HomeMy WebLinkAbout2012-09-11; City Council; 20997; Contract Administration Workers' CompensationCITY OF CARLSBAD - AGENDA BILL
AB# 20.997 CONTRACT FOR THIRD PARTY
ADMINISTRATION OF WORKERS'
COMPENSATION CLAIMS
DEPT. HEAD ^^SJT^
MTG. 9/11/12
CONTRACT FOR THIRD PARTY
ADMINISTRATION OF WORKERS'
COMPENSATION CLAIMS CITYATTY. /^^^
CITY MGR. DEPT. HR
CONTRACT FOR THIRD PARTY
ADMINISTRATION OF WORKERS'
COMPENSATION CLAIMS CITYATTY. /^^^
CITY MGR.
RECOMMENDED ACTION:
Adopt Resolufion No.2012-214Awarding a contract forthe third party administration of workers'
compensations claims to Keenan & Associates.
ITEM EXPLANATION:
The current provisional contract with TRISTAR Risk Management, administrator of the City's workers'
compensation claims will expire on September 30, 2012.
Staff distributed a request for proposal for workers' compensation benefits administration on April 3,
2012, and subsequently received responses from ten (10) firms. The proposals were evaluated based
on quality of the proposals, cost, experience, staff qualifications and level of services available. Four (4)
firms were selected to interview. The four firms were evaluated based on cost, experience with a full
service city, ability to retain staff and quick response time to determine best value and level of service
available.
Based on the results of the evaluation process, staff is recommending that Council approve the
agreement with Keenan & Associates as shown in Exhibit 2. The proposed agreement contains a
proposed fee of $125,000 for claims administration in the first year. This is an increase from $117,214
with the previous claims administrator.
FISCAL IMPACT:
The administrative fee will increase by two percent (2%) per year in Fiscal Years 2013-14 and 2014-15
and will be $127,500 and $130,050, respectively. If the contract is extended for Fiscal Years 2015-16
(contract year 4) and 2016-17 (contract year 5) the administrative fee will be $132,651 and $135,304
respectively.
A complete scope of services is included in Attachment A. A fee schedule for ancillary services is
included in Attachment B.
Sufficient funds have been included in the Fiscal Year 2012-13 budget for the fees described above.
Future fiscal year impacts will be reflected during the annual budget process.
DEPARTMENT CONTACT: Cheri Abbott 760-602-2496 Cheri.Abbott@Carisbadca.gov
FOR CITY CLERKS USE ONLY. T7~ COUNCIL ACTION: APPROVED X CONTINUED TO DATE SPECIFIC •
DENIED CONTINUED TO DATE UNKNOWN •
CONTINUED • RETURNED TO STAFF •
WITHDRAWN • OTHER - SEE MINUTES •
AMENDED •
Page 2
ENVIRONMENTAL IMPACT:
The proposed action does not qualify as a "project" under the California Environmental Quality
Act (CEQA) per State CEQA Guidelines Section 15378 as it does not result in a direct or
reasonably foreseeable indirect physical change in the environment.
EXHIBITS:
1. Resolution No. 2012-214
2. Agreement with Keenan & Associates
1 RESOLUTION NO. 2012-214
2 A RESOLUTION OF THE CITY COUNCIL OF THE CITY
OF CARLSBAD. CALIFORNIA, AUTHORIZING AWARD
^ OF CONTRACT TO KEENAN & ASSOCIATES.
WHEREAS, the City Council has determined that the City requires professional
services of a third party administrator that is experienced in managing and administering
the City's workers' compensation claims.
NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of
^ Carisbad. California, as follows:
10 1. That the above recitations are true and correct.
11 2. That the City Council approves the attached Agreement (Exhibit 2) awarding
12 the contract to Keenan & Associates to provide third party administration of
workers' compensafion claims.
3. That the City Council authorizes the mayor to sign the contract on behalf of
the City.
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PASSED, APPROVED AND ADOPTED at a Regular Meeting ofthe City Council
of the City of Carisbad on the 11th day of September 2012, by the following vote to wit:
AYES:
NOES:
Council Members Hall, Kulchin, Blackburn, Douglas and Packard.
None.
ABSENT: None.
MATT HALL, Mayor
ATTEST:
J
LORRAINE M. WOOD, City Clerk
(SEAL)
AGREEMENT FOR THIRD PARTY ADMINISTRATIVE SERVICES
KEENAN & ASSOCIATES
^HIS AGREEMENT is made and entered into as of the //^ clay of
j> jJ'j> ^ ^lyJ 20/<A , by and between the CITY OF CARLSBAD, a municipal
cor^ratioh, ("City"), and KEENAN & ASSOCIATES, ("Contractor").
RECITALS
A. City requires the professional services of a third party administrator that is
experienced in worker's compensafion claims administrafion.
B. Contractor has the necessary experience in providing professional services and
advice related to worker's compensation administration.
C. Contractor has submitted a proposal to City and has affirmed its willingness and
ability to perform such work.
NOW, THEREFORE, in considerafion of these recitals and the mutual covenants
contained herein, City and Contractor agree as follows:
1. SCOPE OF WORK
City retains Contractor to perform, and Contractor agrees to render, those services (the
"Services") that are defined in attached Exhibit "A", which is incorporated by this reference in
accordance with this Agreement's terms and condifions.
2. STANDARD OF PERFORMANCE
While performing the Services, Contractor will exercise the reasonable professional care and
skill customarily exercised by reputable members of Contractor's profession practicing in the
Metropolitan Southern California Area, and will use reasonable diligence and best judgment
while exercising its professional skill and expertise.
3 TERM
The term of this Agreement will be effective for a period of three years (3) from the date first
above written The City Manager may amend the Agreement to extend it for two additional one
year periods or parts thereof in an amount not to exceed the compensation schedule as listed
below in Section 6. Extensions will be based upon a satisfactory review of Contractor's
performance, City needs, and appropriation of funds by the City Council. The parties will
prepare a written amendment indicating the effective date and length of the extended
Agreement.
4. TIME IS OF THE ESSENCE
Time is of the essence for each and every provision of this Agreement.
5. COMPENSATION
The total fee payable for the Services to be performed during the initial Agreement term will be
Year One (1) $125,000
Year Two (2) $127,500
Year Three (3) $130,050
and if an amendment is executed to extend this Agreement:
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Year Four (4) $132,651
Year Five (5) $135,304
This fee covers handling of all new and continuing indemnity files, and all medical only files for
the stated period of the Agreement.
Additional costs related to safety audit and safety/loss control services are outlined in the
attached Exhibit "B".
No other compensation for the Services will be allowed except for items covered by subsequent
amendments to this Agreement. The City reserves the right to withhold a ten percent (10%)
retention until City has accepted the work and/or Services specified in Exhibit "A".
Incremental payments, if applicable, should be made as outlined in attached Exhibit "A".
6. STATUS OF CONTRACTOR
Contractor will perform the Services in Contractor's own way as an independent contractor and
in pursuit of Contractor's independent calling, and not as an employee of City. Contractor will be
under control of City only as to the result to be accomplished, but will consult with City as
necessary. The persons used by Contractor to provide services under this Agreement will not
be considered employees of City for any purposes.
The payment made to Contractor pursuant to the Agreement will be the full and complete
compensafion to which Contractor is entitled. City will not make any federal or state tax
withholdings on behalf of Contractor or its agents, employees or subcontractors. City will not be
required to pay any workers' compensation insurance or unemployment contributions on behalf
of Contractor or its employees or subcontractors. Contractor agrees to indemnify City within
thirty (30) days for any tax, retirement contribution, social security, overtime payment,
unemployment payment or workers' compensation payment which City may be required to
make on behalf of Contractor or any agent, employee, or subcontractor of Contractor for work
done under this Agreement. At the City's election, City may deduct the indemnificafion amount
from any balance owing to Contractor.
7. SUBCONTRACTING
Contractor will not subcontract any portion of the Services without prior written approval of City.
If Contractor subcontracts any of the Services, Contractor will be fully responsible to City for the
acts and omissions of Contractor's subcontractor and of the persons either directly or indirectly
employed by the subcontractor, as Contractor is for the acts and omissions of persons directly
employed by Contractor. Nothing contained in this Agreement will create any contractual
relationship between any subcontractor of Contractor and City. Contractor will be responsible for
payment of subcontractors. Contractor will bind every subcontractor and every subcontractor of
a subcontractor by the terms of this Agreement applicable to Contractor's work unless
specifically noted to the contrary in the subcontract and approved in writing by City.
8. OTHER CONTRACTORS
The City reserves the right to employ other Contractors in connection with the Services.
9. INDEMNIFICATION
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Contractor agrees to indemnify and hold harmless the City and its officers, officials, employees
and volunteers from and against all claims, damages, losses and expenses including attorneys'
fees arising out of the performance of the work described herein caused by any negligence,
recklessness, or willful misconduct of the Contractor, any subcontractor, anyone directly or
indirectly employed by any of them or anyone for whose acts any of them may be liable.
The parties expressly agree that any payment, attorney's fee, costs or expense City incurs or
makes to or on behalf of an injured employee under the City's self-administered workers'
compensafion is included as a loss, expense or cost for the purposes of this secfion, and that
this section will survive the expirafion or early terminafion of this Agreement.
10. INSURANCE
Contractor will obtain and maintain for the duration of the Agreement and any and all
amendments, insurance against claims for injuries to persons or damage to property which may
arise out of or in connection with performance of the services by Contractor or Contractor's
agents, representatives, employees or subcontractors. The insurance will be obtained from an
insurarice carrier admitted and authorized to do business in the State of California.^ The
insurance carrier is required to have a current Best's Key Rating of not less than "A-:VH". OR
with a surplus line insurer on the State of California's List of Eligible Surplus Line Insurers
(LESLI) with a rafing in the latest Best's Key Rating Guide of at least "A:X".
