Workers Compensation Third Party Administrator Services

The Vendor is required to provide third party administrators to provide claim management services for workers’ compensation.
- Claim reviews
• The city requires quarterly file reviews that will be coordinated and conducted by the TPA account executive (ae) or designee.
• The city will select claims for review, typically based on claim complexity, litigation status, paid-to-incurred ratios, age of claim, outstanding reserves and incurred value, and other unique claim characteristics as deemed appropriate by the city and the city’s broker of record.
• The city requires a follow-up report including questions, concerns, and agreed action plan from the ae on a timely basis following the review.
- Claim management philosophy
• TPA to manage all claims utilizing a “best practice” approach in resolving each claim.
• The “best practice” approach requires that the TPA demonstrate proficiency in the following areas: 1) claim setup and assignment, 2) coverage determination, 3) investigation and compensability and liability, 4) quality assurance, 5) damages determination, 6) disability and medical case management, 7) litigation management, 8) settlement and reserve management, 9) reporting and notification, and 10) compliance with special account instructions.
• Complete interaction and cooperation is required.
• It is essential that communication with injured in employees is timely and consistent, payments are made on a timely basis, and reserve increases are posted and revised representing the most probable final claim outcome based upon current available information.
- Assignment of losses
• TPA must have the capability to accept claim reports 24 hours a day, seven days a week, and have immediate responses when requested.
• TPA must have claim escalation protocols in place and be able to notify and deploy appropriate resources in the event of a catastrophic claim(s).
• Claim reporting will be done electronically, which is currently through email from the city risk management.
- Claim handling
• The city requires aggressive, proactive claim handling.
• We expect TPA adjusters to establish an action plan upon receipt of a claim and continually update the plan to resolve the claim in the most effective manner.
• Adjusters must plan the activities that will occur, including but not limited to, compensability and liability determinations, applicable defenses, medical treatment, recovery plan, return-to-work plan, claim evaluation, and act reporting, litigation management and resolution.
• The action plans must be innovative and aggressive.
• The city believes claims must be managed, not merely processed, and expects its TPA to have the same aggressive philosophy.
• TPA to abide by customized special handling instructions, which will address various aspects of specific claim handling requirements.