RFP_5800_SLW3034_0600_v1.xlsx
XLSX spreadsheet 42 KB Posted
- Attached to
- Worker's Compensation Medical Management Service
- Solicitation number
- RFP 5800 SLW3034
- Issued by
- Texas
About this file
This is a Request for Proposal (RFP) spreadsheet for the City of [jurisdiction] in Texas seeking qualified offerors to provide workers' compensation medical management services. The scope of work encompasses administration of an exclusive 504 Physician Panel, workers' compensation medical cost containment, case management, pharmacy benefits management, information systems, and related ancillary services. The RFP document outlines detailed service requirements, performance standards, and operational expectations for managing the city's workers' compensation medical program. Specific response dates, due dates, site visits, and bidders' conference details are contained within the spreadsheet, along with the proposed contract term and any renewal options available to the city.
The pricing terms, set-aside requirements, incumbent vendor information, and current program environment are detailed in the spreadsheet. Funding for this contract will be provided by the city's workers' compensation insurance budget and related health benefit accounts. Additional salient information regarding minimum qualifications, service level agreements, staffing requirements, network adequacy standards, and reporting obligations specific to the city's workers' compensation medical management needs are included in the RFP documentation.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP_5800_SLW3034_PAC1_v2.pdf | ||
| RFP_5800_SLW3034_PAC2_v1.docx | DOCX document | |
| RFP_5800_SLW3033_PAC2_v1.docx | DOCX document | |
| RFP_5800_SLW3034_PAC1_v1.pdf | ||
| RFP_5800_SLW3034_ATT_3_v1.docx | DOCX document | |
| RFP_5800_SLW3034_ATT_1_v1.docx | DOCX document | |
| RFP_5800_SLW3034_ATT_2_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3034_ATT_6_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3034_ATT_4_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3034_ATT_5_v1.pdf | ||
| RFP_5800_SLW3034_ADD_1_v1.pdf | ||
| RFP_5800_SLW3034_0600_v2.xlsx | XLSX spreadsheet |
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Text version
Cover
| The City of Austin |
| Request for Proposal # 5800 SLW3034 |
| for |
| Worker's Compensation Medical Management Service |
Tab 1
| 504 Physician Panel Scope of Work Requirements, Vendor Experience, Account Team, Resumes, Project Technical Plan and Strategy | ||
| All vendors must complete this section. | ||
| # | Specification | Vendor Response |
| 1 | Vendor has read Scope of Work Section IV C. 1-22 504 Physician Panel Development & Implementation Requirements and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 3 of this workbook. | |
| 2 | Identify the name of the firm that will be working directly with the City to design, implement, and manage the 504 Physician Panel. | |
| 3 | Provide, in 2 pages or less, the firm's history, mission, organizational stability, dedicated resources, and experience in the implementation and management of 504 Physician Panels. | ATTACH TO PROPOSAL |
| 4 | Identify the key individual at the firm that will be working with the City to develop, implement, and manage the 504 Physician Panel. | |
| 5 | Identify other key positions by employee name and title, or by title if not currently hired, that will work with the City to adminster the 504 and list their top functions. | |
| 6 | Provide the bios/resumes for all positions listed in question # 5 and #6 and if not currently hired, identify the minimum job requirements. Do not include the experience or resumes of employees who will not actively participate. | ATTACH TO PROPOSAL |
| 7 | Complete Tab 2 of this workbook requesting references. | COMPLETE TAB 2 |
| 8 | Confirm your company is in good standing with all relevant licensing and regulatory agencies by answering YES in your response. If your firm is not in good standing identify and disclose all complaints, suspensions, fines, sanctions or other disciplinary actions received by your firm that are associated with a network or panel and issued by Texas regulatory agencies within the past five years. | CONFIRM OR ATTACH TO PROPOSAL |
| 9 | Provide a detailed implementation plan to include a specific timeline for establishing the exclusive City's 504 Physician Panel. | ATTACH TO PROPOSAL |
| 10 | Describe how medical providers will be selected and what role the City will play in the decision making process. If any other entities will assist in this process describe their role. | |
