Workers’ Compensation Bill Review, Pharmacy Benefits, and Physical Therapy Services

The Vendor is required to provide a self-insured and self-administered government entity providing workers compensation coverage to more than 14,000 employees, and processing approximately $6.5m in medical payments annually.
- Provide a detailed accounting of all savings, duplicate bills, prescription charges and physical therapy charges with the agency invoice. Bill review charges must be billed at least monthly.
- The average number of bills received is 9,000 annually. For fiscal year 24-25, the number of bills received was 8520 with a total amount billed of $7,646,178.69; these totals are less duplicate billings.
- A pharmacy benefit manager (PBM) to provide workers’ compensation prescription benefit management services through a network of pharmacies.
- A physical therapy service network (PTSN) provider to provide a network of physical therapy service providers on an as needed basis for the county employees on workers’ compensation.
- Review individual bills and identify improperly coded medical procedures. Notify provider of incorrect coding, return invoice for proper coding, and instruct provider on resubmission procedures
- Track prescription usage and alert the agency assigned adjuster for potential abuse when identified.
- County has contracted with certain vendors at below-state-mandated fee schedules, agency shall scan, and upload bills and attachments from these vendors into the county’s claims database, without processing, at no additional cost.
- Check writing services shall also include internal revenue service (IRS) form 1099 filing and associated follow-up, bank reconciliation, and bank fees specifically related to such processing.
- Must be able to interface with origami risk database, a web-based risk management software system, to include the following data interface (at minimum) at no additional cost to the county:
• Claim file
• Vendor file
• Payment file
• History load (history data to be provided by the incumbent bill review vendor)
• Check number and payment information import
• Master Boot Record (MBR) interface
- The report shall include the following categories:
• Total dollar amount of bills submitted for audit
• Bill review reductions
• PPO reductions
• Recommended allowance
• Gross savings
• Gross percentage of savings
• Total monthly fee for service
• Overall net savings
• Net percentage of savings.