Third Party Administration Services

The vendor is required to provide third-party administration (TPA) services required:
• Administrative services;
• Settlement authority and consultation;
• Litigation management;
• Banking procedures;
• Loss fund reconciliation;
• Workers' compensation claims services;
• Workers' compensation first notice of injury services;
• Workers' compensation network access services;
• Workers' compensation medical bill review, cost containment and audit services;
• Workers' compensation pharmaceutical benefit management services;
• Third party liability claims services;
• First party claims services; and
• Loss statistic services.
- Claims and organizations include:
• Although any resulting contract will be with the county, the self-insurance program maintained by the county for workers' compensation and third party liability includes the county (board of county commissioners), the clerk of the circuit court, the property appraiser, the supervisor of elections, the tax collector and any affiliated or subsidiary board, authority, committee, independent agency or other organization (including newly constituted) provided that such affiliated or subsidiary board, authority, committee, independent agency or other organization is either a body politic created by the county, or the listed constitutional officers, or one in which controlling interest or membership therein is vested in the county or the listed constitutional officers.
- Staffing requirements:
• ONE (1) designated liability adjuster
• One (1) designated workers' compensation medical only adjuster
• One (1) designated workers' compensation loss time and legal/litigation adjuster
• One (1) designated telephonic nurse case manager
• Additional adjusting staff to be assigned, in coordination with the county, as needed to provide the required services.
• Appropriate supervision
• Proposers who provide the county input and approval of staffing.
• Access to Spanish speaking adjusters for situations when injured workers are more comfortable conversing in Spanish.
• All phone conversations, discussions and meetings held shall be clearly documented in the claim file.
• The third-party administrator is responsible for providing all IRS required form 1099's to vendors relating to vendor services.
- Compliance with rules of division of workers' compensation:
• Respondent agrees to reimburse the county for payment of any fines, penalties or assessments assigned by the state for failure to comply with such rules and regulations, including EDI reporting, associated with the performance or responsibility of the service company.
• All penalties and interest incurred due to any audit of claims management by the state, or their representative(s), and shown to be the TPA’s responsibility, shall be paid by the TPA.
• The county, or their representative reserves the right to request, and obtain in a format and place of the county’s choosing, any documents including but not limited to adjuster’s notes, medical bills, forms and the like necessary for the claims management services to comply with all applicable state, federal and administrative codes.
- Administrative services
• In accordance with state mandated time frames, prepare (with the county’s assistance) and file with the appropriate state agencies all applications, bonds, documentation, and data required (if any) for implementation and continuance of the program.
• In accordance with state mandated time frames, prepare, maintain, and file all records and reports as may be required by legal authorities (state, local, and federal).
• In accordance with state mandated time frames, prepare, maintain, and file statistical information required by workers' compensation rating bureaus and, as applicable, medicare secondary payor, or other appropriate state agencies, including EDI and data necessary for the promulgation of experience modifications.
• Assist the county with its return-to-work program, including identifying return-to-work opportunities.
- Litigation management
• Defense counsel will be a county assigned counsel.
• The adjuster must conduct a litigation planning session with defense counsel in order to develop a strategy for the management of the claim in the most efficient and economical way.
• Billing: billings should be itemized on a per claim basis, by date, activity, hourly rate, and time. 
• They should be forwarded to the adjuster monthly.
- Workers' compensation pharmaceutical management services
• Provide details regarding its recommended prescription benefit management (PBM) vendor services.
• Include information regarding the PBM's network access, utilization review services, provider penetration guarantees and coordination of claims data and reporting.
- Banking procedures
• The respondent will pay county claims expenses by means of checks issued on a designated claims payment account established and funded by the county.
• The respondent will be responsible for the administration of the designated account, including, but not limited to, performance of monthly bank reconciliations and related activities. 
• The county will pay all customary bank service fees on the designated account.
• Assume liability for unauthorized or improper transactions on the designated account including errors, fraud, forgeries, fraudulent checks, e-checks, unauthorized debits or credits, and claims by third parties who are a holder in due course as described in the uniform commercial code, and reimburse the county for all banking fees, charges, fines, and other losses related to such improper activity on the designated account.
• The format of the file shall be developed in collaboration with the county and the designated bank.
• Provided limited on-line access, if available, to the designated account for the purpose of adding and canceling issues (handwritten re-issues and voids).
• Take appropriate action to review and clear checks outstanding more than ninety (90) days on the designated account including, but not limited to, notification to the payee.
• Provide a bank account specification sheet for the designated account to the respondent
- Workers' compensation claims services:
• Establish reporting procedures which are compatible with the needs and organizational structure of the county.
• Provide necessary forms and instructions for use.
• Provide customer toll-free phone line for employees.
• Enhanced efforts shall be taken to identify possible fraudulent claims including recorded statements from claimants and discussions with the injured worker's supervisors
• Review all medical bills and bills for other services for which a claim is being made for reasonableness and conformity to rules, regulations, and legally imposed medical and surgical fee schedules.
• While working in conjunction with the county assigned counsel, aggressively pursue all possibilities of subrogation, excess insurance reimbursement, third party liens, contribution or indemnity and/or recovery from special or second injury funds on behalf of the county.
• Aid in communications/coordination with the county's safety staff as necessary including providing claims data needed to target safety, prevention and loss reduction initiatives.
• Receive and examine on behalf of the county all reports of employee injury claims.
• Coordinate data between first report of injury and claims administration system.
- Workers' compensation network access services
• Provide the county access to a provider network that contains appropriate providers.
• The county is interested in working with the proposer to assure that high quality providers, particularly in key specialties, are encouraged to participate in the network and who contractually agree to preferred appointment setting criteria, reporting and standards to best address the medical and rehabilitative needs of the county's injured employees.
• Key specialties include internists, orthopedics, neurology, neurosurgery, occupational medicine, pulmonology, infectious disease, ear/nose/throat, allergists, psychiatry and psychology.
• Provide reporting regarding network access, provider costs and outcomes.
- Workers' compensation medical bill review, cost containment and audit services:
1. For medical bill review:
• Duplicate billings
• Unbundling of charges
• Upcoding of charges
• Approval and appropriate precertification
2. Review all medical bills that:
• Are not subject to fee schedule coding
• Are for services not specifically addressed in the fee schedule
• Need an in-depth medical interpretation of the rules and regulations
• In the exercise of professional judgment, specifically warrant review.
3. For medical auditing services:
• Audit all in-network and out-network hospital/provider bills exceeding five-thousand ($5,000.00) dollars.
• Develop and provide communication materials to explain the policies and procedures of the medical bill review and audit services to medical providers.
- County administered claims:
• The county will administer and adjust in-house any first party claims.
• The county will administer and adjust in-house third-party property damage claims which have a maximum settlement amount of $9,999 or less per claim.
• Provide county staff with secure access to its electronic claims information systems for the purposes of managing the county's in-house administered claim files.
• The county currently handles some claims in-house.
• For those claims, the current TPA provider will provide secure passwords to so that we are able to enter claims and documents.
- First party claims services:
• Respondent is required to make available, on an as needed basis, first party claims services to include assistance with automobile physical damage claims and also assistance with claims involving physical damage to property other than automobiles. 
• Such first party claims services shall be provided solely at the request of the county and paid at the proposed hourly rate.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: July 3, 2025