10.1 Coverages and Limits.
Contractor will maintain the types of coverage and minimum limits indicated below, unless Risk
Manager or City Manager approves a lower amount. These minimum amounts of coverage will
not constitute any limitations or cap on Contractor's indemnification obligafions under this
Agreement. City, its officers, agents and employees make no representation that the limits of
the insurance specified to be carried by Contractor pursuant to this Agreement are adequate to
protect Contractor. If Contractor believes that any required insurance coverage is inadequate,
Contractor will obtain such additional insurance coverage, as Contractor deems adequate, at
Contractor's sole expense.
10.1.1 Commercial General Liabilitv Insurance. $1.000.000 combined single-limit
per occurrence for bodily injury, personal injury and property damage. If the submitted policies
contain aggregate limits, general aggregate limits will apply separately to the work under this
Agreement or the general aggregate will be twice the required per occurrence limit.
10.1.2 Automobile Liabilitv (if the use of an automobile is involved for
Contractor's work for City). $1,000,000 combined single-limit per accident for bodily injury and
property damage.
10.1.3 Workers' Compensation and Emplover's Liabilitv. Wori^ers' Compensation
limits as required by the California Labor Code. Workers' Compensation will not be required if
Contractor has no employees and provides, to City's satisfaction, a declaration stating this.
10.1.4 Professional Liabilitv. Errors and omissions liability appropriate to
Contractor's profession with limits of not less than $1,000,000 per claim. Coverage must be
maintained for a period of five years following the date of completion of the work.
Q If box is checked, Professional Liability
City's Initials Contractor's Initials Insurance requirement is waived.
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10.2. Additional Provisions. Contractor will ensure that the policies of insurance required under
this Agreement contain, or are endorsed to contain, the following provisions:
10.2.1 The City will be named as an addifional insured on Commercial General
Liability which shall provide primary coverage to the City.
10.2.2 Contractor will obtain occurrence coverage, excluding Professional
Liability, which will be written as claims-made coverage.
10.2.3 Should any of the above described policies be cancelled before the
expiration date thereof, notice will be delivered to the City in accordance with policy provisions
of the insurer providing notice to the insured.
10.3 Providing Certificates of Insurance and Endorsements. Prior to City's execufion of this
Agreement, Contractor will furnish certificates of insurance and endorsements to City.
10.4 Failure to Maintain Coverage. If Contractor fails to maintain any of these insurance
coverages, then City will have the option to declare Contractor in breach, or may purchase
replacement insurance or pay the premiums that are due on existing policies in order to
maintain the required coverages. Contractor is responsible for any payments made by City to
obtain or maintain insurance and City may collect these payments from Contractor or deduct the
amount paid from any sums due Contractor under this Agreement.
10.5 Submission of Insurance Policies. Citv reserves the right to require, at anytime, complete
and certified copies of any or all required insurance policies and endorsements.
11. BUSINESS LICENSE
Contractor will obtain and maintain a City of Carisbad Business License for the term of the
Agreement, as may be amended from fime-to-fime.
12. ACCOUNTING RECORDS
Contractor will maintain complete and accurate records with respect to costs incurred under this
Agreement. All records will be cleariy identifiable. Contractor will allow a representative of City
during normal business hours to examine, audit, and make transcripts or copies of records and
any other documents created pursuant to this Agreement. Contractor will allow inspection of all
work, data, documents, proceedings, and activities related to the Agreement for a period of
three (3) years from the date of final payment under this Agreement.
13. OWNERSHIP OF DOCUMENTS
All work product produced by Contractor or its agents, employees, and subcontractors pursuant
to this Agreement is the property of City. In the event this Agreement is terminated, all work
product produced by Contractor or its agents, employees and subcontractors pursuant to this
Agreement will be delivered at once to City. Contractor will have the right to make one (1) copy
of the work product for Contractor's records.
14. COPYRIGHTS
Contractor agrees that all copyrights that arise from the services will be vested in City and
Contractor relinquishes all claims to the copyrights in favor of City.
15. NOTICES
The name of the persons v^ho are authorized to give written notices or to receive written notice
on behalf of City and on behalf of Contractor under this Agreement.
City Attorney Approved Version 2/17/12
For City For Contractor
Name Cheri Abbott Name John Stephens
Title Human Resources Manager Title Senior Vice President
Department Human Resources Address 901 Caile Amanecer. Suite 200
City of Carisbad San Clemente, CA 92673
Address 1635 Faraday Ave. Phone No. 949.940.1760 ^
Carlsbad. CA 92008 Email istephens@keenan.com
Phone No. 760 602 2496
Each party will notify the other immediately of any changes of address that would require any
notice or delivery to be directed to another address.
16. CONFLICT OF INTEREST
Contractor shall file a Confiict of Interest Statement with the City Clerk in accordance with the
requirements of the City of Carlsbad Confiict of Interest Code. The Contractor shall report
investments or interests in all four categories.
17. GENERAL COMPLIANCE WITH LAWS
Contractor will keep fully informed of federal, state and local laws and ordinances and
regulations which in any manner affect those employed by Contractor, or in any way affect the
performance of the Services by Contractor. Contractor will at all times observe and comply with
these laws, ordinances, and regulations and will be responsible for the compliance of
Contractor's services with all applicable laws, ordinances and regulafions.
Contractor will be aware of the requirements ofthe Immigration Reform and Control Act of 1986
and will comply with those requirements, including, but not limited to, verifying the eligibility for
employment of all agents, employees, subcontractors and consultants whose services are
required by this Agreement.
18. DISCRIMINATION AND HARASSMENT PROHIBITED
Contractor will comply with all applicable local, state and federal laws and regulafions prohibifing
discrimination and harassment.
19. DISPUTE RESOLUTION
If a dispute should arise regarding the performance of the Services the following procedure will
be used to resolve any questions of fact or interpretation not otherwise settled by agreement
between the parties. Representatives of Contractor or City will reduce such questions, and their
respective views, to writing. A copy of such documented dispute will be fon/varded to both
parties involved along with recommended methods of resolution, which would be of benefit to
both parties. The representative receiving the letter will reply to the letter along with a
recommended method of resolufion within ten (10) business days. If the resolufion thus
obtained is unsatisfactory to the aggrieved party, a letter outlining the disputes will be fonA^arded
to the City Manager. The City Manager will consider the facts and solufions recommended by
each party and may then opt to direct a solution to the problem. In such cases, the action of the
City Manager will be binding upon the parties involved, although nothing in this procedure will
prohibit the parties from seeking remedies available to them at law.
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1
20. TERMINATION . o ^*
In the event of the Contractor's failure to prosecute, deliver, or perform the Services. C»ty may
terminate this Agreement for nonperformance by notifying Contractor by certified mail of the
termination If City decides to abandon or indefinitely postpone the work or services
contemplated by this Agreement, City may terminate this Agreement upon written riofice to
Contractor Upon notification of termination. Contractor has five (5) business days to deliver any
documents owned by City and all work in progress to City address contained in this Agreement.
City will make a determination of fact based upon the work product delivered to City and of the
percentage of work that Contractor has performed which is usable and of worth to City in having
the Agreement completed. Based upon that finding City will determine the final payment of the
Agreement.
Either party upon tendering thirty (30) days written notice to the other party may terminate this
Agreement In this event and upon request of City. Contractor will assemble the work product
and put it in order for proper filing and closing and deliver it to City. Contractor will be paid for
work performed to the terminafion date; however, the total will not exceed the lump sum fee
payable under this Agreement. City will make the final determinafion as to the portions of tasks
completed and the compensafion to be made.
21 COVENANTS AGAINST CONTINGENT FEES
Contractor warrants that Contractor has not employed or retained any company or person, other
than a bona fide employee working for Contractor, to solicit or secure this Agreement, and that
Contractor has not paid or agreed to pay any company or person, other than a bona fide
employee any fee. commission, percentage, brokerage fee, gift, or any other consideration
contingent upon, or resulfing from, the award or making of this Agreement. For breach or
violafion of this warranty, City will have the right to annul this Agreement without liability or in
its discretion, to deduct from the Agreement price or consideration, or otherwise recover, the full
amount ofthe fee, commission, percentage, brokerage fees, gift, or confingent fee.
22. CLAIMS AND LAWSUITS . ^ ^ * ^ *
Bv signing this Agreement, Contractor agrees that any Agreement claim submitted to City must
be asserted as part of the Agreement process as set forth in this Agreement and not in
anticipafion of litigation or in conjuncfion with lifigation. Contractor acknowledges that if a false
claim is submitted to City, it may be considered fraud and Contractor may be subject to criminal
prosecution Contractor acknowledges that California Government Code sections 12650 eLseg,.
the False Claims Act applies to this Agreement and, provides for civil penalties where a person
knowingly submits a false claim to a public entity. These provisions include false claims made
with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of
information If City seeks to recover penalfies pursuant to the False Claims Act. it is eritified to
recover its litigation costs, including attorney's fees. Contractor acknowledges that the filing of a
false claim may subject Contractor to an administrative debarment proceeding as the result of
which Contractor may be prevented to act as a Contractor on any public work or improvement
for a period of up to five (5) years. Contractor acknowledges debarment by another junsdiction
is grounds for City to terminate this Agreement.
23. JURISDICTIONS AND VENUE ...
Anv acfion at law or in equity brought by either of the parties for the purpose of enforcing a nght
or rights provided for by this Agreement will be tried in a court of competent jurisdiction in the
County of San Diego. State of Califomia, and the parties waive ail provisions of law providing for
a change of venue in these proceedings to any other county.
