Workers Compensation Third Party Administration Services

The Vendor is required to provide for third-party administration (TPA) services for its workers’ compensation (WC) program.
- Account Management
- Account manager: this individual will play an essential role in the successful administration of this program and should have authority and overall responsibility for the following key components of the program:
• Service agreement administration and management of TPA staffing on the city’s account.
• Performance incentive - authority to enter into a joint agreement of annual goals, objectives, and incentive amount with the city.
• Troubleshooting and providing effective solutions to resolve issues or problems with the service agreement and/or claims management services.
• Work with the city to identify key outcome-based measurements that are tracked and deliver program improvements and cost reduction results.
• Monitor claim trends and audit claim handling procedures to ensure a high level of customer service and best-in-class claim service deliverables.
• Coordinate regular claim reviews for the city, with the participation of the appropriate dedicated claim staff, city department representatives, other appropriate city staff and as needed; defense attorneys.
• Assist in the coordination of an annual stewardship meeting to present/discuss program changes, performance metrics, benchmarking, and claim trending/loss analysis reports.
• Provide or facilitate any custom data download, report requests and/or regular data feed to the city’s WC claim system (origami).
- Key claims administration requirements
• Employee appointments – monitor and schedule all physician treatment and evaluation appointments for its injured employees and provide notification to the employee and department representatives of pending appointments; in the event an employee misses an appointment, verify the missed appt within 24 hours and reschedule the appointment for the employee as quickly as possible.
• Provide a weekly status report listing all pending appointments for the week and any missed appointments from the prior week.
• Fraud control – aggressively investigate and control fraud and report all claims meeting the state fraud reporting guidelines.
• Pursue restitution in all fraud cases and notify the city of all claims involving potential fraud and initiation of fraud investigation activities.
• Claim Reviews – quarterly claim reviews on-site.
• Send dedicated claim staff to attend claim reviews.
• Litigation reviews are required on a semi-annual basis and the presence of defense counsel at these reviews will be required.
- The TPA’S risk information system must have the following abilities:
• Cloud-based claim system with access 24 hours a day, 7 days a week to view claim adjuster and supervisor notes, generate loss runs or other pre-scheduled or ad hoc loss management/claim reports.
• Provide RMIS technical support for questions, problems or development of customized reporting.
• Quality control program to ensure data integrity and claimant confidentiality; any RMIS problems will be resolved within 24 hours or less.
• Provide a list of occupation codes, injury codes and payment type codes.
• Image system to scan all documents received pertaining to the case.
• Secured system that may include, but not limited to; security audits, protected by intrusion prevention and intrusion detection systems, communications of any claimant’s personal information or personal health information is protected (i.e. monitoring of email and internet traffic, encrypted email, access restricted by user id and password, or other similar security methods).
• Describe disaster recovery plan regarding the continuation of your claims management and risk management information system.
- Contract Period/Term: 5 years
- Questions/Inquires Deadline: April 17, 2025