| 11 | Indicate the estimated number and types of providers you anticipate to contract with for an effective and quality 504 Program. How many clinics would you recommend for the City workforce? | |
| 12 | Provide a detailed summary of your process for contracting providers to include how both reimbursement rates and contracts are negotiated with providers. | ATTACH TO PROPOSAL |
| 13 | Provide a sample contract that you consider to be one that the City might want to adopt for this program. | ATTACH TO PROPOSAL |
| 14 | Specify who the parties are to the contracts and what will be required should the City change Third Party Administrators in the future. | |
| 15 | Indicate how the completed fee schedule will be shared with the medical bill audit provider. | |
| 16 | Specify your provider credentialing process in detail including credentialing criteria and frequency of re-credentialing. | ATTACH TO PROPOSAL |
| 17 | Provide an example provider handbook that includes all the provisions you recommend be included in the handbook. | ATTACH TO PROPOSAL |
| 18 | What process do you recommend for removing a provider from the 504 Physician Panel? | |
| 19 | Provide a list of treatment guidelines you recommend the City adopt that will facilitate return to work and provide for more effective and efficient claim resolution. | ATTACH TO PROPOSAL |
| 20 | Outline the procedures that will be in place to ensure medical providers treat within the guidelines established by the Physician Panel. | |
| 21 | Describe how treatment outside the established Panel treatment guidelines will be handled with the medical provider and with the employee. | |
| 22 | Describe how medical providers are educated in the requirements of the 504 Physician Panel to include treatment guidelines, utilization review, preauthorization, cooperation with case managers, return to work programs, and employee complaints and provider disputes. | |
| 23 | Providers should provide objective and clear information to City employees. Describe the types of instruction requirements you plan to give to providers for communication with a City employee. | |
| 24 | Recommend how the 504 Physician Panel will handle employees that do not live within the designated area. | |
| 25 | Identify the process for after hours medical treatment including emergency treatment for injured employees. | |
| 26 | Describe your process and schedule for updating your provider list/directory on the website. | |
| 27 | Describe the complaint and/or dispute processes for injured employees or medical providers and the communication of such to each party. | |
| 28 | Describe the process by which the TPA, cost containment provider and the 504 Program will share information to ensure prompt and accurate payment to medical providers and reporting to the DWC including information regarding the fee schedule, provider enrollment, preauthorization and referrals. | |
| 29 | Recommend the proper use of utilization review and retrospective review and how often this should be required. | |
| 30 | Describe how the 504 administrators will train City staff and educate City employees on access to the 504 Physician Panel services and City employees’ rights and responsibilities. | ATTACH TO PROPOSAL |
| 31 | Provide samples of educational and training materials including the acknowledgement forms. | ATTACH TO PROPOSAL |
| 32 | Provide a sample notice posting that the City would use at employment sites. | ATTACH TO PROPOSAL |
| 33 | What days and what hours are local or toll-free numbers available to employees? | |
| 34 | Describe how the 504 Program will objectively and systematically monitor and evaluate the quality and appropriateness of care and services including medical case management and return to work. | |
| 35 | Specify the types of monthly reports or other reports that you will provide to the City to ensure the exclusive 504 Physician Panel is effective. | |
| 36 | The Panel will be handling all new claims with dates of injury 10/1/25 and beyond; describe how claims with dates of injury prior to that will be managed/potentially moved into the 504 Physician Panel. | ATTACH TO PROPOSAL |
Tab 2
| 504 Physician Panel References | ||
| All vendors must complete this section. | ||
| REFERENCE INFORMATION | ||
| # | Specification | Vendor Response |
| 1 | Indicate the number of Texas 504 Physician Panels that your firm has implemented in the last 5 years. |
| 2 | List the Texas 504 Physician Panels that your firm currently manages or has managed that have operations similar to the City in the last 5 years. | ||||
| NAME OF ENTITY | CONTACT NAME | CONTACT PHONE AND EMAIL | TYPE OF SERVICES | CONTRACT START/END DATE |
These references may be contacted as part of the evaluation process.
