Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
on a timely basis.
We have reviewed and will comply with this requirement.
Paying appropriate and timely benefits is critical in our business. AIMS has multiple levels of assurances in this regard. Before a payment is issued, it is verified for appropriateness, accuracy, and reserve adequacy. When applicable, minimum statutory requirements are adhered to or exceeded. All payments are listed in each file, and distinguished by the following basic categories: Indemnity, Medical, Legal/Allocated, and Vocational Rehabilitation. AIMS policy is all payment d ocumentation is contained within the claims file.
C. Review, compute, and, after approval by the City, pay all informal ratings, findings and awards, and settlements; arrange for informal disability ratings whenever possible to avoid unnecessary litigation.
We have reviewed and will comply with this requirement.
Once a claim has reached the point of serious settlement negotiations, we collect all pertinent data and present it to authorized City personnel in a Settlement Authorization Request. Included in our Settlement Authorization Request is the reserve documentation indicating the adequacy of the reserves for eventual settlement offers, a summary of paid- to-date amounts, any disability ratings, medical reports, and a synopsis written by the handling Claims Examiner. The synopsis includes a complete risk assessment with any available alternative options authored by defense counsel (if applicable). The Settlement Authorization Request is approved by the Claims Manager and/or Supervisor and presented to the City in a timely fashion and in a format customized to meet the needs of the City. AIMS does not enter into any settlement negotiations without prior approval from the authorized City representative.
Additional focus and coordination is provided for those claims within the City’s ADR/Carve out Program; as the goal and objective of is to provide expedited claim resolution – up to and including claim settlement.
All awards are processed for payment within the statutory requirements or within fourteen (14) calendar days, whichever is less. All appropriate accrued interest is included in the award payment unless the approved award has had the interest waived by the parties and the court in the settlement document.
Please see Exhibit 7 – Settlement Authority Request Worksheet
D. Pay any and all penalties due in accordance with the California Labor Code. Such penalties shall be paid by the claims administrator with liability for the action determined by the record unless such penalties we re incurred as a result of the City’s action or Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
inaction.
We have reviewed and will comply with this requirement.
AIMS has a robust Penalty Prevention Process , which is augmented by our ability to track incoming documents and scheduled benefit payments. While it is never our intent to incur penalties, in the rare instances when they happen, AIMS immediately corrects the issue and makes the penalty payment. At the same time the payment is made, the Claims Team produces a Penalty Prevention Form which is c irculated inside the appropriate departments at Corporate for reimbursement to the Client. It is always our desire to take notice of any penalties rather than being made aware of them through outside sources. AIMS understands and takes very seriously the fact that these payments are not the fault of the Client and quickly works with our Accounting Department to refund these to the Client Trust Fund. Careful reconciliation of these payments occurs within the Accounting Department and the Claims Management System so all parties are aware of the occurrence and reimbursement schedule.
E. Establish files containing medical and factual information on each reported claim, together with complete accounting records and maintain in accordance with statutory time requirements.
We have reviewed and will comply with this requirement.
Captured Claim File Data : A file is established for each reported claim and a ll claims- related documents are stored electronically, retrievable by claim number. The electronic file can be sorted and filtered by all of the index fields including date ranges and types of documents.
All files include pertinent information (such as litigated court case number, cross - referencing, future medical award, “closed” and date closed, etc.).
All electronic files are include the following documents:
Correspondence (all non -medical, non -rehabilitation, non -payment documents including the Employer’s First Report, letters file memos, reserve analysis, legal correspondence, data input sheets, index returns, etc.). Legal Information (all information relating to the litigation of the claim). Medical (all medical reports, notes, disability notes signed by medical personnel, except subpoenaed records, photo-copied records).
Payment documentation (such as approved bills, invoices, etc.).
Paperless Solution: AIMS has partnered with a global leader in IT solutions, to provide a paperless solution that includes document -based business process management (BPM) with ease of usage and accessibility. The AIMS paperless system (AX) is directly integrated with the claims system. AIMS Clients have appropriate access to the paperless documents through the claim system. When a claim is open in the claims system the City staff select a hotkey that ope ns all associated files for the requested Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
claim. Our paperless environment also has the ability to provide documents to the City by searching by date, physician name and/or medical report type, pulling the data across all claims and mail received. This eliminates the need to access each individual claim file to review reports.
All claims related documents are centrally captured, indexed, and stored in the paperless system. The paperless system has customized key index values to simplify file organization and search ability. A customized global workflow process has been created to eliminate the possible loss of documents, the duplication of documents, and the accuracy of filing. Customized business workflow processes are attached to each document type (medical, legal , bills, etc.) to streamline activities required by Claims Examiners during the claims process. Documents requiring time sensitive processing have built-in triggers and management oversight flagging to ensure expedited handling of those documents.
The paperless system is separate and distinct from the claim system. AIMS’ paperless solution is built on a separate database and storage platform that is virtualized for redundancy and high availability. All documents are accessible through a separate interface from AIMS’ claim system and can be opened simultaneously.
F. Prepare, file, and maintain all information and reports as required by the State of California, Department of Self-Insurance.
We have reviewed and will comply with this requirement.
Claims are entered into the claim management system within one (1) day from receipt of the first notice of claim and a ll files are maintained on a 30 -day diary by the assigned Examiner to ensure the claim is progressing as expected and that all required information has been received and or the request for the information is documented in the claim file.
The standing plan of action is reviewed at each diary date and updated accordingly.
The City is kept appraised of the status of their claims via a claims status repo rt created and sent every 90-days when the Plan of Action Review has been completed.
All statutory State and Federal reporting requirements are prepared in a timely manner, in accordance with the required specifications of the regulating agency. Annual re ports to the State regarding claims and financial experience are prepared on behalf of the Client in accordance with the rules and regulations of the jurisdiction.
G. Provide the City with information and recommendations for implementation strategies for changes or proposed changes in statutes, rules and regulations affecting the City under the California Labor Code for workers’ compensation.
We have reviewed and will comply with this requirement.
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
AIMS prides itself on providing the kind of pro -active Client service seldom seen in our industry. From in -person meetings with the City to year-end performance reporting on the program development, we are always available to go the extra step.
AIMS has developed a variety of training programs for employers that can be customized and incorporated into the Client’s own training programs. These programs are overseen by our Vice President Workers’ Compensation, Cheryl Agee , and our Senior Vice President Operations, Lynn Cavalcanti. Cheryl manages a team of staff who provide training on a wide range of topics including; California Education Code Benefits, “Workers’ Comp 101”, legislative changes, fraud prevention, return-to-work (RTW), and State laws, etc. When requested, training sessions on proper reporting, new case law or changes in the methodology set by the State of California on the delivery of workers' compensation services training is provided as an integral part of our value -added partnership. Training sessions are held at our offices, Client locations or other specific areas designed to accommodate a number of our Clients. This service comes at no additional charge.
Please see Exhibit 2 – Sample Legislative Advocate Report
H. Review with the City the program’s progress, including identification of problem areas and conduct periodic root cause analysis and recommended solutions to reduce claims cost and attend monthly regularly scheduled meetings required by the City relative to the workers’ compensation program.
We have reviewed and will comply with this requirement.
As a true partner with the City, AIMS attends monthly department meetings and litigation meetings where all high profile and claims on disability are reviewed and discussed. It is important for the department heads of the City to know and understand their current inventory of employees receiving disability and/or nearing finalization of their claims where permanent restrictions are likely. Key claims are discussed at these meetings to insure that all parties (Risk Management, Department & AIMS) are in agreement with how the claim should proceed and what the ultimate claim resolution goal is. These meetings are key to the success of this program and AIMS respects and admires the City for continuously conducting them.
Typically, monthly meetings include a discussion of:
Current case status, reserves, and resolution plan
Functioning of the workers' compensation program
Develop coordinated plans for specific claims handling Cost savings plans
Coordinate plans for returning employees to work
In addition, AIMS advises the City of individual claim development(s) in multiple formats Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
(written notifications are customized on an individual Client basis) which include but not limited to:
Claim Status Report Forms
Electronic Mail Updates
Letter - Narrative
Customized Reports
The program analysis we provide presents hard data to benchmark results and determine strategies to improve and optimize the program created specifically for the City. Also planned is reports on the outcomes of the ADR/Carve -Out Program implemented early this year. AIMS captures key events, which are directly related to the ADR Program so that analysis and benchmarking can be done of the outcomes and cost savings. Samples of previous benchmarking reports have been included in the noted exhibit.
Please see Exhibit 10 – AIMS Sample Claims Reports
I. Arrange for and supervise all necessary investigations to determine eligibility for compensation benefits and liability of negligent third parties.
We have reviewed and will comply with this requirement.
As indicated previously, it is AIMS protocol for the Examiner to review and investigate the claim for compensability upon claim assignment. This includes the initiation of 3 -point contact w ithin 24 hours of receipt of new workers’ compensation indemnity claims. Examiners evaluate all claims for Arising out of Employment (AOE) / Course of Employment (COE), delay, denial, subrogation, or referral for investigation of issues surrounding injury. Examiners request all required documentation f rom Doctors, Client, and Injured Worker. All claims which are to be denied or delayed, pending a compensability decision, shall be done in keeping with all applicable statutory rules and regulations (and/or case law). All denials and delays are approved by the team Supervisor. Authority to delay or deny a claim is first obtained from the City , unless express written authority for this purpose is granted to AIMS.
All questionable claims are investigated in a prompt, thorough, and legal manner to determine compensability or to validate issues in question. The Examiner identifies the need for investigation and will refer the case for same within three (3) days from receipt of claim, or knowledge of questionab le issues which give rise to the need for investigation.
The City’s authorization is first obtained before initiati ng any field investigation. This authorization is documented in the notepad section of the claims file.
In addition, AIMS Claims Examiners understand they have the responsibility to review Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
each claim for possible subrogation potential. Any file which indicates the possibility of subrogation is forwarded to a Claims Supervisor for review to determine if further investigation is required. When authorized by our Client, consultation with AIMS liability specialists to evaluate the strengths and weaknesses of the subrogation will take place.
AIMS will review and identify the cause of the accident for each new claim received and AIMS assigned Claims Examiner will serve as the main subrogation “adjuster”. Notice of third party credit recovery is sent out once the relevant party is identified. A notice letter is also sent out to the injured worker. A diary for the statute of limitation is set as a backup and the file is reviewed online in the maintained diary for subsequent follow up.
Upon receipt of the recovery, the adjuster will forward the check with a cover letter indicating the amount of the recovery to be returned to each department.
Some of the points considered may include, but not be limited to injured worker was injured as a result of:
Injuries away from employer’s premises
A motor vehicle accident
An assault
Malfunction of a tool or piece of equipment
Use of a type of machinery
Negligence of any other person
Animal bite
In addition:
It shall be the responsibility of the Claims Examiner to periodically request a status report from the attorney who is protecting the third party interests, or from the attorney who has filed a lien or intervening petition on behalf of our Client. Our Clients will be advised at least semi -annually regarding our efforts to recover moneys which have previously been paid.
Determination shall be made if Client has other damages to recover. Prior to entering into a recovery agreement, approval of the agreement should be given by our Client. This will protect our Client’s interest in recovery of all expenses, including damage to company automobiles, etc., as opposed to simple recovery of workers’ compensation costs.
Upon receipt of the check or checks from the responsible third party or parties, these moneys should be made payable to our Client and credited to the workers’ compensation file in the appropriate category.
In the event where a Police Officer is assaulted by a suspect who is later convicted of the crime and is incarcerated, the Claims Examiner will attempt to pursue Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
recovery as a condition of the suspect’s probation. This arrangement will be made with the local District Attorney’s office.
Outside Investigation:
1. All claims requiring an investigation shall be documented as such in the claim file, with an explanation of the issues, the reasons for the investigation, and the objective of the investigation.
2. All investigative assignments (either oral or written) shall be documented by completion of the approved Investigation Assignment Sheet. The assignment will be documented in the claims system.
3. Unless contractually specified otherwise, all investigative assignments shall have the prior approval of the Client.
4. The Examiner or his/her designee(s) shall monitor the results produced by the investigator(s) with the following criteria:
Quality of the report
Turnaround time
Cost
The ability to testify or support the findings in court Sub-rosa:
Sub-rosa is designed to develop evidence to verify unsubstantiated facts or activities of claimants. Initial report from investigator is to be received within 15 days of assignment. Subsequent Reports should be received from the investigator no less than every 30 days.
All surveillance assignments should include the precise type of surveillance required with a specific time limitation for the assignment (a maximum of 2 -3 days is recommended for the initial authorization).
Subrogation:
AIMS will pursue recovery on behalf of our Clients from any responsible third party causing a workers’ compensation claim. Examiners and Supervisors have the responsibility to review each claim for possible subrogation potential.
Our attempts to recover will be based on the merits of successful recovery versus the hazards and delays of litigation.
Any responsible third party will be notified in a general form letter within 30 days following a decision to pursue recovery. Particular attention will be paid to any applicable Statutes of Limitation which might affect the ability to recover. As long as there is subrogation potential, the file shall be kept in an active status with appropriate diary dates.
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
The Examiner will pursue recovery. If it is determine d that a Subrogation Attorney is needed, the Examiner will discuss and request authorization for the referral with the City.
It is the responsibility of the Examiner to periodically request a status report from the attorney who is protecting the third party interests, or from the attorney who has filed a lien or intervening petition on behalf of our Client. The City will be advised at least semi-annually regarding our efforts to recover money which has previously been paid.
Determination will be made if Client has other damages to recover. Prior to entering into a recovery agreement, approval of the agreement should be given by the Client. This will protect the Client’s interest in recovery of all expenses, including damage to company automobiles, etc., a s opposed to simple recovery of workers’ compensation costs.
In a situation where a Police Officer is assaulted by a suspect who is later convicted of the crime and is incarcerated, the Examiner will attempt to pursue recovery as a condition of the suspect ’s probation. This arrangement will be made with the local District Attorney’s office.
In addition, monthly statistics are maintained to determine the number of assignments made and to whom they were assigned.
J. Establish procedures to support the payment of all benefits and allocated expenses together with appropriate documentation necessary to reconcile a trust fund checking account provided by the City.
We have reviewed and will comply with this requirement.
AIMS has extensive expertise establishing Workers’ Compensation Trust Fund accounts for our Clients. AIMS Claims Manager will work with the Client to coordinate Client trust funds/checking accounts to ensure accuracy and appropriate funding levels. The Claims Manager function includes providing weekly/monthly check registers directly to Clients.
AIMS established procedures support the payment of all benefits and allocated expenses together with appropriate documentation necessary to reconcile a trust fund checking account provided by the City. All payment requests shall be made with the necessary documentation to allow for an audit trail.
Banking is managed from a separate and distinct division at our headquarters; thus facilitating additional fund management oversight, security, and monitoring.
A monthly reconciliation report is provided to the City detailing trust account activity. The detailed accounting includes the date and check number of all benefits and allocated loss payments. All payment requests are made with the necessary documentation to allow for Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
an audit trail.
The cost for this service is included in our fees.
Please see Exhibit 6 – Cost Proposal
K. Sponsor and pay for a membership in the nationwide Index System on the City’s behalf; submit all claims to the Index System as regular practice.
We have reviewed and will comply with this requirement.
All indemnity claims are indexed. AIMS and other organizations submit tens of millions of reports on individual insurance claims to the Insurance Service Office (ISO). ISO stores those reports in a single database that helps insurers, self -insurers, law enforcement agencies, and state fraud bureaus detect and prevent fraud, evaluate risk, and process meritorious claims. The system furnishes essential data for researching prior -loss histories, identifying claims patterns, and detecting suspect claims.
AIMS will re-index as frequently as the City requires and when claim facts indicate that other claims may exist for which more information is needed.
L. Provide (at no cost to the City) informational pamphlets in appropriate languages to employees as require d by the State of California relative to their workers’ compensation benefits.
We have reviewed and will comply with this requirement.
AIMS provides the City with Claim Reporting Kits, which include the following forms and information:
Welcome Letter
Employers Report of Work Injury or Illness (5020)
Employee’s Claim Form (DWC1)
Work Injury posters
Informational pamphlets about AIMS and the claims team Instructions for reporting claims
M. Refer litigated cases to attorneys approved by the City for the purpose of defending the City’s interest before the Workers’ Compensation Appeals Board and courts of law.
We have reviewed and will comply with this requirement.
AIMS works with the City’s approved panel of defense firms/attorneys and establishes the agreed upon legal defense panel for the City, which includes referrals to a defense attorney when approved by the City.
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
When a decision to refer to defense counsel has been made, the Claims Examiner sends a narrative letter to the attorney with an outline of th e case, along with the issues and clear directions for further handling by the attorney. The Claims Examiner remains actively involved in the claim and performs as much of the routing handling as possible on these cases. Once a claim has been referred to defense counsel, the Claims Examiner will continue to oversee all activity on the claim, direct all legal activity and monitor performance in accordance with the Client’s criteria. This method of active involvement helps mitigate legal costs associated wi th unnecessary discovery proceedings, helps to gather all required evidence and witnesses as well as arranges expert testimony from the medical community.
N. Attend, where indicated, trials, hearings, arbitrations, rehabilitation hearings and any and all legal proceedings.
We have reviewed and will comply with this requirement.
Yes, within their capabilities and as statutes allow, the AIMS Claims Examiner and/or Supervisor may represent a Client before the Appeals Board of California or judicial body.
If the case has a defense attorney assigned, it may not be necessary for the AIMS Claims Examiner to attend the hearing, unless issues call for their attendance.
O. Produce computer generated reports as specified by the City; including, comparison reports with data from similar agencies (anonymous) that may be similar in size or in demographic area.
We have reviewed and will comply with this requirement.
AIMS provides various standard monthly reports and custom reports upon request for each department and division requested by the City . Our system is an extremely powerful data management claims system for both standard and ad hoc report generation. Our web based system, provides convenience and access to real -time and “point in time” financials for generating customized ad hoc reports, multiple program reports for data downloads and monthly loss reports which can be exported into other applications such as PDF or Excel.
Please see Exhibit 10 – AIMS Sample Claims Reports
P. Coordinate Medicare and Medicaid set aside agreements in compliance with Section 111 of the MMSEA including required reporting.
