Loading...
HomeMy WebLinkAboutAllied Managed Care, Inc. - 2018-09-15 PROFESSIONAL SERVICES CONTRACT BETWEEN THE CITY OF HUNTINGTON BEACH AND ALLIED MANAGED CARE, INC. TO PROVIDE WORKERS' COMPENSATION MEDICAL AND DISABILITY BILL REVIEW SERVICES THIS AGREEMENT ("Agreement") is made and entered into by and between the City of Huntington Beach, a municipal corporation of the State of California, hereinafter referred to as "CITY, and ALLIED MANAGE CARE, INC., a California corporation hereinafter referred to as "CONSULTANT." WHEREAS, CITY desires to engage the services of a consultant to provide workers' compensation medical and disability management services; and Pursuant to documentation on file in the office of the City Clerk, the provisions of the Huntington Beach Municipal Code, Chapter 3.03, relating to procurement of professional service contracts have been complied with; and CONSULTANT has been selected to perform these services, NOW, THEREFORE, it is agreed by CITY and CONSULTANT as follows: 1. SCOPE OF SERVICES This Agreement between CONSULTANT and CITY relates to the provision of workers' compensation medical bill review services which CONSULTANT shall provide as described in Exhibit "A," which is attached hereto and incorporated into this Agreement by this reference. These services shall sometimes hereinafter be referred to as the "PROJECT." CONSULTANT hereby designates Mark Denison who shall represent it and be its sole contact and agent in all consultations with CITY during the performance of this Agreement. Pagel of 13 19-7375/197598 2. CITY STAFF ASSISTANCE CITY shall assign a staff coordinator to work directly with CONSULTANT in the performance of this Agreement. 3. TERM; TIME OF PERFORMANCE Time is of the essence of this Agreement. The services of CONSULTANT are to commence on September 15, 2018 (the "Commencement Date"). This Agreement shall automatically terminate on November 1, 2018, unless extended or sooner terminated as provided herein. All tasks specified in Exhibit "A" shall be completed within time frame required for each task until this Agreement terminates. The time for performance of the tasks identified in Exhibit "A" are generally to be shown in Exhibit "A." This schedule may be amended to benefit the PROJECT if mutually agreed to in writing by CITY and CONSULTANT. In the event the Commencement Date precedes the Effective Date, CONSULTANT shall be bound by all terms and conditions as provided herein. 4. COMPENSATION In consideration of the performance of the services described herein, CITY agrees to pay CONSULTANT a fee as specified in Exhibit "B," which is attached hereto and incorporated by reference into this Agreement. Such fee, including all costs and expenses for services provided pursuant to this Agreement, shall not exceed Seventy Thousand Dollars ($70,000.00) annually. In the event the cost and expenses exceed $70,000.00, the CONSULTANT shall inform CITY of the amount over and why the extra cost was incurred. This extra cost will then be negotiated between the CITY and CONSULTANT. Page 2 of 13 19-7375/197598 5. EXTRA WORK In the event CITY requires additional services not included in Exhibit "A" or changes in the scope of services described in Exhibit "A," CONSULTANT will undertake such work only after receiving written authorization from CITY. Additional compensation for such extra work shall be allowed only if the prior written approval of CITY is obtained. 6. METHOD OF PAYMENT CONSULTANT shall be paid pursuant to the terms of Exhibit "B." 7. DISPOSITION OF PLANS, ESTIMATES AND OTHER DOCUMENTS CONSULTANT agrees that title to all materials prepared hereunder, including, without limitation, all original drawings, designs, reports, both field and office notices, calculations, computer code, language, data or programs, maps, memoranda, letters and other documents, shall belong to CITY, and upon expiration or termination of this Agreement or upon PROJECT completion, whichever occurs first CONSULTANT, shall turn these materials over to CITY, at no cost to CITY whatsoever, in a readable, identifiable format all data and programs identified herein. These materials may be used by CITY as it sees fit. 8. HOLD HARMLESS CONSULTANT hereby agrees to protect, defend, indemnify and hold harmless CITY, its officers, elected or appointed officials, employees, agents and volunteers from and against any and all claims, damages, losses, expenses, judgments, demands and defense costs (including, without limitation, costs and fees of litigation of every nature or liability of any kind or nature) arising out of or in connection with CONSULTANT's (or CONSULTANT's subcontractors, if any) negligent (or alleged negligent) performance of this Agreement or its failure to comply with any of its obligations contained in this Agreement by CONSULTANT, its Page 3 of 13 19-7375/197598 officers, agents or employees except such loss or damage which was caused by the sole negligence or willful misconduct of CITY. CONSULTANT will conduct all defense at its sole cost and expense and CITY shall approve selection of CONSULTANT's counsel. This indemnity shall apply to all claims and liability regardless of whether any insurance policies are applicable. The policy limits do not act as limitation upon the amount of indemnification to be provided by CONSULTANT. 