Third Party Administrator Services

The vendor is required to provide from qualified third-party administrators (TPAs) for claims administration of boulder county’s workers’ compensation program.
- This request is for comprehensive claims administration services to include managed care, information systems, and any other costs of business associated with claims administration appropriate for the management of the program.
- The proposing firm’s staff should have proper licensing to perform claims administration services. the proposing firm should have a strong regional presence in state and depth of staff necessary to perform the claims administration services requested now and into the future.
- TPA partner who demonstrates an innovative and effective claims management process that is streamlined and user-friendly, has strong customer service focus, solid reporting capabilities, effective technological capabilities, proactive and consistent management of employee occupational absences, competitive rates and fees, and the ability and willingness to comply with boulder county’s performance standards
- Key service benchmarks and goals include:
• Engaged and experienced service team
• Focused management of the return to work (RTW) process
• Prompt access to authorized treating providers
• Responsiveness – within 24 hours
• Manageable caseload of no more than 125 indemnity or 300 med only
• Management support
• System support, including data migration
1. County utilizes origami as its RMIS
• Knowledge of state public safety including law enforcement
• Coordination of benefits (job injury leave)
- Program administration
• Provide staff, professional and clerical, as required to administer county’s workers’ compensation program in compliance with all rules and regulations governing the administration of self-insurance pursuant to state revised statutes and by 7 state code of regulations 1101-4.
• Prepare a claims manual for use by county.
• This manual shall specify claims activities and processing, organization of claims files, and procedures for reporting industrial injury claims.
• TPA shall conduct or assist in conducting orientation meetings for the personnel directly involved in processing such claims not less than one time per year.
• Provide to county information on changes or proposed changes in statutes, rules, and regulations affecting county’s responsibility and the responsibilities of its members under a self-insured workers’ compensation program.
• Review with county the program progress, including identification of problem areas, and recommend solutions.
• Provide consultative services as required to assure success of the program.
- Claims administration
• Review and process all claims for workers’ compensation benefits in accordance with the requirements of the state for reporting and notification.
• Determine the compensability of claimed injuries and illnesses in accordance with the state workers' compensation laws, statutes, rules, and regulations.
• Determine eligibility for and recommend payment of medical benefits and authorize examinations to determine the nature and extent of disability when appropriate.
• Obtain and evaluate medical expert opinion as to the nature, extent and duration of temporary disability and the amount of any residual permanent impairment to be anticipated.
• Review, compute, recommend and authorize payment of temporary disability and permanent impairment benefits due an injured employee whether paid voluntarily or under decisions, orders, or findings and awards of the division of workers’ compensation.
• Refer litigated cases to attorneys acceptable to boulder county. assist the attorneys in the preparation of litigated cases, negotiations of settlements, and subrogation actions.
• As necessary and appropriate investigate, or arrange for investigation of, questionable cases and the status of disabled employees.
• Review claims which involve a suspicion of fraud with boulder county. maintain a heightened level of administration for management of these claims.
• Represent boulder county at hearings which involve workers’ compensation claims against boulder county.
• Report claims, maintain records on, and effect collections from, excess reinsurers on behalf of boulder county.
• Administer claims promptly to avoid self-imposed penalties and penalties for unreasonable delays. boulder county reserves its right to be reimbursed for all administrator-caused penalties and interest. such payments shall be reported to boulder county monthly.
• Notify boulder county of reserves exceeding $50,000 and for any future increases or decreases in any amount modifying the reserve for the life of those claims exceeding a $50,000 reserve.
• Prepare and file, in a timely manner, all reporting which are now, or will be, required by the state or other governmental agencies with respect to self-funded programs. prepare and provide reporting necessary for actuary.
• Calculate and maintain accurate records for temporary disability benefits with consideration of job injury leave provided by county
- Medical administration and control
• Evaluate the performance of the authorized treating providers to ensure quality medical care, optimal recovery outcomes, accurate medical reporting, consideration of work relatedness, identification of co-morbidities, past medical and injurious history, and any other areas which may ultimately affect optimal outcomes.
• Performance of authorized treating providers must be part of monthly, quarterly, and annual meeting discussions.
• Monitor treatment programs for injured employees, including review of all "doctor's first report of work injury" to assure that treatment is related to a compensable injury or illness.
• Maintain close liaison with treating physicians to assure that employees receive proper care and to avoid over-treatment situations.