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24. SUCCESSORS AND ASSIGNS
It is mutually understood and agreed that this Agreement will be binding upon City and
Contractor and their respective successors. Neither this Agreement or any part of it nor any
monies due or to become due under it may be assigned by Contractor without the prior consent
of City, which shall not be unreasonably withheld.
25. ENTIRE AGREEMENT
This Agreement, together with any other written document referred to or contemplated by it,
along with the purchase order for this Agreement and its provisions, embody the entire
Agreement and understanding between the parties relating to the subject matter of it. In case of
conflict, the terms of the Agreement supersede the purchase order. Neither this Agreement nor
any of its provisions may be amended, modified, waived or discharged except in a writing
signed by both parties.
26. AUTHORITY
The individuals executing this Agreement and the instruments referenced in it on behalf of
Contractor each represent and warrant that they have the legal power, right and actual authority
to bind Contractor to the terms and conditions of this Agreement.
CONTRACTOR CITY OF CARLSBAD, a municipal
corporation of the State of California
(print name/title)
If required by City, proper notary's
attached. If a corporation. Agreement
following two groups.
Group A
Chaimian,
President, or
Vice-President
)RRAINE M. WOOD
City Clerk
knowledgment of execution by contractor must be
ust be signed by one corporate officer from each of the
Group B
Secretary,
Assistant Secretary,
CFO or Assistant Treasurer
Otherwise, the corporation must attach a resolution certified by the secretary or assistant
secretary under corporate seal empowering the officer(s) signing to bind the corporation.
City Attorney Approved Version 2/17/12
24. SUCCESSORS AND ASSIGNS
It is mutually understood and agreed that this Agreement will be binding upon City and
Contractor and their respecfive successors. Neither this Agreement or any part of it nor any
monies due or to become due under it may be assigned by Contractor without the prior consent
of City, which shall not be unreasonably withheld.
25. ENTIRE AGREEMENT
This Agreement, together with any other written document referred to or contemplated by it,
along with the purchase order for this Agreement and its provisions, embody the enfire
Agreement and understanding between the parties relating to the subject matter of it. In case of
conflict, the terms of the Agreement supersede the purchase order. Neither this Agreement nor
any of its provisions may be amended, modified, waived or discharged except in a writing
signed by both parties.
26. AUTHORITY
The individuals execufing this Agreement and the instruments referenced in it on behalf of
Contractor each represent and warrant that they have the legal power, right and actual authority
to bind Contractor to the terms and conditions of this Agreement.
CONTRACTOR CITY OF CARLSBAD, a municipal
corporation of the State of California
(print name/title)
[sign here)
(print name/title)
Mayor
ATTEST:
LORRAINE M. WOOD
City Clerk
If required by City, proper notary's acknowledgment of execution by contr^JtiDf i^ust.^^e
attached. If a corporation. Agreement must be signed by one corporate officer from ^^tJh'W the
following two groups.
Group A
Chairman,
President, or
Vice-President
Group B
Secretary.
Assistant Secretary,
CFO or Assistant Treasurer
Otherwise, the corporation must attach a resolution certified by the secretary or assistant
secretary under corporate seal empowering the officer(s) signing to bind the corporation.
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ACKNOWLEDGMENT
State of California
County of C3 K (
On me,
personally appeared
(insert name and title of the officer)
who proved to me on the basis of satisficiory evidence to be the person^whose nam^^erf is/afe-
subscribed to the within instrument and acknowledged to me that ho/eho/tlwy executed the same in
his/1 lei/ll iglT authorized capacity^teSTTand that by his/hcr/thpir signature(;8^on the instrument the
personjli^or the entity upon behalf of which the persoi>(^acted, executed the instrument.
1 certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature
^„ JMttRiOMfl
COMM. •1864256 2
NoHfyFuMic Caiifornia S
Us AngtiM County
(Seal)
2^
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of Orange _} ss.
On p^iA/V{/[A ^ before me, _
personally appeared pVu^
^"^(^ before me, James Pak Notary Public,
who proved to me on the basis of satisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies). and that by
his/her/their signatures(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
JAMES PAK P
Commission # 1843747 K
Notary Public - California 1
1 ^^''^il^^ Orange County g
A My Comm. Expires May 6.2013 L
(seal)
OPTIONAL INFORMATION
Date of Document
Type or Title of Document
Number of Pages in Document
Document in a Foreign Language
Capacity of Signer:
Corporate Officer - Title(s): \)^^^ YcU^^sS^
Partner - • Limited • General \
Attorney In Fact
Trustee
Guardian or Conservator
Other:
Thumbprint of Signer
Signer Is Representing:
APPROVED AS TO FORM:
RONALD R. BABb City Attorney
^Goiotont CityT^ttorney
City Attorney Approved Version 2/17/12
ATTACHMENT"A"
SCOPE OF SERVICES
EXAMINER CLAIM HANDLING GUIDE
Unrepresented Claims
• Claim reported to employer and set-up
Injured Worker has 30 days to report injury up to 1 year, othenA/ise assert statute of
limitation defense (L.C. Sections 5400 & 5405)
Employer must immediately authorize medical treatment once injury reported (L.C.
Section 4600)
Provide medical treatment, subject to Utilizafion Review (L.C. Sections 4600 & 4610)
Pay indemnity compensation in accordance with Bargaining Agreements and Labor
Code (LC. 4650 & 4850)
If medical treatment appears excessive or not medically necessary per Utilization
Review, issue 4062 objecfion and proceed with panel QME process. (L.C. Sections
4062 & 4062.1)
Once claimant is declared P&S by primary treafing physician with no permanent
disability and if in agreement with the P&S report proceed with closing file within 30-
45 days of P&S if there is no dispute raised by the claimant.
Once claimant is declared P&S and if there is undisputed permanent disability and or
future medical treatment, pay permanent disability and attempt to resolve claim
formally by way of Compromise and Release or Stipulated Award to toll the 5 year
statute of limitations. (L.C. Secfion 5410)
Once claimant is declared P&S and if there is a dispute over the level of permanent
disability, future medical treatment, apportionment, etc, proceed with the panel QME
process.
Once panel QME report has been received, pay any additional compensation due
and attempt to resolve claim by way of C&R or Sfipulated Award based on the QME
report or immediately file an applicafion with the WCAB to get matter on hearing
calendar (L.C. Section 4063). Note if proceeding with filing application, this is subject
to the paying applicant attorney's fees if claimant retains attorney. (L.C. Sections
4064)
If claimant fails to voluntarily sign C&R or Stipulated Award consider filing application
to get matter before l&A Officer or request trial in order to have Findings & Award
issued by the WCAB.
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Represented Cases
• Claim reported to employer and set-up
• Injured Worker has 30 days to report injury up to 1 year, otherwise assert statute of
limitation defense (L.C. Sections 5400 & 5405)
• Employer must immediately authorize medical treatment once injury reported (L.C.
Section 4600)
• Provide medical treatment, subject to Ufilization Review (L.C. Secfions 4600 & 4610)
• Pay indemnity compensafion in accordance with Bargaining Agreements and Labor
Code (L.C. 4650 & 4850)
• If medical treatment appears excessive or not medically necessary per Utilization
Review, issue 4062 objection and proceed with panel AME/QME process. (L.C.
Sections 4062 & 4062.2)
• Once applicant is declared by P&S by primary treating physician with no permanent
disability and if in agreement with the P&S report, attempt to resolve claim by C&R or
stipulated Award.
• Once applicant is declared P&S and if there is undisputed permanent disability, pay
permanent disability and attempt to resolve claim formally by way of Compromise
and Release or Stipulated Award.
• Once injured worker is declared P&S and if there is a dispute over the level of
permanent disability, future medical treatment, apportionment, etc.. proceed with the
AME/Panel QME process.
• Once AME/Panel QME report has been received, pay any addifional compensation
due and attempt to resolve claim by way of C&R or Stipulated Award based on the
AME/Panel QME report.
• If claimant fails to participate in the settlement process, file DOR to get matter set for
trial in order to have WCJ issued Findings & Award.
Delayed/Denied Claims (Unrepresented or Represented)
• Medical treatment must be authorized up to $10,000 once claim form (DWC1) has
been filed up to date of compensability. (L.C. Secfion 5402)
• Must have a medical, legal or factual basis to deny claim. If medical evaluation is
necessary to determine compensability, proceed with the panel QME/AME (L.C.
Section 4060), if unable to deny claim based on the primary treating physician's
report.
• If AME/Panel QME issues medical opinion that injury is non-industrial and if claimant
is unrepresented and does not dispute report by way of filing application, close file
within 30-45 days from denial. If claimant is represented, file DOR in order to get
matter on trial calendar to resolve AOE/COE issue.
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The most important claim handling funcfion in controlling lifigafion is prompt contact with the
injured employee. If we explain benefits and assure that prompt and proper medical care will
be provided, quesfions are resolved and an immediate rapport is established with the
employee. The California workers' compensation Institute's recent litigation study points to
the fact that injured workers who seek an attorney do so often times because of the failure
of the administrator to properiy contact the injured employee and explain the complicated
benefit system.
One of the primary goals of our personalized claims management philosophy is to avoid
lifigafion. If an injury results in permanent disability, it is our obligation to insure that the
employee receives all benefits called for by the Labor Code. By maintaining close and
confinuous contact with the employees through the "disability event", the issue of permanent
disability can be resolved through the informal process and, if necessary, with the
assistance ofthe Information and Assistance Ofi'icers located at each ofthe WCAB offices.
