Workers’ Compensation TPA and Managed Care Program Services

The Vendor is required to provide workers’ compensation claims administration and managed care services for all existing claims (open and closed) and new claims for the agreement term.
- TPA does not provide medical cost containment or other ancillary services through an internal managed care division or affiliated vendor partners.
- Requirement
1. Program administration
•    Interface directly with the city’s injured employees in close coordination with the city’s risk management division. 
•    Maintain effective communication with city staff regarding claim status, issues, and developments. 
•    Advise the city of proposed or enacted changes in statutes, rules, regulations, and case law that may impact the city’s workers’ compensation program. 
•    Administer claims in accordance with all applicable federal and state laws, regulations, and the city’s alternative dispute resolution (ADR) program requirements.
2. Dedicated and designated assigned personnel
•    The TPA shall provide adequate staffing to perform all services outlined in the contract in a manner satisfactory to the city. 
•    The contract shall specify an appropriate maximum caseload per claims examiner and include a staffing and implementation plan. 
•    The TPA shall assign a designated claims unit supervisor responsible for regular review and oversight of the claims examiner(s)’ work product. 
•    All claims examiners assigned to the city must be certified by the state and have demonstrated experience handling workers’ compensation claims for public safety officers.
3. Claims management services
•    Administer workers’ compensation benefits in full compliance with the state labor code. 
•    Make initial contact with the injured employee and establish a claim file within twenty-four (24) hours of receipt of the employer’s first report of injury for the city. 
•    Maintain claim files that are available for review by the city at any time during the TPA’s regular business hours. 
•    Resolve city-identified issues immediately and to the city’s satisfaction, which may include reassignment of claims examiner staff when necessary. 
•    Make and document compensability determinations (acceptance, denial, or delay pending investigation), including the rationale for each determination. 
•    Provide guidance and information regarding workers’ compensation benefits to city employees. 
•    Respond to city staff inquiries within twenty-four (24) hours and address critical issues on the same business day. 
•    Monitor medical treatment programs to ensure injured employees receive appropriate care and to prevent excessive or unnecessary treatment. 
•    Establish initial claim reserves and continuously review and adjust reserves throughout the life of each claim to reflect current exposure. 
•    Identify and pursue suspected abuse of the workers’ compensation system or potential fraud. 
•    Investigate questionable claims and, with the city’s consent and coordination, recommend and facilitate independent outside investigations. 
•    Obtain prior authorization from the city for all claim settlements. 
•    Notify the city of all penalties incurred due to the TPA’s failure to comply with statutory requirements or reimbursement obligations. 
•    Such penalties shall be the sole responsibility of the TPA and reimbursed to the city on a quarterly basis. 
•    Identify subrogation opportunities and, in consultation with the city’s risk management division, pursue subrogation when appropriate. 
•    Conduct file and claims review at the discretion of the city. 
•    Assist with the ongoing development, administration, and continuous improvement if ADR carve-out programs in compliance with state labor code requirements.
4. Claims management software
•    The claims management software should provide a claim description, financial data, and ad hoc reports on claims using criteria such as reserves, paid, indemnity, etc. 
•    The claims management system must be read-only accessible to city risk management with licensing allowing a minimum of three (3) individual computers to access claim information simultaneously. 
•    The selected firm will be required to provide training to risk management staff on report generation and the use of software.