S000000390 Managed Care for Workers Compensation Q and A.pdf

QUESTION NUMBER QUESTION SUBJECT QUESTION TEXT ANSWER TEXT

1 General Who is the incumbent contractor?

USABLE with CompBR doing bill review, Systemedic, Inc. doing Nurse Case

Management and Precertification.

2 General Can you provide current pricing structure?

Bill Review per line with 3 line minimum. Percentage of savings PPO access fee.

Rate per hour nurse case management. Rate per hour specialized bill review. Peer

Review Fixed Dollar Rate per review with minimum # of pages. Precertification

Fixed rate per precert.

3 General Please define cooperative use?

Cooperative use means that once a contract has been awarded, any State public procurement unit may utilize the services of the contract by completing a

Participating Addendum agreement executed between the State agency and the

Contractor.

4 Minimum Qualifications

2.3.C - The State indicates that the Prospective Contractor SHALL be a certified

MCO by the AWCC Medical Cost Containment division. If the Contractor is not certified but intends to utilize subcontractors that are certified, does this meet the minimum requirement?

Utilizing subcontractors which are certified MCO's by the Arkansas Workers'

Compensation meets the minimum requirement.

Please see revised RFP Section 2.3.C.1.

5 Minimum Qualifications

2.3.C - In 2.3.C in the solicitation it mentioins that the bidder "shall be a certified

MCO by the AWCC." While we are not technically an MCO, we operate as one as we have direct partnerships for UR, Nurse Case Management, Peer Review, and many other services. We perform the rest of the services requested by this bid ourselves. Is this certification requirement immediately exclusionary?

The Contractor or a Subcontractor must be an MCO certified by the Arkansas

Workers' Compensation Commission.

6 PPO

Would the Division be willing to release a data file containing their provider billed charges for 2024 so that a retrospective PPO cost savings analysis can be performed and submitted with our response?

No. We will provide the summary data requested in question 8.

7 PPO

2.5. What networks do you use today? What is your current network stacking by state?

We currently use the USABLE True Blue network for Arkansas. We do not have additional PPO networks in place.

S000000390 Managed Care for Workers' Compensation Q&A

To accurately assess and aim to meet your goals, we would like to conduct a thorough analysis of your existing program. We kindly request the following information from you:

Option 1: Detailed data: Line Level or Bill Level (for the most recent 12 months).

Line-Level Detail Fields

Bill ID Duplicate Flag

PPO Network Reconsideration

Client Charges

Claim ID Allowance

Provider Number Bill Review Reductions

Provider Name PPO Reductions

Jurisdiction Other Reductions

Bill Type TIN (Tax Identification Number)

Option 2 Summary Data:

Alternative Data Request (if detailed data is unavailable). If the above level of detail cannot be provided, please share the following, for the last three years:

a) Number of bills processed per month/year

b) Total charges and total payments (excluding duplicate bills)

c) Breakdown of savings by type:

d) Fee schedule savings

e) PPO savings

f) Specialty review savings (e.g., nurse review, enhanced bill review, hospital bill review)

Please exclude duplicates, denials, Rx, and non-medical bills from the summary data provided.

Please provide this information categorized by:

1) Jurisdiction

2) Product type (Workers' Compensation/Auto)

8 Medical Bill Review/PPO

Option 2: Arkansas Jurisdiction. Workers' Compensation Only, Amounts are by Fiscal Year FY2024: a. Total

Bills Reviewed: 13,997, b. Total Charges: $15,068,684.11 Total Payments:

$5,213,577.46, d. Bill Review Savings: $3,287,562.33. e: PPO Savings:

$4,149,583.06, f: Supplemental UR Savings: $1,613,265.11.

FY2023: a. Total Bills Reviewed: 13,291, b. Total Charges: $15,978,994.36

Total Payments: $5,348,852.97, d. Bill Review Savings: $4,645,817.04 e: PPO Savings: $4,537,365.83, f: Supplemental UR Savings: $1,446,958.52

FY2022: a. Total Bills Reviewed: 11,754, b. Total Charges: $13,664,588.17

Total Payments: $4,780,787.12, d. Bill Review Savings: $3,742,072.60

e. PPO Savings: $3,831,674.89, f. Supplemental UR Savings: $1,310,053.56

9 Medical BIll Review Are you using any other companies for out-of-network negotiations? Very rarely.

10 Medical BIll Review Would the $15,000 cap apply to out-of-network negotiations on bills?

No.

