Audit and Consultation Services

The vendor is required to provide audit and consultation services for managed care cost containment of the county’s workers’ compensation claims.
- Managed care audit checklist:
1. Bill review (BR) and PPO
•    Evaluate BR procedures to address the following:
•    Duplicate billing and reconsideration processes.
•    Processes and fees for reviewing out of network bills to ensure maximum savings are negotiated.
•    Second surgeon or assistant surgeon fees.
•    Review and confirmation of bills with contracted providers that are required to be submitted at contracted rate(s).
•    Review PPO and MPN contracts, application methods as necessary.
•    Specify any areas for improvement and savings
•    Fees and handling process of bills on catastrophic claims.
•    Accuracy and consistency of review only fee being applied
•    Specify any areas for improvement and savings.
2. Utilization review (UR)
•    Contractor shall evaluate UR procedures to address the following:
•    Whether or not claims examiners are able to authorize specific forms of treatment; what forms of treatment; and how that is that determined.
•    After claims examiner authorization, evaluate treatment tracking and incorporation into UR statistics.
•    Evaluate the protocol for elevating a request for UR to the physician level.
•    Evaluate the process for obtaining medical records before rendering an administrative delay or denial (e.g., is the provider contacted? within what timeframe?)
•    Evaluate the oversight in place to ensure all submitted medical records are reviewed before a denial is made.
•    Evaluate the percentage of denials that are overturned.
•    Evaluate the process for conducting peer to peer phone reviews.
•    Evaluate the integration of bill review and UR to ensure bills are not paid for services and procedures that have been denied by UR.
•    Evaluate how contractor ensures that only accepted body parts are reviewed for medical necessity.
•    Evaluate how UR fits in with a pharmacy benefits management system.
•    Evaluate how duplicate requests for authorization (RFA) captured.
•    Specify any areas for improvement and savings.
3. Nurse case management (NCM)
•    Evaluate how NCMS strategize with claims examiners to move claims toward resolution.
•    Evaluate if appropriate cases are being referred by claims examiners.
•    Evaluate how the decision to discontinue NCMs is made and by whom.
•    Review and comment on NCM referral protocols.
•    Evaluate if case managers are being used for non-medical issues, such as return to work.
•    Identify and evaluate the minimum qualifications required when nurses are hired and contracted.
•    Review and make recommendations on provisions in NCM contracts. (Billing rates, reporting requirements, etc.)
•    Determine how outcomes and return on investments are determined.
•    Specify any areas for improvement and savings.
4. Pharmacy benefits management (PBM)
•    Evaluate how effective the PBM is at reducing costs.
•    Identify if generics are being used as required. if not, identify what is being done to address it.
•    Identify if changes are needed, either to the formulary, or to the PBM.
•    Identify if any dispensing fees are charged.
•    Evaluate if manufacturing rebates are available to the county of orange.
•    Specify any areas for improvement and savings.
5. Medical provider network (MPN)
•    Evaluate if MPN doctors are following MTUS, ACOEM and other evidence-based guidelines when providing and recommending and requesting treatment.
•    evaluate what action is taken if they are not following guidelines.
•    If there are issues with MPN physicians related to UR, RFAs, IMR, treatment guidelines and work restrictions, identify available training and how frequently the training is conducted.
•    Identify if MPN doctors are referring patients to specialty or ancillary providers within the network.
•    Evaluate if MPN doctors are providing appropriate and clearly worded work restrictions.
•    Evaluate what procedures are used to resolve complaints re: medical providers?
•    Evaluate if the MPN website is user-friendly.
•    Evaluate if the MPN website is customized for the county of orange.
•    Evaluate if the provider lookup process is easy to navigate.
•    Evaluate if the MPN contains sufficient providers in all the appropriate specialties needed for an employer that is the size and complexity of the county.
•    Specify all areas for improvement and savings.

- Contract Period/Term: 5 years
- Questions/Inquires Deadline: October 9, 2025