Audit and Consultation Services

The vendor required to provide audit and consultation services for managed care cost containment of the county’s workers’ compensation claims.
- Contractor responsibilities:
•    Contractor shall examine monthly, quarterly semi-annual or annual reports for bill review to include independent bill review; utilization review to include independent medical review, medical provider network, telephonic and field nurse case management and ancillary services.
•    The managed care provider’s policies, procedures and client service instructions pertaining to managed care cost containment services, as well as the pertinent computer system(s) business rules and fee structure.
•    Based on audit results, the contractor shall identify opportunities to reduce costs through changes in claims management and cost containment practices.
•    Provide the county with three (3) hard copies of each year’s final audit report including an executive summary within 30 days of approval of the draft report.
•    Provide an electronic version of the final report to the county, managed care provider(s) and TPA as necessary.
•    Conduct a post-audit debrief with the county, managed care vendor(s) and the TPA AS needed.
- Managed care audit methodology:
•    Contractor shall review current and historical TPA reporting for all managed care cost containment services.
•    Interview bill review and TPA or managed care cost containment staff on bill review procedures, documentation approvals, management oversight and work flow.
•    Internal reports such as turnaround time, reconsiderations and EDI process. 
•    Audit 300 bill review explanations of review (EOR) or explanations of benefits (EOB) by category of reduction to ensure accuracy, timeliness and vendor costs related to the review.
•    Categories of review include DME, pharmacy, outpatient surgery, in patient surgery, physical therapy and chiropractic reductions.
•    Interview utilization review vendor and TPA staff regarding utilization review timeliness, procedures, documentation of approvals, management oversight and work flow.
•    Audit 100 UR decisions by category
•    Audit an agreed upon selection of bills with MPN and PPO contracted reductions to ensure accuracy and vendor costs related to the reductions.
•    Audit 25 field and 25 telephonic case management claims and invoices to ensure effective case management services are being provided, reports are timely and action oriented and invoices are an accurate reflection of case management services provided.
- Managed care audit checklist
1. Bill review (BR) and PPO
•    Duplicate billing and reconsideration processes.
•    Processes and fees for reviewing out of network bills to ensure maximum savings are negotiated.
•    Up coding, second surgeon or assistant surgeon fees.
•    review PPO and MPN contracts, application methods as necessary.
•    fees and handling process of bills on catastrophic claims.
•    accuracy and consistency of review only fee being applied
2. Utilization review (UR)
•    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.
•    The protocol for elevating a request for UR to the physician level
•    The process for obtaining medical records before rendering an administrative delay or denial
•    Evaluate the process for conducting peer to peer phone reviews.
•    The integration of bill review and UR to ensure bills are not paid for services that have been denied by UR
•    UR fits in with a pharmacy benefits management system.
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.
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. 
•    Specify any areas for improvement and savings.
5. Medical provider network (MPN)
•    Evaluate if MPN doctors are following other evidence-based guidelines when providing, 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. 
•    MPN doctors are referring patients to specialty or ancillary providers within the network. 
•    MPN doctors are providing appropriate and clearly worded work restrictions. 
•    Evaluate procedures are used to resolve complaints re: medical providers
•    The MPN website is user-friendly. 
•    The MPN website is customized for the county. 
•    Provider lookup process is easy to navigate. 
•    MPN contains sufficient providers in all the appropriate specialties needed for an employer that is the size and complexity of the county.

- Questions/Inquires Deadline: November 21, 2025