We have reviewed and will comply with this requirement.
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
AIMS has a formal plan in place to comply with the mandatory reporting requirements of Section 111 (“Medicare Secondary Payer”) of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA). AIMS’ strategic partner provides Mandatory Insurer Reporting (MIR) Services to our Clients, including State Children’s Health Insurance Program (SCHIP) reporting and ensures MSP compliance. Our strategic partner is used for all Qualified Referrals (claim settlements determined to require a Medicare Set Aside (MSA), Claim Settlement Allocation (CSA) and other services related to MSP compliance identified in their fee schedule).
AIMS has selected ExamWorks Clinical Solutions, t he nation’s most respected Medical Secondary Payer (MSP) compliance leader, to provide MIR Services to our Clients, including SCHIP reporting, and to ensure MSP compliance. ExamWorks Clinical Solutions is AIMS’ sole vendor for all Qualified Referrals (clai m settlements determined to require a Medicare Set Aside (MSA), Claim Settlement Allocation (CSA) and other services related to Medicare Secondary Payer (MSP) compliance identified in their fee schedule). Also, AIMS continuously evaluates the use of strat egic partner services to ensure performance-levels and continued value-added to our Clients.
There are no additional fees to the City for this reporting service
Q. Comply with the PRISM claims adjusting requirements dated 7/1/2011.
We have reviewed and will comply with this requirement.
AIMS has over one-hundred (100) Clients of which approximately 80% are public entities in the State of California. Several of these Clients are contracted with PRISM. AIMS has worked with PRISM for many, many years and AIMS is familiar with their guidelines.
AIMS’ own protocols mirror those of PRISM and AIMS applies these guidelines to the management of the City’s claims.
Bill Review
The AIMS senior operating management team has reviewed the Bill Review Scope of Work outlined detail. Our team fully complies with all requirements as presented in the Scope of Work. Please see the Bill Review response under the Specific submittal Requirements section for complete details.
A. Review all bills in a timely manner for compliance with applicable fee schedules and reduce accordingly, including those that fall outside of a fee schedule or PPO network.
B. Identify and reduce all duplicate billings.
C. Deny charges for all items not required for injury described.
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
D. Identify all unauthorized charges to ensure billing does not exceed parameters of injured workers’ treatment plan.
E. Maintain contracts with effective PPO organizations (including pharmacies), that include providers in the City of Richmond area.
F. Provide reports on a monthly and annual basis outlining bill review activity, savings and costs. Provide ad hoc reports as requested
G. Provide a computer system that interfaces with both the City’s workers’ compensation TPA and utilization review provider.
H. Handle all provider inquiries regarding bill reductions.
Utilization Review
The AIMS senior operating management team has reviewed the Utilization Review Scope of Work outlined below. As the incumbent, our team fully complies with all requirements as presented in the Scope of Work. Please see the Utilization Review response under the Specific submittal Requirements section for complete details. AIMS is also fully aware and participating in the coordinati on of medical treatment inside of the City’s ADR Program, whose goal is to expedite treatment to impact return to work status and claim resolution. AIMS is working closely with the City to monitor those industrial clinics participating in the ADR Program and provide feedback and suggestions on areas of improvement for delivering medical treatment.
A. Approve or disallow service requests within the applicable time standards and provide medical advice as warranted.
B. Provide timely reports to the City outlining utilization review requests, approvals, denials, and costs/savings.
C. Recommend, for City approval, panels of medical professionals, specialists, and treatment facilities to which injured employees should be referred for long - term or specialized treatment.
D. Provide medical management of all cases to assure cost -effective and appropriate treatment, including assurance that treatment is related to the compensable injury or illness.
E. Arrange for medical/legal opinions in disputed cases, conferring with medical examiners, professional personnel, the City, and legal counsel where indicated.
F. Provide a computer system that interfaces with the selected TPA and bill review service provider.
Attachment I
EXHIBIT 10 –
AIMS Sample Claims Reports (2
pages per sample)
Attachment I
Sample Loss Run Reports
Attachment I
2/21/17 2/22/17 2/2/17
1/29/16 2/2/16 1/27/16
0 10
0 0
0 0
0 0
0 0
6,614.97 0.00 0.00 6,625.03
32,622.53 0.00 0.00 35,444.65
As of: 08/29/2019 Activity Period: 08/25/2019 - 08/29/2019 Claims Activity
Claim No Examiner Clmnt Name
Status
Type
Loss
Date
Knowledge
Date
Add
Date
Rec'd
Date
Last
Closed
Last
R'open
RTW
Date Juris
ACT. PERIOD
Period
Paid
TOTALS Through 8/29/19
Asof Paid TotalReserves
Activity Code LOB Body Part
OTPalmer CA
IndemnityWC Ears, both
Reopened:
New Claims:
Closed:
Initial Reserve:
Closed w/Payment in Period:
Open w/Payment in Period: Non-Initial Reserve Change:
Open, No Financial Activity:
Returned to Work:
Ending Open:
Ending Closed:
End of Period
O CA
IndemnityWC Multiple body parts
Confidential & Proprietary DAVID
2/2/17
1/27/16
09/27/2019
Period
Incurred
TOTALS
Claims Activity : 08/25/2019 - 08/29/2019
Report Run: Data Date: Page 1 of 6
1. Closed in Period 2. Reopened in Period 3. Opened in Period 4. Open with Payment 5. Closed with Payment 6. RTW in Period 7. Initial Reserve. 8. Change of Reserve. 9. Denied A. Open w/o Financials
LOSS DETAILS
A
Activity Period
A
09/27/2019 14:12
0.00 0.00
0.00 0.00
0.00 0.00
1 1
1 1
Open
Total
Total
Total
Total
INDEMNITY CLAIMS
Paid
Incurred
Reserves
INDEMNITY
Financial Activity 08/25/2019 thru: 08/29/2019 As Of: 08/29/2019 Claim Status Summary as of 08/29/2019
Redacted - Department 1
Redacted - Department 1
Redacted
Attachment I
0 10
0 0
0 0
0 0
0 0
As of: 08/29/2019 Activity Period: 08/25/2019 - 08/29/2019 Claims Activity
Claim No Examiner Clmnt Name
Status
Type
Loss
Date
Knowledge
Date
Add
Date
Rec'd
Date
Last
Closed
Last
R'open
RTW
Date Juris
ACT. PERIOD
Period
Paid
TOTALS Through 8/29/19
Asof Paid TotalReserves
Activity Code LOB Body Part
Reopened:
New Claims:
Closed:
Initial Reserve:
Closed w/Payment in Period:
Open w/Payment in Period: Non-Initial Reserve Change:
Open, No Financial Activity:
Returned to Work:
Ending Open:
Ending Closed:
End of Period
Confidential & Proprietary DAVID
09/27/2019
Period
Incurred
TOTALS
Claims Activity : 08/25/2019 - 08/29/2019
Report Run: Data Date: Page 2 of 6
1. Closed in Period 2. Reopened in Period 3. Opened in Period 4. Open with Payment 5. Closed with Payment 6. RTW in Period 7. Initial Reserve. 8. Change of Reserve. 9. Denied A. Open w/o Financials
LOSS DETAILS
Activity Period
09/27/2019 14:12
0.00 0.00
0.00 0.00
0.00 0.00
1 1
1 1
Open
Total
Total
Total
Total
INDEMNITY CLAIMS
Paid
Incurred
Reserves
INDEMNITY
Financial Activity 08/25/2019 thru: 08/29/2019 As Of: 08/29/2019 Claim Status Summary as of 08/29/2019
Redacted - Department 2
Redacted - Department 2
Redacted
Attachment I
Sample Monthly Reports
Attachment I
Status. Loss Knowledge Act Type Juris L
Days
Activity Paid Paid Reserves Incurred
Loss Desc:
16543110 02/02/2017 N
xxx-xx-8
Inde 1885C CA N 0 0 0.00 6,625.03 6,614.97 13,240.00 Indemnity 0.00 0.00 1,740.00 1,740.00
Medical 0.00 6,459.85 3,540.15 10,000.00
Other 0.00 165.18 1,334.82 1,500.00
0.00 13,240.00 6,625.03 6,614.97
0 0
1 1
As of: 08/31/2019 Activity Period: 08/01/2019 - 08/31/2019 Claims Cost Detail
Loss
Age
Job
Code
Life
Med
This claim involves a 58 year old Construction Inspector II who went for an annual physical at work and failed his hearing test. He was referred to CVO for follow up. Delayed claim - Bilateral hearing loss, Hearing loss, cumulative to Ears, both from EXPOSURE LOUD NOISE by Repeated noise at 00:00 Claim #:
Total
Total:
Ending Closed:
Ending Open:
Confidential & Proprietary @2012 DAVIDCORP
R
Dates
Claimant:
0 9/27/19
TOTALS
Report Run: Page 1 of 5
O 58 02/02/2017
LOSS DETAILS
09/27/2019 14:22 Data Date:
Tax ID:
Other
Medical
Indemnity 0.00 0.00 1,740.00 1,740.00
0.00 6,459.85 3,540.15 10,000.00
0.00 165.18 1,334.82 1,500.00
0.00 6,625.03 6,614.97 13,240.00Total
Redacted - Department 1
Redacted
Attachment I
Status. Loss Knowledge Act Type Juris L
Days
Activity Paid Paid Reserves Incurred
Loss Desc:
15491130 01/27/2016 N
xxx-xx- 3
Inde 1100B CA N 79 0 151.73 35,596.38 32,470.80 68,067.18 Indemnity 0.00 6,397.42 13,419.76 19,817.18
Medical 141.78 24,653.51 17,296.49 41,950.00
Other 9.95 4,545.45 1,754.55 6,300.00
151.73 68,067.18 35,596.38 32,470.80
79 0
1 1
(Continued)
As of: 08/31/2019 Activity Period: 08/01/2019 - 08/31/2019 Claims Cost Detail
Loss
Age
Job
Code
Life
Med
57 year old female Accounting Clerk II tripped on area rug in front of lobby and fell. EE broke her fall, injuring right wrist, right knee, low back and hit head on elevator., Multiple injuries to Multiple body parts from CONTUSIONS by Walking at 09:00 Claim #:
Total
Total:
Ending Closed:
Ending Open:
Confidential & Proprietary @2012 DAVIDCORP
R
Dates
Claimant:
0 9/27/19
TOTALS
Report Run: Page 2 of 5
O 56 01/27/2016
LOSS DETAILS
09/27/2019 14:22 Data Date:
Tax ID:
Other
Medical
Indemnity 0.00 6,397.42 13,419.76 19,817.18
141.78 24,653.51 17,296.49 41,950.00
9.95 4,545.45 1,754.55 6,300.00
151.73 35,596.38 32,470.80 68,067.18Total
Redacted - Department 2
Redacted
Attachment I
Sample Frequency Reports
Attachment I
0 19
31 54
0 0
200
241
284
56 0
0 7
16,437
3,545
2,258
0 0
3,112
2,895
2,268
56 0
0 0
104
21 0
0 0
84 0
3 0
0 0
August 27, 2019
11:48AM
11 997 15,533.28 47.7 2.1 1.6 362,074.50 377,607.78 363.16 3,046.78 77 859 1,214,951.94 41.1 56.8 47.6 9,971,191.74 11,186,143.68 11,607.91 335,661.22 9 116 376,518.60 5.5 7.1 6.9 1,246,457.01 1,622,975.61 10,745.32 207,918.07 23 42 647,686.09 2.0 10.2 10.4 1,788,533.92 2,436,220.01 42,584.14 253,465.82 21 21 0.00 1.0 0.0 0.0 0.00 0.00 0.00 0.00
18 18 0.00 0.9 0.0 0.0 0.00 0.00 0.00 0.00
5 16 114,172.53 0.8 3.7 3.3 656,618.20 770,790.73 41,038.64 150,334.91 8 12 3,221,929.32 0.6 10.6 21.6 1,861,710.68 5,083,640.00 155,142.56 511,163.39 1 8 22,747.87 0.4 5.2 4.0 912,115.08 934,862.95 114,014.39 253,470.11 1 1 308,555.91 0.0 1.6 2.5 279,810.20 588,366.11 279,810.20 279,810.20 0 1 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00
0 1 0.00 0.0 2.8 2.1 485,685.54 485,685.54 485,685.54 485,685.54
Paid Incurred
As Of 07/31/2019
Open Total Avg. Paid Max. Paid Reserves Claims Paid IncurredLoss Type Avg. DaysLostRest.
Days
Confidential & Proprietary DAVID
Temp. Total or Part. Dis. (0.00% PD)
FM Minor permanent partial 24.999% or <
Closed Death Claim, C&R AOECOE/denial
Minor permanent partial 24.999% or <
FM Major permanent partial 25% or >
Frequency Analysis - Loss Type
Medical Only
Indemnity
NEVER USE<Not Assigned>
Major permanent partial 25% or >
Death
First Aid (CA)
Information Only
% of Insured's Total
All Insureds
Loss Dates: 01/01/1900 - 07/31/2019
Totals
Report Run:08/27/2019 Data Date: 08/27/2019 Page 1 of 3 Attachment I
15 30,578 212
August 27, 2019
11:48AM
174 5,922,095.54 2,092 23,486,292.41 17,564,196.87 8,395.89 511,163.39
Paid Incurred
As Of 07/31/2019
Open Total Avg. Paid Max. Paid Reserves Claims Paid IncurredLoss Type Avg. DaysLostRest.