9. PROFESSIONAL LIABILITY INSURANCE CONSULTANT shall obtain and furnish to CITY a professional liability insurance policy covering the work performed by it hereunder. This policy shall provide coverage for CONSULTANT's professional liability in an amount not less than One Million Dollars ($1,000,000.00) per occurrence and in the aggregate. The above-mentioned insurance shall not contain a self-insured retention without the express written consent of CITY; however an insurance policy "deductible" of Twenty-Five Thousand Dollars ($25,000.00) is permitted pursuant to a executed Insurance and Indemnification Wavier Modification Request form. A claims-made policy shall be acceptable if the policy further provides that: A. The policy retroactive date coincides with or precedes the initiation of the scope of work (including subsequent policies purchased as renewals or replacements). B. CONSULTANT shall notify CITY of circumstances or incidents that might give rise to future claims. CONSULTANT will make every effort to maintain similar insurance during the required extended period of coverage following PROJECT completion. If insurance is terminated for any reason, CONSULTANT agrees to purchase an extended reporting provision Page 4 of 13 19-7375/197598 of at least two (2) years to report claims arising from work performed in connection with this Agreement. If CONSULTANT fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the CITY with required proof that insurance has been procured and is in force and paid for, the CITY shall have the right, at the CITY's election, to forthwith terminate this Agreement. Such termination shall not effect Consultant's right to be paid for its time and materials expended prior to notification of termination. CONSULTANT waives the right to receive compensation and agrees to indemnify the CITY for any work performed prior to approval of insurance by the CITY. 10. CERTIFICATE OF INSURANCE Prior to commencing performance of the work hereunder, CONSULTANT shall furnish to CITY a certificate of insurance subject to approval of the City Attorney evidencing the foregoing insurance coverage as required by this Agreement; the certificate shall: A. provide the name and policy number of each carrier and policy; B. state that the policy is currently in force; and C. shall promise that such policy shall not be suspended, voided or canceled by either party, reduced in coverage or in limits except after thirty (30) days' prior written notice; however, ten (10) days' prior written notice in the event of cancellation for nonpayment of premium. CONSULTANT shall maintain the foregoing insurance coverage in force until the work under this Agreement is fully completed and accepted by CITY. The requirement for carrying the foregoing insurance coverage shall not derogate from CONSULTANT's defense, hold harmless and indemnification obligations as set forth in Page 5 of 13 19-7375/197598 this Agreement. CITY or its representative shall at all times have the right to demand the original or a copy of the policy of insurance. CONSULTANT shall pay, in a prompt and timely manner, the premiums on the insurance hereinabove required. 11. INDEPENDENT CONTRACTOR CONSULTANT is, and shall be, acting at all times in the performance of this Agreement as an independent contractor herein and not as an employee of CITY. CONSULTANT shall secure at its own cost and expense, and be responsible for any and all payment of all taxes, social security, state disability insurance compensation, unemployment compensation and other payroll deductions for CONSULTANT and its officers, agents and employees and all business licenses, if any, in connection with the PROJECT and/or the services to be performed hereunder. CONSULTANT shall comply with all CITY rules, regulations or instructions regarding the Scope of Work contained herein. 12. TERMINATION OF AGREEMENT 1. Termination Without Cause. Either party may terminate this Agreement without cause by giving the other party 60 days' written notice. 2. Termination For Cause. The CITY may terminate this Agreement for cause upon written notice to the CONSULTANT. For purposes of this Agreement, cause includes, but is not limited to, any of the following: (a) breach of any term of this Agreement by the CONSULTANT, (b) violation by the CONSULTANT of any applicable laws. 3. Such notice shall specify the reason for termination and shall indicate the effective date of such termination. After written notice of breach, CONSULTANT has 30 days to cure the breach. At the end of 30 days if the CONSULTANT fails to cure the breach the CITY will provide 60 day written notice of termination. Page 6 of 13 19-7375/197598 4. In the event of termination, the CONSULTANT will deliver to the CITY the original of all finished and unfinished documents, exhibits, reports, and evidence and any other work performed by the CONSULTANT, as described this Agreement, and upon receipt thereof, the CONSULTANT will be paid for services performed and reimbursable expenses incurred to the date of termination. At the option of CITY, the above items shall become the property of CITY. 13. ASSIGNMENT AND DELEGATION This Agreement is a personal service contract and the work hereunder shall not be assigned, delegated or subcontracted by CONSULTANT to any other person or entity without the prior express written consent of CITY. If an assignment, delegation or subcontract is approved, all approved assignees, delegates and subconsultants must satisfy the insurance requirements as set forth in Sections 9 and 10 hereinabove. 14. COPYRIGHTS/PATENTS CITY shall own all rights to any patent or copyright on any work, item or material produced as a result of this Agreement. 