Workers Compensation Certified Network and Cost Containment Services

The Vendor is required to provide for medical cost containment services through a workers’ compensation certified network for the self-insured workers’ compensation program and agreeable to engage in performance guarantees and deliverables agreement (PGA).
- Medical fee audit services
•    Provide to contractor the medical bills and reports that have been submitted for hospital services, physician services, prescription drug services, and other ancillary medical services and supplies.
•    The medical fee audit services to be provided by contractor under this agreement shall include the following:
o    Staff of professional bill auditors shall be responsible for all bill audits.
o    Audit staff shall keep apprised of changes in department rules and regulations that affect bill processing and contractor shall modify internal procedures to ensure prompt compliance with all department rules and regulations.
o    Assign a team of professional bill auditors and data entry
o    Automated medical bill review and adjustment services to be conducted in conjunction with the processing of workers' compensation medical bills.
o    Maintain paper copies of all hospital, physician, and pharmacy bills.
o    Return processed bills to the city’s TPA within twenty-one
o    When no payment is due on a bill, contractor shall mail a form and annotated bill or approved alternate to the provider.
o    Provide a toll-free telephone number for inquiries and complaints from providers and the city.
o    Computer system to maintain an on-line history of a minimum of 48 months of claim history for the city of all bills processed for the city to prevent duplicate payments, payments for unrelated charges, unbundling of charges, charges for surgery follow-up care, and over-utilization.
o    Provide monthly and annual statistical reports to the city showing the number of bills reviewed, dollar amounts reviewed, amounts of recommended reductions, total charges, net savings, percentage of gross and net savings, and return on investment ratio.
- Utilization review
•    Responsible for recommending cases for utilization review. 
•    Each recommendation from contractor shall include the parameters of review and estimated utilization review fee.
•    A utilization review will be performed by contractor only after the TPA adjuster responsible for the claim has approved the parameters and estimated fee.
•    Parameters may be expanded and estimated fees increased beyond the initial recommendations by contractor only upon approval of the TPA adjuster.
•    The TPA will not pay for utilization review services that exceed the scope of the approved parameters and estimated fees.
•    Utilization reviews shall include in-depth reviews of objective findings and treatments as documented in each claim record.
•    The opinions and recommendations stated in each review shall be medically reasonable and based on statewide medical practices.
•    Responsible for verifying the credentials of and ensuring the quality of the work product of all physicians, chiropractors, and physical therapists who perform utilization reviews on the city claims.
•    Utilization review findings shall be provided to the TPA adjuster within 14 calendar days after the date review findings are received by contractor.
•    Provide a paper copy of utilization review findings at the request of the TPA.
- Medical case management
•    Returning the claimant to productive employment; 
•    Acquiring certification of maximum medical improvement by the claimant’s treating physician and assignment of a medically reasonable impairment rating; 
•    Gaining or maintaining control over medical expenditures; and 
•    Bringing closure to a claim.