It is our recommendation that we arrange meefings with the Informafion and Assistance
Officers for those employees who have additional questions on informal rafings. We find that
many employers/administrators do not go far enough in the informal process to avoid
litigation. Frequenfiy. the employee is suspicious regarding permanent disability payments,
and assistance from the Information and Assistance Officer assures the employee that it is
not Keenan & Associates or the City that is determining the cash value of permanent
disability, but rather the State of California.
Our Claims Unit will perform many ofthe functions previously performed by Legal Counsel in
the event a formal application is filed with the WCAB. On an as needed basis, we will:
File and serve answers
File and serve medical reports on behalf of the City
Set up all medical/legal evaluations
Arrange for outside invesfigafions, including sub-rosa, if necessary
Share medical and personnel records with all interested parties to avoid unnecessary
subpoena and photocopy costs
Arrange for Agreed Medical Examinafions where indicated
Arrange for consultative permanent disability evaluations
Meet and confer with applicant's attorneys to work out stipulations or settlements
direct, without the necessity of appearing at the WCAB
Keenan & Associates will protect and preserve the City's interests, and supervise their legal
obligafions under the Labor Code. We will compute and pay all Findings and Awards and
Compromises and Release Settlements. We will identify negligent third parties and take
whatever steps are necessary, in conjunction with your legal counsel, to preserve
subrogation rights.
As a result of our personalized claims service philosophy and 24 hour employee contact
program, statistics reveal that we have been able to keep our Workers' Compensation
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litigation rate at approximately 7.5%. We are acutely aware that reforms and controls in the
legal profession are both necessary and inevitable, and accountability to our clients is
extremely important regarding work product and corresponding fees Keenan communicates
with clients regulariy to review new legal files, status of serious legal cases, and all claims
that are scheduled for formal disposition. We find that by communicafing properly with our
clients via regular review meetings, superior work product results. In some litigated cases,
the examiner is able to manage the lifigafion through conclusion. In these cases the
examiner works with the applicant's attorney for fimely resolufion.
Functions on lifigated claims which cannot be handled by Keenan & Associates' staff will be
referred to defense firm approved by the City Attorney for the City. The need for defense
counsel representation can be triggered by the following:
• Post termination claims
• Psyche allegafions
• Denied claims where applicant has later retained legal council
• Suspicious claims in need of deposifions, etc.
• Claims where applicant and defense medicals differ greatly
• Claims where parties cannot agree on reasonable settlement
• All claims proceeding to Trial before the WCAB
All requests for settlement will be submitted to the City for approval, to include written claim
summary, esfimate of permanent disability and defense counsel's comments and
recommendafions if any.
Keenan's policy and procedure is to index all open indemnity claims at the fime of set up,
and as long as the file remains open to re-index annually. All indexing is performed
automatically through our claims system at both of these pre-determined intervals and is
sent electronically to ISO. All matches are returned within 24 hours electronically and
automatically uploaded into our claims system for the examiner to review. These matches
are documented directly into the claim notes through this electronic procedure.
Having all indexing performed automafically with immediate delivery to the examiner allows
our staff to focus their attention on management of the claims process and is just one
example of the "bells and whistles" of our iVOS claims system as a claims tool for the
examiner.
ISO maintains records up to one year, and will automatically return a match to all
subscribers for any industry claim filed within the one year period. Re-indexing at one year
re-files the claim with ISO so that we are notified of all subsequent claims. Through
Keenan's claim system, iVOS. all indemnity claims are indexed at the time of claim set up
and re-indexed automafically every nine months unfil the file is closed.
There are no charges for this service and no fees are charged to the claim file.
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EARLY RETURN TO WORK
Keenan works collaboratively with our clients to design and implement outcome oriented
Return-To-Work programs. The specific features of the program can be customized to fit
individual employer's needs. As we know, ever-increasing direct and indirect costs
associated with an employee's lost fime are causing employers to implement structured
Return-To-Work programs. Employers feel the need to implement these Return-To-Work
programs because of rising workers' compensafion costs, legislation, (including the
Americans with Disabilities Act), increases in litigafion costs and the drive to reduce overall
expenditures.
Keenan has designed customized Return-To-Work programs comprised, at a minimum, of
the following components:
1. Why an employer needs a Return-To-Work program
2. Return-To-Work Program Assessment Survey
3. ADA compliance information
4. Job modifications/accommodafions
5. Benchmarks
6. Training and implementation
Our Return-To-Work programs are effective and will help your injured employee's return to
their usual and customary occupafion while increasing productivity and morale. It will aid you
in your compliance with anfi-discriminafion legislation (ADA) and lessen the legal exposure
you may now be experiencing. Keenan's Return-To-Work program can also assist you in
identifying the essential functions of your present occupations and assist in doing
reasonable accommodafion investigations - as required by the ADA.
Installing our customized Return-To-Work Program will save you money while you do "the
right thing" for the City and its employees. Everyone will benefit!
We will coordinate with the City of Carisbad on the creation of a panel of qualified Vocational
Rehabilitafion firms, which best suits the needs of the City.
BILL REVIEW
Keenan, in associafion with Anthem Blue Cross of California, has developed a managed
care medical delivery system for work-related injuries. We call it PRIME® (Partnership for the
Review and Integration of Medical Expense). PRIME® revolves around four major
components, which together form the basic approach to achieving quality medical care.
They are Medical Provider Network (MPN) / Preferred Provider Organization (PPO),
Management and Utilization Review, Bill Review and the PRIME® Rx pharmacy
program.
Keenan's managed care division, PRIME®, has been providing bill review for more than 18
years to our municipality, school, health care, and community college clients.
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IP
PRIME® BILL REVIEW
The PRIME® Bill Review department is located in the Keenan Torrance offlce and is
comprised of one Bill Review Manager, one Bill Review Supervisor, one Senior Bill Review
Specialist two Bill Review Specialists and five Bill Review Analysts. All members of the bill
review staff are certified as Experienced Medical Bill Reviewers with a total of 86 years of
experience.
With PRIME®, all provider bills are reviewed for compliance with applicable fee schedules
and prevailing billing practices. Bills are processed by Keenan ufilizing Anthem Blue Cross
software for re-pricing. During this process, fee schedule excesses, duplicate charges and
billing infractions are identified and corrected, thereby generating substanfial cost savings^
We also offer review (pre-scanning and audit) of hospital bills not subject to PRIME
contracted provider discounts.
All requests for reevaluation are reviewed to determine cause of error if an error in
processing was made. If an error is found a code is assigned at the bill level. This allows the
tracking of the activity for purpose of quality measurement as well as identificafion of cause
of errors and identification of training, system enhancements or other actions to insure
quality.
PRIME® ADVANTAGE MPN
As you are aware, effective January 1, 2005. or anyfime thereafter. California employers
have been given the opportunity to optimize their workers' compensation program by
establishing a medical provider network (MPN).
Keenan's PRIME® Advantage Medical Network is another cost cutting, quality driven
opportunity for California public agencies. In partnership with Anthem Blue Cross. Keenan is
offering their customers an opportunity to increase medical control and provide high quality
medical treatment in a responsible manner that will ulfimately drive down medical expenses
and the overall costs associated with your workers' compensafion program.
The PRIME® Advantage Medical Network is an MPN unparalleled to anything else in the
industry Keenan is working in partnership with Anthem Blue Cross, which is a certified
Health Care Organization (HCO) and already deemed to meet the qualificafions of a Medical
Provider Network.
The Anthem Blue Cross partnership offers numerous advantages, some of which include:
• A simplified MPN applicafion process that meets all geographical and access
requirements
• Frontline industrial providers who are prescreened and educated by Anthem Blue
Cross to ensure the best outcomes for the pafient and the employer
• One of the largest medical networks statewide that meets the legislative goal of
having at least 25% of the providers primarily engaged in the treatment of non-
occupafional injuries and gives employers an advantage whose group health
program is also with Anthem Blue Cross!
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. Lower medical costs as a result of many provider fees below the Official Medical Fee
Schedule
Building on the many advantages Anthem Blue Cross brings. Keenan. through the PRIME®
Advantage Medical Network, offers additional strategic advantages, some of which include.
• A proven result-oriented team-based workers' compensation program that offers
customers all resources in one consolidated package
. Administrative support for our customers. We take the burden off the employer by
preparing and filing the MPN applicafion on their behalf. Once the MPN applicafion is
approved we implement, measure and monitor the program.
• Education of MPN front-line providers and physicians
• Outcome Analysis of MPN Providers
. Keenan recognizes the opportunity that the Califomia legislation has bestowed on
employers. We are here to provide our customers the solutions necessary to
capitalize on this opportunity.
PRIME® Rx
The latest enhancement to the PRIME® Managed Care program is a joint venture with
Express Scripts called PRIME® Rx. Express Scripts is among the larges fully integrated
Pharmacy Benefit Manager (PBM) independent of pharmaceufical manufacturer or retail
Pharmacy ownership in the United States and has one of the most comprehensive networks.
Wel -Tnown chain pharmacies such as Rite Aid. Wal-Mart. Kniart. Vons. Safeway
Prfce/Costco. Medicine Shoppe, Albertsons/ Sav-On and Target, plus thousands of
independently owned and operated retail pharmacies are accessed.
To best meet the needs of our clients. PRIME® Rx is a tailored program utilizing ele^^^^^^^^
interfaces with network pharmacies and our claims system to provide on line first fill
c^Ss as well as r^ail service benefits for long term therapy. This no-r.sk program
guarantees that prescriptions will not be billed under workers' compensation if they are not
compafible with the claim.
Through our PRIME® Rx program, all requests for pharmacy services undergo an intensive
ufilization review process to identify potentially inappropnate prescnptions prior to
ds^^^^^^^^^^ process checks for early refills, duplicate refills, dosage limits
Vindicated drugs and generic substitutions. A drug formulary has been developed with
the assistance ^ a clinical pharmacist at Express Scripts and any request for a medication
which is not on the list is referred to a PRIME® Nurse Case Manager for review.
