. The Contractor must determine and process payments on the proper benefits due on compensable WC claims within one (1) business day prior to the due date under Florida Statute 440. Any full denial of compensability will be discussed with the County Attorney and Risk Management prior to proceeding with the denial.

o. The Contractor must provide a monthly report outlining all active litigation Workers’ Compensation claims. The report must include, but is not limited to, date of injury;

accident description; compensability; covered body part(s); authorized physician(s);

diagnosis; medical summary; prior litigation summary; work restrictions and work status;

status of reserves.

p. The Contractor must confirm with the claimant's employer's payroll department that base wages were paid in full for the first seven (7) days of disability and report that time period as employer-paid in the Electronic Data Interchange (EDI) report to the DWC.

Notification must occur within one business day of instances, where the employer-paid position exceeds 7 days.

q. Contractor must be available to discuss claims directly with claimants.

5. Handling of Litigated Claims

a. The Contractor must apply the following Litigation management: i. Work with the County Attorney's OƯice, or outside counsel, if any, to 1) prepare a response and corresponding documentation for the defense of WC claims considered non-compensable, 2) respond timely to Petitions for Benefits on the Judge of Compensation Claims (JCC) website and 3) assist the County Attorney's OƯice or outside counsel, if any, in preparation of cases for hearings, appeals and mediations and attend same as requested by the County Attorney's OƯice or outside counsel, if any. Adjusters must be made available for depositions and meetings to prepare for depositions and to attend mediations in person or by telephone, or by video conferencing, at the discretion of the County or its legal counsel.

b. Coordinate investigation of any heart presumption cases, as defined by Fla. Stat. 112.18, with the County Attorney's OƯice or outside counsel, if any, regardless of whether the claimant is represented by counsel. The Contractor must not file a denial without approval from the County Attorney's OƯice or Risk Management.

c. On cases with an active petition for benefits, timely notify the County Attorney's OƯice.

or outside counsel. if any, of all activity relevant to the issue(s) in the petition for benefits including but not limited to when a claimant reaches maximum medical improvement (MMI), when a claimant's work restrictions have changed, when impairment ratings are assigned, and when a claimant has a change of physicians.

d. Work with the County to mitigate litigation and claim costs and promote settlements. All wash out settlements must be approved by the County in writing prior to the initiation of settlement discussions and once the file is settled it must be Medicare compliant.

e. Respond to requests for production and redact any protected information and/or qualifying employee data prior to submission. Have the County Attorney's OƯice or outside counsel, if any, review and approve and formally respond to the request for production.

f. Respond to requests for benefits, including requests for medical provider or service authorizations and other requests in a professional manner and within the time requirements set forth in Florida Statute 440.

g. All correspondence to claimants' attorneys on cases with an active petition for benefits must be reviewed and approved by the County Attorney's OƯice or outside counsel, if any, before being sent such review and approval does not diminish the Contractor's warranty pertaining to deliverables.

h. The Contractor must provide a cost-eƯective, legally compliant, and automated method for reporting WC claims to Medicare. Please describe what your current method is and how you follow up on queries and settlements.

i. The Contractor must schedule claims management meetings at a minimum of one time per month, and as requested by the County within three (3) business days for WC claims involving pending litigation, complex issues (large exposure flies, monetary or political) or questionable aspects (potential denials or fraud), and at the County's sole discretion.

j. The Contractor must meet all the requirements for Medicare reporting under Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), Section 111, and ensure that any and all settlements meet the Medicare conditional payment and future payment needs of the claimant.

k.The Contractor must advise the County departments, PSCO, and WC program participants of any Centers for Medicare & Medicaid Services (CMS) liens received and review the CMS liens received on pending and/or closed WC claims and respond to Medicare timely. The Contractor must negotiate and resolve the same.

6. Financial and Administrative Terms.

a. The Contractor does not have the authority to settle or deny claims. Prior authority must be obtained from Risk Management and the County's Attorney or outside counsel. The Contractor must provide recommendations for settling or denying claims, in writing with detailed reasoning.

b. Contractor must communicate with MHO and assist in gathering all required documentation, including DWC-25s after every visit to track duty status and work restrictions.

c. Invoices will be sent to County Risk Department monthly on or shortly after the 1st of each month. The payment will be authorized by Risk and processed by Finance, payment sent via ACH within 30 days.

d. WC Final Settlements will be negotiated/mediated by County Risk and County Attorney’s OƯice and Settlement checks will be issued directly by the County.

e. Excess Policy Coverage will be monitored and managed by Contractor.

f. The County has approximately 100 open claims as of the writing of this RFP.

Approximately 2/3’s of those are older claims that require minimal regular attention. The County is actively working to close some of these older claims so as to reduce future liabilities. Additionally, the County averages approximately 20 new work-related injuries per month. Some of those are report only and require no follow-up, others require additional follow-ups, referrals, etc. At any one moment in time, the County has approximately 50 active claims and no more than 130 open/reopen claims total.

g. Due to significant revenue reductions and budget constraints, including the possible passage of property tax elimination legislation, the County cannot pay more than $200,000 annually for administering these claims (“Annual Flat Fee”). Additional fees for Cost- Containment services are negotiable, but must also likewise be capped at an agreed upon rate to provide cost certainty for the County.

h. Special Handling instructions to be discussed so as to align with the County’s Risk WC policy and philosophy.