Workers' Compensation Third Party Administrator Services

The Vendor is required to provide workers' compensation third party administrator services for include:
- Administrative services
•    Any required 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 any required time frames, prepare, maintain, and file all records and reports as may be required by legal authorities (state, local, and federal). 
•    Prepare and follow service instructions that have been approved by the county in the handling of the county’s claims. 
•    The service instructions shall outline the details of the expected tasks, timeframes for completion and authority levels for all claim activity. 
•    Provide monthly and annual reports summarizing claims and shall recap each year’s experience, including prior years, to date. 
•    The reports shall be on a fiscal year basis, with an October 1 anniversary. 
•    Reports shall be provided within 30 days of the end of the period for which each report applies.
•    Prepare, maintain, and file statistical or other records and reports as required by the county’s excess insurers. 
•    Report claims to the county’s excess insurer(s) in accordance with the requirements of the excess insurer(s) and include a copy to the county. 
•    Comply fully with all rules, regulations, guidelines or procedures established by the county and the state, including electronic data interchange (EDI), and Medicare secondary payer requirements. 
•    Any required time frames, prepare, maintain, and file statistical information required by workers' compensation rating bureaus, Medicare secondary payer, and other appropriate state agencies as applicable, including electronic data interchange (EDI) and data necessary for the promulgation of experience modifications. 
•    Prepare and distribute all required 1099 forms. 
•    Annually, provide the county with consultant’s soc-1 report and bridge letter. 
•    Provide the county with consultant’s procedures for response to emergencies, including the name(s) and office and telephone number(s) of consultant’s emergency contact(s). 
•    Have a business continuity plan for ensuring that in the event of an emergency, e.g., hurricane preparedness, how consultant’s services will continue, how the county’s employees will be paid indemnity, and how they will be instructed on obtaining medical care. 
•    Regularly keep the county informed of any significant regulatory or industry changes that may impact the county or its workers’ compensation program. 
•    Meet with county staff monthly to address any administrative items and meet quarterly for claim reviews to review any claims or overall program performance. 
•    Provide an annual stewardship meeting with program results and benchmarking information comparing the program with state and national data.
- Claims handling
•    Provide the county with consultant’s reporting procedures, such as but not limited to 24-hour telephonic or internet-based claim reporting and intake capabilities. 
•    Send first notice of injury to the state in a timely manner and accept responsibility for penalties for late notice to the state unless the delay was caused by the county. 
•    Receive and examine on behalf of the county all reports of employee injury claims timely and in accordance with state regulations and guidelines. 
•    Refer injured workers to appropriate medical services, and as appropriate and based upon pre-established criteria agreed upon by the county, provide immediate referral to specialty medical providers for injuries. 
•    Complete 3-point contacts: contact injured worker, supervisor, and medical provider, either in writing or orally, within 24 hours of consultant’s receipt of claim report and when assuming an already existing claim. 
•    Use its best judgment in settling or denying claims and in setting reserves for future payment, and perform the following functions regarding claims:
o    Comply with all applicable laws and regulations regarding workers’ compensation benefits. 
o    Perform necessary investigations and other measures to assure claim validity. 
o    Establish and maintain complete claims files on each claim. 
o    Maintain communication with injured workers, supervisors and medical providers at appropriate intervals (after medical appointments and claim milestones related to the plan of action) throughout the claim to determine status and next steps toward recovery and claim conclusion.
o    Assist the county with its ongoing efforts to maintain a stay at work program, including the creation and offer of light duty positions. 
o    Claim management throughout the light duty assignment, with regular reporting of status outcomes, in line with the requirements of the county light duty program is required. 
o    Properly review, process, and pay claims on a timely basis. 
o    Establish and update claim reserves. 
o    Obtain prior approval from the county’s risk manager or its designee on claim reserve increases in excess of $25,000.00. 
o    Provide copies of all pertinent medical, legal and investigative reports.
o    Prepare and maintain files necessary for legal defense of claims and other litigation or other proceedings, such as actions for subrogation, contribution, or indemnity. 
o    Attend hearings, depositions, mediations, and other proceedings as necessary. 
o    Prior to any scheduled proceedings, prepare status reports for county risk management staff outlining the case details, status, and plan of action to resolve the claim. 
o    Provide for timely notification of excess insurers, as required by excess insurance policies. 
o    Pursue all second injury funds, subrogation and other recovery opportunities. 
o    Consult with the county on the selection of and referral to outside professionals such as surveillance personnel, expert witnesses, and attorneys, to assist in the investigation, adjustment, and defense of claims.
- Banking and reconciliation services
•    The county’s claim funding account will be maintained at a financial institution chosen by the county. 
•    Consultant shall assist county in establishing a zero-balance loss fund account at a financial institution chosen by the county (the loss fund account). 
•    Consultant shall debit from the county’s designated account, via daily ach transfers, an amount sufficient to meet all claims payment obligations that were issued by consultant the prior day, and such amount shall be deposited into the loss fund account. 
•    The county reserves the right to direct consultant in writing regarding payment of claims. 
•    The county reserves the right to establish a limit on the amount of payment that can be made by consultant without county authorization; this will be outlined in the special instructions.
•    All claims or expense payments shall be made by consultant on checks drawn on the county’s claim funding account. 
•    All funds in this account are the county’s funds and shall be returned to the county upon request or termination of the contract. 
•    No payments due to consultant for administrative fees or reimbursable expenses shall be deducted from these funds.
•    Consultant shall provide the county with a monthly list of all checks issued for the prior month and outstanding checks by the 10th of the following month.