Third Party Workers' Compensation, Claims Administration and Ancillary Services

The Vendor is required to provide for the administration of claims, third party administration of the district’s self-insured workers’ compensation program, and ancillary services (the "services").
- TPA services
•    The services you propose to provide the district. 
•    Use sufficient detail so that the district can determine what occurs during the life of a claim that is processed in your claims management system. 
•    It is important to demonstrate a proactive case closure system for existing and future claims.
•    Maintain communications with district risk management staff and the supervisors of injured employees
•    Communicate with injured employees and how frequently
•    Assist the district to meet its legal requirements to educate employees about the workers compensation systems
•    Assist district risk management staff to stay informed with regard to legal requirements and best practices in workers compensation case management
•    Keep the risk management division updated on the financial trends exhibited by the district’s plan
•    Able to prepare claims information required by the district’s consulting actuary and excess insurance carrier
•    Ongoing relationships with medical providers in the district’s geographic area, which will provide the timeliness and objectivity of reporting, required for the effective administration of benefits
•    Existing relationships with the workers’ compensation legal community in district so as to enable you to assist in selection of the most effective attorney to handle each litigated case
•    Existing relationships with the workers’ compensation investigator community in district so as to enable you to assist in selection of the most effective investigative firm to handle each case requiring such a referral
•    Advise of your proposed take-over fee which would be charged to facilitate your assumption of control and data conversion of existing files claims management.
•    The staffing levels you will have in place to administer this account including how staff members will be assigned files.
•    Plan to provide staffing for the district account should you be awarded the TPA contract. 
•    This point should be answered from the perspective that the district will insist on experienced, dedicated adjusters being assigned to manage the body of claims in existence and that will occur in the future.
•    Forth your criteria for referring cases for medical case management ("mcm".)
•    Criteria for making utilization review (“UR”) referrals.
•    Criteria for referring cases for investigative services.
•    Criteria for referring cases for legal defense services.
•    Assuming you are selected to perform only a portion of the services describe your ability to work with other ancillary providers in an integrated manner that maximizes effective claims management for the district.
- Ancillary services
•    Medical provider network (MPN)
•    Ongoing relationships with medical providers in the district area, which will provide the timeliness and objectivity of reporting, required for the effective administration of benefits
•    Provide a list of contracted providers within district by type of facility or specialty and describe your selection procedures for physicians and ancillary providers.
- Utilization review (UR) 
•    Methodology in handling referrals, meeting mandated timelines for decisions, handling peer review and appeals, and communicating UR issues with all parties.
•    Set forth your proposed criteria for determining the types of issues that should be referred for UR while ensuring statutory compliance and maximizing cost effectiveness.
- Bill review 
•    Medical bill review is currently required on every billing processed by the TPA. 
•    The district has found this to be cost-effective. 
•    Process for receipt and assessing bills for review. 
•    It is important to gain an insight into your administrative process to ensure confidence in accuracy of payments compatible with official medical fee schedule (“OMFS”).
•    Provide an appropriate annual administrative fee for services commensurate with true administrative costs and an acceptable profit margin?
- Medical case management (mcm)
•    To perform services related to auditing of medical bill review, PPO, UR and case management fees for accuracy of billing.
•    Perform services related to providing on-going consultative advice on the cost, structure and effectiveness of managed care services.
•    Ability to perform services under a percent of new savings identified and recovered pricing model. 
- Banking
•    Procedures for claims payment and accounting of district funds.
- Claims handling
•    Claims philosophy. 
•    Approach to handling claims and ensuring their timely resolution including you plans of action for claims. 
•    Plan to achieve the most efficient and best probable outcome of a claim.
•    Compliance with statutes and regulations.