15. CITY EMPLOYEES AND OFFICIALS CONSULTANT shall employ no CITY official nor any regular CITY employee in the work performed pursuant to this Agreement. No officer or employee of CITY shall have any financial interest in this Agreement in violation of the applicable provisions of the California Government Code. 16. NOTICES Any notices, certificates, or other communications hereunder shall be given either by personal delivery to CONSULTANT's agent (as designated in Section 1 hereinabove) or to Page 7 of 13 19-7375/197598 CITY as the situation shall warrant, or by enclosing the same in a sealed envelope, postage prepaid, and depositing the same in the United States Postal Service, to the addresses specified below. CITY and CONSULTANT may designate different addresses to which subsequent notices, certificates or other communications will be sent by notifying the other party via personal delivery, a reputable overnight carrier or U. S. certified mail-return receipt requested: TO CITY: TO CONSULTANT: City of Huntington Beach Allied Managed Care, Inc. ATTN: Director of Human Resources 10360 Old Placerville Road 2000 Main Street Sacramento, CA 95827 Huntington Beach, CA 92648 17. RECORDS The CONSULTANT shall maintain financial records adequate to show that the CITY funds paid under this Agreement were used for purposes consistent with the terms of the contract. These records shall be maintained during the term of this Agreement and for a period of three (3) years from termination of this Agreement or until all claims, if any, have been resolved, whichever period is longer, or longer if otherwise required under other provisions of this Agreement. 18. CONSENT When CITY's consent/approval is required under this Agreement, its consent/approval for one transaction or event shall not be deemed to be a consent/approval to any subsequent occurrence of the same or any other transaction or event. 19. MODIFICATION No waiver or modification of any language in this Agreement shall be valid unless in writing and duly executed by both parties. Page 8 of 13 19-7375/197598 20. SECTION HEADINGS The titles, captions, section, paragraph and subject headings, and descriptive phrases at the beginning of the various sections in this Agreement are merely descriptive and are included solely for convenience of reference only and are not representative of matters included or excluded from such provisions, and do not interpret, define, limit or describe, or construe the intent of the parties or affect the construction or interpretation of any provision of this Agreement. 21. INTERPRETATION OF THIS AGREEMENT The language of all parts of this Agreement shall in all cases be construed as a whole, according to its fair meaning, and not strictly for or against any of the parties. If any provision of this Agreement is held by an arbitrator or court of competent jurisdiction to be unenforceable, void, illegal or invalid, such holding shall not invalidate or affect the remaining covenants and provisions of this Agreement. No covenant or provision shall be deemed dependent upon any other unless so expressly provided here. As used in this Agreement, the masculine or neuter gender and singular or plural number shall be deemed to include the other whenever the context so indicates or requires. Nothing contained herein shall be construed so as to require the commission of any act contrary to law, and wherever there is any conflict between any provision contained herein and any present or future statute, law, ordinance or regulation contrary to which the parties have no right to contract, then the latter shall prevail, and the provision of this Agreement which is hereby affected shall be curtailed and limited only to the extent necessary to bring it within the requirements of the law. Page 9 of 13 19-7375/197598 22. DUPLICATE ORIGINAL The original of this Agreement and one or more copies hereto have been prepared and signed in counterparts as duplicate originals, each of which so executed shall, irrespective of the date of its execution and delivery, be deemed an original. Each duplicate original shall be deemed an original instrument as against any party who has signed it. 23. . IMMIGRATION CONSULTANT shall be responsible for full compliance with the immigration and naturalization laws of the United States and shall, in particular, comply with the provisions of the United States Code regarding employment verification. 24. LEGAL SERVICES SUBCONTRACTING PROHIBITED CONSULTANT and CITY agree that CITY is not liable for payment of any subcontractor work involving legal services, and that such legal services are expressly outside the scope of services contemplated hereunder. CONSULTANT understands that pursuant to Huntington Beach City Charter Section 309, the City Attorney is the exclusive legal counsel for CITY; and CITY shall not be liable for payment of any legal services expenses incurred by CONSULTANT. 25. ATTORNEY'S FEES In the event suit is brought by either party to construe, interpret and/or enforce the terms and/or provisions of this Agreement or to secure the performance hereof, each party shall bear its own attorney's fees, such that the prevailing party shall not be entitled to recover its attorney's fees from the nonprevailing party. Page 10 of 13 19-7375/197598 26. SURVIVAL Terms and conditions of this Agreement, which by their sense and context survive the expiration or termination of this Agreement, shall so survive. 27. SUFFICIENT FUNDING This Agreement is contingent on the appropriation of sufficient funding by the CITY for the services provided by this Agreement. If funding is reduced or deleted by the CITY for purposes of this Agreement, the CITY has the option to either terminate this Agreement by giving ninety (90) days written notice to CONSULTANT or to offer an amendment to the Agreement with modified terms. CONSULTANT shall have thirty (30) days to accept or reject an amendment to the Agreement. 28. NON-COMPETITION The CITY recognizes that the employees of CONSULTANT and its sub- contractors have substantial information regarding the rates, customer policies and procedures of the CONSULTANT which are CONSULTANT's trade secrets and are very valuable to CONSULTANT and its other clients. The CITY also recognizes that, if an employee of CONSULTANT leaves CONSULTANT to work for the CITY, its subsidiaries, agents, or employees, CONSULTANT may be substantially damaged by its employees' use of those trade secrets. Furthermore, the CITY recognizes that proof of the misuse of trade secrets is difficult even in the most egregious cases and is always expensive. Therefore, to avoid any potential of misuse of those trade secrets, the CITY agrees during the term of this agreement, and for a period of one year following its termination, that it will not employ any person employed by CONSULTANT or its sub-contractors without prior written consent of CONSULTANT. Page 11 of 13 19-7375/197598 29. GOVERNING LAW This Agreement shall be governed and construed in accordance with the laws of • the State of California. 