Worker's Compensation Third Party Administrator Services

The vendor required to provide worker's compensation third party administrator services to telephonic 24-hour claim intake process where injured employees can receive treatment advice and claims can be filed.
- Requirement:
•    Receive notice of, and create files for, each claim reported and maintain these files for the county for the prescribed statutory period. 
•    It is understood that the files remain the county’s property. 
•    Investigate all claims, as required or at the request of the county, to determine validity and compensability. 
•    Special investigations that require the use of outside investigators will be conducted at the direction of the county. 
•    In coordination with county risk management, timely acceptance of clearly compensable claims, determine and issue appropriate benefits due. 
•    Ensure a balance between an employee-focused approach and being good stewards of county funds. 
•    Establish contact with the county within 1 business day of claim notification on all claims and report-only incidents. 
•    Establish contact with the injured worker and medical provider within 1 business day on all indemnity claims. 
•    Establish contact with medical provider within 2 business days on all medical only claims. 
•    Establish contact with injured worker at the discretion of county risk management on any medical only claim. 
•    Follow up on unsuccessful attempts must be made via letter or email until voice-to-voice contact is made. 
•    Make timely payments of benefits due to injured workers in accordance with payment procedures established by statute, administrative rules, and county policy. 
•    This includes calculating and paying any temporary partial disability payment due in addition to pay continuation. 
•    Further, any additional payment of benefits to the injured worker, medical provider or other parties must be made timely and in accordance with statutory requirements. 
•    The county shall be responsible for providing such funds as may be required for payments. 
•    Prepare documentation and defense of cases to be litigated; assist legal counsel selected by the county in the preparation of cases for hearing, appeal, and trial. 
•    Represent the county at the workers' compensation board hearings and at mediations and any other conferences with legal counsel as required. 
•    It is the expectation that claims staff will partner with county risk management staff and designated counsel in the resolution of litigated issues. 
•    Maintain active engagement with claims throughout litigation.
•    Maintain pertinent data on all claims payments in a manner approved by the county and provide such information to the county in an approved format. 
•    Produce and submit in a timely manner all required workers’ compensation related reports required by the department.
•    Manage and administer all workers’ compensations claims according to the rules, guidelines and regulations outlined by department 
•    Implement and maintain the ability for county employees to file claims using a 1-800, 24/7 phone number with a telephonic nurse triage and an internet-based claim intake system. 
•    Implement and maintain any required outgoing and incoming data feeds from and to the county’s internal risk management information system (RMIS) (currently origami risk) and county’s employee database system (currently workday.) 
•    Maintain an information technology system available to county risk management 24 hours a day, 7 days a week. 
•    Online access to payments, claims status, notes, and reporting which tracks time loss, days on modified duty and provides the ability for the county to easily produce osha 300 logs, loss runs, payment registers, and any other reports the county may require. 
•    Respond by no later than the next business day to all inquiries regarding claims. 
•    This includes medical providers, employees, regulator etc. 
•    Establish and proactively maintain accurate claims reserves for the most probable cost of all claims, based on all available facts, when they become available. 
•    Review at least monthly or more frequently as the claim requires. 
•    Changes over $25k require county approval and should be accompanied by rationale and substantiated by case facts. 
•    With approval from the county the third-party administrator (TPA) will provide an adjuster with a minimum of ten years’ experience handling state workers’ compensation claims with a focus on indemnity claims. 
•    They should have experience working with public and governmental entities, preferably ones including law enforcement. 
•    Prepare written notification to the county’s excess carrier when claim reserves reach 50% of the self-insured retention levels and comply with all reporting requirements to the workers’ compensation excess carrier. 
•    Provide assistance and reports for excess workers’ compensation renewal and budget purposes as required by the county and its workers’ compensation excess carrier. 
•    Obtain approval from county risk management before assigning case managers, counselors, independent medical examiners, therapists, etc. 
•    Notify county risk management immediately, both electronically and via postal mail of any litigation, regardless of reserve.