Please see revised RFP Section 2.6.N, 2.15.G.

Please also see revised Official Price Sheet Table 4.

11 Medical BIll Review

For air ambulance, would the State be comfortable with us recommending reduced payments as long as the state is not exposed to paying any amount beyond the original billed amount in provider disputes?

Recommendations are acceptable. Our current policy is we pay no more than 3 x

Medicare Fee Schedule. This is currently in litigation before an Administrative Law

Judge at the Arkansas Workers' Compensation Commission. The final outcome of the litigation may affect the Division's policy.

12 Medical BIll Review The RFP only references us sending the State a payment recommendation file (with bills and images). What additional data files are exchanged in the current program?

We currently send eligibility files and updates with the basic claim information and whether we have accepted or denied the claim.

13 Medical BIll Review

a) Who is your current Medical Bill Review vendor?

b) What do you like the most about your current workflow/vendor?

c) Are there any pain points with the current workflow or bill review vendor?

a) CompBR.

b) Integration with our claims administration software - FileHandler by JW

Software.

c) Yes. Switchover of bill review vendor occurred on 8/1/2024. Vendor was way behind on processing bills/EOB's for months. They are finally catching up this month. Numerous mistakes of placing the EOB on the wrong claim or claimant.

Utilization review has not up to standard on some bills.

14 Medical Bill Review Please provide your current bill review workflow.

Paper bills are received in the Division. Division personnel date stamp the bills and place them in courier package. Courier picks up bills and takes them to CompBR office where they are imaged and processed. The Division receives the two separate electronic image files for each of the bills. One file contains just the

EOB's. The other image files contains the EOB, original bill, and attached medical records. These files are electronically uploaded into the FileHandler claims administration system. At the same time a corresponding data file is received in the

FileHandler system. Division administrative personnel review the images and data and make sure we have a good vendor number for processing the payment in the

Arkansas Administrative Statewide Information System (AASIS), selects the benefit type and posts the payment in the FileHandler system. The WCC Claims

Specialist or Analyst handling the claim reviews and approves or denies the payment in the FileHandler system. Every afternoon, the payment file is sent to

AASIS by SFTP. AASIS processes the payment overnight. We receive the state warrants and match them to paper copies of EOB's, place them in window envelopes and mail them to the medical provider.

We are in the process of transitioning to ACH payments.

15 Medical Bill Review

a) Besides the current contract coming to an end, are there any other business reasons for the bill review to be put out for bid?

b) Can you provide current pricing?

a) No.

b) This information is not necessary to respond to the RFP.

To accurately assess and aim to meet your goals, we would like to conduct a thorough analysis of your existing program. We kindly request the following information from you:

Option 1: Detailed data: Line Level or Bill Level (for the most recent 12 months).

Line-Level Detail Fields

Bill ID Duplicate Flag

PPO Network Reconsideration

Client Charges

Claim ID Allowance

Provider Number Bill Review Reductions

Provider Name PPO Reductions

Jurisdiction Other Reductions

Bill Type TIN (Tax Identification Number)

Option 2 Summary Data:

Alternative Data Request (if detailed data is unavailable). If the above level of detail cannot be provided, please share the following, for the last three years:

a) Number of bills processed per month/year

b) Total charges and total payments (excluding duplicate bills)

c) Breakdown of savings by type:

d) Fee schedule savings

e) PPO savings

f) Specialty review savings (e.g., nurse review, enhanced bill review, hospital bill review)

Please exclude duplicates, denials, Rx, and non-medical bills from the summary data provided.