• Utilize telephonic and field nurse case management with approval of boulder county to obtain reasonable treatment plan and targets for return to work and medical improvement.
• Authorize hospitalization, surgery and any other types of approved treatment as required after determination of liability in conformance with division of workers’ compensation rules of procedure.
• Review, audit, compute, and authorize payment of all medical bills in conformance with the medical fee schedule.
• Provide liaison with any cost containment services with whom boulder county chooses to utilize.
• Complete administration and processing of all medical cases awarded or ordered by the division of workers’ compensation.
- Legal services
• Manage a panel of attorneys approved by boulder county who specialize in the defense of workers’ compensation litigation. monitor all litigated cases until final disposition is rendered.
• Consult with boulder county and attorneys as required to ensure that all facts and investigations necessary will be available on a timely basis.
• Ensure that necessary subpoenas for records and/or witnesses are issued and depositions taken.
• Ensure timely filing and serving of answers and of medical records requests.
• Review and consult with boulder county and on all proposed settlements. approval of all settlements on claims must be secured from boulder county before settlement negotiation takes place.
• Protect the interests of boulder county in third party cases, including protection of statutes and filing of complaints in subrogation, where appropriate.
- Employee services
• Provide information and guidance to the employees of boulder county members regarding workers’ compensation benefits, inquiries on specified injuries and permanent impairment ratings.
• Assist in resolving employee problems related to an industrial injury claim.
• Proactive communication with employees is required to ensure that there are no surprises with claim decisions, including the need for further investigation, denial of benefits, and documents pending that will directly affect the employees access to benefits.
• Assist in the development of policies and procedures as needed to accommodate an employee’s temporary or permanent restrictions.
- Reporting services and record retention
• Loss experience report
• Location report
• Organizational structures
• Trend analysis
• Loss narrative report
• Management summary report
• Monthly claims summary report
• Monthly incurred change report
• Monthly claims financial report
• Annual report to state
• Review of large and litigated claims
• Penalty and interest payment report
• Authorized treating provider report cards
• Actuary review report
• NCCI filing
- The claims administrator is responsible for working closely with boulder county’s risk management in reconciling the loss runs in total and current activity to the cash activity.
- Financial workflows will be determined upon TPA selection and understanding of financial needs.
- Claims administrator will provide necessary documentation in a timely manner:
• Weekly claim payment registers so that claim clearing bank accounts may be adequately funded.
• Quarterly activity reconciliations by line of coverage of claims paid, voids, refunds, recoveries, vouchers, and any other adjustments that are needed to reconcile the loss run reporting to the cash transactions.
• Maintain a listing of excess recoveries outstanding by claim including a listing of amounts that are calculated but not recoverable.
• Any amounts not recoverable should be brought to county for review and approval.
• Quarterly and annual loss report in excel format period to date (all) that summarize by:  o Reserve category
o Banking
o Shared
o Excess
o The above reports will be provided both by policy year and office or department.
- Imprest accounts
• County shall establish imprest accounts to cover payments and reimbursements applicable to the self-insured workers’ compensation program and any other programs as necessary.
• Deposits shall be made to the account as required to ensure that funds are available for payment of claims for settlement and allocated loss expenses upon presentation of check or warrant
• TPA shall not draw on the imprest account for any purpose other than adjustment of claims and payment of allocated loss expenses.
• TPA service and fee payment shall be submitted separately for review, approval, and payment.
• The TPA shall monitor the imprest and make recommendations to boulder county as to the appropriate level of funding to comply with established laws.
• The TPA shall be responsible for uploading transactions for each check run for positive pay and be responsible for monitoring and following up on positive pay exceptions on a timely basis
• The TPA shall provide boulder county with a detailed accounting of all benefits and allocated loss expenses paid from the fund on at least a monthly basis
• The detailed accounting shall include the date and check number of all benefit and allocated loss payments and shall also include appropriate supporting documentation for allocated loss expense payments
• A monthly check register summary shall be provided
• The TPA is responsible for erroneous payments made from the account by their error and any such payments shall be reimbursed separately by the TPA.
• TPA shall develop, implement, and maintain security procedures to ensure safeguard of funds in the account and the bank checks.
• The TPA agrees that boulder county shall have access to and the right to examine, audit, excerpt, copy, or transcribe any pertinent records pertaining to the contract.
- NCCI filing
• The TPA shall complete all reports and erm-6 forms necessary to file for the WC experience rating.