Days
GRAND TOTALS 100.0 100.0 100.0
Confidential & Proprietary DAVID
Frequency Analysis - Loss Type
% of Insured's Total
Loss Dates: 01/01/1900 - 07/31/2019
Totals
Report Run:08/27/2019 Data Date: 08/27/2019 Page 2 of 3 Attachment I
Sample Dashboard Screenshots
Attachment I
3 Sample Dashboard Screenshots
Attachment I Page 349 of 1565
4Sample Dashboard Screenshots
Attachment I Page 350 of 1565
Sample Claim Status Report
Attachment I
CLAIM STATUS REPORT
Claim Overview Claimant: John Doe1005
Loss Date: 06/13/2005 Claim Number: 05138028
Dept.: 0900/1000 Public Safety Job Title: Police Dispatch Hire Date: 06/04/2004 LDW: 06/13/2005
Age at Injury: 25 Age: 35
Birthdate: 10/18/1979 RTW: TBD
Medicare Eligible: No
Claim Coding
Examiner: Dee Poser Loss Type: Indemnity
Accident Description: Nature of accident: REPETITIVE MOTION Nature of injury: CARPAL TUNNEL SYNDROME Body part: WRIST, RIGHT Incident type: REPETITIVE MOTION/TYPING Nurse Case Manager: Flora Nightingale TTD Rate:$0.00
Legal
Defense Counsel:
Applicant Attorney:
Case Resolution:
Financial Detail
Reserve Category Incurred Paid Outstanding
Indemnity
$ 5,965.43 $ 5,438.96 $ 526.47
Temporary Disability $1,345.43 $ 5,438.96 $ 526.47
Permanent Disability $4,620.00 $ 4,620.00 $ 0.00
Medical $ 9,687.77 $ 912.84 $ 8,774.93
Legal $ 0.00 $ 0.00 $ 0.00
Other $ 1,470.91 $ 390.57 $ 1,080.34
Total
Last TD Paid: Last PD Paid:
Plan of Action/Status
Disability status:
Current Issues:
Medical Status:
Plan of Action:
Dated: November 24, 2019
Attachment I
Key Metrics by Location
Attachment I
0 10
20 30
40 50
60 City Clerk City Corp Environmental
Resources
Facilities
Maintenance
Fire Dept Fleet Services Human Resources Human Services Info Only 0 0 0 0 0 0 0 0
First Aid 0 0 2 1 1 4 0 1
Med Only 0 1 10 0 30 3 0 0
Indemnity 1 0 18 2 23 4 2 0
Claims Count
Claims Count by Department
Fi
scal Year 2016/2017
Attachment I
0 20
40 60
80 100
120
Leisure And Recreation Police Dept Public Works Wastewater Department Water Department Info Only 0 0 0 0 0
First Aid 0 0 0 0 0
Med Only 1 52 2 3 0
Indemnity 1 49 1 5 1
Claims Count
Claims Count by Department
Fi
scal Year 2016/2017
Attachment I
Claims Administration Fees
and Claim Payments
Attachment I
9 0
0 1
0 11,894.47
0.00 0.00
-96.41
0.00 11,798.06
TotalCount
Payments:
Reversals:
Reinstatements:
Refunds:
Reversed Refunds:
Net Amount
Bank Account: Emerald City
AA-ACME-WC Demo / 0900/1000 Public Safety
06/17/2011 Check 06/17/2011 I8 2030026 Doe890 , John 1,456.00 16772 06/17/2011 Voucher 06/17/2011 I40 ME110079 Doe940 , John 1,680.00 16773 06/17/2011 Voucher 06/17/2011 I94 ME110079 Doe940 , John 840.00 16774 06/17/2011 Voucher 06/17/2011 I40 ME110064 Doe344 , John 1,552.03 16777 06/17/2011 Voucher 06/17/2011 I94 ME110064 Doe344 , John 776.10 16778 06/17/2011 Voucher 06/17/2011 I40 ME110087 Doe1028 , John 697.26 16779 06/17/2011 Voucher 06/17/2011 I40 08220491 Doe945 , John 1,946.48 16781 06/17/2011 Voucher 06/17/2011 I94 08220491 Doe945 , John 973.22 16782 06/17/2011 Voucher 06/17/2011 I40 06174393 Doe159 , John 1,973.38 16783 06/23/2011 Refund 06/23/2011 M47 8600505 Doe165 , John -96.41 0 1 6/17/20
3:09:38PM
Page Number:
Date Report Run:
Time Report Run:Activity Period:
Check No Effective Trans Type Check Date Type Payee Name Claim No Claimant Name Amount Totals for AA-ACME-WC Demo / 0900/1000 Public Safety
* = Break in check number sequence or duplicate check number(s) Financial Activity Ledger
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Attachment I
4 0
0 0
0 4,872.45
0.00 0.00
0.00 0.00
4,872.45
TotalCount
Payments:
Reversals:
Reinstatements:
Refunds:
Reversed Refunds:
Net Amount
AA-ACME-WC Demo / 1100 Public Works Operations
06/17/2011 Voucher 06/17/2011 I40 ME100056 Doe1828 , John 1,147.39 16775 06/17/2011 Voucher 06/17/2011 I40 ME100005 Doe1835 , John 1,205.44 16776 06/17/2011 Voucher 06/17/2011 I40 ME110075 Doe1559 , John 1,321.23 16780 06/17/2011 Voucher 06/17/2011 I40 ME090023 Doe1359 , John 1,198.39 16784 2 6/17/20
3:09:38PM
Page Number:
Date Report Run:
Time Report Run:Activity Period: 6/17/11 - 6/23/11
Check No Effective Trans Type Check Date Type Payee Name Claim No Claimant Name Amount Totals for AA-ACME-WC Demo / 1100 Public Works Operations * = Break in check number sequence or duplicate check number(s) Financial Activity Ledger
Redacted
Redacted
Redacted
Redacted
Attachment I
Sample Reconciliation Report
Attachment I
Pay
Check No Date Amount Type Type Payee Claim No Claimant
79139 √ 11/03/2014 720.38 Payment I1 Dolores Machtolff 00200308 Machtolff, Dolores 79140 √ 11/03/2014 352.50 Payment M25 Allied Managed Care, Inc. 01201848 Poplawski, Evelyn 79141 √ 11/03/2014 648.00 Payment M3 ECONOMY TRANSPORT LLC 01201848 Poplawski, Evelyn 79142 √ 11/03/2014 1,200.00 Payment M44 myMatrixx 00200341 Alcaraz, Raleigh 79143 √ 11/04/2014 340.00 Payment I2 Arnulfo Velasco 01200654 Velasco, Arnulfo 79144 √ 11/05/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79145 √ 11/05/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79146 √ 11/05/2014 396.00 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 01201049 Molina, Francisco 79147 √ 11/05/2014 412.50 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 01201049 Molina, Francisco 79148 √ 11/05/2014 506.80 Payment L1 LAW OFFICES OF VILEISIS, BRUSH A150000282 Robinson, Ladonna 79149 √ 11/05/2014 564.39 Payment M37 One Call Care Transport & Translate 02000336 Hall, Stephen 79150 √ 11/06/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79151 √ 11/06/2014 799.24 Payment I2 Evelyn Poplawski 01201848 Poplawski, Evelyn 79152 √ 11/06/2014 355.20 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79153 √ 11/06/2014 589.86 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79154 √ 11/06/2014 140.00 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79155 √ 11/06/2014 14.56 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79156 √ 11/06/2014 8,211.92 Payment L1 Floyd, Skeren, & Kelly, LLP 00200341 Alcaraz, Raleigh 79157 √ 11/06/2014 1,127.45 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L04000276 Perez, Naborina 79158 √ 11/06/2014 80.30 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L03000126 Maya, Nina 79159 √ 11/06/2014 155.60 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L01200647 Rodriguez, Francisco 79160 √ 11/06/2014 105.00 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L01201848 Poplawski, Evelyn 79161 √ 11/06/2014 2,232.78 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L02000362 Romo, Maria 79162 √ 11/06/2014 752.60 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L01200810 Ryan, Claudia 79163 √ 11/07/2014 .00 Payment M47 BAY AREA PAIN & WELLNESS CENTE 01201464 Adame, Kathryn 79164 √ 11/07/2014 54.99 Payment M44 Coastal Express Pharmacy 03000126 Maya, Nina 79165 √ 11/07/2014 264.36 Payment M44 Coastal Express Pharmacy 00200341 Alcaraz, Raleigh 79166 √ 11/07/2014 159.02 Payment M46 DAVID TORREZ PHD MFT A COUNSEL 01200647 Rodriguez, Francisco 79167 √ 11/07/2014 .00 Payment M54 Diogenes Anesthesia Medical Gr 00200341 Alcaraz, Raleigh 79168 √ 11/07/2014 .00 Payment M54 Diogenes Anesthesia Medical Gr 00200341 Alcaraz, Raleigh 79169 √ 11/07/2014 353.29 Payment M44 Express Scripts Inc 01201464 Adame, Kathryn 79170 √ 11/07/2014 137.05 Payment M47 Isaac Schmidt, MD 00200341 Alcaraz, Raleigh 79171 √ 11/07/2014 125.14 Payment M47 Joshua Prager MD MS 01201848 Poplawski, Evelyn 79172 √ 11/07/2014 719.56 Payment M47 Joshua Prager MD MS 01201848 Poplawski, Evelyn 79173 √ 11/07/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79174 √ 11/07/2014 120.86 Payment M44 MICHAEL`S PHARMACY 01200989 Velasco, Arnulfo 79175 √ 11/07/2014 74.60 Payment M47 P.R.I.M.E. PAIN MEDICINE INSTI 02000114 Lyle, James 79176 √ 11/07/2014 474.56 Payment I2 Maria Tapia 00200217 Tapia, Maria 79177 11/10/2014 616.96 Payment I2 Nina Maya 03000126 Maya, Nina 79178 √ 11/10/2014 305.54 Payment I14 Raleigh Alcaraz 00200341 Alcaraz, Raleigh 79179 √ 11/10/2014 431.14 Payment I2 Richard Menendez 02000102 Menendez, Richard 79180 √ 11/11/2014 124.78 Payment M47 BAY AREA PAIN & WELLNESS CENTE 01201464 Adame, Kathryn 79181 √ 11/11/2014 124.78 Payment M47 BAY AREA PAIN & WELLNESS CENTE 01201464 Adame, Kathryn 79182 √ 11/11/2014 .00 Payment M28 MSC GROUP INC 00200217 Tapia, Maria 79183 √ 11/11/2014 465.00 Payment M28 MSC GROUP INC 00200217 Tapia, Maria 79184 √ 11/11/2014 .00 Payment M28 MSC GROUP INC 00200217 Tapia, Maria 79185 √ 11/11/2014 .00 Payment M28 MSC Group, Inc. 00200217 Tapia, Maria 79186 √ 11/11/2014 .00 Payment M28 MSC Group, Inc. 00200217 Tapia, Maria 79187 √ 11/12/2014 180.00 Payment O6 DocCentral 02000102 Menendez, Richard 79188 √ 11/12/2014 182.30 Payment O6 DocCentral 02000102 Menendez, Richard 79189 11/12/2014 128.00 Payment L1 Altman, Lunche & Blitstein A250002778 Pillot, Mary 79190 √ 11/12/2014 168.35 Payment L6 DocCentral 02000102 Menendez, Richard 79191 11/12/2014 240.00 Payment L1 LAW OFFICES OF MARGARET R. STE 01201377 Sharp, Marsanna 79192 √ 11/12/2014 115.50 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 02000543 Macias, Rafael 79193 √ 11/12/2014 132.00 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 01201049 Molina, Francisco 79194 √ 11/12/2014 1,480.03 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 02000543 Macias, Rafael 79195 √ 11/12/2014 360.00 Payment L1 LOUIE & STETTLER, A LAW CORPOR 00200217 Tapia, Maria 79196 11/12/2014 300.25 Payment L1 LOUIE & STETTLER, A LAW CORPOR 00200217 Tapia, Maria Sample Client Reconciliation Check Register
November 1 - 30, 2014
Attachment IPage 360 of 1565
Pay
Check No Date Amount Type Type Payee Claim No Claimant
79197 √ 11/12/2014 540.50 Payment L1 LOUIE & STETTLER, A LAW CORPOR 00200217 Tapia, Maria 79198 √ 11/14/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79199 √ 11/14/2014 352.50 Payment O34 Allied Managed Care 00200217 Tapia, Maria 79200 √ 11/14/2014 352.50 Payment O34 Allied Managed Care, Inc. 02000102 Menendez, Richard 79201 √ 11/14/2014 549.13 Payment M25 CASE MANAGEMENT SOLUTIONS 02000336 Hall, Stephen 79202 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79203 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79204 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79205 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79206 √ 11/14/2014 194.95 Payment M44 Coastal Express Pharmacy 01201049 Molina, Francisco 79207 √ 11/14/2014 270.00 Payment M30 COSSIOS INTERNATIONAL LINGUIST 00200217 Tapia, Maria 79208 √ 11/14/2014 .00 Payment M47 DARREL H. BURNSTEIN, M.D. A ME 02000102 Menendez, Richard 79209 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79210 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79211 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79212 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79213 √ 11/14/2014 411.15 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79214 √ 11/14/2014 30.79 Payment M44 Express Scripts Inc 01201464 Adame, Kathryn 79215 √ 11/14/2014 188.99 Payment M44 Express Scripts Inc 01201464 Adame, Kathryn 79216 √ 11/14/2014 388.96 Payment M47 Grabow Medical Group Inc. 00200217 Tapia, Maria 79217 √ 11/14/2014 130.19 Payment M47 HAIDER SPINE CENTER MEDICAL GR 01201049 Molina, Francisco 79218 √ 11/14/2014 197.12 Payment M47 Hamlin Psyche Center 02000102 Menendez, Richard 79219 √ 11/14/2014 125.14 Payment M47 Joshua Prager MD MS 02000102 Menendez, Richard 79220 √ 11/14/2014 120.00 Payment M8 Maid Pro 00200217 Tapia, Maria 79221 √ 11/14/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79222 √ 11/14/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79223 √ 11/14/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79224 √ 11/14/2014 120.86 Payment M44 MICHAEL`S PHARMACY 01200989 Velasco, Arnulfo 79225 √ 11/14/2014 .00 Payment M46 MIRFAK ASSOCIATES, INC. 02000114 Lyle, James 79226 √ 11/14/2014 1,864.90 Payment M44 myMatrixx 02000336 Hall, Stephen 79227 √ 11/14/2014 101.13 Payment M44 myMatrixx 01201117 Diaz, Rosa 79228 √ 11/14/2014 112.21 Payment M44 myMatrixx 01201117 Diaz, Rosa 79229 √ 11/14/2014 74.60 Payment M47 P.R.I.M.E. PAIN MEDICINE INSTI 02000114 Lyle, James 79230 √ 11/14/2014 187.39 Payment M28 Priority Care Solutions LLC 00200217 Tapia, Maria 79231 √ 11/14/2014
.00 Payment M18 Priority Care Solutions LLC 00200217 Tapia, Maria 79232 √ 11/14/2014 40.00 Payment M28 RS MEDICAL 00200217 Tapia, Maria 79233 √ 11/14/2014 40.00 Payment M28 RS MEDICAL 00200217 Tapia, Maria 79234 √ 11/14/2014 152.21 Payment M47 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79235 √ 11/14/2014 289.22 Payment M47 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79236 √ 11/14/2014 203.79 Payment M47 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79237 √ 11/14/2014 45.16 Payment M44 STONERIVER PHARMACY SOLUTIONS 01201848 Poplawski, Evelyn 79238 √ 11/14/2014 1,353.11 Payment M44 STONERIVER PHARMACY SOLUTIONS 01201848 Poplawski, Evelyn 79239 √ 11/14/2014 202.44 Payment M44 Stoneriver Pharmacy Solutions 00200217 Tapia, Maria 79240 √ 11/14/2014 270.46 Payment M44 TMESYS, INC 00200217 Tapia, Maria 79241 √ 11/14/2014 44.15 Payment M44 TMESYS, INC 00200217 Tapia, Maria 79242 √ 11/17/2014 720.38 Payment I1 Dolores Machtolff 00200308 Machtolff, Dolores 79243 √ 11/18/2014 340.00 Payment I2 Arnulfo Velasco 01200654 Velasco, Arnulfo 79244 √ 11/20/2014 799.24 Payment I2 Evelyn Poplawski 01201848 Poplawski, Evelyn 79245 √ 11/21/2014 474.56 Payment I2 Maria Tapia 00200217 Tapia, Maria 79246 11/21/2014 180.00 Payment O6 DocCentral 02000102 Menendez, Richard 79247 11/21/2014 223.40 Payment M36 FRANCISCO MOLINA 01201049 Molina, Francisco 79248 11/21/2014 120.00 Payment M8 Maid Pro 00200217 Tapia, Maria 79249 11/21/2014 120.00 Payment M8 Maid Pro 00200217 Tapia, Maria 79250 √ 11/21/2014 970.07 Payment L1 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79251 11/24/2014 304.54 Payment I14 Raleigh Alcaraz 00200341 Alcaraz, Raleigh 79252 √ 11/24/2014 431.14 Payment I2 Richard Menendez 02000102 Menendez, Richard 79253 11/25/2014 616.96 Payment I2 Nina Maya 03000126 Maya, Nina 79254 11/26/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 78616 √ 11/03/2014 -35.99 Reversal M33 Francisco J. Rodriguez 01200647 Rodriguez, Francisco 79068 √ 11/17/2014 -833.00 Reversal I14 Kathryn Adame 01201464 Adame, Kathryn
Attachment IPage 361 of 1565
EXHIBIT 14 –
Certificate of Insurance
Attachment I
INSR ADDL SUBR
LTR INSR WVD
DATE (MM/DD/YYYY)
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
E-MAIL
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER
POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
INSURER(S) AFFORDING COVERAGE NAIC #
Y / N
N / A
(Mandatory in NH)
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
EACH OCCURRENCE $
DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
$
PRO-
OTHER:
LOCJECT
COMBINED SINGLE LIMIT
$(Ea accident)
BODILY INJURY (Per person) $ANY AUTO
OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
AUTOS ONLY
HIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
$
OCCUR EACH OCCURRENCE $
CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below POLICY
NON-OWNED
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
National Fire Ins of Hartford
The Continental Insurance Company
State Compensation Ins. Fund
Landmark American Ins. Co.
Valley Forge Insurance Co
Houston Casualty Co.
12/17/2021
Edgewood Partners Ins Center
One California Street, Suite 400
Lic#0B29370 (415)356-3900
San Francisco, CA 94111
Laurie Martin
-
[email protected]
Acclamation Insurance Management
10445 Old Placerville Road
Sacramento, CA 95827
20478
35289
35076
33138
20508
42374
A X
X
X
6056760864 01/01/2022 01/01/2023 1,000,000
1,000,000
15,000
1,000,000
2,000,000
2,000,000
E
X
X X
6056760850 01/01/2022 01/01/2023 1,000,000
B X X
X 10000
6056760878 01/01/2022 01/01/2023 10,000,000
10,000,000
C
N
908337922 01/01/2022 01/01/2023 X
1,000,000
1,000,000
1,000,000
D
F
Professional Liab
Privacy Liability
LHR843573
H21NGP20937501
07/11/2021
07/11/2021
07/11/2022
07/11/2022
$5,000,000 agg E&O
$5,000,000 agg Cyber
$25,000 SIR E&O & Cyber
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; CarivaCare, Inc. (See Attached Descriptions)
City of Richmond ATTN: Risk
Manager
450 Civic Center Plaza 3rd Floor
Richmond, CA 94804-0000
1 of 2
#S3022525/M3022241
ACCLINSUClient#: 6105
LMA4
Attachment I
SAGITTA 25.3 (2016/03)
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: Travelers Property & Casualty Insurance Company. #107196186 EFF: 1/1/22 EXP: 1/1/23 DISHONESTY LIMIT: $2,000,000 $20,000 DEDUCTIBLE Claims administration services and cost containment contract.
The City of Richmond, its officers, officials, employees, agents and volunteers are listed as additional insureds for all liability arising out of the operations by or on behalf of the named insured including bodily injury, deaths and property damage or destruction arising in any respect directly or indirectly in the performance of this contract, where required by written contract. General Liability insurance is primary and non-contributory with certificate holder's insurance. Workers Compensation Waiver of Subrogation endorsement is attached to the Workers Compensation policy. 2 of 2
#S3022525/M3022241
Attachment I
CNA PARAMOUNT
FinancialServices- GeneralLiability
ExtensionEndorsement
It is understoodand agreedthat this endorsementamendsthe COMMERCIALGENERALLIABILITYCOVERAGEPART as follows. If any other endorsementattached to this policy amends any provision also amended by this endorsement, then that other endorsementcontrols with respect to such provision, and the changes made by this endorsementwith respectto such provisiondo not apply.
TABLEOF CONTENTS
1. AdditionalInsureds
2. AdditionalInsured- PrimaryAnd Non-ContributoryTo AdditionalInsured’sInsurance
3. BodilyInjury– ExpandedDefinition
4. BroadKnowledgeof Occurrence/Noticeof Occurrence
5. BroadNamedInsured
6. Estates,LegalRepresentativesand Spouses
7. ExpectedOr IntendedInjury– Exceptionfor ReasonableForce
8. In Rem Actions
9. IncidentalHealthCare MalpracticeCoverage
10. JointVentures/Partnership/LimitedLiabilityCompanies
11. LegalLiability– DamageTo Premises
12. MedicalPayments
13. Non-ownedAircraftCoverage
14. Non-ownedWatercraft
15. PersonalAnd AdvertisingInjury– Discriminationor Humiliation
16. PersonalAnd AdvertisingInjury- LimitedContractualLiability
17. PropertyDamage- Elevators
18. SupplementaryPayments
19. UnintentionalFailureTo DiscloseHazards
20. Waiverof Subrogation– Blanket
6056760864CNA75102XX(1-15) PolicyNo:
6Page1 of 14 EndorsementNo:
Nat'l Fire Ins Co of Hartford 01/01/2022EffectiveDate:
ACCLAMATION INSURANCE MANAGEMENT SERVICES, INCInsuredName:
CopyrightCNA All Rights Reserved. Includes copyrightedmaterialof Insurance ServicesOffice, Inc., with its permission. 00020006460567608648327
Attachment I
CNA PARAMOUNT
FinancialServices- GeneralLiability
ExtensionEndorsement
1. ADDITIONALINSUREDS
a. WHO IS AN INSUREDis amendedto includeas an Insuredany personor organizationdescribedin paragraphs A. throughK. below whom a Named Insuredis required to add as an additionalinsured on this CoveragePart undera writtencontractor writtenagreement,providedsuch contractor agreement:
(1) is currentlyin effect or becomeseffectiveduringthe term of this CoveragePart; and (2) was executedprior to:
(a) the bodilyinjuryor propertydamage; or
(b) the offensethat causedthe personaland advertisinginjury, for which such additionalinsuredseeks coverage.
b. However,subject always to the terms and conditionsof this policy, including the limits of insurance,the Insurer will not providesuch additionalinsuredwith:
(1) a higherlimit of insurancethan requiredby such contractor agreement;or (2) coveragebroaderthan requiredby such contractor agreement,and in no event broader than that described by the applicableparagraphA. throughK. below.