30. SIGNATORIES • Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify CITY fully for any injuries or damages to CITY in the event that such authority or power is not, in fact,held by the signatory or is withdrawn. CONSULTANT's initials 9-- 31. ENTIRETY m� The parties acknowledge and agree that they are entering into this Agreement freely and voluntarily following extensive arm's length negotiation, and that each has had the opportunity to consult with legal counsel prior to executing this Agreement. The parties also • acknowledge and agree that no representations, inducements, promises, agreements or • warranties, oral or otherwise, have been made by that party or anyone acting on that party's behalf, which are not embodied in this Agreement, and that that party has not executed this Agreement in reliance on any representation, inducement, promise, agreement, warranty, fact or circumstance not expressly set forth in this Agreement. This Agreement, and the attached exhibits, contain the entire agreement between the parties respecting the subject matter of this Agreement, and supersede all prior understandings and agreements whether oral or in writing between the parties respecting the subject matter hereof. Page 12 of 13 19-7375/197598 32. EFFECTIVE DATE IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and through their authorized officers. This Agreement shall be effective on the date of its approval by the City Attorney. This Agreement shall expire when terminated as provided herein. ALLIED MANAGED CARE, INC. a CITY OF HUNTINGTON BEACH, a California corporation municipal corporation of the State of /, - - California By: /� " v .+ I ,, /1oty Mayor print name ITS: (circle one)Chairman/Presiden ice President City Clerk AND By: 1-144 ° INITIATED AND APPROVED: Jerisc0 ITS: (circle oSecretary/ hief Financial Director of Human Resources Officer/Asst.Secre arr- reasurer REVIEWED AND APPROVED: APPROVED AS TO FORM: City Attorney City Manager COUNTERPART Page 13 of 13 19-7375/197598 32. EFFECTIVE DATE IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and through their authorized officers. This Agreement shall be effective on the date of its approval by the City Attorney. This Agreement shall expire when terminated as provided herein. ALLIED MANAGED CARE, INC. a CITY OF HUNTINGTON BEACH, a California corporation municipal corporation of the State of California By: 40,r, print name 9.4i2V241.144d ITS: (circle one)Chairman/President/Vice President City Clerk AND By: ' INI ,AND VE . print name ITS: (circle one)Secretary/Chief Financial t ctor of uman Resources Officer/Asst. Secretary-Treasurer • REVIEW APPROVED: APPROVED City Attorney NW it anager COUNTERPART Page 13 of 13 19-7375/197598 .. EXIJI3IT A • SCOPE OF SLRVICi S WORICERS COMPENSATION CLAIMS The Consultant will provide the following services for workers' compensation claims for the City as described more specifically below: A.Professional Fees Bill Review B.Bill Payment Recommendation Data C.Hospital Bill Audit D.Utilization Review(inpatient and Outpatient) B.Medical Case Management(Telephonic and On-site-Field)F. Peer Review Services 0.Medical Director Management Services IL Computer Programming and Data Management I. Systems J. Reporting K.Negotiations A, PROFESSIONAL PEES BILL RIIVIRW 1. The CONSUI TANT agrees to conduct bill review of professional service fecs, including but not limited to pharmacy bills and durable medical equipment bills. 2. This bill review will consist of: a, Detection of duplicate claims and unbundling b. Comparison to California's fee schedule, and/or to the PPO or negotiated fee arrangements and reduction to whichever is lower.The CITY will have access to a list of PPO providers. c. Review of the pre-certification status of the services, d. Contact with providers when the validity of CPT-4 codes is in question. e, Re-coding of old CPT-4 codes with currently valid codes included in the California Official Medical Fee Schedule, 3. •The CONSULTANT will manually review surgical bills for unbundling and upcoding. d. Disputed bills will he handled directly by the CONSULTANT. The CITY may override decisions made by the CONSULTANT if it is determined to be in the best interests of the CITY. 5, The CONSULTANT will use its best efforts to assist the CITY to recover overpayments and mis-payments to wrong provider. 6. The CONSULTANT will reimburse the CITY for penalties incurred by the CITY in favor of a provider that the CITY is able to prove were a result of the CONSULTANT's negligent or willful action or Inaction. 7. The CONSULTANT will be responsible for provider relations,e.g., the CONSULTANT will Rage 1 of 6 _ 10-2616.0o1/53o66 EXHIBIT A respond to all inquiries regarding payment recommendations,bill reductions,finis-payments, lost invoices, etc If bills require additional information (e.g., report not attached, missing CPT codes), the CONSULTANT will contact provider to obtain needed information for bill processing. • B. BILL PAYMENT RECOMMENDATION DATA I. The CONSULTANT agrees to provide bill payment recommendation data and explanation of review C°EOR")data to the CITY daily. 2, The CONSULTANT agrees to provide explanations of review("EORS'),which shall include each of the following items of rnfomlatlon, to the extent that such items of information have been provided to the CONSULTANT: a, The name of the patient. b. Patient social security number. c. The date services were rendered, d. The amount of the bill, e The amount of the reduction/adjustment, 1. The amount recommended for payment. g. The masons for payment reduction or denial, h, The provider's address. 