The claims team and the PRIME® Nurse Case Managers identify claims where maintenance
Wpe m^SioIl^^ should be transifion to mail order service. The Express Scnpts customer
service department also proactively sends letters and contacts injured workers via phone to
convert high volume and long term maintenance type medications to mail order.
All billing through the PRIME® Rx program is billed electronically to the claim file.
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PRIME® is designed to be mutually beneficial for everyone involved: the employee, the
employer and provider. PRIME® recognizes that today, more than ever, a high level of
employee safisfaction with employer-furnished treatment is critical.
Annually. Keenan's PRIME® department is currenfiy processing approximately 158.225 bills.
PRIME® NURSE CASE MANAGEMENT/UTILIZATION REVIEW
The whole of Keenan's Claims Department thoroughly understands the mandated fimelines
and how this impacts access to appropriate and necessary medical care for our injured
workers. The Claims Department reviews all appropriate incoming requests and fon^/ards
the request electronically via our PRIME® Service Queue applicafion. From there, our
standard demands a one hour turnaround time (of which we have reporting capabilities to
review system efficiencies). The Ufilizafion Review team adheres closely to the UR fimelines
as defined by California Labor code through the date and timestamp entry of each step of
the Ufilizafion Review process. Oversight is maintained through the applicafion's reporting
capabilities. We also have developed "Quick Treat Protocols" to allow claims examiners the
technical expertise to review and authorize specific procedures and thereby reducing the
utilization costs associated with your program.
Registered Nurse Case Managers monitor provider utilization by comparing the frequency
and duration of care with the diagnosis-specific treatment guidelines in accordance with UR
guidelines under the Labor Code and treatment within MTUS (Medical Treatment Ufilizafion
Schedule) Guidelines. PRIME® Case Management Nurses evaluate treatment plans,
consultations, and hospitalization requests and will provide certifications or referral to a
PRIME® Physician Advisor who will intercede with the provider.
The PRIME® nurse case manager focus is to ensure injured workers' receive prompt and
appropriate medical care while assisting the City by facilitating eariy return to work. To that
end. the nurse case manager's focus with frontline providers is to ensure they are
addressing injured worker ability, return to work and appropriateness of medical care.
Utilization Review is performed by our partners. Anthem Blue Cross. We believe that this
operation is best suited to an organization that has URAC accreditation which includes key
quality benchmarks for network management, provider credenfialing. ufilizafion
management, quality management and improvement and consumer protecfion. Health
Ufilizafion Management Accreditation standards provide assurance to pafients. providers,
purchasers, regulators and employers that the practices of the organizafion performing
these services are fair and equitable for all parties.
The Utilizafion Review (UR) nurses maintain a growing medical management staff of 50
Registered Nurses, who hold unrestricted nUrsing licenses. Average case management/
disability experience is 8.5 years; average Utilizafion Review experience is 4.6 years. Full
time RN Ufilizafion Review Trainer, Lead Nurses, and RN supervisors provide reinforcement
and training as well. Medical Director provides Confinuing Education Units (CEU) updates
quarteriy to the RN Utilization Review staff.
Upon request by the Provider, the PRIME® Nurse refers the case for reconsiderafion to the
specialty matched Physician Advisor within 24 hours, forwarding any addifional information
that may have been received, along with the original Physician Advisor review.
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On reconsiderafion, the Physician Advisor attempts to contact the Provider to discuss the
requested service. If the services are certified or partially certified, the PRIME Nurse
notifies the Provider telephonically the same day the determination is made, and issues a
certification or partial certificafion letter to the Provider with a copy of the letter to the Injured
Worker within one (1) business day.
If the Physician Advisor upholds the original non-certificafion, the Physician Advisor notifies
the Provider telephonically, and the Keenan Nurse issues a non-certificafion letter to the
Provider with a copy of the letter to the injured worker within one (1) business day.
COMPLETION OF MEDICAL REVIEWS
Prospective or concurrent reviews must be completed not to exceed 5 working days from
receipt of the informafion reasonably necessary to a determinafion. The timeframe can be
extended up to no more than 14 days from the request for authorization of medical
treatment recommended by the physician.
Expedited reviews must be completed within 72 hours from receipt of the information
reasonably necessary to a determination.
Retrospective reviews must be completed within 30 days for receipt of the informafion
reasonably necessary to a determination.
Our tracking mechanism which ensures state mandated compliance is automated by our
software application. Follow up dates and notifications alert the nurse and the Physician
Advisors every step of the way. Each task is date stamped (i.e., when cases are assigned
when supportive data is received, and completion is for each Peer Revievv, Referral and
Appeal). Notificafion of parties (e.g., the providers, claims staff, injured workers and
attorneys) are also logged and dated electronically. PRIME® has the capacity to run ad hoc
reports which can identify abhorrent pracfice patterns.
PHYSICIAN ADVISOR PROGRAM
Anthem Blue Cross of Califomia Workers' Compensafion Services department niaintains a
forty four (44) member proprietary Physician Advisor panel represenfing 22 different
specialties. They provide specialty-matched peer reviews with direct contact with the treafing
Physician, when necessary.
Physician Advisor Qualifications
• Unrestricted medical license
• Board Certificafion in their specialty
• Current, active clinical pracfice
OVERVIEW OF SERVICE DIVISIONS
The following chart details the services that are provided and the division providing them:
lilaims Handling
Utilization Reviev,
Bill Review
Keenan WC Claims TeaiTi
PRIME^
PRIME^
17
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Investigative (Sub rosa anj^^PE£QQf )
Nurse Case Managemei
Pharmacy Benefit Networl
Health Care Oraanization/Medicj
Network (HCO/Ml
Litigation Maiitg<
Nurse Case M^agemWrft
RA9®IL*^y-5i^'irA^'-ny^-3^^°--^
PRIME®
PRIME^
PRIME®
Keenan WC Claim Team
STANDARDS & ACCOUNTABILITIES
Keenan ensures compliance standards with the Department of Industrial Relafions ufilizing a
multitude of programs for effective claims management and best practices.
Keenan has established strict timelines, in accordance with the rules and regulafions, for the
administration of benefits, medical payments and issuance of all notices, timely and
accurate payment of TD and PD, timely and appropriate claim decisions, through resolution
of the claims. Our Standards and Accountabilities are closely monitored and measured
through regular supervisor claim audits, corporate technical audits, corporate operational
audits as well as various external and state audits. Adherence to all internal protocol is also
tied into annual performance appraisals.
Supervisor Review
In order to ensure that all claims are handled appropriately and to ensure that our internal
Standards and Accountabilities are met, our supervisors are involved in many aspects of the
claims management process. Our supervisors are required to review all files with a reserve
of $75,000 total incurred or greater and all settlements of $50,000 or greater. Regular
supervisor involvement in a file is triggered by all of the following:
30-day review of all new indemnity claims
Reserves over $75,000 total incurred
Setfiements over $50,000
Review of all legal mail
Review of all litigafion referrals
Review of all calculations of payments on settlements
All delayed claims
All denials
All confinuous trauma claims
All catastrophic injuries
Any conflict-of-interest issues or politically sensitive issues
All 132(a) or S&W claims
All File Reviews
All penalty payments
The supervisor review includes feedback to the claims examiner, documented in claim notes
that provide recommendafions to improve the overall file plan of action. The supervisor's
feedback focuses on the resolufion of issues, adequate identification and assessment of
exposures reserve accuracy, facilitafion of settlements and improving customer^service.
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Feedback and direction from the supervisor ultimately impacts the performance appraisal of
the claims examiner.
Claims Supervision
Keenan's best practice for claims supervision is the review and direction provided to the
examiner on all cases oufiined above at intervals no greater than every 120 days^ If acfion is
required by the examiner, the supervisor is to follow up to ensure complefion within required
firrJelines. Supervisor documentation should provide the examiner with clear direcfion for
further handling the claim with emphasis on resolufion of issues and closure.
Manager Review
In order to ensure that all claims are handled appropriately and to ensure that our internal
Standards and Accountabilifies are met, our managers are involved in many aspects of the
claims management process. Our managers are required to review all files with a reserve of
$150,000 total incurred or greater and all setfiements of $100,000 or greater. Regular
manager involvement in a file is triggered by all ofthe following:
Claims over $150,000 total incurred
Setfiement of $100,000 and over
All defense legal referrals
All polifically sensitive claims
All penalties
RESERVING PHILOSOPHY
Keenan maintains realistic estimates of the future costs of all work-incurred liabilities. This
information is essenfial to the proper funding and direcfion of your program. Our reserving
philosophy is to establish future cost estimates based upon the informafion available at the
time of calculation. As developments occur in the course of a claim, reserves are likewise
adiusted in either direcfion. Our reserve philosophy is in compliance with DSIP guidelines
and Califomia Rules & Regulafions. Each claim stands on its own merit with no allowance
for actuarial or mathematical averaging techniques. Completion of reserve worksheets are
required by each examiner upon inifial and revised incurred loss esfimates. Supervisors are
responsible for review and approval of all cases that exceed an examiner's specific reserve
authority leave, usually above a mutually agreed upon level ofthe total incurred.
Managers are responsible for review and approval of all cases that exceed both the
examiner and supervisor reserve authority level, usually above a mutually agreed upon level
of the total incurred.
Additionally we track statisfical reserve development in accordance with the Departnient of
Self-Insured Plans for each of our client's benchmark for paid to incurred rafios. and data is
tracked annually for each of our programs.