Any coveragegrantedby this endorsementshall apply only to the extentpermissibleby law.
A. ControllingInterest
Any personor organizationwith a controllinginterestin a NamedInsured, but only with respectto such personor organization’sliabilityfor bodilyinjury, propertydamageor personaland advertisinginjuryarisingout of:
1. such personor organization’sfinancialcontrolof a NamedInsured; or
2. premises such person or organization owns, maintains or controls while a Named Insured leases or occupiessuch premises;
providedthat the coveragegrantedby this paragraphdoes not apply to structuralalterations,new constructionor demolitionoperationsperformedby, on behalfof, or for such additionalinsured.
B. Co-ownerof InsuredPremises
A co-ownerof a premisesco-ownedby a NamedInsuredand coveredunder this insurancebut only with respect to such co-owner’sliability for bodily injury, propertydamageor personaland advertisinginjury as co-owner of such premises.
C. Grantorof Franchise
Any person or organization that has granted a franchise to a Named Insured, but only with respect to such person or organization’sliability for bodily injury, property damage or personal and advertising injury as grantorof a franchiseto the NamedInsured.
D. Lessorof Equipment
Any person or organizationfrom whom a Named Insuredleases equipment,but only with respect to liability for bodily injury, propertydamageor personaland advertisinginjury caused,in whole or in part, by the Named Insured’smaintenance,operation or use of such equipment,provided that the occurrencegiving rise to such bodily injury, propertydamageor the offense giving rise to such personaland advertisinginjury takes place prior to the terminationof such lease.
6056760864CNA75102XX(1-15) PolicyNo:
6Page2 of 14 EndorsementNo:
Nat'l Fire Ins Co of Hartford 01/01/2022EffectiveDate:
ACCLAMATION INSURANCE MANAGEMENT SERVICES, INCInsuredName:
CopyrightCNA All Rights Reserved. Includes copyrightedmaterialof Insurance ServicesOffice, Inc., with its permission.
Attachment IPage 366 of 1565
EXHIBIT 15 –
Proposer Qualifications
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Exhibit 15 – PROPOSER QUALIFICATIONS
Proposer Qualifications
Claims Administration
A. Firm’s s: Describe the firm and provide a statement of qualifications for performing the requested scope of services as outlined in Scope of Services- Claims Administration Services. Identify the firm’s primary service office for the City’s account. Provide a company-wide organizational chart with reference to the proposed service office and proposed service team.
Please see the main body of our proposal Firm Description and attached Exhibit of AIMS Organization Charts.
B. Service Team Qualifications: Provide an organizational chart outlining your proposed service team including names, titles, and length of service in your organization. For each proposed team member, provide a summary of qualifications including claims handling experience, indemnity case load, experience working with public entity self- insured entities, education, and any professional designations and awards. Include full resumes for each member of your proposed service team. If you have not designed staff to service the City’s account, provide the selection qualifications for any staff necessary to service the City’s account.
See attached Exhibit of AIMS Organization Charts and Team Resumes.
C. Claims Administrative Services: Describe your firm’s claims administration policies, procedures, and best practices that ensure superior service to City employees while maintaining economic and administrative control over claims costs. Discuss your claims reserving philosophy and indicate the maximum number of indemnity files handled by your proposed claims examiners.
Policies and Practices: AIMS has customized all procedures to meet the Scope of Work requirements of the City. AIMS administers our California Clients’ self-insurance plans in full compliance with all laws, rules and regulations governing the administration of self - insurance pursuant to Sections 3700 et seq . of the Labor Code and the California Administrative Procedure Act as set forth in Government Code, Title 2, Div. 3. Part I, Chapter 4 and 5 in effect at the time of submission of our response to this RFP as amended during the period that any contract wit h the Client is in effect and any other laws, rules, and regulations that govern the handling of California Workers’ Compensation claims.
A true partnership between the Client and the administrator is imperative to the successful management of a workers’ compensation program. This relationship takes a high level of communication, trust and a lot of work. Our hands -on team approach is what has led to the development of many strong partnerships over the years. This has involved partnering with the City to ass ess specific needs and then developing a customized claims Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
management program designed to combat claim exposures and costs for the City. The key elements of the program are:
Define - Learn and evaluate needs of the customer
Perform - Deliver and be accountable to expectations
Measure - Analyze effectiveness
Report – Present hard data
Recommend – Suggest proactive strategies to improve results Superior Client Service to City employees: As a Client -driven organization, AIMS delivers measurable financial results to our Clients through our intelligent use of innovative technology and a flexible, yet disciplined, approach to service delivery with fiscal accountability. We nurture long -term relationships by providing our Clients with technically competent, experienced, and dedicated staff, acting with integrity in all that we do.
Our commitment to great Client servi ce is the same at every level of our organization - from our front line employees to our senior managers. Clients evaluate our performance based on the responsiveness of our employees. When we consistently meet our commitments with enthusiasm and timelines s, the entire organization benefits, and our Clients becomes our advocates.
It is every employee’s responsibility to:
Listen for understanding
Show empathy
Find solutions
Anticipate needs
Follow through on commitments
“Serving Clients is our purpose. Client service is our passion.” Client Service Initiative: Seven years ago we launched a Client Service initiative directed at improving and providing a higher level of Client service for our current and future Clients. In the initial phase of the progra m we focused specifically on training and investing in our managers and staff bringing them on board with our goals and initiatives. Our training efforts have continued regularly since that time with an ultimate objective: to better understand, from our Client's perspective, how we at AIMS interact with you on a day to day basis.
Client Relations Director: AIMS has implemented the second phase of our Client service program by establishing a Client Relations role within AIMS. We felt it was vitally important to have a position solely focused on maintaining and improving client satisfaction. Therefore, we have established and assigned the position of Director of Client Relations. This individual is in charge of developing a better understanding of how we wo rk together and how we at AIMS can provide even better service. Our Director of Client Relations contacts Client staff that interacts with us on day to day basis and asks questions concerning Client experiences with AIMS, both good and bad. This informati on is then provided to AIMS senior management for review and issue resolution responsibility.
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Meetings, Training, Stewardship Reporting: AIMS prides itself on providing the kind of pro-active Client service seldom seen in our industry. From in-person Client meetings to completing specialized data reports on the program development, we will always go the extra step. Our management staff is responsible for our in -service training. When requested, training sessions on proper reporting, new case law or chan ges in the methodology the State expects the delivery of workers’ compensation services to be accomplished is an integral part of our value-added partnership. These training sessions may be held at our offices, Client locations or other specific areas des igned to accommodate a number of our local Clients who share the same need for up -to-date status on the ever changing climate of workers’ compensation in California.
As part of our philosophy with regard to continual and seamless communication with the City, we expect there will be times when agency or department heads will inquire about specific cases and the strategy for disposition. On those occasions and with the City’s permission, we will schedule file reviews or in-person meetings to inform the department of progress on a specific claim(s). AIMS provides the City regular face -to-face meetings with the Examiner(s) at the City’s desired location. Pre-meeting status reports are developed and any issue that is allowed to be discussed will be placed on an agenda.
Privacy issues will be protected from those employees who are not authorized to discuss those topics.
Economic and Administrative Control Over Claims Costs : Our approach to the management of our Clients’ claims and programs centers on quality, service and results.
We are committed to a constant focus on these key elements of our Loss Portfolio Management® approach. Our Clients are not just the employers but also the employees who have sustained industrial injuries or illnesses while working within the course and scope of their employment. We focus upon promptly providing these employees the benefits due them and maintaining open and on -going communication with them during the course of their claims. Programs that provide this positive approach will produce lower overall workers’ compensation costs, including significantly reduced litigation rates.
Loss Portfolio Management®: Our “Loss Portfolio Management®” approach ensures that we are always focused on identifying key issues that have a large financial impact on the overall claim and to proactively utilize all available internal and external cost containment resources to address and resolve these issues in an expedient fashi on.
AIMS management and staff have a singular objective: assist the City to be productive and profitable while providing compassionate care of its injured employees. We work in partnership with our Clients to achieve optimal results from their self-insured workers’ compensation program. AIMS goes beyond ordinary third party administration services, to offer our Clients a customized, flexible loss management program and services designed to generate lower claims costs and better outcomes.
Quality Assurance: AIMS asserts a strong Quality Control Program, in which we consistently monitor, measure performance, and review the quality of the services being provided to ensure superior customer service and cost saving results for our Clients. In addition to the standard supervisory audit, our Internal Audit Unit, headed by Cheryl Agee (Vice President Workers’ Compensation), conducts audits against our best practice standards as well as the Client’s Special Handling Instructions. The Audit Unit’s p rocess Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
involves notification that an audit is to be conducted in the Branch or local office. The Manager makes available all requested information, claim files, logs, contracts, etc. In addition, the Manager participates in the actual audit itself. All fi les with deficiencies and/or recommendations are immediately returned to the Claims Examiner for corrective action. The Claims Managers review the file for compliance at each diary date. The Supervisors carry independent diaries for this purpose. Audit scores are incorporated into Performance Evaluations conducted annually for each employee. The audit conducted by our internal audit unit is comprehensive and takes into consideration all facets of claim file handling.
Diary System: The key to good claims management, avoiding penalties and keeping deadlines, is an effective diary system that enables the Claims Examiner to properly manage each claim in an expedient manner. Claims Examiners are required to review open Indemnity claims at least every 45 days. Our computer system has an automated diary system that is utilized by all of our staff. A detailed list of diaries is displayed each time a user logs onto the computer. At a minimum the claims unit supervisors are required to review open Indemnity claims within 10 days of a new claim filing and thereafter every 120 days. Our knowledgeable, dedicated managers and supervisors provide strong supervisory oversight. AIMS internal audit team reviews claims to assure legal and regulat ory compliance, as well as conformity to best practices and Client -specific performance standards.
We employ a “supervisor’s overview” of the daily diary to monitor when a file is due to be reviewed and whether or not the Examiner has conducted the diary. This is one of the key components of our internal audit process.
In addition to the standard supervisory audit, our own Internal Audit Unit (headed by the Vice President of Workers’ Compensation), conducts audits against our established procedures as well as the Client’s Special Handling Instructions. The Audit Unit’s process involves notification that an audit is to be conducted in the Branch or local office. The Manager shall make available all requested information, claim files, logs, contracts, etc.
In addition, the Manager shall participate in the actual audit itself. All files with deficiencies/recommendations are immediately returned to the Claims Examiner for corrective action. The Claims Managers review the file for compliance at each diary date.
The Supervisors carry independent diaries for this purpose. Audit scores are incorporated into Performance Evaluations conducted annually for each employee. The audit conducted by our internal audit unit is comprehensive and takes into consideration all facets of claim file handling.
The following Time Performance Standards are part of our Best Practices audit standards, which are used to help keep claims on track for prompt resolution.
TASK TIMEFRAME
Claim set up in Computer Within one (1) working day of date of receipt Initial Claimant Contact Within one (1) working day of date of receipt Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
TASK TIMEFRAME
Subsequent Claimant Contact Every 14-days of continued disability – or every thirty (30) days if on modified duty
Initial Client Contact Within one (1) working day of date of receipt Initial Medical Provider Contact Within one (1) working day of date of receipt Initial Payment of Disability Within fourteen (14) days of first day of disability Investigation Within five (5) days of knowledge of condition requiring investigation & approval by Client
Investigation Reports Within fifteen (15) days of assignment – subsequent reports maximum of every thirty (30) days
DWC Benefit Notices Within fourteen (14) days of the event causing the need for notice Penalty Report Form To be completed within 72 hours of notice of penalty -Form to home office within 5 working days
Penalty Payments Self-imposed penalty to accompany delayed benefit Auto Pay Schedules Not to be authorized for more than seven (7) periodic payments (84) days
Advance Travel Expense At least ten (10) days before examination date Transportation Reimbursement Approval for payment within fifteen (15) working days of request for reimbursement
Medical Treatment Billings Approval for payment within ten (10) calendar days of receipt of bill
Payment of electronic bills Within fifteen (15) days of electronic receipt Contested medical bills Notice to provider within twenty (30) calendar days that bill is contested, denied or incomplete
Payment of Awards, C & R ’s,
stipulations
Approval for payment within fourteen (14) calendar days of receipt or Statutory Requirements.
Litigation Referral to defense council no more than ten (10) days from date of decision to refer (sooner if impending court date or other deadline)
Initial status report from defense
counsel
Maximum of fifteen (15) days from date of referral
Subsequent reports Maximum of thirty (30) days from last report Subrogation Notification/Contact with negligent third party within thirty (30) days of determination of existence of subrogation
Balancing of Claim File Every 180 days or end of benefit, whichever occurs first Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
TASK TIMEFRAME
Excess
Reporting/Reimbursement
Initial reporting —within ten (10) working days of date of knowledge that any reporting Criterion has been met
Requests for reimbursement Maximum of every ninety (90) days Case Closure Within thirty (30) days of the final payment, notice, or as provided by law
Telephone Inquires Return Calls —within one (1) working day of original telephone inquiry
Plan of Action Review Every ninety (90) days a full plan of action update is noted in the system
Return Correspondence Written answer completed and returned within five (5) working days of receipt
Supplemental Job Displacement
Vouchers (Potential Notice)
Within 10 days of last payment of temporary disability
Conversion of Medical Only to
Indemnity
Within one (1) day of knowledge that file needs to be converted and reviewed/approved by Supervisor
Reserves At initial file setup
Within seven (7) days for any event that triggers the need for a reserve change
Reserve reviews required at a maximum of every ninety (90) days Status Reports Every ninety (90) days created and provided to Client Examiner File Review No less than every forty-five (45) days – documented by notepad activity under “Examiner review”
Supervisory File Reviews At a maximum of every one-hundred and twenty (120) days
AIMS will customize these response times if the Client has specific requests and these will also be reflected in the Client Special Handling Instructions. These instructions will incorporate AIMS Best Practices (AIMS4Excellence), Case Review Details, and assertive quality control measures that include all Client specified timelines.
All of these standards and procedures, along with our hands-on proactive involvement in the claims, ensure cases continually move toward a timely and cost effective closure without jeopardizing necessary high quality of care for the injured worker.
AIMS Supervisors are focused on providing continuous oversight of the claims and Client programs. A monthly review is conducted on a percentage (minimum 10%) of each Examiner’s files to ascertain that the Claims Examiner is performing up to our standard as well as the agreed upon standards of the Client. The Supervisor subsequently reviews claims at regularly timed intervals (not less than every 120 days) or when specific events Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
occur such as surgery or litigation, when the claim meets reserving or payment thresholds, and in the course of continuous random audits.
AIMS Supervisor has numerous duties including frequent reviews of Claim Examiner’s claims. Supervisors do not carry caseloads as they are focused on providing continuous oversight of the claims and Client programs. The following are exam ples of Supervisor duties:
The Supervisor will review all new losses received daily to confirm contact was made timely and make an entry in the computer’s supervisor notepad. The Claims Management Information System will set an automatic supervisor diary for 10 days following claim entry to confirm that all issues on the claim have been addressed. (i.e., subrogation, notices, benefit provision, etc.) By the 6th business day of the following month the Supervisor will provide a report to the Branch Manager and corporate office outlining the total lost time claims received, the total timely contacts and the percentage of timely contacts. Each Supervisor is to monitor the payment diary of their staff for timeliness and accuracy.
The Supervisor is to monito r the review diary of their staff for timeliness and accuracy no less than once a month.
All denials and delays shall be approved by the team supervisor. Authority to delay or deny a claim shall first be obtained from the Client. As soon as suspect issues arise, they must be written up by the Claims Examiner and given to the immediate Supervisor with the file to be reviewed and consideration for fraud investigation will be made.
Any file which indicates the possibility of subrogation should be forwarded to a Supervisor for review to determine if further investigation is required. Upon receipt of a Decision or Order, the Supervisor shall make a prompt analysis regarding an appeal. If the Supervisor feels the decision should be appealed, the file should be documented as to the reasons and referred to the Branch Manager. Upon receipt of the “Reinsurance Report” each Unit Supervisor or Branch Manager shall verify that all cases listed on the report have been reported to the Excess/Reinsurance carrier.
All non -senior level Team member closures shall be approved by the Team Supervisor or Manager.
In addition to the above duties, the Supervisor, as a part of his/her performance evaluation has to review a select percentage (minimum 10%) of each Claim Examiner’s files on a monthly basis. This review is conducted to ascertain that the Claim Examiner is performing up to our standard as well as the agreed upon standards of the Client. For sensitive or high exposure cases, the supervisor utilizes a personal oversight di ary, identifying those cases that warrant periodic management review. The Supervisor Review is clearly noted in the notepad. Appropriate action is taken to ensure completions of all tasks are met. Our Supervisors provide technical oversight of the individual claims and of the employers’ workers’ compensation programs, ensuring quality, service, results as well as compliance with regulatory and Client -specific program performance Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
standards. Supervisors do not carry a caseload. All Senior Claim Examiners and above are State certified to administer self-insured workers’ compensation claims unless waived by the Client.
Monitor and Manage Case Loads: On a continual basis, we review the Claim Examiner activity dashboards that capture all new claims and closing ratios and pending open files.
The Supervisors consistently manage the Claim Examiner’s caseloads to ensure caseload levels are managed based on Client specific requirements. All files with deficiencies/recommendations are immediately conveyed to the Claim Examiner for corrective action.
AIMS is committed to fully comply with the regulations for Workers’ Compensation Examiner Certification regulations (CCR, Title 10, Sections 2592 to 2592.14) that were developed to implement Insurance Code Section 11761 effective February 22, 2006.
Education and Training: Our management staff is responsible for conducting and/or coordinating all in -service training and our Vice President of Workers’ Compensation (VP), responsibility includes monitoring for compli ance with the Insurance Code 11761, training and continuing education, on a bi -annual basis. The VP currently publishes a schedule for each branch manager indicating who in the respective office is subject to the CEU requirement annually. It becomes the responsibility of the Manager to then arrange for outside CEU opportunities or arrange to schedule in -service seminars by inviting industry professionals into our offices to conduct DWC approved courses. All professional staff is invited as well as interested Clients.