1. The date received by the CITY(from the CITY date stamp on the bill). j. Description of service provided. k, Provider's name. i, Medical service code. tn, The date contractor received the bill • n. The date contractor reviewed the bill C. HOSPITAL BILL AUDIT All hospital bills are run through a stringent AMC coding verification process.Hospital bilis are reviewed by various levels of our staff, all the way up to the Mediae'director and/or the Senior Vico President of AMC,depending on the circumstances of the bill and where it falls within AMC's internal levels of authority. Hospital bills are a particular strength of AlvtC in that we insist on the integration of nurses' and physicians' expertise in review of not only inpatient hospital bills, but other complex medical procedures, such: as surgeries, extensive diagnostic testing, and other bills commonly identified as demonstrating complex coding issues. AMC nurses and physicians commonly evaluate these types of bills before released back to the client for payment, to ensure that the coding and fee allowance accurately reflects the services performed, California In-Patient Hospital Fee Schedule reimbursements are driven by DRO codes, which are derived from a multitude of procedure codes and diagnoses codes,AMC's process verifies each and every code on the bill in conjunction with the supporting documentation provided in the report. We ensure that the proper procedure and diagnoses codes are rolled up into the proper PRO code,which dictates the payment allowance. This process, in itself, is an "audit' process that every In-patient Page2 of 6 10 26t6.0Uii53066 EXHIBIT A • hospital bill at AMC goes through. Once the proper DRG code is determined, the Fee Schedule is applied,any PPO discounts taken,and the Lrxplanation of Benefits(BOB) generated to reflect the new code,the reason for the new code,and the recommended allowance. D. UTILIZATION REVIEW Inpatient Utilization Bevlcw I. The CONSULTANT agrees to provide pre-admission review, concurrent review, for all workers' compensation eases requiring inpatient stays after notification by the CITY or the network provider. 2. The CONSULTANT will provide Peer Review upon approval front the CITY.Physician Peer Review is physician to physician evaluation of eases for medical appropriateness(which often includes second surgical opinion by the physician pear reviewer) upon request'of Utilization Review,Telephonic Case Management/Meld Case Management or claims person, 3. These utilization review programs will be administered in accordance with Title 8, California Code of Regulations,Section 9792.6,concerning utilization management. 4. The CONSULTANT will strongly encourage network providers to contact the CONSULTANT for preadmission approval.When non-network facilities are used,CITY's Claim Administrator will icier provider to the CONSULTANT for pre-admission approval, 5. Non-Certification of inpatient services by the CONSULTANT will be done in accordance with the State of California regulations on Utilization Review. 6. The CONSULTANT will provide the CITY and the appropriate facility notification of all denials and approvals for Inpatient stays and the conditions of that stay. Outpatient Utilization Review I. The CONSULTANT agrees to pre-certify/ authorize treatment for chiropractic services, physical therapy,MRIs, durable medical equipment costing in excess of$250, and outpatient surgeries performed outside of a physician's office,and agrees to maintain a concurrent review program for physical medicine,inoluding physical therapy orchiropiactic services. 2. The CONSULTANT will provide Peer Review upon approval from the CITY.Physician Peer Review is physician to physician evaluation of oases for medical appropriateness(which often includes second surgical opinion by the physician peer reviewer) upon request of Utilization Review,Telephonic Case IvianagernentJPield Case Management or claims person. 3. These utilization review programs wilt be administered in accordance with Title 8, California Code of Regulations,Section 9792.6,concerning utilization management 4. The CONSULTANT will strongly encourage network providers to contact the CONSULTANT directly for preauthorization of outpatient services. 5, Non-Certification of outpatient-services by the CONSULTANT will be done in accordance with the State of California regulations on Utilization Review. Page 3 of 6 104616001/53066 BXHIBIT A E. MEDICAL CASE MANAGEIvMENT The CONSULTANT agrees to provide for ease management at the request of the CITY: I. Help the CITY establish criteria for recommending case management. 2. Interact with the injured employee, the providers of medical care, and the CITY's Claims Administrator. 3. Use criteria to establish maximum medical improvement and retina to work time-frames. 4. Use protocols to establish acceptable patterns of tmatment and to assist the CONSULTANT in identifying excessive or inappropriate treatments, Case management will be administered in accordance with Title 8,California Code of Regulations,Section 9792.6,concerning utilization management. 5. Medical case management services will include; a. On-site(Field)Nurse Case Management b. Telephonic Nurse Case Management F. PEER REVIEW SERVICES Upon request by the City,the Consultant shall providepeer review services.The Consultant will provide peer review services("Peer Review"),consistent with the regulations of the State of California and URAC, that include first level and second level review by licensed professionals (Mvl.D., D.C., Acupuncturist,etc.),within the regulatory time frames.Physician Peer Review is physician to physician evaluation of cases for medical appropriateness (which often includes second surgical opinion by the physician peer reviewer)upon request of Utilization Review,Telephonic Case Management/Field Case Management or claims person. G. MEDICAL DIRECTOR MANAGEMENT SERVICES Upon request by the City,the Consultant shall provide Medical Director Management services. A medical director(an and licensed in California)will be provided to the City for overseeing the City's'Utilization Management system at no additional coat to the Peer Review process. H. COMPUTEIPROGRAMMING AND DATA MANAGEMENT 1. The CONSULTANT will perform the initial programming requirements for the interface between the CONSULTANT and the CITY's claims management system-initial programming is included at no charge. 