Reserve Quality Assurance
Reserve adjustments are tracked in our claims system and a permanent record is recorded
with a date and time stamp, amount, and user identificafion of each reserve transaction^
Stair-stepping is monitored by the supervisor and manager at regular intervals and
automated through iVOS Business Rules. This is also a common topic for our corporate
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target audits, which occur frequently and are always a "surprise". Our philosophy on
management oversight and audifing is to identify trends and correct problems before they
are identified by an outside source.
Addifionally. members of our Corporate Claims Team will review "large loss" claims at
$250,000 and above, for the identification of appropriate settlement/resolution posture,
possibility of structured settlement, life care plan or excess carrier authorizafion. This review
process includes roundtable discussion ofthe plan of acfion with the claims team (examiner,
supervisor, manager, and nurse case manager).
SUBROGATION
Our claims examiners and claim assistants are trained to properiy identify and pursue
subrogafion. All subrogafion potential is explored and pursued under strict fimeframes.
FINANCIAL SERVICES
Keenan & Associates has checks and balances in place to ensure the security of check
issuance and benefit payments. Under a Self-Insured Trust Account, Keenan recommends
a positive pay bank account for maximum ease and security. This type of account is
established between the City and your banking institution based on a line of credit or
financial instrument. Keenan & Associates does accept funding contributions by wire
transfer. Keenan has experience in handling all types of bank accounts from traditional
accounts to zero balance, to positive pay.
• Tradifional Account - These accounts generally allow for an unlimited number of
transacfions.
• Zero Balance Account (ZBT) - This means that the balance at the end of the day is
always zero. Each day. the account pulls its funds from a separate account, or
corporate account, into their workers' compensafion account. Your financial
institution will deposit, into the workers' compensafion account, the exact dollar
amounts that will allow for an unlimited number of transactions.
• Posifive Pay Account - Where on a daily basis, Keenan & Associates will present a
check register to the bank for checks issued that day. Only checks issued will be
eligible for cashing. There is an added benefit of security with this type of account. At
the time, the bank provides verification of the check before cashing based on
security parameters, requires signatures and other controls set up at onset of the
account between the bank and the City.
Keenan will assist the City in the set up and ongoing administration of a trust account for the
purpose of paying benefits. We will provide the City with monthly transacfion registers,
voids, stop payments, refunds and bank account deposits and balances.
We do not anficipate the need to handle cash under any circumstance in the claims
management process. However, Keenan's Claims Examiner, in partnership with the Claims
Assistant, is responsible for reconciliation of all benefits and payments made off the claim
file. This is done through various system security workflow and strict approval processes.
Additionally, balances are performed by audits of the manual payment cards against the
claims system payment history. Payment cards require examiner approval every three
weeks. Balances are performed again at the fime of settlement via usage of the Balance
Sheet Form, which also requires supervisory approval prior to any final settlement payment
issuance. Additionally, management must approve aii checks over $5,000.
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EXCESS REPORTING & RECOVERY EXPERTS
Unlike most claims administrators we have a Reinsurance Manager dedicated to ensuring
your claims are reported timely to your excess carrier, and equally important, that you are
reimbursed accurately and timely. Our Reinsurance Manager will promptly report all claims
that reach the SIR to your reinsurance carrier.
Excess Reporting Specialist
Keenan & Associates has an on-site Reinsurance Manager responsible for filing excess
insurance reports. Our success rate for prompt filing exceeds industry standards.
Through coordinated efforts between the Examiner and our Reinsurance Manager, we
report all claims for client's self-insured run-off claims at 50% of the Self-Insured Retention
(SIR)
RESOLUTION EXPERTS
We design strategies to fit the individual needs of our clients. Many public entities and
community colleges are experiencing challenges in resolving old claims. Across the state
these old claims confinue to experience reserve development, causing financials to be
upside down. We look fon/vard to partnering with you to develop an aggressive plan to
resolve your older claims with an emphasis on those claims setfied by sfipulation or finding
and award. Our strategy will include:
• Preparing Analysis
o By Age of Claims (Many claims with a date of injury 15+ years ago and sfill
open!)
o By Date of Birth (Many injured employees either retired or in refirement age.
Offers unique setfiement opportunifies)
o By Outstanding Liabilifies (Many times only 20% of the open claims are driving
80% of the outstanding reserves. Focused resolution of those 20% can
significantly improve your financials)
• Implemenfing Resolution Strategies
o Resolution Team
• Aggressive Claims Examiner
• Structured Settlement Analysis
• Nurse Case Manager Assist to Control Treatment Plans and ensure
treatment is within ACOEM or other medical treatment guidelines.
• Corporate Claims Analyst as "Fresh Perspective"
• Taking Advantage of Legislative Reform and Pushing Back
o Presumpfion of Correctness Eliminated for all Dates of Injury
o Treatment Utilization Guidelines (ACOEM) in Place and Under Development
o Presumption is "Evidence Base"
o Medical Provider Network (MPN), when appropriate, to transfer medical care and
regain medical control
LITIGATION MANAGEMENT
Keenan maintains our proprietary "PPO" program for litigafion management called PRIDE.
This program is managed by our Corporate Claims Team for reduced hourly rates, billing,
integrity and overall performance. Our relafionship is 'management to^management' so that
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we keep pace with industry trends and focus on quick resolufion and cost containment. As
part of this program, we have identified 'separation of duties' protocols to ensure that
administrative tasks are performed by our claims team and professional responsibilifies are
handled by the defense firm. Our corporate claims team also conducts regular audits to
ensure overall efficiencies and adherence to all program procedures.
Keenan will work closely with the City on litigation management and obtain approval for all
depositions, investigafion and sub-rosa activities.
All litigated claims require ongoing and active management by the examiner. All examiners
will inifiate proper medical and legal control. Keenan does not and will not turn over control
for any aspect of lifigated claims to the attorney. Addifionally. all lifigated claims require
active supervisor involvement to ensure proper direcfion.
Keenan will work closely with the City and will provide frequent updates to the maintained
Hearing Calendar of all conferences, MSC's or Trials. Our calendar will include case name,
type, venue, time, defense attorney, applicant attorney and desired disposifion.
We make every effort to resolve litigated claims without the assistance of defense counsel.
Our examiners maintain ratings for all medical reports resulting in permanent disability, and
they will formulate our recommendafion for settlement and resolution. We do not and will not
wait for defense attorney's acfion on a setfiement plan. Addifionally. all litigated claims
require active supervisor involvement. Under no circumstances are files abandoned to the
defense attorney.
Keenan will work with the City to ensure adequate defense coverage and will make any
necessary changes in partnership with the City.
PRIDE Panel Qualifications
Law firms' practice must be at least 80% Workers' Compensation defense
All attorneys are Certified Workers' Compensation Specialists (or are eligible) before
the California State Bar
Sole practifioners and/or managing partners of the firm must have at least 10 years
experience in Workers' Compensation defense
All firms must have experience in handling Keenan's clients (i.e. school districts,
health care organizafions and municipalifies)
All attorneys must provide proof of adequate insurance coverage
Statewide firms have AV rafing in the Martindale-Hubbell
Added Value for Our Customers
All PRIDE panel members have met rigorous qualification standards, in addifion to:
• Negotiated houriy rates of $155.00 through life of claim
o Must have technology capable to track performance
• Keenan maintains a negofiated rate with all PRIDE Panel firms that is 10 - 15%
lower than the industry's usual and customary rates
• Keenan has the lowest statewide-negotiated houriy rates, in line with the California
Insurance Guarantee Association (CIGA)
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^1
Keenan will continue to keep a low number of firms on the panel in order to better
monitor and manage our legal defense costs and uphold management philosophies
consistent with those of Keenan and our customers
Keenan branch managers and corporate liaison have developed a working
relafionship with each PRIDE firm, and handling attorney
Our PRIDE firms have partnered with us to provide quarteriy trend reports on costs
and duration statistics
Quarteriy communication meetings are held to review status of projected costs and
progress on fime frame to bring case to resolution, according to their original
estimate
Claims examiners must uphold strict claims handling guidelines according to our
internal standards and accountabilifies
Claims examiners have overall responsibility for the primary direcfion. resolufion
strategies and prompt closure of all legal cases while working in partnership with our
PRIDE attorneys
PRIDE firms are required to provide esfimated cost and durafion of litigafion
management at onset of referral and are held accountable to adhere to their original
projected estimates
Keenan discourages use of hearing representatives - doing so must be pre-
authorized by our corporate claims coordinator
Semi-annual training is provided to all staff in all areas of lifigafion management
Keenan manages all aspects of lifigafion, including cases assigned to defense attorney, in
accordance with all of the above.
Keenan will work closely with the City for each referral to defense counsel and obtain
approval of the attorney assignment.
Keenan works closely with our panel defense attorneys throughout the life of the claim. As
part of our comprehensive management of legal claims, we will ensure that all opening
reports, regular status reports and resolution/settlement reports are fimely and maintained in
the claim file.
LEGISLATIVE AND REGULATORY COMPLIANCE
Keenan is electronically linked to key legislative sites on the Internet, and are able to
retrieve up-to-the-minute status reports on all pending legislafion so we can report any
significant developments to our clients and claims teams. If you need informafion on a
specific bill, we can provide it almost instantly. We look to mitigate addifional costs
associated with legislative changes affecfing your program.
Our Legal Department maintains dedicated personnel who regularly track both pending and
newly enacted legislation in order to provide updates to our clients in a fimely manner.
Communication of legislative issues is provided by Briefings, Webinars and onsite meefings.
Additionally, all of Keenan's service team personnel are briefed on current legislative issues
and potential changes to legislation and regulafions. As critical legislafion is enacted.
Keenan will provide the City with comprehensive resources to ensure you receive the
information needed to keep abreast of the changes.