AIMS pays for our Claim Examiners and Assistants to complete their Insurance Educational Association (IEA) certificate. We also pay for the Self-Insured Administrators test if the current position requires certification. We pay for outside s eminars and conferences and provide the staff with frequent in-house educational presentations. AIMS recognizes the only way to ensure compliance with workers’ compensation laws, regulations and statutes is to maintain a high level of continuing education and training in order to keep up with legislative, legal, and regulatory changes in our industry. We conduct training on a regular basis in the areas of subrogation, fraud, medical management and other key training areas within our Best Practices Performa nce Standards. At AIMS, we require all staff to attend and complete training sessions regarding legislative, legal and regulatory changes in the workers’ compensation industry.
Partial List of Recent Mandatory Training Sessions: EDI Training, Utilization Review, Medicare Set-Aside Trusts, AMA Guides & PD Rating, Fraud Training, Medical Provider Networks, Security Awareness, 4850 & Public Safety Presumptions, Supplemental Job Displacement Benefits, Ergonomics, and Medical Roundtable.
Reserving: AIMS Claims Examiners are well versed in the tangible and intangible rationale affecting reserves and establish accurate reserves given the state of the claim facts at any point in time. Reserves are constantly reviewed at each scheduled diary.
Reserve worksheets a re prepared to support any changes made in reserving amounts and can be provided to the Client in support of a reserve increase or other change. This information is made available to the Client through online viewing of the Examiner’s electronic file notepad. If the Client desires, prior to any reserve change of a pre-agreed Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
amount or level, the Claims Examiner will confer with appropriate Client personnel to discuss the merits of the proposed change.
AIMS Examiner will review and evaluate the reserve adeq uacy and possible closure at 45 day intervals or as designated by the City.
The criteria that mandates review of reserves is based on the level of authority by position.
Provided below are the corporate guidelines applied to reserving as well as the task performance timeframes:
Examiner $0 - $250,000
Senior Examiner $0 - $500,000
Supervisor $0 - $750,000
Branch Manager $0 $1,000,000
Performance Time Frame Standards – Reserves
TASK PERFORMED TIMEFRAME
Reserves At initial file setup. Within seven (7) days for any event that triggers the need for a reserve change. Reserve reviews required at a maximum of every ninety (90) days.
Status Reports/ Plans of Action Every ninety (90) days.
Supervisory File Reviews At a maximum of every one-hundred & twenty (120) days.
Please see Exhibits 7 – Settlement Authority Request Worksheet and Exhibit 8 – AIMS4Excellence TOC
D. Ancillary Services: Identify any company -owned and affiliated ancillary services to include, but not limited to, bill review, and utilizati on review. Provide a description of each ancillary service including an organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. List all outside vendors you currently work with including the services they provide. If such services were awarded to one or more vendors not owned by or affiliated with your company, describe how your firm would work with such outside providers to ensure effective and efficient service to the City.
Include any limitations you may have in working with outside vendors.
AIMS strives to provide its Clients with a thoroughly customized program. We provide assistance to our Clients in formulating customized claim report generation, customized stewardship reporting, a customized transition plan, customized Medical Provider Networks (MPN), customized Preferred Provider Organization (PPO) Networks, customized Carve-Out Programs to address cost drivers, customized utilization review (UR) and medical case management referral criteria, customized vendor panel, and in - Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
house customized training on workers’ compensation topics and trends to name a few.
For me dical cost containment services, AIMS recommends its sister company, Allied Managed Care, Inc. (AMC). AMC has been providing these services to California public agencies, self -insured’s and insurance carriers since 1995. AMC offers Medical Bill Review, Utilization Review, Nurse Case Management (including telephonic and on -site or field nurse case management) , Customized Medical Provider Networks (MPN), AlliedRx (Prescription Management), AlliedCare Complete (Early Intervention), and CallConnect (Call Center Services).
AIMS researches and will vet service providers for quality and best -value for our Client and will make our recommendations known to the City. If the City has preferences for various service providers, AIMS will use the City’s preferred vendo rs. The service provider “panel” is pre-approved by our individual Clients. Any exceptions to appropriate assignments are managed on a case-by-case basis. Through this platform, we have the ability to streamline the Claims Examiner workflow as well as t rack, manage and run reports on service provider usage.
AIMS coordinates Clients’ vendor panels and approvals in advance and all referrals to vendors in accordance with the Clients’ requirements as part of an integrated cost containment solution, which ent ails managing ancillary services and coordinating programs such as:
Medical Bill Review
Utilization Review
Nurse Case Management
Return to Work (includes on-site programs),
Loss Control
Workplace Safety
Occupational Health Clinics
Job Task Banks
Employee Training and Medical Provider Networks (MPN) Also, AIMS continuously evaluates our strategic partner service providers to ensure performance-levels and continued value-add to our Clients.
AIMS has created an integrated referral platform called AIM S Rapid Referral Program (ARRP) to expedite this process of referral coordination between vendors and AIMS Examiners. The process integrates information directly from the Ventive System and uploads to the ARRP System. The ARRP System documents the referral and uploads the forms into the AX Document Storage System. The uploading and documentation of the referral eliminates the Examiners need to do these steps and instead completes these tasks upon creating the referral in the ARRP System. Reports are generated to track lag times and effectiveness of both the AIMS teams and the Vendors
E. Claims Management System: Describe in detail how your computer system is utilized to provide workers’ compensation services. Discuss the capabilities of the system including whether the system tracks lost time, temporary modified duty and temporary partial disability. Provide samples of standard and customized computer- Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
generated reports you prepare for your clients (Note: limit 1 - 2 pages per sample).
AIMS utilizes Ventiv System, which is an Internet-based claims management system built on Microsoft.Net technology, designed for anytime, anywhere access. The system access is web-based and runs on an SQL database platform.
Our claim management system provides a wide array of information so, the City can immediately evaluate the current condition of its customized program. Access to this information allows the City to effectively manage its workers’ compensation program and to confidently make high impact risk management decisions. Our system provides the City with extensive on-line capabilities for reporting claims, customized report generation, and immediate real time access to key information from any location.
Claim System Features of benefit to the City:
Direct viewing of Claims System with description and details Key data at fingertips: financial data, claims diaries, notes, lost time, temporary partial disability, and RTW
Self-Generated ad-hoc reporting when you need it
User defined report queries
Web-based entry of (Employers' First Report of Industrial Injury or Illness) 1099 reporting to the Internal Revenue Service
Self-Insurers Annual Report generation
Occupational Safety and Health Administration (OSHA) reports – Lost Work Days
Electronic interface with the Index Bureau and Workers’ Compensation Insurance System
Production of all required reports and data exports (real time and viewed archived reports)
Electronic Data Interface compliant
Access all performance metrics (dashboard view)
AIMS claims management system accepts unlimited levels of location coding, allowing Client data to be sorted by location or cost center for loss control and financial purposes.
The department names and organizational coding is customized to fit the needs of each Client. Similarly, custom code sets allow each Client to define their own tables, such as notepads, pay types, class codes, and job descriptions.
By customizing our coding tables, we are able to extract accurate and relevant data that satisfies the needs of each Client. The primary categories for reserves have been expanded to allow us to more effectively track benefit payment, reserve, and incurred data. The system tracks lost time, t emporary modified duty, and temporary partial disability. Listed below are some of the reserve categories:
Temporary Disability
Permanent Disability
Labor Code 4850
Medical Expenses
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Legal Expenses
Other Expenses (includes investigations)
Vocational Rehabilitation Benefits
As mentioned above, the RMIS is upgraded on a continuous basis. Our claims information system utilizes state -of-the-art technology including access security, nightly back -ups with off-site storage, an uninterrupted power source to ensure continued use in the event of a power shortage, and a formal business interruption plan.
Access to our system is only gained through user specific security codes; therefore, only select personnel who have been given clearance have access to data and mo netary functions. Various security levels are granted to users, which preclude change of data and generation of payment or reserve changes unless pre -authorized. Also, the system allows password security at the location code level so user can access only their location information.
Standard & Monthly Reports: In addition to extensive reporting, the following information is a sample of what type of reports and data AIMS Clients can view within the claims system: Claims Summary, Claims Examiner Notes, Detailed Payment Information, Detail Transaction, Managed Care (UR, Fee Schedule), Billing Information, and Prior TPA Information. In addition, correspondence such as medical legal reports, depositions, denial letters, and attorney correspondence information is also captured. AIMS electronic database is capable of producing specialized and ad hoc reports in addition to those required by the State of California. AIMS can provide various standard monthly reports and custom reports upon request. AIMS supports its Clients with a robust report library. Our system is an extremely powerful data management claims system for both standard and ad hoc report generation. Our web based system also provides convenience and access to real -time and “point in time” financials for generating customized Ad Hoc reports, multiple program reports for data downloads and monthly loss reports which can be exported into other applications such as Portable Document Format (PDF) or Microsoft Excel. Types of data available which will electronically be available to the County range from Claims Summary, Adjuster Notes/Diaries, Detailed Payment Information, Detail Transaction, Managed Care (UR, Fee Schedule), billing details to prior TPA information.
Please see Exhibit 10 – AIMS Sample Claims Reports
F. SAS 70 Audit Compliance: Indicate your firm’s compliance with SAS70 annual audit compliance reporting and indicate the date of the most recent completed audit report.
AIMS undergoes SSAE 18 audits annually to ensure our contr ols are effective because we are very earnest about our business and the security of our Client’s information. The Company has successfully undergone the audit process and is compliant with the Statement on Standards for Attestation (SSAE) No. 18, Reportin g on Controls at a Service Organization.
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Proposal for City of Richmond
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The SSAE No. 18 audits effectively reports (SOC1 & SOC2 reports) on the relevant internal controls established by LJR Holdings, Inc. (LJRH) for AIMS, especially the financial controls and the information systems relevant to security, availability, processing integrity, confidentiality or privacy in performing our services for our Clients. The Company’s compliant report for Service Organization Controls (SOC1 & SOC 2) has been included in the noted exhibit.
Please see Exhibit 11 – SSAE 18/ SOC 1 & 2 Reports (CONFIDENTIAL)
G. Client References: Provide a list of five (5) clients (including full contact information) from which similar types of claims-related services are provided by your proposed service team office. Include the length of your contract with each client including the approximate number of indemnity claims annually. The City will contact these references to discuss the bidder’s performance.
The longevity of our Client relationships is based in part on the types of programs AIMS establishes, which reinforce the strategic goals of workforce excellence, organizational effectiveness, and fiscal responsibility. Provided below are references for Clients with programs similar to the City of Richmond.
REFERENCE – Claims Related Services
Agency Name
Central San Joaquin Valley Risk Management Authority (52 Member Cities JPA) Contact Name
Kevin Werner, City of Ripon, City Administrator
Contact Phone Number
(209) 599-2108
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
Client since 1995 / 1000
REFERENCE – Claims Related Services
Agency Name
City of Bakersfield
Contact Name
Jena Covey, Risk Manager
Contact Phone Number
661-326-3090
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
Client since 2007 / 500
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REFERENCE – Claims Related Services
Agency Name
City of Huntington Beach
Contact Name
DeAnna Soria, Risk Manager
Contact Phone Number
715-536-5519
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
Client since 2010 / 500
REFERENCE – Claims Related Services
Agency Name
City of Clovis
Contact Name
Lori Shively, Personnel/Risk Manager
Contact Phone Number
559-324-2726
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
Client since 2007 / 175
REFERENCE – Claims Related Services
Agency Name
County of Madera
Contact Name
Jason Blanks, Risk Manager
Contact Phone Number
559-675-7703
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
2005 to present / 300 open claims
Bill Review
A. Firm’s Qualifications: Describe the firm and provide a brief statement of qualifications in providing bill review services. Describe your experience doing business with self- insured public entities in California. Discuss what distinguishes your company fr om other bill review providers. Provide a company -wide organizational chart with reference to the proposed service office and proposed service team.
AIMS recommends its sister company, AMC for bill review (BR) services. AMC has one central goal – provide p rofessional medical cost containment solutions that result in improved program costs. AMC has over 100 Clients consisting of approximately 80% Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
self-insured public entities and 20% private entities throughout the continental United States and Hawaii. AMC audits approximately 230,000 bills per year.
AMC’s philosophy is, in part, that the greatest net savings and not just the lowest fee bill review company should be any employers’ decision point. Our goal is to ensure our Clients only pay what they are lega lly obligated to pay, no more or no less . Some competitors offer an extremely low fee and, to do so, they also automate nearly all of the bill review process. Fully automating BR leads to an increase of inquiry and dispute calls from the provider to the TPA/Employer, an increase in provider litigation (liens), and ultimately an increase in claims cost because of inaccurate and unjustifiable bill reviews.
Qualifications: As a full -service medical BR company, AMC adjusts medical, hospital, surgical and pharmacy bills using the Official Medical Fee Schedule (OMFS), the Official Inpatient and Outpatient Fee Schedules, and we apply discounts generated by MPN, Preferred Provider Organization (PPO) and pharmacy networks.
AMC does not simply “process” medical bills by pushing them through scanning and OCR technology for repricing, rather our certified bill reviewers manually review each and every bill in order to ensure we are recommending the most appropriate fee for the services provided. We strive to obtain the highest net savings for our Clients.
AMC Distinguishing Features: Our approach to the management of our Clients’ Medical Bill Review programs center on quality, ser vice, and results. AMC is committed to a constant focus on these key elements and provides these services in accordance with the California Labor Code and California Code of Regulations. A paperless single source solution for BR processing
Director of Client Services (single point of contact) Over 20 years of expertise in California public entities including but not limited to having over 65 Clients that have safety officer employees and over 30 school districts. We have firsthand knowledge of the claim exposures, which allow us to effectively utilize all cost containment measures. Offer a variety of PPO’s with the ability to geographically assess the best PPO Enforcement of UR determinations/interfaced with BR
Health Insurance Portability and Accountability Act (HIPPA) Compliant Electronic document storage and retrieval
Claims Examiner ToolBox (Web -based portal) – Electronic Claims Examiner Approvals/Objections
AMC maintains a partially manual process to ensure the ability of the BR analyst to verify via reading the corresponding medical reports the services billed were actually the services provided.
Higher savings
Improved accuracy
Less provider disputes
Less lien litigation
Enhanced Value for our Clients:
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Proposal for City of Richmond
Workers’ Compensation and Managed
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Experience/Stability
o California focus and expertise
o Over 21 years’ experience providing bill review/utilization review services – California public and private entities
o Mandatory ongoing continuing education - effective solutions and increased cost containment savings
o Fully licensed/dedicated technical staff
o Managed care professionals collectively has over 100 years of experience o Management structure
o Proven savings results
Consistent superior audit results
Client specific customization of programs
o Customized Special Account Instructions based on the Client’s requirements for desired results
o Special Handling Instructions Allied Customer Expectations (ACE) o Customized protocols based on Client’s requirements
Innovative programs for cost effective handling of medical cost containment programs
o Dedicated Client Services Director – single point of contact o Paperless Process – increased productivity, security/management o Excellent references
AMC BR Service Office and Org Chart: 10360 Old Placerville Road, Sacramento, CA, 95827.
A company-wide organizational chart has been included in the exhibit noted below.
Please see Exhibit 1 – Organizational Charts
B. Service Team Qualifications: Provide a brief summary of the qualifications and experience of each proposed team member, including their length of service with your firm and their resume. Provide an organization chart representing your staff and identify any sub-consultants you plan to utilize to supplement your proposed staff.
The AMC BR team identified below is supplemented by an ex tensive management, technical, and support staff in multiple offices located throughout the continental United States and Hawaii. Listed below are key personnel and members of the AMC Corporate Team. We do not use sub-consultants for the identified BR services.
Mark Denison, Senior Vice President of Operations : Mark oversee s the entire customized Bill Review/Utilization Review/Nurse Case Management Program. Mark’s role is to monitor all contract compliance with performance standards, audit compliance to individualized Special Account Instructions; legal and regulatory compliance; and provide ongoing communication with our Clients. Mark provides unparalleled leadership and direction to all AMC staff. He oversees all operational and administrative components of Allied Managed Care’s services, including Medical Bill Review, Utilization Review, and Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
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Case Management. He has over 23 years of experience in workers’ compensation cost containment, strong multi -jurisdictional managed care knowledge and practical application. His involvement ensure s that our Client’s performance standards are met and communication is ongoing. Mark is always available to meet with our Client’s staff to discuss issues and performance when requested to do so. Mark is a state board certified licensed Chiropractor, Certified Di sability Evaluator and past Division of Workers Compensation (DWC) appointed Qualified Medical Evaluator (QME). Mark joined the AMC team in 2008.
Lea Morales-Mendez, Director of Client Services : Lea has over 26 years of workers’ compensation exp erience in roles of operations and management as well as Client Services. Lea has received training in Disability Management, Health Insurance Portability and Accountability Act (HIPAA) and Utilization Review Accreditation Commission (URAC). Lea’s role is to a ssist the management team in addressing all issues related to the contract as well as serving as a resource for workers’ compensation decisions that may affect our Client. As well, as interacting with AMC’s management team to resolve all issues that may arise in UR and Bill Review; provide timely communication to the management staff of any critical developments that may affect the product delivery; meet regularly with the management team to assess AMC’s performance; discuss business decisions, and address concerns. Lea is a resource for our Clients. Lea joined AMC in 2006.
Melissa Miller, Bill Review Director: Melissa has over 20 years of experience in the industry including working for large national bill review companies. Melissa is a California Designated Bill Reviewer. She provides supervisory oversight and quality control of the entire medical bill review process for our Clients to ensure timely processing of payments.
Melissa is responsible for all administrative and operational components of the bill review unit, including staffing, training, quality, timeliness and accuracy of work performed in the unit, ensuring efficie nt and optimum workflows. She has a working knowledge of the entire bill review process, from bill entry, tracking of bills in and out of the office, review of all bill types, check-offs, invoicing, export file generation and sending, report generation according to the Special Account Instructions , the re -evaluation process and the lien process. Melissa joined AMC in 2009.