2. Prior to commencing any additional work requested by the CITY, the CITY and the CONSULTANT shall agree, in a written document signed by both parties, on the scope of the work to be performed and the estimated number of hours requited for completion. I. SYSTI3M.1 1. The CONSULTANT agrees to provide integrated bill payment data, case management and utilization management systems in the form of file-based data exchange and user-friendly Page 4 of 6 14.2616 401/53066 EXHIBIT A • screen interface directly integrated Into the CITY's system, 2, The CONSULTANT agrees to allow the CITY access to the CONSULTANT's system for . status and inquiry purposes. CITY access to the CONSULTANT'S system will secured by password. 3. The CONSULTANT will seas all medical bills, check claims history, and index the medical bills with The appropriate claim number prior to processing through bill review.In addition,the CONSULTANT will cheek the provider identification number and date of service to prevent duplicate payment.Further,the CONSULTANT will link two or more claim numbers together because they are claims of the same employee.The CONSULTANT will link the multiple claim numbers in the CONSULTANT's system and will cross.check for duplicates on the claim numbers as so linked. 4, The CITY will review recommended allowance by the CONSULTANT'and authorize payment of medical bills In the CITY's system. 5. The CONSULTANT will import a daily transmittal of basic claims data and vendor master file data from the CITY's claims database; this database should be refreshed daily through a new transmission of the CITY's claims database. The CONSULTANT will enter bill payment information and then run a batch program that matches medical bills to claim information and produce a listing of rejected bills that require CITY review. 6, The CONSULTANT agrees to transmit medical bill payment recommendation information Into- the CITY's olaims management system or designee for the purposes of processing payments The CITY's claims management system or designee interfaces with the CITY's central accounting system. The CONSULTANT will supply daily a data transmittal of medical bill payment recommendation information to be transmitted into the CITY's claims management system or designee following the current Bill Review Import and Export Interface Specifications requirements.These include but not limited to the following data: a. Claim number. b. Employee's name. c. Employee's Social Security Number. d. Provider's name. e. Provider's address. f, Date received by the CITY(from CITY date stamp). g. Amount bil led. h. Date of Service. t Description of service. J. Amount recommended. k. Amount of reduction, 1, Date of payment recommendation by the CONSULTANT. m, Warrantnumber. n. Date the contractor received the bill o. Date the CONSULTANT reviewed the bill Page 5 of 6 1024I6.oasIS.3066 EXHIBIT A • i J. ABPORTINO A. Standard Reports The CONSULTANT agrees to produce and provide the CITY with standard written reports.The CONSULTANT will provide a monthly report on referrals for all services and numbers of bills reviewed as it relates to the services. A. Ad Hoc Reports CONSULTANT agrees to provide ad hoc written reports containing data captured in CONSULTANT's UR and Case Management SmatNNotes database at no charge.Bill Review database ad hoc reporting will require a pass thru charge of$150/hour when requested by the CITY. K. NEGOTIATIONS CONSULTANT routinely negotiates fee reductions on bills meeting standard criteria. It includes but is not limited to in-patient hospital bills, surgical procedures, and other high dollar exposures. Our negotiation approach, which includes a signed negotiation letter by both CONSULTANT and the medleal provider,serves(2)two purposes: 1. Acceptance of payment as full and final payment(eliminating lien potentials),and 2. Additional savings below Pee Schedule allowances,for expanded bill review savings for our clients The CONSULTANT Negotiation Unit is able to negotiate additional savings beyond PPO discounts and/or in place of when no PPO reduction Is applied by the specific PPOs.The Negotiation Unit has built relationships with providers who are now submitting requests directly for additional savings and ptompt payments. Additionally,all bills regardless of status that are in excess of$1,200.00(after reductions)are reviewed`for potential referral to the negotiation unit, It should be noted that our clients pay only a percent of these additional savings,if we achieve savings above and beyond the fee schedule. Page 6of6 io2sIc.ou1t53u66 EXHIBIT A EXHIBIT,B PRICING AND BILLING On a monthly basis the Consultant will invoice for alhservi'ces included in the Fee for Service.The invoice will include a report by claim number, employee name,and date and type of serviceprovided 1. Consultant shall be entitled to monthly progress payments toward'the fixed fee set forth herein in accordance with the following progress ,and payment schedules, a. Bill Peer Review: Per bill Pricing is$8_00per bill b. Hospital Bill-Audit: Hospital, Bill Audit is billed at 10% of savings as measured against billed charges c. Professional services'bill review and,PPO network access 18-26% d Utilization Review' Utilization Review is an evaluation for appropriateness of treatment for a, specific procedure or block of treatment. This includes pie- certification/authorization, PT, chiropractic review, concurrent review. Nurse, level