Workers' Compensation Third Party Administrator and Managed Care Services

The Vendor is required to provide workers’ compensation third party administration and managed-care cost containment services for the district’s self-insured workers’ compensation program.
- The selected TPA shall maintain continuous coordination with the District’s Human Resources, Finance, and Legal Departments, as well as designated outside counsel, throughout the duration of the engagement.
- These services will be provided under the direction of the District’s Insurance Consultant and Business Office in accordance with agreed upon terms and compensation.
- The claims administrator will serve under the auspices of the District’s Business Office and the Insurance Consultant of the District. The District has approximately 6000 employees.
- The TPA shall maintain a high level of professionalism, responsiveness, and technological capability to support the district’s workers compensation program through the following:
• Coordination of communications between injured workers, District personnel, medical providers, attorneys, and other involved parties
• Prompt investigation and evaluation of claims to reduce unnecessary litigation exposure and identify potential fraud
• Active pursuit of subrogation opportunities and Second Injury Fund recoveries where appropriate
• Effective medical cost containment practices designed to provide quality care at the most efficient cost
• Utilization of electronic systems to support real time claim access, communication, and data reporting
• Delivery of meaningful risk management reporting to support safety and loss control initiatives
• Timely response to all District inquiries and requests
• Full compliance with all mandatory state and federal reporting requirements, including Section 111 reporting obligations
- Claims Intake and Administration:
• Receive and process First Reports of Injury electronically within one business day of notice
• Assign a qualified adjuster within one business day and provide the district with assignment details and contact information
• Complete three-point contact involving the district, employee, and medical provider within two business days of assignment
• Issue acknowledgment correspondence to all applicable parties within five business days
• Conduct timely investigations regarding compensability, coverage, and fraud indicators while maintaining complete claim documentation and diary management standards
- Disability and Return to Work Management
• Maintain regular communication with treating providers and medical professionals
• Monitor treatment progress, rehabilitation efforts, and anticipated return to work Timelines
• Provide the District with timely updates on temporary disability, permanency exposure, and claim developments
• Support safe and timely return to work initiatives whenever appropriate
- Medical Management and Cost Containment
• Aggressive negotiation of provider reimbursement rates
• Comprehensive bill review and audit procedures
• Validation of coding accuracy and billing integrity
• Timely submission of medical bills to repricing vendors
• Follow up on incomplete documentation and outstanding medical records
• Prompt payment processing following repricing review
• Utilization review procedures consistent with applicable treatment guidelines and statutory requirements
• Pharmacy management oversight and prescription utilization controls
- Litigation Management and Legal Coordination
• Litigation strategy development
• Exposure analysis and settlement evaluations
• Requests for settlement authority when applicable
• Maintenance of complete and current litigation documentation accessible to the district.