Darcy Olivares, Bill Review Supervisor: Darcy is a California Designated Bill Reviewer with over 16 years in the workers’ compensation industry. She reports to Melissa and is responsible for all administrative and operational components of the bill review unit; including staffing, training, quality, timeliness and accuracy of work performed in the unit, efficient and optimum workflows, and maintaining the positive and professional attitudes of unit members. Darcy also has a working knowledge of the entire bill review process, from bill entry, tracking of bills in and out of the office, review of all bill types, check -offs, invoicing, exporting files, report generation according to Special Account Instructions, the re-evaluation process, and the lien process. Darcy joined AMC in 2007.
Please see Exhibits 1 – Organizational Charts and Exhibit 4 – Team Resumes C. Services: Describe your bill review services, features of your system, unique capabilities, and ability to customize the delivery of your services. Provide an Attachment I
Proposal for City of Richmond
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Care Services
organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. Discuss your ability to work with TPAs in delivering bill review services and provide a list of three (3) you currently work with. Include your average monthly bill volume processed by your office.
AMC brings innovative medical cost containment programs for cost effective management at the onset of all claims. These programs include appropriate medical case management, formal customized utilization review programs, medical bill review, Medical Provider Networks, Preferred Provider Networks, and all necessary ancillary services to maximize all areas of medical cost containment to bring real savings back to the Client.
We bring paperless single source solutions for utilization review treatment planning and bill review processing.
Average monthly bill volume processed by your office: AMC processes approximately 21,350 (3/1/21 – 2/28/22) bills on average per month in California. As the current Bill Review services provider, AMC has reviewed 9,556 Bills between 3/1/21 – 2/28/22 for the City of Richmond.
Third Party Administrators: AMC provides BR services through the following TPA’s:
Acclamation Insurance Management Services (AIMS), TRISTAR, and several self - insured/self-administered programs.
AMC’s Bill Review Services
Client specific customization of programs: AMC develops a customized Allied Customer Expectations (ACE) for each Client and for each cost containment service. The ACE document outlines all expectations and any special requests of the Client that is required of AMC in order to comply with contract requirements. Customized Special Account Instructions based on the Client’s requirements Special handling instructions detailed in the ACE service document Customized protocols based on Client’s requirements
AMC Clients benefit by having a si ngle point of contact, our Director of Client Services who is available to our Client to develop and maintain specific strategies ensuring proactive program management and compliance with all Client’s requirements. We understand medical cost containment pr ograms for public agencies. We have firsthand knowledge of the claim exposures, which allow us to effectively utilize all cost containment measures.
Innovation: These innovative programs include services to maximize all areas of cost containment and bring real savings to the City.
Single Source Solution: AMC will provide paperless single source solutions for BR processing and UR treatment planning.
Director of Client Services : AMC will provide a Director of Client Services (single-point-of contact) for the City to develop and maintain strategies to Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
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ensure proactive program management and compliance with the City’s requirements.
TPA Insight: We understand medical cost containment programs for public agencies. We understand the requirements, specific pro cedures and overall goals of the City. Having AIMS, a workers’ compensation claims administration firm, as our sister organization, AMC management is uniquely informed and experienced in designing programs that improve claims administration workflows and reducing costs while improving injured employee outcomes. Best Suited PPO : AMC does not own its own PPO, therefore, AMC can provide an objective analysis as to the best suited PPO. Interface between BR and UR : AMC has an established interface between BR and UR. We have had this in place for over 8 years, many years before it was recognized by the industry that it is a critical component to cost containment.
Education: A key aspect of our services has been ed ucating the Claims Examiners of the importance of timely submissions, appropriate UR referrals and full documentation. Educating the Claims Examiners on SB863, ensuring they understand their responsibilities and the penalties that apply as well as the proper workflow. Training is provided to the TPA by our Medical Director, Alan Randle.
Medical Director : AIMS/AMC’s Medical Director, Dr. Randle provides oversight, leadership, and medical expertise to all Managed Care Services provided by AMC. Dr. Randle has served as our Medical Director since 2008.
AMC’s BR services include but are not limited to:
Fee Schedule and/or Usual & Customary Review
Duplicate bill detection
Offer a variety of PPO’s with the ability to geographically assess the best PPO PPO re-pricing and administration
Code review and re-bundling of services
Inpatient line-item audit reviews
Outpatient line-item audit reviews
Complex, specialty, and rush processing
Enforcement of UR determinations/interfaced with UR
National Bill Review Service
Pharmacy review/PBM services
Explanation of Benefits with appropriate State language Hearing Representation at no cost
Negotiated Discount Services
Guaranteed turnaround time
Interface with claim systems or overnight pick up
Health Insurance Portability and Accountability Act (HIPPA) Compliant 100% audit of reviews
Electronic document storage and retrieval
Examiner ToolBox (Web-based portal)
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Proposal for City of Richmond
Workers’ Compensation and Managed
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Flexible account structure, customized work flows
Provider inquiry explanation and resolution
Extensive management/savings analysis reports (choose from a wide range of reports to gain instant access to important data)
Data reporting to State regulatory agencies (AMC is State reporting and electronic billing compliant)
AMC’s Software Platform: AMC can provide a state of the art BR program that utilizes a highly sophisticated software platform enhanced by the expertise of the dedicated AMC Client team trained to review bills in accordance with the specific requirements of the Client. The features of our system can be customized for each of our Client’s unique needs and specific reporting requirements.
Our analysts use a web -based, automated system to generate accurate reviews and maximize savings. AMC identifies treatment that is not appropriate under America n Medical Association (AMA) guidelines, monitor and identify duplicate bills and adjust medical, hospital, surgical and pharmacy bills using the updated and accurate Official Medical Fee Schedule (OMFS), the Official Inpatient Hospital Fee Schedule, and ap ply discounts generated by the MPN and PPO providers. Our BR software is updated on a regular basis to reflect current fee schedules and PPO networks. Our qualified trained staff reviews each bill to determine appropriateness of treatment and to ensure pro vider compliance with fee schedule ground rules. AMC will provide a paperless single source solution for the processing of all medical bills through scanning technology hardware.
In addition to the distinguishing BR features previously described in this proposal provided below are capabilities unique to AMC.
Integration of Bill Review and Utilization Review : The electronic interface between AMC’s BR and UR/Nurse Case Management is already established. When BR and UR share data, greater savings and better medical control result. Additionally, the electronic interface between AMC’s managed care services to the AIMS Claims System is already established. Because these interfaces are already established, there is no delay in taking control of the medical cost containment aspect of a Client’s program. The Client can be confident that this aspect of their program is not only in place, which often never happens on unbundled programs, but has been in place for many years with workflows streamlined and perfected over time.
AMC’s system ensures integration of real time current information and communication on all claims is available to all cost containment practices/specialists through shared screen access. All UR and case management decisions regarding treatment limits and authority are placed directly into the BR software for retrieval and review during the audit pr ocess of all incoming bills. The Claims Examiner and/or telephonic nurse case manager can easily determine if retrospective UR is potentially needed based on AMC’s advanced ability to electronically return medical bill review information sorted by prior pr ospective or concurrent UR involvement. In other words, integrated platform ensures, on an automated basis, that services approved are the services paid.
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Workers’ Compensation and Managed
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If treatment that was never requested or authorized is billed, the BR system will flag the treatment and allow the Claims Examiner and/or telephonic nurse case manager to send the treatment through UR for a retrospective look at whether the treatment is authorized or denied.
Reports: AMC is able to track trends for Clients by providing numerous BR reports including savings reports, PPO savings, and penetration reports, provider savings, duplicate billing, claim charges, top billers, hospital reviews, and many more. The City can also request ad -hoc reporting to meet specific needs. A wide variety of report s are available to the City and can be run on any schedule required. These reports can be generated in multiple formats including: PDF, Excel, RTF, HTML, etc. The reports include information such as claim number, provider, dates of service, billed charge s, recommended allowances, etc.
Quality Assurance: AMC provides quality assurance in medical bill review on several levels as follows:
1. An override report is run at the end of each business day, to determine that all overridden bills were checked for duplicates.
2. A retrospective Quality Assurance (“QA”) is performed using reports that identify all bills reviewed by each analyst . QA is performed during the daily functions while researching bill history and processing of Add-recs. The QA is performed by the senior analysts and supervisors on a daily basis. The following is an abbreviated list of the QA points that are stringently looked at:
Keying – ensure bill data and demographics has been correctly added into the system.
Claim – ensure the bill has been processed against the correct claim. Reductions – whether correctly taken or calculated.
Reports – ensure all required reports are attached.
Negotiated Discounts – ensure negotiated discounts have been applied. Treatment Plans – confirm the treatment plan has been followed. Vendor/Provider – confirm the correct vendor/provider has been selected for payment purposes.
Billed Charges – confirm all attached billing documents and charges are for the same patient and from the same vendor/provider while ensuring no charges are missed.
Coding – ensure correct diagnosis, service codes and DOS are entered. EOR Message Codes – ensure the message codes applied are applicable to the services being reviewed.
3. Results are addressed with each individual analyst, noted as part of their production standards, and are logged for monthly reporting as well as performance review.
4. Results are further utilized for individual and group training sessions.
5. While conducting a QA audit, should an AMC error be discov ered, our Client will not be charged for the correction and a new EOR will be sent to our Client.
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Proposal for City of Richmond
Workers’ Compensation and Managed
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6. All found issues are provided to the Manager of BR who maintains spread sheets of production counts and errors. This data is used for the monthly reviews of the analysts and to determine where additional training is required.
AMC’s turnaround time averages four (4) days: AMC’s average company turnaround time is four (4) days. It is important to define and explain AMC’s turnaround time guarantee. Sometimes, a bill cannot be properly reviewed without additional information. Approximately 8 - 12% of bills received fall into this category for any number of reasons beyond AMC’s control. The AMC guarantee speaks directly to the timeframe once a bill arrives in the AMC office which has no issues relating to the accuracy of the information on the bill or the completeness of the bill.
AMC adjusts medical, hospital, surgical and pharmacy bills using the Official Medical Fee Schedule, the Official Inpatient and Outpatient Fee Schedules, and applies discounts generated by PPO and pharmacy networks. At AMC we don’t just don’t run the CPT codes as billed by the provider. In our process each bill is looked at to ensure that documentation supports the level of service being billed.
Negotiated Bills: AMC’s pro -active approach to maximizing potential savings is demonstrated in AMC’s practice that dictates we send fee schedule exempt bills as well as non-PPO bills to the negotiation unit within the AMC BR department. This unit is able to negotiate additional savings beyond PPO discounts and/or in place of when no PPO reduction is app lied by the specific PPOs. The Negotiation Unit has been building relationships with providers who are now submitting requests directly for additional savings and prompt payments. Savings are obtained by way of LOAs (letters of agreement) that apply when a 7-10 day turnaround on payments are made.
Additionally, all bills, regardless of status, that are in excess of $2,000.00 (after reductions) are reviewed for potential referral to the negotiation unit. It should be noted that our Clients pay only a perc ent of these additional savings, if we achieve savings above and beyond the fee schedule. Simply put, if no additional savings are achieved, our Client pays nothing for our review. Currently, our Negotiation Unit is averaging a 10% savings for our Clients.
AMC routinely negotiates fee reductions on bills meeting standard criteria (including in - patient hospital bills, surgical procedures, and other high dollar exposures) that fall outside our contracted PPO Network. Our negotiation approach, which include s signed negotiation letters by both AMC and the medical provider, serves two purposes:
1. Acceptance of payment as full and final payment (eliminating lien potentials).
2. Additional savings below Fee Schedule allowances (or in place of) for expanded Bill Review savings for our Clients.
Automated Recalculation of Savings and Fees of Duplicate Bills: When AMC displays data that is for additional allowance recommendations on previously reviewed bills, the billed charges are shown as zero (which is accurate) and the “savings” is shown as a negative number. In this way, we do not artificially inflate the billed charges and our total savings is actually reduced, so that at the end of each month our Client sees a true Attachment I
Proposal for City of Richmond
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Care Services
“net” savings. If our Clients BR fee was ba sed on a percent of savings, then AMC recalculates the full BR fee and refunds the appropriate amount based on the updated savings on the bill. Any reconsideration with a credit to our Client is done automatically in the system. Our Client does not have to rely on the manual intervention on an individual which may be subject to error.
Unbundling is a significant cost driver that is virtually overlooked by many BR systems.
Embedded in our software platform are bundling criteria from multiple sources, including Correct Coding Initiative (CCI), AMA, and American Academy of Orthopedic Surgeons (AAOS). The system is able to identify inappropriate billing patterns through logging vendor ID numbers associated with bills that are up-coded, bundled, fall outside medical treatment guidelines, and/or exhibit excessive fees. A report is then generated to reflect these providers so action can be taken if indicated. AMC’s system reviews all CPT ranges but we pay special attention to CPT codes in the range of 97010-98778 and 98940-98943 because of the mandated limits on physical therapy and chiropractor treatments. AMC’s system generates an automatic alert indicating the 24-limit visit rule has been exceeded.
Provider Networks: AMC can provide both MPN and PPO, to be used exclusively by our individual Clients. These workers’ compensation specific networks incorporate the medical providers with extensive, specialized experience in dealing with injuries incurred at the work place or job site. AMC does not own its own PPO, therefore, AMC can provide an objective analysis as to what PPO is best suited for the Client.
Allied Managed Care Service Entity Medical Provider Network (MPN): The Division of Workers’ Compensation Medical Unit for the Allied Managed Care MPN, MPN Identification Number 2360. The approval is for a period of four (4) years. Allied Managed Care Network is filed as a “Network Service Entity” which means that we can add the City without having to refile with the state, saving many months for implementation.
On 2019 AMC received re-approval (#2360) from the Department of Industrial Relations, Division of Workers’ Compensation Medical Unit. This approval is valid for a period of four (4) years.
As a “Network Service Entity” AMC offers Clients:
Only one filing
Less customization
Only one website
Only one audit
Better control of Network
Preferred Provider Organization (PPO): AMC has an ever-growing list of PPO’s to offer and will work with the City to determine the best PPO’s for the City’s program. Our broad menu of network relationships is designed to offer our Clients the ability to match their own experience with the PPO option that would maximize cost effectiveness. By not being tied to or owning any PPO network we avoid the potential for a conflict of interest when selecting the best PPO for our Client.
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Proposal for City of Richmond
Workers’ Compensation and Managed
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Additionally, the system allows several ways in which we can maintain and support Client specific contractual discounts. AMC can load virtually any PPO or negotiated fee arrangement by individual provider, into the BR software engine for automated application of discounts.
We work with the Client to determine the be st PPO. During the transition phase, we discuss the PPO options. We are able to use the provider zip codes from our Client’s most recent BR data to let our Client know which PPO offers the most coverage in its area. Ultimately, the Client will choose wh ich PPO provider we use. The Client may select access to one, two or three PPO’s. If more than one is selected, the PPO’s are then categorized in our BR system as primary, secondary and tertiary.
Provided below is a partial list of some of the available PPO networks:
Blue Cross – CA
First Health / Coventry
Procura
PRIME
InterPlan
ClarisPointe
ASI Flex
Lesser of Language: In order for a PPO Network to be utilized by AMC for its BR services, the contract must contain the “Lesser of Language”, which all ows the reviewer to apply the lesser of fees between Fee schedule and the PPO contract.
Pharmacy Program: AMC can track narcotic prescription drug usage and recommend UR and/or Medical Case Management to work with the prescribing physician and injured worker to establish an alternative treatment course to avoid the potential for addiction and abuse.
Integration with PPO, MPN, UR, and PBM Programs:
AMC’s BR System has a variety of PPO’s a Client can choose from and AMC can also cascade up to three PPO’s to assure maximum savings for our Clients. AMC will load the Client’s specified MPN providers and discounts into the Bill Review System so MPN providers are assured appropriate payment. AMC BR System can accept UR determinations from UR companies to assure only treatment approved will be paid. AMC can provide the City’s UR Company a layout of needed information in order to accept the determination in the BR System.
AMC has an Approved Ancillary Networks Panel: AMC has gone through an extensive process of researching and interviewing numerous ancillary network vendors in order to establish a complete ancillary network vendor panel which will give our Clients the best possible service. AMC does not receive any f ees for referrals to the AMC Ancillary Network Panel vendors . Any discounts received are based upon AMC’s collective buying power and passed through to our Clients. Our Clients can use the AMC networks, or AMC will work with any network preferred by the Client.
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Provider Inquiries Bill Review: Provider/vendor inquiries or appeals are received via phone, mail and fax regarding underpayments and/or denial of reviewed bills. Phone calls are returned within 24 hours. Inquiries that come through the mail ar e distributed within 24 hours of receipt. If the inquiry is an appeal, that appeal will be completed within 30 days. Each appealed bill is reviewed against the claim history to determine if the bill was paid correctly on the initial review, processed und er a different document control number (DCN) or processed if the missing information/documentation is attached for further review. Upon completing an additional or follow -up review, the results are sent back to the provider via an EOR or letter.
Independent Bill Review (IBR): We work with each Client in determining the best process by which to manage the Second Requests as well as the IBR determinations. As each Client has a different workflow process, we have a questionnaire that we will complete with our Client in order to determine the best way to manage the process.
A testament of Quality Bill Review is demonstrated by AMC’s Bill Review error of less than 1% and the fact that AMC has only received a total of four (4) IBR’s from the inception of the IBR process.
AMC Implementation of Request for Second Review
1. AMC can create either pend or denial rules based on proposed time frames. Determination of which type of rule will be upon Client request.
2. AMC has created specific message codes to be utilized in conjunction with the legislation.
3. Tracking of the 14 day response timeframe to the provider can be managed by the Client in a variety of ways including the creation of specific Bill Review queues, assignments to work specific pend queues, and use of reports.
4. Any current Penalty and Interest reports will be updated to include the time frames for Request for Second Review.
Lien Resolution: AMC works together, at no additional cost , with any represen tative appointed by the Client to resolve a lien. The Bill Review Re -Evaluation Specialist advises the Claims Examiner as to the process by which the bill was reduced (OMFS or which specific PPO was applied) so this information can be passed along to the lien claimant and defense counsel if the claim is litigated. In the event of a lien trial, if paper documentation of our process does not suffice, the Bill Review Re -Evaluation Specialist is available to attend the trial to testify and will appear as need ed for expert testimony at no additional cost . We try to prevent billing disputes through a thorough re -evaluation process.