Utilization Reviews are billed at the flat rate of$80.00'per nurse level. review. e. Peer;Review: Physician peer review is physician to physician evaluation of cases for medical appropriateness, (which ,often includes second surgical opinion by the physician peer review) upon request of UR, TCM of claims person,Peer review is4211O_O0 per review. f. Telephonic Case Management: Telephonic Case Management as a stand alone service is $80.00 per hour. This includes Hospital Pre-Certification, ,Length of Stay Review, and Discharge Planning as well as Utilization Management for all services. g, Field Case Management: Field Case Management as a stand alone service will be charged at $9Q.00 per hour. This includes Hospital Pie-Certification, Length of Stay Review, and Discharge Planning as well as Utilization Management for all services. h Negotiation Service: Consultant will conduct negotiation attempts on all bills meeting or exceeding the cost outlier or are exempt from State Fee Schedules. The fee for negotiations is 15% of sayings off billed charges, up to a maximum of$15,000 per negotiation. 2. Delivery of work product: A copy of every memorandum, letter, report, calculation and other documentation prepared by Consultant shall be submitted to'City to demonstrate progress toward completion of tasks. In the event City rejects or has Page I of 2 EXHIBIT B 10-2616 OOUNdC Dchtbt13 dac t - - ` • comments on any such product, City shall identify specific requirements for satisfactory completion, 3. Consultant shall submit to City an invoice for each monthly progress payment due. Such invoice shall; A) Reference this Agreement; B) Describe the services performed; C) Show the total amount of the payment due; D) Include a certification by a principal member of Consultant's firm that the work has been performed in accordance with the provisions of this Agreement;and E) For all payments include an estimate of the percentage of work completed. Upon submission of any such invoice, if City is satisfied that Consultant is making satisfactory progress toward completion of tasks in accordance with this Agreement,City shall approve the invoice,in which event payment shall be made within thirty (30) days of receipt of the invoice by City. Such approval shall not be unreasonably withheld. If City does not approve an invoice,City shall notify Consultant in writing of the reasons for non-approval and the schedule of performance set forth in Exhibit "A" may at the option of City be suspended until the parties agree that past performance by Consultant is in, or has been brought into compliance, or until this Agreement has expired or is terminated as provided herein. 4. Any billings for extra work or additional services authorized in advance and in writing by City shall be invoiced separately to City. Such invoice shall contain all of the information required above, and in addition shall list the hours expended and hourly rate charged for such time. Such invoices shall be approved by City if the work performed is in accordance with the extra work or additional services requested, and if City is satisfied that the statement of hours worked and costs incurred is accurate. Such approval shall not be unreasonably withheld. Any dispute between the parties concerning payment of such an invoice shall be treated as separate and apart from the ongoing performance of the remainder of this Agreement. Page 2 of 2 EXHIBIT B I0.26I6 60I/AMC Exhibit Bloc r Cityof Huntington Beach UTILIZATION REIVEW TRIGGERS PHYSICAL THERAPY,CHIROPRACTIC,MASSAGE&ACUPUNCTURE Initial PT/OT exceeding 18 visits and exceeding 18 visits if post surgery . Initial Chiropractic visits exceeding 18 visits Acupuncture Massage Gym membership Work Harding/Work Conditioning,Functional Capacity Evaluations Biofeedback All Non-Medical exercise or treatment programs Including: Reflexology Aerobics Personal Trainers Aquatics Pilates TESTING Diagnostic testing to include: Repeat MRI's with no clear objective findings,prior to six months same body part as Initial MRI CT Scan Arthrogram(MRI/Dye,GAD or MRA) Myelogram Video Fluoroscopy Discogram EMB/Nerve Conduction Studies ECSWT—Extracorporeal$hockwave Therapy PAIN MANAGEMENT All Epidurals Experimental Treatment Chronic pain management interdisciplinary pain programs Morphine pumps/implanted pumps Facet Nerve Blocks,Selective Nerve Root Blocks Chemonuclenlysls Detox Programs All Spinal Cord Stimulators Pain Pumps Prolotherapy Botox External and Implantable Done Growth Stimulators Synvlsc,Hyaiagen,or$upartz injections IDET(intradiscal Electrothermal Therapy) Radiofrequency intoning of any nerve(RFA) SURGERIES AND HOSPITALIZATIONS Ali of the following: Inpatient surgeries In-patient hospitalizations/or length of stay Concurrent reviews for extended stays Skilled nursing facility/rehab/step down or transitional Home health care PRESCRIPTIONS All of the following: Prescriptions for opiates,narcotics,and all medications not directly related to accepted condition or body part, Prescriptions for sleep aids,psyche medications in excess of six month period Prescriptions for life style drugs,such as Viagra and compounded medication All IV or IM Antibiotics and SQ administered in the Home Over the counter medications exceeding$300,00 or if not medically substantiated OTHER All of the following: Weight loss programs Durable Medical Equipment,on-going rentals for DME or supplies over$500.00 Dental Sevices including dental care of dental appliances All non-medical home services Home modifications Home exercise equipment Mattresses Vehicles or vehicle modifications All treatment that exceeds or are not recommended in MTUS/ACOEM/ODG Client#: 6105 ACCLINSU YYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 7/10 DATE(M/2018 M/DD/YWDD/Y THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Laurie Martin Edgewood Partners Ins.Center PHONE 415 356-3934 FAX (A/C,No,Ext): (A/C,No): 425 