Tab 3
| Exceptions/Comments to Scope of Work Requirements | ||
| If you have any Deviations to the Proposal Requirements and Specifications, OR need to add additional commentary on any item in the Workbook Tabs, please include this here | ||
| # | Specification | Deviation/Commentary |
Tab 4
| Medical Cost Containment and 504 Physician Panel Performance Guarantees | |||||
| All vendors must complete this section. | |||||
| # | Performance Measure | Acceptable Performance | Liquidated Damage | Calculation | Agree |
Yes/No
| 1 | Annual Audit of Workers’ Compensation Claims Management & Subrogation, Preauthorization and Bill Review | Audit results for any categories audited are responded to by the TPA within 10 business days of receipt and action plans implemented within 30 calendar days to improve in any areas below 90%. | Annual: $5,000 for each category where the audit result is below90%. The 3 categories are: 1. Claims Management 2. Pre-authorization 3. Bill Review. | Annual Audit – final audit results as provided by external audit company | |
| 2 | Performance Log Results for 3 categories: 1. Claims Management 2. Utilization Management/Bill Review. 3. EDI | Quarterly average for each category must be a minimum of 95%. Each report must be delivered accurately and timely by the 10th of October. Timely is defined as receipt by 11:59 p.m. on the 10th of October. If the 10th falls on a weekend or holiday the report is due on the next business day by 11:59 p.m. The TPA shall have one business day after notification of a report inaccuracy by the City to produce an accurate report. | Quarterly: $2,500 for each category that is below a 95% average score. Not to Exceed $15,000 annually. | Contract Quarters are October thru December/Jan thru March/April thru June/July thru September. | |
| 3 | City's 504 Panel website is updated and | ||||
| maintained regularly. | The website is available to all employees and the physician and clinic information is updated on a monthly basis. Website is not down for more than 1 business day per month and the clinics and physicians listed on the site are updated monthly. | $5,000 per month penalty if either: 1) the website is down for more than 1 business day per month or 2) the provider and clinic information is not updated based on all agreement changes completed within the prior month. | Provider and clinic information quality assurance shall be based on physician and clinic information being updated based on signed contracts generated during the prior month; the website is not down more than 1 business day in the prior month. | ||
| 4 | Panel administrator shall capture the primary ICD- |
10 diagnosis code from the claimants treatment records for all treatment completed within each
| contract year. | 90% of all ICD-10 diagnosis codes are properly captured in an annual report that must be delivered accurately and timely by the 15th of following month. Timely is defined as receipt by 11:59 p.m. on the 15th of the month. If the 15th falls on a weekend or holiday the report is due on the next business day by 11:59 p.m. The TPA shall have one business day after notification of a report inaccuracy by the City to produce an accurate report. | $10,000 annually; calculated per contract | ||
| year. | Timeliness and accuracy are defined under Acceptable Performance. Panel administrator shall generate the ICD-10 diagnosis code report for all treatment performed within the previous calendar year. Pharmacy bills, exposure claims and emergency room procedures shall be excluded from the report. | |||
| 5 | A report of panel treating physicians shall be generated each month with the average Return to Work timeframe by diagnosis code indicated and compared to the Occupational Disability Guideline for that diagnosis. | Monthly report delivered accurately and timely by the 15th of the following month. Timely is defined as receipt by 11:59 p.m. on the 15th of the month. If the 15th falls on a weekend or a holiday the report is due on the next business day by 11:59 p.m. The TPA shall have one business day after notification of report inaccuracy by the City to produce an accurate report. | $5,000 per month penalty if report is | |
| inaccurate or late. | Timeliness and accuracy are defined under |
Acceptable Performance.