We regulariy distribute Compliance Advisories designed to inform clients of news and
legislation that may impact them. During the past three years, Keenan has conducted many
client seminars and educational programs, provided at no cost to our clients.
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In addifion Keenan holds an annual summit for our clients. The summit addresses key
public policy issues that may impact client programs related to various lines of insurance^
The 2012 Keenan Summit was held on February 29, 2012 in Berkeley, California and March
1 2012 in Burbank Califomia. The Summit focused on the dialog between the vanous
stakeholders on the emerging issues of Health Care Reform. Public Retirement, Risk
Management and Workers' Compensafion, emphasizing the impact these developments
could have on organizafions. These events provide an open exchange of ideas across a
wide range of viewpoints.
IMPLEMENTATION AND TRANSITION MANAGEMENT
The implementafion process is of utmost importance as we know a smooth transifion and
implementafion is crifical to the ongoing success of your workers' compensafion program.
We believe in careful planning and follow through. Our goal is to make the process
seamless to the client and the employees.
Transifion and implementafion meefings are meticulously planned to carefully review the
implementafion strategy and identify any addifional tasks that need to be accomplished.
We will work with the City to contact your current TPA so that a smooth transition of services
can occur In addition to that, we have found that regulariy scheduled meetings can facilitate
a quick and seamless transifion from other service provider to our services. Therefore we
work with you to identify appropriate times and frequencies for meetings with your
appropriate personnel, so that we can train you on any processes while mifigafing disrupfion
to your personnel's workflow.
During the inifial meefings we will sit down with the City to determine if there are any special
handling instrucfions that need to be incorporated into our operations, with respect to your
claims including the transitioning of hard copy claim files to paperiess claims or vice versa if
required by either party.
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ATTACHMENT"B"
PRICING
Following are Keenan's /greed Claims Administration fees for tlie City of Carlsbad:
infnrmation svst«m s..nnort and M transition and intake fees are waived. Fees include
post 90 day detailed report of reserves and overall assessment of open indemnity claims
inventory.
The State of Califomia requires that all first Report of Inquiry (FROI) and Subsequent Report
of Inquiry (SROI) be reported to the Sate electronically (EDI). Fees are waived for these
electronic submissions.
Keenan's solution is based on a bundled approach, incorporating Bill Review, Utilization
Review and Case Management through Keenan's PRIME* program fees are included on
the next page.
Additionally Keenan's Regency Investigation Services can be utilized for investigation
sS The Regency Fee Schedule is included just after the PRIME Fee Schedule.
Consistent with industry practices, insurers may also pay insurance brokers, such as
Keenan indirect compensation based upon volume efficiencies, client renewals, marketing
services product development, technology investments and other additional services
Keenan seeks written assurances from insurers that any such indirect compensation will not
adversely impact the pricing or coverage temis that Keenan is able to obtain for rts c lents^
The amount of any available indirect compensation shall not be included in the calculation of
any commission that may be due to Keenan as a result of the placement of an insurance
product.
Keenan shall comply with all applicable state and/or federal laws and regulations regarding
asclosure of com,^nsation, and embraces industry efforts for transparency. We believe it is
important that clients have access to infomiation that may be relevant to their choice of
insurance products, including the cost of such insurance and services, and the
compensation that may be directly or indirectly paid to Keenan in connexion with the
products or services that are selected. Your Keenan account representative will be happy to
address any questions you have regarding this matter.
City Attorney Approved Version 2/17/12
2.?
A Keenan Solutl
Fee Schedule - Effective January 1, 2010
(Subject to change upon notice)
MANAGED CARE SERVICES
• Early Intervention Inifial Assessment/Triage
• Total Case Management
- PPO Channeling
- 4 PT Contact
- Inifial Evaluafion
- RTW Plan
• RN File Review
- Medical Care Evaluafion
- RTW Evaluation
- Written/Case Management Action Plan
• Physician Advisor
- Medical Necessity Determination
- Physician-to-Physician Contact
• Physician Medical Record Review
- Assessment Report of Medical History
IN PATIENT STAY REVIEW
• Pre-Admission Review
• Concurrent Stay Review
• Discharge Coordination
UTILIZATION REVIEW
$ 45 / Hour
$ 95 / Hour
$ 95 / Hour
$ 180/ Referral
$ 300 / Hour
$ 95 / Hour
$ 95 / Hour
BILL REVIEW
FEE:
Flat Rate - $4.50 per bill plus $ 1.25 per line
Plus 24% of PPO Savings below OMFS
No fiat fee or per line charge. 24% of total savings *
No fiat fee or per line charge, 18% of total savings *
No fiat fee or per line charge, 20% of PPO savings
below OMFS
No fiat fee or per line charge, 24% of total savings
Medical EDI processing (Effective 1/1/09) Flat Rate - $4.50 per bill plus $ 1.25 per line
(Medical Non-Reviewable, Medical Transportation, Zero pay due to an objecfion. etc.)
In-Pafient and Out-Patient Hospital bill review fees will not exceed $10,000.00
TYPE QF SERVICE
• Professional
• In-Patient Hospital
• Out-Pafient Hospital
• Pharmacy
• Negotiated
License #0451271
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P.O Box 4248
Torrance, CA 90501-3325
(310) 618-6858 Phone
(310) 212-0330 Fax
A Keenan Solution
mREGENCY
Regency specializes in invesfigafions for school districts, community colleges, hospitals and
municipalifies. Now. over twenty years in existence, we are experts in working with public
agencies We complete our assignments timely and efficienfiy. Our reports are of the highest
quality. All investigations are completed at a very reasonable cost to the client. We have
excellent references.
Our services include but are not limited to:
Workers Compensation Investigations:
- AOE/COE Invesfigafions
- Surveillance/Sub Rosa
- Activity Checks
- Subrogafion
- Photos & Diagrams When Necessary
- Doctor/Clinic Invesfigafions
- Police Reports
- Coroner Reports
Liability Investigations:
- General Liability
- Auto Liability
- Products Liability
- Discriminafion
- Sexual Harassment
- Wrongful Termination
- Photos and Diagrams When Necessary
- Police Reports
- Coroner Reports
Data Base Services:
- Department of Motor Vehicles
- Criminal and Civil Court Checks
- Witness Locates/Skip Trace
- Public Records
- Asset Checks
- People at Work search
- Business Searches
- Photos and Diagrams When Necessary
License Number PI 22147
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^REGENCY
.A Keenan Solution
P.O Box 4248
Torrance, CA 90501-3325
(310)618-6858 Phone
(310) 212-0330 Fax
2012 FEE SCHEDULE
WORKERS' COMPENSATION/LIABILITY
*Sub Rosa includes surveillance, activities checks, and court appearances.
**NOTE: No Additional Charge for Rush Assignments
Updated 12/15/11
License Number PI 22147
28
City Attorney Approved Version 2/17/12
PUBLIC WORKS SAFETY AUDIT
The Risk Department periodically audits the illness and injury prevenfion program (lIPP)
associated with departments performing duties associated with maintenance and public works.
The purpose of the audit is to measure compliance with safety regulations (operations and
programs), the level of preparedness for an audit by a regulatory agency, an the level of lIPP
implementation. Contractor will conduct a meeting to review the work activities at the sites
listed below to confirm the specific regulatory requirements with jurisdiction over City operations.
The scope ofthe agency identification process will be limited to State and Federal agencies
which have oversight over employee health and safety issues. These include Cal/OSHA,
Cal/EPA, Cal/Trans, the CHP and the DOT. The review will also include identificafion of health
and safety requirements for the facilities and work practices observed, and corresponding
inspection and recordkeeping practices. Finally, the review includes an evaluation of the
adequacy of the audit form. Work area reviews will include the following departments:
Street Maintenance
Facility Maintenance
Fleet Maintenance
Construction Management and Inspecfions
Maintenance and Water Operations (water and sewer)
Parks Maintenance
Storm water Protection and Administration
Reviews will include interviews with department superintendents or representatives to be
determined and site visits to:
a) Confirm the scope of work activities present.
b) Use existing audit form and identify an needed enhancements. Ask quesfions to provide
greater depth than the form.
c) Determine if accident invesfigafions are adequate and recommend any addifional
quesfions not currently asked by supervisors.
d) Determine the extent to which safety is included in performance evaluations, i.e.. the
extent to which safety is treated as any other key factor in job performance/
e) Determine if site inspecfions are conducted and follow-up done.
f) Determine if required written programs are in place and implemented.
Deliverables:
A report including findings of the audit and specific recommendations, substanfiated with
regulafion citation and describe deficiencies in work practices, recordkeeping, required training
and the basis for these recommendations. The organization of findings and recommendations
to be identified as to the area of work. Recommendation will also include any changes or
revisions to the audit form.
In the event that a safety audit is requested the fees associated with the work will be performed
at $125.00 per hour. Prior to commencing work the parties will agree to a complete scope of
work.
City Attorney Approved Version 2/17/12
2.9
STANDARDS & ACCOUNTABILITIES
DEPARTMENT STANDARD MEASUREMENT
TECHNICAL:
Overall File Handling
Inifial 3-point contact • 24 hours
• Documentation/oufiine in claim notes
Supervisor Review of New
Incurrals
Target Audit
Technical Audit
Operafional Audit
File set up • 72 hours Supervisor Review of New
Incurrals
Target Audit
Technical Audit
Subsequent employee
contact
• Upon any change in benefits.
• Every 4 weeks of TD
Supervisor Diary Review
Technical Audit
Plan of Acfion/lssues
Identified
• Within 5 days of new file set-up and upon
each diary.
• Documentafion/oufiine in claim notes.
Supervisor Diary Review
Technical Audit
Subrogafion Identified
and Recovery
• Within 5 days of new file set-up and upon
each diary.