California Street,24th Floor E-MAIL ADDRESS: certs@epicbrokers.com LIC#0B29730(415)356-3900 INSURER(S)AFFORDING COVERAGE NAIC# San Francisco,CA 94104 INSURER A National Fire Ins of Hartford 20478 INSURED INSURER B:The Continental Insurance Company 35289 Acclamation Insurance Management INSURER C:State Compensation Ins Fund 35076 10445 Old Placerville Road Navigators INSURER D: Specialty Insurance Company 42307 Sacramento, CA 95827 20508 INSURER E:Valley Forge Insurance Co INSURER F: Lloyds of London COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 6056760864 01/01/2018 01/01/2019 EACH OCCURRENCE $1,000,000 ' CLAIMS-MADE X OCCUR DAMAGE O(Ea RENTED $1,000,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECOT X LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ E AUTOMOBILE LIABILITY 6056760850 01/01/2018 01/01/2019 COMBIaccideNEDnt)SI $NGLE LIMIT 1,000,000 (Ea X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB X OCCUR 6056760878 01/01/2018 01/01/2019 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED RETENTION$ $ C WORKERS COMPENSATION 908337918 01/01/2018 01/01/2019 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Professional Liab CE18MPL090671C 07/11/2018 07/11/2019 $5,000,000 Ann Agg-E&O F Privacy Liability 507097 07/11/2018 07/11/2019 $3,000,000 ea claim/agg $25,000 SIR E&O&Cyber DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Claims administration services including Nurse Case Management and Bill Review. Named insured includes:Acclamation Insurance Management Services, Inc.;Allied Managed Care, Inc.; LJR Holdings, Inc.; LJR Properties, LLC (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Cityof Huntington Beach SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2000 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Huntington Beach, CA 92648-0000 AUTHORIZED REPRESENTATIVE edellWria ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD #S1121677/M1121608 LLIA1 DESCRIPTIONS (Continued from Page 1) Thirty day notice of cancellation will be provided to the certificate holder but 10 days for non-payment of premium. EMPLOYEE DISHONESTY/CRIME COVERAGE: Federal Insurance Company.#82344565 EFF: 1/1/18 EXP: 1/1/19 DISHONESTY LIMIT: $2,000,000$35,000 DEDUCTIBLE Third party claims administration services. SAGITTA 25.3(2016/03) 2 of 2 #S1121677/M1121608 ,637. +, CITY OF HUNTINGTON BEACH RECEIVED _9! = Professional Service Approval Form FEB 2 5 2019 ;y� r roe ,,,,%= PART I Date: 2/20/2019 Project Manager Name: DeAnna Soria Requested by Name if different from Project Manager: Sandy Henderson Department: Human Resources PARTS I OF THE PROFESSIONAL SERVICES CONTRACTS APPROVAL FORM MUST BE COMPLETED BY THE REQUESTING DEPARTMENT AND SIGNED BY THE CITY MANAGER, FOR APPROVAL, BEFORE PROCEEDING WITH THE SOLICITATION OR CONTRACT PROCESS. PART I MUST BE FILED WITH ALL APPROVED CONTRACTS. 1) Briefly provide the purpose for the agreement: Workers compensation bill review services 2) Estimated cost of the services being sought: $ 70,000 3) Are sufficient funds available to fund this contract? ® Yes ❑ No If no, please explain: 4) Ch below how the services will be obtained: Bid solicitation process in accordance to the MC 3.03.060 procedures will be conducted. C 3.03.08(b)—Other Interagency Agreement procedure will be utilized. ElilC 3.03.08—Contract Limits of$30,000 or less exempt procedure will be utilized. Is is contract generally described on the list of professional service contracts approved by the City ouncil? If the answer to this question is "No," the contract will require approval from the City Council.) ® Yes ❑ No ,7/5-1( fiscal Services Manager Signature (Purchasing Approval) Date 6) Amount, Business Unit (8 digits) and Object Code (5 digits) where funds are budgeted (Please note that a budget check will occur at the object code level): Account number Contractual Dollar Amount Business unit. object# Fiscal Year Fiscal Year Fiscal Year Fiscal Year 18/19 55131001 . (pR WO $70000 $ $ $ $ $ $ $ $ $ $ $ 3 ,,/5' Bud p ov--"6. ' 4e,4 /a0/ � Date D partment Head Signature(s) Date Chief Fin ci I Officer Signature Date Assistant City Manager's Signature Date APPROVED DE JE r7 ? -2S 15 ri , Manager's Signature Date professional service approval form-amc part i 2016.doc REV: February 2015 NT� CITY OF HUNTINGTON BEACH FEB 2 5 2019 9t _ Professional Service Approval Form 9 •Q , oUN ,� PART II Date: 2/20/2019 Project Manager: DeAnna Soria Requested by Name if different from Project Manager: Sandy Henderson Department: Human Resources PARTS I & II OF THE PROFESSIONAL SERVICES CONTRACTS APPROVAL FORM MUST BE COMPLETED BY THE REQUESTING DEPARTMENT AND SIGNED FOR APPROVAL. PART I& II MUST BE FILED WITH ALL APPROVED CONTRACTS. 1) Name of consultant: Allied Managed Care, Inc 2) Contract Number: HR (Contract numbers are obtained through Finance Administration x 5630) 3) Amount of this contract: $70,000 Account number Contractual Dollar Amount Business unit. object# Fiscal Year Fiscal Year Fiscal Year Fiscal Year 18/19 55131001 , (,q`l/p $70,000 $ $ $ $ $ $ $ $ $ $ $ 4) Is this contract less than $50,000? ❑ Yes ® No 5) Does this contract fall within $50,000 and $100,000? ® Yes ❑ No 6) Is this contract over$100,000? ❑ Yes ® No (Note: Contracts requiring City Council Approval need to be signed by the Mayor and City Clerk. Make sure the appropriate signature page is attached to the contract.) 7) Were formal written proposals requested from at least three available qualified consultants? ❑ Yes ® No 8) Attach a list of consultants from whom proposals were requested (including a contact telephone number.) 9). Attach Exhibi A, which describes the proposed scope of work. 10) Attach ibit B, whic escri es the payment terms of the contract. rtment Head ate c3X/t9 Fiscal Service anager(Purchasing) Date �i a � 1 f' Budget Manager oval Signature ate Chief Financial Of icerf (or designee) Signature Da e professional service approval form amc-part ii 2016.doc