| 6 | Maintain ongoing contact with COA employees on No Duty or Limited Duty status. | Employees on No Duty Status shall be contacted by Nurse Case Manager no less than every 15 days while the employee is on No Duty or Limited Duty status as required by Scope of Work 0500 Section K.5. | $500 per verified incident. | Verified service failure due to lack of documentation in the claim file through a screen shot or call log that contact was attempted at least twice and then an email sent to the department WC rep indicating contact was unsuccessful. | |
| 7 | Response to emails and phone calls within 1 | ||||
| business day | A response to City employee generated phone calls or emails is communicated back to the City employee within one business day of the inquiry; an acceptable response can be acknowledgement of receipt of the inquiry and an indication that it is being worked on. Follow-up responses shall be made within 1 business day. | $500 per verified incident. | Verified service failure due to lack of response through a screen shot or call log. | ||
| 8 | Contractor and/or it's subcontractors shall not to utilize Artificial Inteligence (AI) for any human decision making related to claims and medical determinations involving City claimant data. | Compliance by Contractors to the City's AI Policy is mandatory. The Chief Information Officer (CIO) will work with Department Directors to ensure compliance with the policy. Non-compliance may result in department leaders imposing disciplinary action, restriction of access, or more severe penalties up to and including termination of employment or vendor contract. Violations by contractors/vendors/partners may be considered breach of contract and may result in removal from assignment. Any AI-related activities which appear to violate applicable laws/regulations | |||
| will be reported to external law enforcement and/or regulatory agency. | $50,000 per verified incident. | Adherence to this requirement will be determined by the City. | |||
| 9 | Medical procedures that are performed in the medical office of the provider shall be flagged by bill review, to the claims examiner. This will afford the claims examiner the opportunity to send the medical information to UR to address with the medical provider, if necessary. | Bill review provider shall flag all medical bills for medical procedures performed in the medical office of the provider, and then notify the assigned claims examiner within 1 business day from discovery. | $500 per verified incident. | Adherence to this requirement will be determined by the City. |
Tab 5
| Account Team, Resumes, and Scope of Work Requirements | ||
| All vendors must complete this section. | ||
| # | Specification | Vendor Response |
| 1 | Identify the Account Manager for the City and provide the percentage of time this position will be dedicated to the City's account. Identify the other accounts this manager will also be handling while working on the City's account. | |
| 2 | Provide the resume/bio for the Account Manager. If the Account Manager is not currently employed, provide your minimum qualifications for the position. | ATTACH TO PROPOSAL |
| 3 | Identify the two 100% Dedicated Certified Telephonic Case Managers for the City's account. If these TCM's have not been identified indicate TBD. | EITHER TBD OR NAMES |
| 4 | Provide the resumes/bios for the two TCM's for the City's account. If these TCM's are not currently employed, provide your minimum qualifications for these positions. | ATTACH TO PROPOSAL |
| 5 | Identify other executives that may be involved in the City's account when an escalation of an issue may arise, and briefly describe their background and expertise in resolving account challenges. | ATTACH TO PROPOSAL |
| 6 | Verify that you have read Scope of Work Section IV.G. 1-5 and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 3 of this workbook. |
Tab 6
| Claims Administration Technical and Bundled Services Questions | ||
| All vendors must complete this section. | ||
| # | Administration Questions | Vendor Response |
