Third Party Administration Firefighter's Workman's Compensation Claims Services

The Vendor is required to provide the city currently utilizes the services of a third-party administrator (“TPA”) for the purposes of adjusting workers' compensation claims for the city’s self-insured sworn firefighters within the city’s fire department.
- Pharmacy Benefit Management (PBM) shall be incorporated into the proposal's responsive documents. The current PBM is Mitchell Pharmacy Solutions, and the current PBM is self-performed by the current TPA
- Preferred Provider Organization (PPO) is self-performed by the current TPA.
- A Risk Management Committee, comprised of five (5) senior City officials, meets monthly to review and approve all claim settlements of $25,000 or greater.
- Claims Management/Loss Control Emphasis:
•    The City’s elected officials and top management teams have a longstanding commitment to a sound risk management program with special emphasis on claims management and loss prevention/reduction. The Risk Management Division provides administration and oversight of the claims adjusting function. Employees with the Risk Management Division perform safety audits and implement loss prevention programs, including loss prevention training for the City.
•    Through September 30, 2020, the City currently had excess carrier coverage that covered all City self-insured programs. As of October 1, 2020, the City no longer has excess carrier coverage over worker’s compensation claims.
•    There are currently eighty-seven (87) claims and approximately half of those are indemnity claims.
•    There are currently six (6) sworn firefighter claims that are piercing the excess carrier’s coverage.
- Risk Management Committee: This Committee is charged with responsibility for, and guidance of, the self-insurance program. The Committee is comprised of high-level administrative executives who are uniquely familiar with, and committed to, the goals of the program. This Committee is also responsible for the review and approval of all settlements greater than $25,000.
- Light Duty Program: The City has an aggressive light duty program and most employees can be temporarily placed in sedentary positions.
- Workers' Compensation Claim Service Standards
•    Participate in claim reviews of selected files.
•    Act as service provider representative on any claim issues or problems.
•    Act as liaison between the insurer, adjusters, field staff, Medical Network, Claims Information Systems department, and City
- A diary system will be established so that each medical only case is reviewed by the adjuster at least every sixty (60) days, or more often as needed.
- A realistic reserve will be established within five working days. Reserves will be reviewed at 30 days, 60 days, 90 days, and at least every six months thereafter. File notes must reflect reserves were reviewed.