Physical location and number of employees: AMC provides all of its managed care services out of its office located at 10360 Old Pla cerville Road, Sacramento, California 95827.
As of February 2021, AMC has approximately 69 employees.
Attachment I
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Org Chart : As requested a company -wide organizational chart with reference to the proposed service office and proposed service team has been provided in the noted exhibit.
Please see Exhibit 1 – Organizational Charts
D. Client References: Provide three (3) client references for your firm for which you provide bill review services including full contact information.
REFERENCE #1 – Bill Review
Agency Name
County of Los Angeles
Contact Name
Alex Rossi, MBA, ARM, Workers’ Compensation Contract Administrator Contact Phone Number
(213) 738-2154
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2006
REFERENCE #2 – Bill Review
Agency Name
Central San Joaquin Valley Risk Management Authority
Contact Name
Kevin Werner, City of Ripon, City Administrator
Contact Phone Number
(209) 599-2108
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2012
REFERENCE #3 – Bill Review
Agency Name
City of Bakersfield
Contact Name
Jena Covey, Risk Manager
Contact Phone Number
661-326-3090
Contact Email Address
[email protected]
Brief Description of Scope of Services
Workers’ Compensation Claims Administration and Managed Care Attachment I
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REFERENCE #4 – Bill Review
Agency Name
Schools Insurance Group SIG
Contact Name
Gabrielle Daniels, Director of Claims and Loss Prevention Contact Phone Number
530-823-9582 X208
Contact Email Address
[email protected]
Brief Description of Scope of Services
Workers’ Compensation Claims Administration and Managed Care / Client since 2013
Also, all requested References have been detailed in Exhibit 5 - Client References Utilization Review
A. Firm’s Qualifications: Describe the firm and provide a brief statement of qualifications in providing utilization review services. Describe your experience doing business with self-insured public entities in California. Discuss what dist inguishes your company from other utilization review providers. Provide a company -wide organizational chart with reference to the proposed service office and proposed service team.
AIMS recommends its sister company, AMC who has been providing expert Util ization Review (UR) Services since 2005. AMC conducts over 30,000 utilization reviews per year. AMC has over 100 Clients consisting of approximately 80% self-insured public entities and 20% private entities throughout the State of California.
AMC’s Utilization Review Service Qualifications
AMC has developed a customized efficient method to handle U R referrals, meet mandated timelines for decisions, handle Peer Review and appeals, and communicate with all parties. This information is captured in a re sponsive and results oriented Policy and Procedures Manual. This manual outlines the metrics AMC uses to ensure a high standard of quality for products and services provided to our Clients.
Accompanying the Policy and Procedures Manual is a proprietary document called, Allied Customer Expectations (ACE). AMC develops a customized ACE for each Client and for each cost containment service. The ACE document outlines all expectations and any special requests of our Client that is required of AMC in order to comply with contract requirements.
Superior Audit Scores: AMC is very proud of our exceptional services being verified by the State, which is reflected in AMC’s State Audit high scores for the past five years.
Independent audits have been performed by the California Department of Workers Attachment I
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Compensation; Statement on Standards for Attestation Engagement No. 1 8 (SSAE 18); and Utilization Review Accreditation Commission (URAC). AMC consistently performs well above the standard level of acceptability; as shown in our recent DWC audits. We also perform extensive in-house quality assurance audits on our employees’ work product and processes.
URAC Accreditation : Since 2010, AMC has been awarded Workers' Compensation Utilization Management Accreditation from Util ization Review Accreditation Commission (URAC). As of October 2019, AMC received a 100% score on the recertification and has been approved for an additional three (3) years. This recertification ensures AMC is consistently providing services at URAC standards.
In 2016 with the passing of SB 1160, URO’s will be required to be a ccredited in Utilization Review: “The bill would, commencing July 1, 2018, require each utilization review process to be accredited by an independent, nonprofit organization to certify that the utilization review process meets specified criteria, including, but not limited to, timeliness in issuing a utilization review decision, the scope of medical material used in issuing a utilization review decision, and requiring a policy preventing financial incentives to doctors and other providers based on the utilization review decision.” Beginning nearly ten years before this legal requirement, AMC invests time, resources and money year after year to be URAC accredited in order to protect the interests of our Clients and their employees.
URAC, an independent, nonprofit organization is a leader in promoting health care quality through accreditation and certification programs. The URAC standards keep pace with the rapid changes in the health care system, and provide a mark of distinction for health care organizations such as AMC to demonstrate their commitment to quality and accountability. This certification and URAC audits of AMC is a benefit to our Clients by providing third party assurance that we are in full compliance with data integrity, Health Insurance Portability and Accountability Act (HIPAA) requirements, proper credentialing.
Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in setting meaningful standards for the health care industry.
AMC is driven toward continual improvement of services by applying quality metrics and benchmarking to ensure we achieve top -quality performance con sistent with the URAC Workers’ Compensation Utilization Management Accreditation. Obtaining URAC accreditation demonstrates Allied Managed Care’s commitment to providing quality services for our Clients to help ensure that injured workers receive the best and most appropriate care.
Client Module – AlliedConnect: An important Part of the U R lifecycle is the Claims Examiner approval process. AMC has developed our own U R platform, AlliedConnect with the understanding that it must be user friendly for Claims Examiners. Having a TPA such as AIMS as our sister company, provides AMC with a strong unders tanding of the “pain points” a Claims Examiner can experience when processing Utilization Review requests. AMC’s AlliedConnect – Client Module is a fully integrated software, automated to help the Claims Examiner approve and distribute appropriate UR requests when Attachment I
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needed. Our proprietary system includes an easy referral process to AMC’s U R when appropriate. All Claims Examiner UR approvals and AMC Utilization Review determinations are captured, tracked, and electronically delivered to our B R platform for enforcement and payment.
Training: We hire and train the best people and streamline all systems and processes to support that goal. We provide our Client’s Claims Examiners with the training necessary to authorize treatment requests that fall within pre -approved screening criteria. We also insist that our UR managers and directors attend all Departmen t of Workers' Compensation (DWC) seminars and conferences to stay current on the constantly changing UR process.
AMC offers assistance to C laims Examiners in making first level UR decisions by providing utilization “Trigger Lists”, and on-going training. Our in-house staff of nurses is trained to review additional medical information and make decisions, within accepted guidelines, regarding treatment specific to each individual employee. For those decisions which are more advanced or when treatment may n ot be medically necessary, AMC escalates the referral to one of our many peer panels for a physician’s decision.
Licensed Nurses and P hysicians: AMC has only licensed nurses and physicians performing all Utilization Review services that go beyond the Claims Examiner. No non- professional staff authorizes treatment or requests referral to Peer Review. The AMC UR Program operates under the direction of the Medical Program Director who is a California- licensed physician. Physicians that serve to evaluate tre atment plans are licensed and board-certified with experience both as practicing physicians and in managed care/medical management. Specialty appropriate physicians are assigned to evaluate and make recommendations on plans of care.
First level reviewers (nurses) must be health professionals with a current, valid and unrestricted license, and have their credentials verified on an annual basis. Our Utilization Review Nurses must be licensed as either a Licensed Practical (Vocational) Nurse (LPN, LVN), or a Registered Nurse (RN).
Our UR team evaluates planned and provided medical care for necessity, frequency, and duration through services that include:
Pre-Certification/Pre-Authorization reviews
Reviews performed by our medical director and specialty peer review network Reviews based on national evidence-based treatment guidelines Utilization Review process are compliant with 8 CCR §9792.9 (l) wherein treatment requests will not be denied on the basis of a lack of information without documentation reflecting an attempt to obtain the necessary information from the physician or from the provider of goods or services identified in the request.
Training: A key aspect of our services has been educating the Claims Examiners of the importance of timely submissions, appropriate UR referrals, and full documentation.
Educating the Claims Examiners on current legislation, ensuring they understand their responsibilities’ and the penalties that apply as well as the proper workflow. AMC’s UR workflow is outlined in a diagram and has been included as an exhibit. Training is provided Attachment I
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to the TPA by our Medical Director, Alan Randle on a yearly basis or as needed with legislative updates.
Satisfaction Surveys: Client satisfaction surveys are conducted annually by the Director of Client Services using a survey instrument that encompasses issues of access, satisfaction with UR decision-making, turnaround time, and AMC’s Client service. The survey data is collected and analyzed by the Client Services staff and is shared with all departments. The survey results and action plan are presented to the Quality Management Committee and the Vice Chairman of the Board, who may modify or add to the plan. The results of the corrective action plan are monitored by the Quality Management Committee and Vice Chairman of the Board.
Medical Director: AIMS/AMC Medical Director, Dr. Alan Randle , who is a California - licensed physician is actively involved with not only AIMS/AMC, but also with our Clients.
Dr. Randle will work with the City to develop a mutually agreeable process for oversight of the Claims Examiner approvals and will be actively involved in the appropriate training or the claims staff in the authorization process to recognize the most appropriate claims for medical case management services.
Dr. Randle received his medical degree from the University of San Francisco in 1973. He completed his residency in Seattle, Los Angeles, and Cincinnati with a focus on general surgery and occupational medicine. Dr. Randle became certified by the American Board of Preventive Medicine in Occupational Medicine i n 1989. Dr. Randle practiced Occupational Medicine while Vice President of RediCare Industrial Medical Clinic through June of 1991. Dr. Randle is board certified in Occupational Medicine and has ultimate oversight of all UR department deci sions; education of nurses and Examiners regarding UR rules and regulations. He stays abreast of current changes in legislation and trains staff on new regulation. Dr. Randle is also the Chairperson of our Quality Management Committee and is accountable to the corporate President & CEO and Senior Vice President.
Dr. Randle has over twenty (20) years of experience with the practice of occupational medicine. This experience encompasses the clinical practice of medicine, medical evaluation, management, and academia. Dr. Ra ndle is a noted industry expert in California Utilization Review. He is a presenter and instructor to physicians, claims personnel and employers, both in private and public, on the California Utilization Review process.
Dr. Randle conducts t raining sessio ns to ensure our Claims E xaminers are aware of various modalities as well as conducting training for our Clients on topics such as best practices to use for UR. He is always available via a phone call or e -mail to immediately address any questions or concerns.
As AMC’s Medical Director, Dr. Randle provides oversight, leadership, and medical expertise to all Managed Care Services provided by AMC. Dr. Randle has served as AMC’s Medical Director since 2008. Additional information about Dr. Randle’s expertis e is further detailed in his resume, which has been included in the noted exhibit.
Physical location and number of employees: The City’s Utilization Review program is Attachment I
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conducted out of AMC’s Sacramento office located at 10360 Old Placerville Road, Sacramento, California 95827.
As of February 202, AMC has approximately 69 employees.
Org Chart : As requested a company -wide organizational chart with reference to the proposed service office and proposed service team has been provided in the noted exhibit.
Please see Exhibits 1 – Organizational Charts, Exhibit 4 – Teams Resumes, Exhibit 11 – SSAE 18 Reports, Exhibit 12 URAC Reports and Exhibit 13 – AMC UR Audits
B. Service Team Qualifications: Provide a brief summary of the qualifications and experience of each proposed team member, including their length of service with your firm and their resume. Provide an organization chart representing your staff and identify and sub-consultants you plan to utilize to supplement your proposed staff.
AMC’s Dedicated, Experienced Medical Management Team: AMC’s UR team is a dedicated group of medical case management professionals with tremendous tenure and collectively over 100 years of experience.
Licensed Nurses and Physicians: AMC has only licensed nurses and physicians performing all UR services that go beyond the Claims Examiner. No non -professional staff authorizes treatment or requests referral to Peer Review.
Peer Review: Allied Managed Care utilizes the physician peer review panels of P&S, National Medical Review (NMR), Dane Str eet, and ClaimsEval; which are all URAC accredited organizations. In addition, physician peer review may be conducted by the Medical Director. The credentialing process for physician peer reviewers is delegated to the respective panels to ensure each phy sician reviewer meets URAC standards. Also, AMC is not sub-consulting any of the proposed staff.
Listed below are the key members of AMC’s UR team.
Mark Denison, Senior Vice President of Operations : Mark oversee s the entire customized Bill Review/Utilization Review/Nurse Case Management Program. Mark’s role is to monitor all contract compliance with performance standards, audit compliance to individualized Special Account Instructions; legal and regulatory compli ance; and provide ongoing communication with our Clients. Mark provides unparalleled leadership and direction to all AMC staff. He oversees all operational and administrative components of Allied Managed Care’s services, including Medical Bill Review, Utilization Review, and Case Management. He has over 23 years of experience in workers’ compensation cost containment, strong multi -jurisdictional managed care knowledge and practical application. His involvement ensure s that our Client’s performance stand ards are met and communication is ongoing. Mark will always be available to meet with our Client’s staff to discuss issues and performance when requested to do so. Mark is a state board Attachment I
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certified licensed Chiropractor, Certified Disability Evaluator and past Division of Workers Compensation (DWC) appointed Qualified Medical Evaluator (QME). Mark joined the AMC team in 2008.
Lea Morales-Mendez, Director of Client Services : Lea has over 26 years of workers’ compensation experience in roles of operations, management as well as Client Services.
Lea has received training in Disability Management, Health Insurance Portability and Accountability Act (HIPAA) and Utilization Review Accreditation Commission (URAC).
Lea’s role is to a ssist the management team in addressing all issues related to the contract as well as serving as a resource for workers’ compensation decisions that may affect our Client. Interact with AMC’s management team to resolve all issues that may arise in UR and Bill Review; provide timely c ommunication to the management staff of any critical developments that may affect the product delivery; meet regularly with the management team to assess AMC’s performance; discuss business decisions; address concerns; Lea is a resource for our Clients such as the City. Lea joined AMC in 2006.
Alan Randle, M.D., Medical Director: Dr. Randle received his medical degree from the University of San Francisco in 1973. He completed his residency in Seattle, Los Angeles and Cincinnati with a focus on general surgery and occupational medicine. Dr. Randle became certified by the American Board of Preventive Medicine in Occupational Medicine in 1989. Dr. Randle practiced Occupational Medicine while Vice President of RediCare Industrial Medical Clinic through June of 1991. Since that time Dr. Randle has served as Medical Director for several of the largest insurance companies and managed care companies in the country. As Medical Director, Dr. Randle provides oversight, leadership, and medical expertise to all M anaged Care Services provided by AMC. Dr. Randle has served as AMC’s Medical Director since 2008.
Caroline Iverson, DC, Peer Review Manager: Caroline has 20 years of UR experience with 9 years in workers’ compensation UR; eight of which were with public entities.
Caroline provides an added level of auditing of the referrals and documents sent from UR nurses to Peer Review physicians and also auditing every completed Peer Review for quality and timeliness. Caroline works closely with the UR Manager and Medical Director to ensure the quality and timeliness of all peer reviews. She coordinates our extensive Utilization Review Quality Management Program and has been a licensed Chiropractor since 1993. Caroline joined AMC in 2008.
Shannon Buelna, LVN, MHA Utilization Review Director: Shannon’s workers’ compensation UR experience includes 15 years working with public entities to ensure performance of UR services in accordance to the state protocols, guidelines, and regulations. Her initial role was as UR Supervisor and she was promoted to UR Manager in 2014 and Director of Nursing Services in 2022. She continues to be extensively involved in ongoing development of AMC’s proprietary software for UR with improved efficiencies, modifications, and adherence to regul atory requirements. She has clinical experience working in a physician’s office, skilled nursing, and as director of a 199 -bed assisted living facility. Shannon assists in the implementation of Client specific instructions and any new processes which might arise out of DWC revisions. Collaborates with Claims Examiners to ensure proper handling of each referral, understanding of claim status and medical/legal implications, and attention to Client specific instructions.
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Licensed Vocational Nurse for over 9 ye ars with licenses in the State of California and the State of Texas. Shannon joined the AMC team in 2008.
Please see Exhibits 1 – Organizational Charts and Exhibit 4 – Team Resumes
C. Services: Describe your utilization review services including standards and guidelines you use to review treatment requests. Describe any unique capabilities or approaches your firm has for reviewing medical treatment requests. Discuss any methods you employ to help clients reduce utilization review costs. Provide an organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. Discuss your ability to work with TPAs in delivering utilization review services and provide a list of three (3) you currently work with.
Capabilities and Approach : As the City’s current UR vendor, AMC provides the City with UR services developed to assess the frequency, duration, intensity and appropriateness of all modalities and procedures common to workers’ compensation.
This includes concurrent management of ho spitalizations and retrospective review of medical treatment not previously reviewed. Reviews are performed by licensed nurses and physicians. The AMC UR program operates under the direction of our Medical Program Director, Dr. Randle. The UR program is co mpliant with all California -specific regulatory requirements. Reviewers use medical care guidelines such as the Medical Treatment Utilization Schedule (MTUS). Other nationally recognized and publicly available medical necessity criteria sets developed by p racticing physicians, such as Work Loss Data Institute/Official Disability Guidelines and Presley Reed/Medical Disability Advisor serve to augment MTUS guidelines. Guideline sets are evaluated annually by the Program Medical Director and updated annually. AMC has created a custom Utilization Review Program for the City of Richmond to address the specific needs called the “Rapid Referral Program”. This program expedites the approval process of services and uploads the auxiliary service request to the desi gnated service provider within 1-day a receiving the information.
AMC integrates all cost containment products electronically for maximum efficiency and centralization of data. We realize cost containment programs are a collection point of critical data to measure program costs. AMC can report virtually any data field captured in our system, and provide valuable reports to our Client. This innovative approach provides our Client’s managed care program wi th improved workflow, security/management of documents and increased productivity/turnaround time.
At AMC we have a single-minded UR goal - to help our Client employees return to work by providing the best, most appropriate treatment as quickly as possible and denying those services that are incongruous or unreasonable cost alternatives to nationally recognized treatment standards. By implementing a customized utilization review trigger list, the Claims Examiner can quickly approve a significant amount of first level treatment which allows treatment to be provided quickly as well as saving UR dollars. At AMC, we do not believe everything must be reviewed by the UR unit. We know that our Clients are Attachment I
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not all the same so AMC empowers the claims staff with the safe tools to authorize treatment which falls within the guidelines and is deemed appropriate.