Please provide this information categorized by:

1) Jurisdiction

2) Product type (Workers' Compensation/Auto)

8 Medical Bill Review/PPO

Option 2: Arkansas Jurisdiction. Workers' Compensation Only, Amounts are by Fiscal Year FY2024: a. Total

Bills Reviewed: 13,997, b. Total Charges: $15,068,684.11 Total Payments:

$5,213,577.46, d. Bill Review Savings: $3,287,562.33. e: PPO Savings:

$4,149,583.06, f: Supplemental UR Savings: $1,613,265.11.

FY2023: a. Total Bills Reviewed: 13,291, b. Total Charges: $15,978,994.36

Total Payments: $5,348,852.97, d. Bill Review Savings: $4,645,817.04 e: PPO Savings: $4,537,365.83, f: Supplemental UR Savings: $1,446,958.52

FY2022: a. Total Bills Reviewed: 11,754, b. Total Charges: $13,664,588.17

Total Payments: $4,780,787.12, d. Bill Review Savings: $3,742,072.60

e. PPO Savings: $3,831,674.89, f. Supplemental UR Savings: $1,310,053.56

16 Medical BIll Review

Do Adjusters approve the front end or back end of your bill review process today?

Do you currently have, or do you allow straight-through processing without manual intervention? Would you consider this functionality to lessen the number of bills your

Adjusters must review?

The Division's WC Claims Specialists and Analysts review the bills at the back end of the process. We do not currently allow straight-through processing. We are willing to consider straight-through processing in line with treatment guidelines with a cap on the amount of the bill. If a bill exceeds a certain amount we would have to require manual review by our staff.

17 Medical BIll Review Please define if it is disputes or reconsiderations that need a response in 5 days?

Reconsiderations. Disputes may take longer.

Please see revised RFP Section 2.6.K.1.

18 Medical BIll Review The vendor still has 30 days to process the reconsideration/dispute correct?

Yes.

Please see revised RFP Section 2.6.K.1.

19 Pre-Certification Please give a definition for Pre- Certification.

Pre-certification is Pre-authorization for nonemergency hospitalizations, transfers between facilities and outpatient services exceeding $1,000 in billed charges for a single date of service by a provider which are referred to the Contractor by the

Division for utilization review. These services are to be provided in compliance with

Arkansas Workers' Compensation Commission Rule 30 Part 1, S.

Preauthorization.

20 Pre-Certification

Section 2.7 PRE-CERTIFICATION OF HOSPITALIZATION / MEDICAL SERVICES

Item C states: The Contractor shall invoice, via EDI, all pre-hospitalization certification charges to the Division within thirty (30) days of services being provided.

Please confirm this requirement is seeking the invoice for the Contractor's Utilization

Review of the pre-hospitalization service within 30 days of the UR determination.

Yes. Within 30 days of the UR determination.

21 Pre-Certification Would the state provide volume and spend over the past three years?

Here is the spend data for the last two and 1/2 years. For the first 6 months of

FY2025 (July 1, 2024 - December 31, 2024) $18,109.68. In FY2024 (July 1, 2023 -

June 30, 2024) $36,293.84; In FY2023 (July 1, 2022 - June 30, 2023) $39,953.58.

22 UR/Peer Review Can the State provide referral utilization review volumes for FY 2024? Preferably this would be split by pre-authorization and retrospective reviews.

For the 1st half of the current fiscal year (FY2025 - July - December, 2024) we have spent $18,109.68 for Preauthorization.

23 UR/Peer Review How are utilization review referrals made to the current vendor? How are decisions communicated out? Can the state provide a workflow overview as reference?

The review referrals are usually by E-Mail over TLS encryption. Decisions are provided by the Contractor's form. The Division is open to utilizing other methodolgies.

24 UR/Peer Review Can the state provide peer review volumes for FY 2024? For FY2024, we had 58 cases for peer review.

25 UR/Peer Review Are there any specific thresholds/scenarios for which the state requires a peer review? Can the State provide a workflow overview as reference?

There are no specific thresholds. These are usually done in situations where a service does not meet Pre-Certification/Preauthorization (Section S, Part I, Arkansas Workers' Compensation Commission Rule 30). Sometimes, it is decided to seek an Independent Medical Evaluation instead of going through peer review. This is by judgment of the WCC Claims Specialist or Analyst.

Medical Case

Management Please define Medical Case Management, does it include TCM and FCM.

Yes. Medical Case Management includes both Telephonic Case Management

(TCM) and Field Case Management (FCM).

Please see revised Official Price Sheet Table 4.

Medical Case

Management

If TCM is included in Medical Case Management, what percentage of cases fall in

TCM and what percent fall under FCM?

Currently, all of our open case management cases fall under Field Case

Management (FCM), but in effect approximately 15% are telephonic.

Medical Case

Management

Can the state provide case management volumes for FY 2024? What is the current open case count? Please clarify referral volume and open cases by type; either FCM or TCM.

The current number of case management cases open is 181. All are listed as field although approximately 15% are really telephonic. For the first half of the current fiscal year FY2025 (July - December, 2024) we have spent $257,897.76 for case management. In FY2024 (July 1, 2023 - June 30, 2024), we referred 191 claims for case management. $528,685.50 in expenditures for case management. We have been paying same rate for telephonic and field.

Medical Case

Management What are the criteria/triggers for a case management referral from the Division?

This is done on a case-by-case basis. This is a decision based on the judgment of the Insurance Program Manager, WCC Claims Specialists and Analysts.

Catastrophic claims are almost always assigned a nurse case manager.

Medical Case

Management

How are referrals made to the current vendor? Can the State provide a workflow overview as reference?

The WCC Claims Specialist or Analyst sends an E-Mail or calls the Contractor requesting a medical case manager be assigned.

Medical Case

Management

Does the State have required templates for initial case, progress, and closure updates from the case manager to the Division?

No.

Medical Case

Management

For catastrophic claims, can the State provide additional information on the current process?

The WCC Claims Specialist or Analyst sends an E-Mail or calls the contractor requesting a medical case manager be assigned.

Medical Case

Management

Does the Division want to receive pricing proposals for both telephonic and Field case management services? If so, can separate fields be added to the pricing template so both can be quoted as the pricing differs.

Yes.

Please see revised Official Price Sheet Table 4.

Medical Case

Management What is the annual number of referrals you make for Medical Case Management? FY2024: 191; FY2023: 201; FY2022: 246

Medical Case

Management

What portion of the current open case count (1,621 claims) have a date of injury on or before 7/1/1994?

4.9%

Medical Case

Management

Industry standard for hourly billing is to bill in tenths of an hour or 6 minute increments. Would the state be willing to allow us to maintain the 6-minute increment structure rather than the 10-minute increments in the RFP? Not only will this assist us in implementing this program more efficiently if selected, but will also be an added cost savings option for the State. For instance, instead of rounding up to 10 minutes if the actual time spent is 6 minutes, a 6 minute activity would be billed at a .1 (6 minute increment at a lower dollar amount and not rounded up to a more costly 10 minute increment as currently defined by the State's RFP.

Yes.

Please see revised RFP Section 2.15.

Medical Case

Management

Would the state provide the number of referrals by referral type, over the past three years?

FY2025 (1st 1/2) 127 (FCM); FY2024: 248 (FCM); FY2023: 271 (FCM)

Medical Case

Management

Would the state provide the number of claims currently open to case management by referral type?

181 Field Case Management (FCM) open.

Medical Case

Management

Would the state provide the case management spend for the past three years by referral type?

FY2025 (1st 1/2 of current fiscal year): $257,987.76; FY2024: $528,684.50;

FY2023: $464,358.93. Same rate so FCM and TCM are not differentiated.

Medical Case

Management

Would the state provide the current case management companies being utilized on panel?

The state has recently utilized service from the following case management companies: Systemedic, JMS Consulting, Genex, Corvel.

Medical Case

Management Would the state provide the geographic locations of open cases? Yes. Over 90% are in Arkansas.

42 Invoicing Section 2.15.E - Please give a definition for Utilization Review (beyond normal Bill

Review)?

Utilization Review is set out in Part IV of Arkansas Workers' Compensation

Commission Rule 30. For a definition, please see Part IV. B Carrier's Utilization

Review Program.

43 Data Security

Would you consider allowing offshore data entry and similar functions under the following conditions:

i. All data is stored securely within the United States.

ii. Access to the data is provided only through a secure, controlled environment.

iii. The infrastructure used is fully compliant with cybersecurity standards.

iv. Data never leaves onshore data centers.

v. Our security team thoroughly vets and continuously checks access controls, which are strictly managed by our operations teams.

No.

44 Medical Pass Thru Do you make the payments to providers, or would we (the vendor) do that? Do you utilize check payment processing today, and how is that handled (in-house, vendor)?

Payment processing is currently handled by the Division. Please see answer to

Question 14.

45 Medical Pass Thru

If you would like us to make your payments, we need the following information:

Please send separate data files for Medical

i. 12 Months of Payments

ii. Tax ID

iii. Total $ Paid to Tax ID

iv. Total Number of Payments to Tax ID

v. Current Payment Modality by Tax ID (EFT, VCC, or Check)

Almost all payments are currently by Check. There are a few by ACH. We can send report of payments by Payee Name and Vendor # for all medical and hospital payments.

46 Medical Pass Thru

Section 2.17. Could you define and elaborate on the term "Medical Pass-Through

Option" and how we would get the payment information and does it apply only to

Medical Providers.

The "Medical Pass-Through Option" would be having the contractor pay the medical providers. For this contract it would only be for medical providers. We are open to negotiating the exact methodology as long as we were able to maintain an audit trail showing that Division personnel approved the payment or that the payment followed guidelines for payments not exceeding a set amount and we are able to have that information imported into our claims administration system.

47 Medical Pass Thru Could you provide some additional information on your Medical Pass-Thourgh option? Where does that selection happen? Can you give any examples?

If the cost of the program is not excessive, the Contractor would pay the vast majority of the medical providers after receiving approval of the bill/EOB and payment from the Division. We do not currently utilize this service.

48 Medical Pass Thru Section 2.17. Do you currently contract with a Payment Vendor(s)? If yes, who?

We do not currently contract with a payment vendor and make all payments through the State's AASIS system.

49 Medical Pass Thru

We have existing payment terms negotiated with many of our medical pass through providers. If the existing terms of payment exceed 5 business days, may we comply with the existing terms instead of the State's 5 day timeframe? If so, please confirm we would not be subject to the "late payment" penalty referred to in Section 2.17.C.

If the Contractor has agreements with payees allowing a longer time to pay which remove the risk of the Division being assessed late payment penalties then the five

(5) day 'late payment penalty provision' will not apply. If the five (5) day time frame is not met and a dispute arises between the Contractor and a payee and a late payment penalty is assessed, the Contractor will be responsible for payment of the late payment penalty assessed by the Arkansas Workers' Compensation

Commission.

Please see revised RFP Section 2.17.C.

50 Medical Pass Thru Please define what these pass through payments could be.

These would be the payment amounts owed to medical providers typically according to the EOB's.

51 Medical Pass Thru Where do these pass through payments come from? The payments would typically come from the EOB's.

52 Medical Pass Thru Are these electronic or manual input?

The Division is open to negotiations regarding the exact methodology. The process envisioned is the Division's personnel would review and approve the

EOB's. Once a week or so, the Division would total all of the amount of the EOB's approved and send a file listing all of the approved EOB's and a payment to the

Contractor in the amount of the total owed for those EOB's and the Contractor would send the payments to the medical providers.

53 Performance Standards

Section 2.19. We have standard KPIs/SLAs. Would you consider using these instead of the stated Performance Standards in the RFP? (We can provide upon request.)

We are open to negotiations regarding performance standards.

54 Pricing What is your current contracted pricing by product This information is not necessary to respond to the RFP.

55 Pricing Please define virtual Card payments

Virtual credit cards are digital credit cards that function like physical credit cards, but without the plastic. This allows companies to limit their exposure to potential fraud by generating different 16-digit card numbers and expiration dates for each transaction.

56 Pricing Peer Review has a flat rate and a rate for each additional page. Please clarify the quantity of 200 for additional pages.

200 pages refers to the number of medical record pages sent to the Peer Review provider.