• Documentation/outline of recovery action
in claim notes.
Supervisor Diary Review
Technical Audit
Operafional Audit
Target Audit
Invesfigation
SlU/Fraud
• Thorough in-house invesfigafion of all
issues within 5 days from new claim set
up.
• Authorizafion from supervisor on all
outside investigafion assignments.
• Appropriate referrals to District Attorney for
all SlU cases will be done by Stacey
Golden.
Supervisor Diary Review
Delay Report
Technical Audit
Target Audit
Diary - Examiner • No files greater than 14 days off diary.
• Active files to remain on diary up to 60
days, including PD awards.
• All claims with active benefits being paid
must be on a 30- day diary.
• Diaries greater than 30/60 days on active
files must have supervisor's approval.
• Delay claims must be on 30 day or less
diary unfil decision is made.
Manager Weekly Report
Technical Audit
Target Audit
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30
DEPARTMENT STANDARD MEASUREMENT
Diary - Supervisor All delayed claims must be on the
supervisor's 30-day active diary until
decision is made.
All denied claims must be approved by a
supervisor and manager. If manager not
available, requires approval by 2
supervisors.
All claims over $75,000 total incurred must
be on supervisor's active diary no greater
than 6 months.
CT, 132(A), S&W claims must be on
supervisor's active diary no greater than 6
months intervals.
Technical Audit
Operafional Audit
Target Audit
Manager Review
Diary - Manager All claims over $150,000 total incurred
must be on manager's active diary no
greater than 6 months.
Operafional Audit
Target Audit
Reserves
Excess
Adjusted within 14 days of significant
event.
Reviewed and commented on at each
diary.
Inifial reserves to be established within 3
working days of notice of injury.
Reserves to be calculated for probable
outcome according to the facts of the
injury at the time.
Rafings appropriately completed within 14
days of notice of permanent disability or
the potenfial for permanent disability.
Supervisor approval over $75,000 total
incurred.
Manager approval over $150,000 total
incurred.
Future medical treatment calculated based
on 3 year average of treatment times life
expectancy once MMI has been reached.
If three years has not lapsed, use average
treatment paid thus far.
90 Day Reserve Review Form completed
90 days from open date and signed off by
supervisor.
Manager Diary
Supervisor Diary
Target Audit
Technical Audit
Operafional Audit
24 hour reporting of catastrophic injuries.
Within 30 days of reserve change where
reserves exceed 50% of SIR level.
Quarteriy Reports by CCT
Technical Audit
Operational Audit
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City Attorney Approved Version 2/17/12
DEPARTMENT STANDARD MEASUREMENT
Medical Management
Case Management • All indemnity claims referred to Case
Management nurse within 24 hours from
notice of injury, with exception of denied
claims and "first and final" claims.
Prime Triage Report
Technical Audit
Bill Review • Treatment bills must be objected to within
30 working days or paid within 45 working
days.
• Medical-Legal bills must be paid or
objected to within 60 days.
• Bills approved for payment sent to bill
review within 5 days from date of receipt
Supervisor Review
Technical Audit
Medical Management • Direct physicians regarding resolufion of
permanent disability and future medical
issues.
• Use of Blue Cross physicians.
• Appropriate use of AME/QME process.
• Eariy return to work addressed.
• Objections made within 20 days (lifigated),
or 30 days (unrepresented) of receipt of
medical informafion.
• Treatment requests must be authorized in
accordance with ACOEM or other
evidence based guidelines.
• Comply with all MPN procedures for
transferring care within the MPN.
Supervisor Review
Technical Audit
Utilization Review • Written and verbal treatment requests
must be submitted to PRIME for ufilization
review within 24 hours upon receipt.
• If examiner verbally authorizes treatment
request, must send provider written
authorization within 2 business days of
authorization. Letter in IVOS.
• Authorization must be provided within 5
days of treatment request.
Technical Audit
Operafional Audit
Supervisor Review
Target Audit
Litigation
Management
PRIDE • Compliance and utilizafion of PRIDE panel
for defense needs
PRIDE Audit
Technical Audit
Operational Audit
Lifigafion-
Management
• Authorization from supervisor and
manager on all legal referrals
• Direcfion given to defense counsel
towards resolution of issues
• File & serves to attorneys, WCAB & lien
claimants within 6 days of receipt of report.
Supervisor Audits
Manager Review
Technical Audit
Supervisor Review
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DEPARTMENT STANDARD MEASUREMENT
Liens • Pay treatment liens within 45 working days
or object within 30 working days from date
of receipt.
• Pay or object to medical-legal liens within
60 days from receipt.
• Proper use of objection letters.
• Objected/resolved liens/bills submitted to
PRIME for Medical EDI reporting.
• CMS (Medicare) liens to be addressed
immediately.
Supervisor Review
Technical Audit
Operational Audit
Evaluafion,
Negofiafion and
Settlement
• Balance sheets used for all settlements.
• Evaluation within 30 days of receipt of all
relevant facts and information.
• Authorizafion obtained from all parties.
• Consider Medicare's interest in all C&R
settlements.
Quarterly Supervisor Audits
Supervisor Review
Technical Audit
Operational Audit
Vocational
Rehabilitation
Pre 01/01/04
• Repealed as of 01/01/2009. Nofices must
be maintained in claim file and benefits
paid balanced in the file.
• Approval by Manager required before
paying any addifional VR benefits.
Supplemental Job
Displacement
Benefit
On/After 01/01/04
Nofice
Voucher
• Nofice of Rights to SJDB due within 10
days of final TD payment.
• SJDB Voucher due within 25 days of
award or before.
Supervisor Review
Technical Audit
Return to Work 01/01/2005
15% Increase/
Decrease
• Eariy RTW addressed at each diary where
TD benefits confinue.
• Send offer of regular work within 60 days
of P&S/MMI to injured worker.
• Send ADA notice & Offer of Modified/Alt
Work to employer immediately upon
receipt of P&S/MMI report.
• Issue 15% increase or decrease in PD
when required for DOI on/after 01/01/05.
Technical Audit
Operafional Audit
Supervisor Review
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DEPARTMENT STANDARD MEASUREMENT
Benefits
Payment of benefits
• TD
• PD
• Other
• Within 14 days from the employers date of
knowledge of injury, and every 14 days
thereafter.
• Within 14 days from last payment of TD or
within 14 days P&S/MMl if no lost fime.
• Medical mileage to be paid along with
nofice of nnedical appointment. Medical
mileage to be reimbursed within 45 working
days from date of receipt of request, all
other reimbursements to be paid within 60
days from date of receipt of request.
Supervisor Review of Paycards
Supervisor Review of New
Incurrals
Supervisor Diary
Penalty Prevention Form
Technical Audit
Operafional Audit
Wage statement • Wage statements to be requested where
employee is not a maximum earner.
• Wage statement calculated within 10 days
of receipt and rates adjusted/paid within 14
days of receipt.
Supervisor Review
Technical Audit
Benefit notices • Same day as benefit payment for TD &
PD. Delay nofices sent within 14 days from
employer's date of knowledge.
• Denial notices sent within 90 days from
employer's date of knowledge.
• Notice of Rights for SJDB due within 10
days of last payment of TD benefits
• All benefit notices must be used in
iVOS/Correspondence.
Supervisor Review
Technical Audit
Penalfies • Zero
• Penalty Prevenfion Folders are to be used
by all examiners.
• Supervisors are to periodically review
Penalty Prevention Folders for compliance
and proper use.
Manager Weekly Accountability
Report
Penalty Prevention Folder
Operafional Audit
Other
Closing Rafio • 100% on active accounts
• 125% on runoff accounts
Manager Weekly Accountability
Report
IVOS Batch Reserve
Approval. Payment
Approval. Under-
Reserved Tabs
• Clean up daily Supervisor and Manager review
Operafional Audit
34
City Attorney Approved Version 2/17/1;
41
DEPARTMENT STANDARD MEASUREMENT
EDI • FROI automafically completed within 5
days of new claim set up.
• SROI (Subsequent Reports of Injury)
completed within 10 days of claim event.
Technical Audit
Operafional Audit
Supervisor Review
File backs • Daily Supervisor review
Operafional Audit
Distribufion of mail • Same day Supervisor review
Operafional Audit
Review/Action on mail • 5 days Supervisor review
Private Label Products
• PRIME
• PRIDE
• Regency
• Vendor panels
• Compliance to utilizafion of all private label
products for bill review, medical case
management, legal representafion,
invesfigafion, rehabilitafion and photocopy
needs.
• Outside vendors must have Manager
Approval.
Monthly usage reports
Technical Audit
Insured & PIPS
Programs
• Immediately report catastrophic claims
• Authorization from carriers for reserves
and settlements over specified amounts,
according to carrier protocol.
• Submit file review form to CCT
Reinsurance Examiner when reporting
threshold has been met and every 6
months thereafter unfil file closure.
• CT worksheets used in all CT files.
• Conflict of interest files handled by team
member.
• Contribution reimbursed on a quarterly
basis unfil file closure.
Insured Audit
Technical Audit
Operafional Audit
Supervisor Review
Claim Coding • Update claim coding at each diary Supervisor Diary
Technical Audit
CLIENT SERVICE:
File Reviews • Quarteriy Manager Weekly Accountability
Report
Team Meetings • Monthly Manager Weekly Accountability
Reports
Customer Tracking • Maintain folder Operational Audit
Client Surveys • Above satisfactory results Results from MCD
QUALITY CONTROL
Technical Audits 1 per year fiscal year Corporate Claims Team
Operafional Audit 1 per year fiscal year Corporate Claims Team
~
Manager Weekly
Accountability Reports
To be completed by Tuesday of the following
1 week
Manager Weekly Accountability
Reports
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