Intake: The request for a UR is received by the Intake Coordinators at AMC. A confirmation email verifying receipt of the referral is sent to the Claims Examiner (and any other personnel designated by the Client) within three hours. Intake staff confirms receipt of all medicals, demographic data, and that the medicals correspond with the referral from the Claims Examiner. The referral documents are sent to the mailroom where they are indexed individually and u ploaded into a queue within AlliedConnect. The UR Manager assigns the referral to the UR nurse who will open the referral, confirm the data fields, identify if valid/invalid/incomplete/duplicate. The nurse also confirms the receipt date of the request for authorization to ensure AMC is operating under the correct due date. The nurse will indicate the claim designation (prospective, concurrent, retrospective, appeal) and process the review according to the statutory regulations and timelines.
Timeframes: All UR referrals are entered by AMC intake staff into AlliedConnect as a prospective review, at which time AlliedConnect automatically calculates the fifth business day due date. As part of the nurse’s daily triage of the new referrals, the nurses will i dentify the designation of prospective, concurrent, expedited, appeals, and retrospective. A new due date will be calculated in AlliedConnect which corresponds to the service type. If the nurses determine additional information is required, again a new due date will be calculated once the nurse submits the formal request in writing for the additional records. AlliedConnect has the ability to calculate the due dates by incorporating weekends and State holidays. The most critical component, though, is to verify the date of receipt which is verified by Intake and again by the nurses. This first critical step will ensure the calculated due dates are correct.
The Supervisor and/or Manager monitor the nurses queues daily to ensure timelines are being met consistently.
The Peer review referrals are submitted to AMC’s internal Peer unit no later than business day three, or two business days prior to calendar day fourteen if additional information has been requested. As such, the UR nurses monitor their invent ory as well throughout the day to ensure that referrals requiring physician review are sent to the Peer unit promptly and with sufficient time for the physician reviewer to make the decision.
If referred to AMC’s internal Peer unit for physician review assignment, the due dates are monitored not only by the UR nurse, but also by the Peer unit via AlliedConnect.
Peer reviews are assigned for physician review with the applicable due date clearl y marked on the referral. The Peer unit then monitors timeframes by first observing the online “pie chart” widget throughout the day in the AlliedConnect Peer module dashboard which reflects the number of reviews due each day, and second by sorting the Pe er module’s AlliedConnect in-box by due date and status to ensure that all referrals are completed by their due date. AlliedConnect reports are run by the Peer unit on a daily basis reflecting all pending physician reviews by due date to verify that the r eviews are timely. The Peer unit further manages the timeliness of physician reviews by controlling the volume of referrals assigned to each of the Peer review panels so as not to exceed the capacity of any given panel.
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Expedited Reviews: Prospective or concurrent decisions related to an expedited review shall be made in a timely fashion appropriate to the injured worker’s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. The requesting physician must indicate the need for an expedited review upon submission of the request.
Peer Review Turnaround Times:
Prospective – 2.8 business days
Retrospective – 9.6 calendar days
Appeals – 3.5 business days
Over-prescribing Opioid Medications: Protocols and triggers have been set up with the City’s pharmacy benefit manager to help identify trends and assist the City with flagging those providers who may be over -prescribing opioid medications. All new narcotic medication requests and any other identified class of medication can be submitted directly to the pharmacy nurse through an electronic link with the Pharmacy Benefit Management (PBM) or to the Claims Examiner who can forward the request to the AMC nurse who will review for medical appropriateness and certification. If not meeting guideline criteria, the nurse will submit this request to the Peer unit for review. If a formal utilization review has not been received when the narcotic medication is requested, and the request is not within the formulary, the nurse will contact the doctor’s office to provide the required documentation for a formal UR review.
AMC has the ability to run UR reports showing what has been requested along with the determination. AMC can identify trends through analysis of this data to identify medications being requested which have been denied or modified and by what prescribing physicians. This data can also be gathered from the PBM. By utilizing both reporting tools, AMC and the City can easily identify the ov er-prescribers of opioid medications.
A daily report is provided to the PBM that includes all information needed to ensure for the proper dispensing of prescriptions for the Client. The data exported has information that includes but is not limited to demographics for injured workers, claims c oding, Examiner information, and claim status information.
Request for Authorization: Whenever an AMC physician reviewer issues a decision to deny a request for authorization (RFA) based on the lack of medical information necessary to make a determination , the claims administrator’s file shall document the attempt by the claims administrator or reviewer to obtain the necessary medical information from the physician either by facsimile, mail, or e -mail. If AMC is in receipt of a RFA as part of a UR referral sent by the Claims Examiner after 5 business days from the documented date of receipt (or after 30 days from receipt of the information necessary to perform a retrospective review) and it is therefore determined that the referral has exceeded the timefram e for prospective or concurrent (or retrospective) decisions, the following procedure will be followed:
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1. The Claims Examiner will be notified that the UR referral has exceeded the 5 business day timeframe for a prospective determination and 30 days for a retrospective review within the UR Standards.
2. If the Claims Examiner can document that there has been a request for additional information issued on or before the fifth business day after the date of receipt that would appropriately allow an extension of the due date to 14 calendar days, the RFA will be managed in the normal manner as outlined above.
3. If there is no documentation of a prior written request for additional information, the Claims Examiner will have the option of either
o Authorizing the treatment request and provide appropriate written notification consistent with the UR Standards.
o Proceeding with the normal UR process for an RFA.
Written decisions approving a request for treatment authorization shall specify the specific medical treatment service approved and the date of the determination.
Written decisions modifying, delaying or denying treatment authorizations will be provided to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker’s attorney and shall only contain the following information specific to the request:
1. The date on which the DWC Form RFA was first received.
2. The date on which the decision is made (The date of the UR report is the date on which the decision was made unless otherwise specified).
3. A description of the specific course of proposed medical treatment for which authorization was requested.
4. A list of all medical records reviewed.
5. A specific description of the medical treatment service approved, if any.
6. A clear, conci se, and appropriate explanation of the reasons for the reviewing physician’s decision, including the clinical reasons regarding medical necessity and a description of the relevant medical criteria or guidelines used to reach the decision pursuant to section §9792.8. If a UR decision to modify, deny or delay a medical service is due to incomplete or insufficient information, the decision shall specify the reason for the decision and specify the information that is needed.
7. The Application for Independent Medical Review, DWC Form IMR-1, with all fields completed, except for the signature of the employee and date. The application, set forth at section 9792.10.1, shall include an addressed envelope, which may be postage-paid for mailing to the Administrative Director or his or her designee.
8. A clear statement advising the injured employee that any dispute shall be resolved in accordance with the independent medical review provisions of Labor Code section 4610.5 and 4610.6, and that an objection to the UR decision m ust be communicated by the injured worker, the injured worker’s representative, or the injured worker's attorney on behalf of the injured worker on the enclosed Application for Independent Medical Review, DWC Form IMR-1, within 30 calendar days of receipt of the decision.
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If the request for authorization of medical treatment is not approved, or if the request for authorization for medical treatment is approved in part, any dispute shall be resolved in accordance with Labor Code sections 4610.5 and 4610.6. N either the employee nor the claims administrator shall have any liability for medical treatment furnished without the authorization of the Claims Administrator if the treatment is delayed, modified, or denied by a UR decision unless the UR decision is overturned by independent medical review or the Workers’ Compensation Appeals Board under this Article.
A request for independent medical review must be communicated by the employee, the employee’s representative, or the employee’s attorney by mail, facsimile, or electronic transmission to the Administrative Director, or the Administrative Director’s designee, within 30 days of service of the Utilization Review decision. The request must be made on the Application for Independent Medical Review, DWC Form IMR -1, and submitted with a copy of the written decision delaying, denying, or modifying the request for authorization of medical treatment.
If expedited review is requested for a decision eligible for independent medical review, the Application for Independent Medical Review, DWC Form IMR-1, shall include, unless the initial UR decision was made on an expedited basis, a certification from the employee’s treating physician indicating that the employee faces an imminent and serious threat to his or her health as described in section 9792.10.1(a)(3).
AMC’s Unique Capabilities:
URAC (Utilization Review Accreditation Commission) Accredited since 2010 Renowned Medical Director
Nurse and Physician Determinations – No Determinations completed by non- medical personnel
Proprietary Software – AlliedConnect Database Access Services (AlliedConnect)
Client Access to AlliedConnect Database of Determinations Claims Examiner Approval Tracking
Auto-populates claim information
Tracking of Request for Authorizations (RFA) from submittal through determination
Referral status/determination “Look up”
Peer Review
Three Medical Specialists Panels – All URAC Accredited Quality Assurance Protocols
Detailed Reporting
Integrated with BR
Independent Medical Review (IMR) Process
AMC’s Proven Medical Cost Containment Savings
No duplicate charges
No charge for reconsiderations within the first thirty (30) days Attachment I
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Single charge for UR referral regardless of the number of procedures on the request
Streamlined Claims Examiner approval process
Direct certified services to Client specific vendors for contracted rates Utilize the prior authorization process
Integration of Bill Review and Utilization Review: At AMC we work within our own proprietary platform called, AlliedConnect database access serv ices ( AlliedConnect).
AlliedConnect is a paperless single source solution for UR and integrates the UR and BR systems on the same proprietary platform. In this module, treatment planning or UR parameters can be entered in a highly normalized fashion into the BR system and is associated with a workers’ compensation claim. Due to the highly normalized nature of AlliedConnect treatment plans, they can be automatically applied by the BR engine during the BR process and require no BR analyst intervention to be applied. This allows UR to communicate directly with BR to ensure the appropriate payment for certified versus modified certified versus non-certified treatment. In other words, this integrated platform ensures, on an automated basis, services approved are the services paid.
AMC has developed a Client Application called, “AlliedConnect Client Module” , in which the Client can view in real time the status of past, current, and pending reviews. A copy of each determination along with fax confirmations may be printed from the Clie nt Module.
The AlliedConnect Client Module can also be provided to the Claims Examiner. From within AlliedConnect Client Module, the Claims Examiner can authorize treatment or submit referrals along with attached medicals to AMC. The Claims Examiner can review past, current or pending referrals in real time. The Claims Examiner can print a determination along with the fax confirmation. This information is also seen by the AMC UR nurses so, they will always know what treatment has been authorized by the Claims Examiner which decreases calls to the Claims Examiner for verification, prevents duplication of services, and thus additional UR fees.
Further benefits include:
Protect documents against unexpected loss or damage
Improve workflow by eliminating the need to manually move documents Increase security by maintaining better control of documents and regulating document access
Improve records management and storage
Portability of documents and information
AMC customizes the workflow to fit the individual nee ds of the Client. As an example, some Clients have requested adding specific service vendors to the certification letters to assist them in utilizing these providers in which they have special rates or contract relationships. AMC will then send a copy of this certification letter to the specified vendor which will then trigger the referral and assignment process for that service request.
AMC Value Added Services to Reduce Costs:
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Care Services
AMC’s policy related to bundling/unbundling the receipt of the RFA: AMC does not unbundle RFA’s. AMC keeps all RFA’s that are made by a provider within in one medical report for authorization together, we keep them “bundled”. One medical report, which contains more than one treatment request will be reviewed as a whole and the Nu rse or Peer Reviewer will make a determination on each treatment request. This is considered one referral with multiple treatment requests. AMC charges one review fee for multiple treatment requests within one referral.
AMC offers a Claims Advice Nurse (CAN-Do) program as value added service to Clients at no additional cost. If the Claims Examiner receives a medical report and requires additional clinical expertise to assist them in understanding the medical condition and treatment requested, the Claims Advise Nurse is available to offer assistance. Many of these discussions result in the Claims Examiner being able to authorize treatment without going through the UR process which expedites the treatment and saves UR fees.
AMC will identify, monitor and coordinate the medication safety awareness program with the Pharmacy Benefit Management (PBM) program for narcotics and opioid use.
Protocols and triggers set up with the City’s pharmacy benefit manager to help identify trends and assist the City with flagging those providers who may be over - prescribing opioid medications. All new narcotic medication requests and any other identified class of medication can be directed to the Claims Examiner by the bill review company who can forward the request to the AMC nurse who will review for medical appropriateness and certification. If the prescribing physician is not meeting guideline criteria , the nurse will submit this request to the Peer unit for review. If a formal utilization review has not been received when the narcotic medication is requested, and the request is not within the formulary, the nurse will contact the doctor’s office to pr ovide the required documentation for a formal UR review.
AMC has the ability to run reports showing what has been requested along with the determination. AMC can identify trends through analysis of this data to identify medications being requested which have been denied or modified and by what prescribing physicians. This data can also be gathered from the PBM. By utilizing both reporting tools, AMC and the City can easily identify the over -prescribers of opioid medications.
A daily report is provided to the PBM that includes all information needed to ensure for the proper dispensing of prescriptions for our Client. The data exported has information that includes but is not limited to demographics for injured workers, claims coding, Claims Examiner information, and claim status information. AMC’s High Employee Retention Rate (Low Turnover)
Over the past three (3) years AMC has brought on board a manager to oversee case management for ten (10) nurse case managers. We have also added two (2) utilization review nurses, and additional administrative support - one (1) for Case Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Management and two (2) for Utilization Review. These are the benefits of a solid/cohesive team for our Clients:
Innovative long term consistent managed care program administration Detailed knowledge and understanding of our Client’s program and needs Satisfied, motivated employees who work hard for our Client to provide cost savings and appropriate outcomes and results
No temporary personnel
AMC currently has a 94% upheld rate with Maximus/IMRs.
AMC provides documentation required to respond to requests for Independent Medical Review (IMR) at no additional cost to the City . To minimize the disruption of claims operations, AMC retains all records provided by claim staff. We use a paperless system/document storage that catalogues historical medical records so they only need to be submitted once. Claims staff submitting a second referral on a particular claim only need to submit updated medical records, thus avoiding a large v olume of medicals. When a modified or non-certification determination is made, a PDF file of all the medical records reviewed by the Peer Provider, along with the determination will be sent to the Claims Examiner. Therefore, if an IMR is requested the Cla ims Administrator can request these documents from the UR staff or AMC can ensure they are provided to the Claims Examiner at the time of the determination distribution so they have the necessary information to provide to Maximus and then only needs to inc lude any medicals within that 6 month period which are not part of the Peer packet.
Third Party Administrators: AMC provides UR services through the following TPA’s:
Acclamation Insurance Management Services (AIMS), TRISTAR, City of Sacramento and other self-insured/self-administered programs.
Physical location and number of employees: AMC provides all of its managed care services out of its office located at 10360 Old Placerville Road, Sacramento, California 95827.
As of February 2022, AMC has approximately 69 employees.
Org Chart : As requested a company -wide organizational chart with reference to the proposed service office and proposed service team has been provided in the noted exhibit.
Please see Exhibits 1 – Organizational Charts and Exhibit 4 – Team Resumes
D. Client References: Provide three (3) references for your firm for which you provide utilization review services including full contact information.
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
REFERENCE #1 – Utilization Review
Agency Name
County of Los Angeles
Contact Name
Alex Rossi, MBA, ARM, Workers’ Compensation Contract Administrator Contact Phone Number
(213) 738-2154
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2006
REFERENCE #2 – Utilization Review
Agency Name
City of Sacramento
Contact Name
Patrick Flaherty, Risk Manager
Contact Phone Number
(916) 808-8587
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care / Client since 2018
REFERENCE #3 – Utilization Review
Agency Name
Central San Joaquin Valley Risk Management Authority
Contact Name
Kevin Werner, City of Ripon, City Administrator
Contact Phone Number
(209) 599-2108
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2012
REFERENCE #4 – Utilization Review
Agency Name
Schools Insurance Group (SIG)
Contact Name
Jaxine Anderson, Return to Work Coordinator
Attachment I
Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
REFERENCE #4 – Utilization Review
Contact Phone Number
(530) 823-9582 x205
Contact Email Address
[email protected]
Brief Description of Scope of Services
Workers’ Compensation Claims Administration and Managed Care / Client since 2013
Attachment I
___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:
Professional Services
Type 2 – Page 1 of 3
Revised: September 2011
In all instances where CONTRACTOR or its representatives will provide professional services (architects, engineers, construction management, counselors, medical professionals, hospitals, clinics, attorneys, consultants, accountants, etc.) to the City of Richmond (City), the City requires the following MINIMUM insurance requirements and limits.
CONTRACTOR shall procure and maintain for the duration of the contract, agreement, or other order for work, services or supplies, insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder and the results of that work by the CONTRACTOR, its agents, representatives, employees or subcontractors. Maintenance of proper insurance coverage is a material element of the contract. Failure to maintain or renew coverage or to provide evidence of renewal may be treated by the City as a material breach of contract.
CONTRACTOR agrees that in the event of loss due to any of the perils for which it has agreed to provide Commercial General Liability insurance, CONTRACTOR shall look solely to its insurance for recovery.
CONTRACTOR hereby grants to CITY, on behalf of any insurer providing Commercial General Liability insurance to either CONTRACTOR or CITY with respect to the services of CONSULTANT herein, a waiver of any right to subrogation which any such insurer of said CONTRACTOR may acquire against the CITY by virtue of the payment of any loss under such insurance.
Original, signed certificates and original, separate policy endorsements, naming the City as an additional insured for general liability coverage, as well as a waiver of subrogation for Workers’ Compensation insurance, shall be received and approved by the City before any work may begin. However, failure to do so shall not operate as a waiver of these insurance requirements.
City reserves the right to modify or require additional coverages for specific risk exposures depending on scope of CONTRACTORS work.
Minimum coverage is detailed below. The policy limits of coverage shall be made available to the full limits of the policy. The minimum limits stated herein shall not serve to reduce the policy limits of coverage of CONTRACTOR.
Minimum Scope of Insurance – the following forms shall be provided and coverage shall be at least as broad as the following:
1. Insurance Services Office Commercial General Liability coverage (ISO Occurrence Form CG 0001), and including coverage for bodily and personal injury, property damage, and products and completed operations (if applicable).
2. Insurance Services Office Automobile Liability coverage (ISO Form CA 0001, