Workers Compensation Third Party Administrator and Managed Care Cost Containment Services

The vendor is required to provide workers’ compensation third party administration (TPA) and managed-care cost containment services for the district’s self-insured workers’ compensation program.
- Claims administration:
• All aspects of complete claim administration from the inception of the claim to closure of the file, including all run off claims (estimated 400)
• All claims’ files and records are the property of the city public schools.
• All new losses are to be assigned and entered into computer system within 24 hours of receipt.
• Reserving of all claims for anticipated final costs. step reserving is unacceptable.
• All bodily injury claims are to be filed with the index bureau system at no charge to the district.
• All claims with questionable medical casualty, serious exposure or subrogation, investigatory services are to be initiated including statements, etc.
• Three-point contact to be made to claimant, claimant attorney and claimant supervisor by adjusters within 24 hours of receipt.
• Investigate each reported claim to determine validity and compensability.
• Maintenance of all claims medicals as well as indemnity;
• State of the art statistical reporting to allow for monthly claim reports
o Ability for district staff to work within the claims system
o Provide regular copies of detailed reports, including but not limited to repeater reports, safety standing reports, etc. on monthly basis
• The reinsurer as well as the district staff.
• Initial indemnity payments on all lost time cases shall occur within 21 days of receipt of loss and medical bill or bills should be processed or paid within 10 working days of receipt.
• Coordinate all legal handling through the district’s selected defense counsel together with providing updates on case status to the district’s staff counsel as well as the business office.
• Provide effective and timely assistance and documentation to legal counsel on litigated cases
• Maintain and report complete loss and payment information as well as cost allocations by school, division and department within the electronic risk master system.
• All claim petition cases estimated with settlement valuation over $15,000.00 must be discussed with the board of education legal counsel as well as the business office.
• The TPA must have the ability to direct all medical care to the selected PPO and MCO network.
• The TPA adjusters must review all treatment plans with the MCO to ensure the delivery of high quality inspections, signed statement investigations, etc. at no additional charge to the district.
• To assure maximum claim handling, indemnity adjusters’ caseloads should not exceed 175 files.
• All claims will be handled to their ultimate conclusion regardless of whether contracts are renewed or extended.
• Maintain and produce PEOSHA reports to business office
• Proper reserve analysis; litigation management, excess claim reporting as well as fraud case maintenance;
• Maintain a computerized diary, in the adjusters’ notes, for each district claim, to include appropriate documentation regarding action and timing.
• Provide all treating physicians with documentation of injured employees’ essential job duties with an emphasis on early return to work practices, in close coordination with the district’s designated representative.
• Attend regularly scheduled meetings and conduct periodic in-person file reviews of claims as may be requested.
• Provide loss/status/control analysis and associated financial reports, no less than monthly, to be used as management tools by the business administrator, designee.
• Provide utilization review and approval for all consults, diagnostics, physical therapy, pharmaceuticals and other employer controlled medical services.
• Investigate and pursue all potential subrogation issues on behalf of the district.
• On a bi-weekly basis a preliminary check run must be submitted to the district in a manner that is acceptable and beneficial to the district. mandatory legal payments such as judgments, orders approving settlements, dismissals, etc., should all be on the same check run.
• The ability to have the check run modified to meet future needs.
• Comply with all state and federal statutes and rules & regulations applicable to workers'
• Compensation and third-party administration services;
- Managed care services:
• Early interventionelephonic case management
• On site and field case management and catastrophic case management
• Telephonic case management to include:
o Client managed care procedures observance
o Hospital bill pre-screening
o Development of treatment/return-to-work plans (in conjunction with transitional work plans)
o Pre-certification of outpatient treatment plans
o Direction, monitoring and support of on-site case managers
o Managed care plan recommendations and updates in electronic claim file records
o Utilization management services
o Medical bills negotiation and re-pricing
o Medical provider network
o Pharmaceutical product plan
o Physician peer review services
- Preferred provider organization network
• The TPA shall participate in and make available with the district’s final selection, an established and extensive preferred provider organization network, as well as pharmaceutical and medical appliance programs.
• These services must provide significant savings below the usual and customary fees contained within the state medical fees schedule.
- Bill review services
• The TPA shall provide bill review services for all invoices received unless otherwise specified by the district.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: April 28, 2025