Case Management and Billing Services

The Vendor is required to provide case management and billing services to secure third-party administration, case management, and claims monitoring for injured on duty claims for the police and fire departments.
- These services shall include: receipt, processing, filing and maintenance of all claims-related forms, reports and notices as required and as needed for controlling losses; verification of all medical billings and determination of state authorized rates for payment; preparation and submission of checks for medical providers for review and issuance by the city; timely follow-up with physicians and claimants and investigation of cases, when necessary, to reduce exposure and costs; recommendations of appropriate salary payments for final decision by the city.
- Requirement:
•    Service provider shall review each claim and determine or provide written recommendations to the city, concerning indemnification or compensability
•    Service provider shall review all claimant medical bills. 
•    Said review shall include the examination of each bill for causation, appropriateness and medical necessity.
•    Each bill shall be set to the state rate setting standard utilizing the appropriate commonwealth CMR. 
•    Service provider shall generate and submit accepted medical and expense provider disbursements and vouchers to the city for payment; and return no approved bills to the provider for processing through the claimant’s group health insurance benefit.
•    Documented support shall be provided through all phases of the injured-on-duty claims management process. 
•    Collective bargaining agreements shall be reviewed for labor relations issues and will be recognized, adhered to and resolved where necessary.
•    This service shall be provided on a support basis.
•    All claims management services shall be provided within state time limitations. 
•    Medical bill review involving complex bills shall be completed within two (2) weeks of receipt.
•    Should medical providers not cooperate, service provider shall recommend withholding payment for services until such time as appropriate documentation is provided.
•    Service provider shall process and report loss data to designated re-insurer’s and to the city on a quarterly basis if applicable as required by the re-insurer.
•    Service provider shall have a demonstrated ability to resolve claims to and through a resolution. 
•    Said resolution shall incorporate a return to work and work hardening program, where applicable.
•    Provider shall attend all hearings, appeals and other administrative actions relative to retirement applications.
•    Service provider shall meet with the city and its committees, sub-committees, etc., on an as needed basis, for the purpose of discussing any and all open areas of concern. 
•    Service providers shall report to the city, all issues of safety, and provide recommendations on loss reduction matters as deemed appropriate.
•    Service provider shall have an established network of complementary service providers, including but not limited to independent physicians; physical therapists; pharmaceutical drug consultants; rehabilitative firms, etc.
•    Service provider shall provide a complete and thorough case management service in connection with chapter 41 111f injured on duty claims, including but not limited to the following:
o    Review of all collective bargaining unit contracts for police (two unions) and fire (one union) personnel. 
o    Obtain current medical information from treating physicians and physicians designated by the appointing authority to assess an employee’s ability to perform temporary modified duty assignments or regular duties.
o    Identify causal connection issues, taking into consideration the appropriate statute and recommend the appropriate means with which to deal with the issue(s).
o    Coordinate medical care and rehabilitation services 
o    Obtain and assess medical reports
o    Assist with work return possibilities and issues or case finalizing process in accordance with applicable case law and collective bargaining requirements.
o    Assist in developing “case-by-case”, case management strategy to provide the most positive outcome, relative to closure by means of a return to work or appropriate finalization to and including assistance in finalizing a proper retirement and employment termination scenario.
o    Prepare cases for, and assist with the retirement process, as dictated by the circumstances of the case.