| 1 | List the functions that the Client Services /Account Manager position will perform for the City. | ATTACH TO PROPOSAL |
| 2 | Some City employees can be hard to reach by phone due to their work shifts or the type of position they hold. When the nurse case manager contacts our injured employee by phone, is your firm name identified as the caller? If not, are there plans to implement this function? If so, when would this be implemented in Texas and for the City? | |
| 3 | Does your firm have the capability of "tracking" incoming phone calls to a specific TCM and determining if the TCM has returned the phone calls? Explain the method, if any, you currently have in place to do this. | |
| 4 | Identify the types of training and continuing education your firm provides to your staff. | |
| 5 | When a claims adjuster requests a peer review, RME or DD to address disputed issues, do you have a quality control process in place to ensure that all the medical and other information has been included with the request? | |
| # | Bill Review, Utilization, Peer Review, RME, RUR and PBM Services | Vendor Response |
| 6 | Identify the legal name of the organization that you will use to perform bill review services. | |
| 7 | Identify the legal name of the organization that you will use to perform preauthorization services. | |
| 8 | Identify the legal name of the organization that you will use to perform peer review services. | |
| 9 | Identify the legal name of the PBM organization that you will use to provide the PBM network. | |
| 10 | For each separate legal entity identified in #'s 6 -9 above, provide, in 2 pages or less, the firm's history, mission, organizational stability, dedicated resources, and experience in the implementation and management of the services they will be providing. | ATTACH TO PROPOSAL |
| 11 | Vendor has read Scope of Work Section IV. E. 1-8 Pre-Authorization and Bill Review and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 3 of this workbook. | |
| 12 | Vendor has read Scope of Work Section IV. F. 1-6 Peer Reviews, RME's and RUR Services and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 3 of this workbook. | |
| 13 | Vendor has read Scope of Work Section IV. H.1-4 PBM Services and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 3 of this workbook. | |
| 14 | Are the Medical Bill review and Utilization Review systems the same or are they separate systems that have been integrated? | |
| 15 | Describe the quality control measures in place to ensure that peer reviews and preauthorization deadlines are tracked. | |
| 16 | What procedures do you have in place for reviewing medical and hospital bills involving catastrophic injuries such as burns, heart attacks, brain injuries, amputations, etc.? For the amount billed, length of hospital stay, or complexity. | ATTACH TO PROPOSAL |
| 17 | Provide an exhibit of the number of specialties available to conduct peer review and RME services and the physician fees. | ATTACH TO PROPOSAL |
| 18 | What type of communications will the injured employee receive from the PBM prior to and after a prescription has been filled? |
Tab 7
| 504 PHYSICIAN PANEL AND EXTENDED SERVICES ALLOCATED EXPENSES | ||||||
| ALL PROPOSERS MUST COMPLETE THIS TAB SHOWING CLAIM FILE CHARGES. THE "COA SERVICE ESTIMATE" COLUMN HAS BEEN PROVIDED FOR COA EVALUATORS TO INDICATE ESTIMATED WORK LOAD FOR TOTAL COSTS. | ||||||
| IF YOUR FIRM CHARGES HOURLY; SHOW THE HOURLY CHARGES ONLY; A TOTAL BY CONTRACT YEAR DOES NOT HAVE TO BE COMPLETED. | ||||||
| ALL CLAIM FILE CHARGES EXCEPT LEGAL FEES ESTABLISHED BY DWC ARE REQUIRED TO BE SHOWN IN THIS CHART. | ||||||
| TYPE OF ALLOCATED CHARGE | ANNUAL ALLOCATED ESTIMATED EXTENDED SERVICE CLAIM FILE CHARGES BASED ON COA ESTIMATE IN COLUMN B | |||||
| MEDICAL COST CONTAINMENT | COA SERVICE ESTIMATE | CONTRACT YR 2025 | CONTRACT YR 2026 | CONTRACT YR 2027 | CONTRACT YR 2028 | CONTRACT YR 2029 |
| USE THE BLANK ROWS DIRECTLY BELOW IN THE CHART TO INDICATE ALL 504 PHYSICIAN PANEL CHARGES THAT WILL BE CHARGED DIRECTLY TO THE CLAIM; INDICATE WHAT THESE CHARGES ARE AND WHAT THEY ARE BASED UPON. EXAMPLE: 'ACCESS FEE PER MEDICAL BILL BEYOND MANAGED CARE PROCESSING CHARGES $8'. EXAMPLE: 'ACCESS FEE PER CLAIM $50' |
| TPA CHARGES FOR MEDICAL COST CONTAINMENT | |
| Charges for auditing Medical Bills (CMS 1500) | 14,948 |
| Charges for auditing Duplicate Medical Bills | 93 |
| What is your formulary calculation on Pharmacy Bills | 3,253 |
| Charges for auditing Hospital Bills (UB-92) | 519 |
| Charges for auditing Reconsiderations | 1,002 |
| TPA CHARGES FOR UTILIZATION REVIEW SERVICES | |
| Fee per review for Pre-Authorizations (nurse only) | 1,637 |
| Fee per review for Pre-Authorizations (physician review) | 780 |
| Fee per review for Peer Review including coordination | 239 |
| Fee per coordination of Required Medical Exams (RME's) | 20 |
| Fee per coordination of DD requests | 100 |
| Fee per coordination of DD summaries | 5 |
| Fee per request for RUR's | 1 |
| Field Case Management (per hour or flat fee) | 10 |
| Vocational Rehab (per hour or flat fee) | 5 |
| EDI Medical Bills per submission | 18,942 |
PROPOSER FOOTNOTE SECTION
Tab 8
| Claims Administration - TCM,FCM, and VOC Rehab | ||
| All vendors must complete this section. | ||
| # | Certified Telephonic Case Management, Field Case Management, Surveillance and Vocational Rehab Services | Vendor Response |
| 1 | What legal entity will be providing Telephonic Case Management services as overflow to the 2 dedicated full time case managers required by this scope of work? | |
| 2 | What legal entity will be providing Field Case Management services as required in this scope of work? | |
| 3 | What legal entity will be providing Vocational Rehab Serivces as required in this scope of work? | |
| 4 | Verify you have read Scope of Work Section IV D. 1-8 CCM and agree to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 3 of this workbook. | |
| 5 | Verify you have read Scope of Work Section IV G. 1-5 FCM and Voc Rehab Services and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 3 of this workbook. | |
| 6 | For each separate legal entity identified in #'s 1-3 above, provide, in 2 pages or less, the firm's history, mission, organizational stability, dedicated resources, and experience in the implementation and management of the services they will be providing. | ATTACH TO PROPOSAL |
| 7 | For each separate legal entity idenfitied in #'s 1-3 above, provide the resumes/bios of key individuals that will be performing work for the City's account. | ATTACH TO PROPOSAL |
| 8 | What do you consider to be the average acceptable case load for telephonic case managers and who quality controls the level of caseloads that TCM's are handling? | |
| 9 | Verify that CCMs and FCM's will have access to Panel and other Guidelines and that these are interfaced into their daily software. | |
| 10 | Provide a sample FCM/VCR initial report and an intermim report and indicate the turnaround time for report receipt by the City. | ATTACH TO PROPOSAL |
Tab 9
| 504 Physician Panel and Claims Admin Services Not To Exceed Fee | |||||
| All vendors must complete this section. Failure to complete a Not To Exceed Fee shall result in the rejection of your proposal. | |||||
| All costs that are not directly charged to a claim file are required to be shown here and included in the Not to Exceed Fee. | |||||
| Use the blanks in the chart below to add any charges or fees that are not specifically listed. | |||||
| Any costs that are one-time charges should be shown in the accurate contract year and leave the other year's blank. | |||||
| SERVICE ITEM | CONTRACT YEAR 1 | CONTRACT YEAR 2 | CONTRACT YEAR 3 | CONTRACT YEAR 4 | CONTRACT YEAR 5 |
| Establish and maintain a 504 Physician Panel | |||||
| 504 Access Cost if Not Included in Tab 9 | |||||
| Credential Providers | |||||
| Contract Providers | |||||
| Create a Fee Schedule | |||||
| InformationSystem Fees to include Contract load and all TPA and DWC Electronic Interface | |||||
| Establish and maintain provider Website | |||||
| Create, distribute and revise a provider Handbook | |||||
| Notify and educate City employees | |||||
| Train City Staff |
TOTAL NOT TO EXCEED FEE
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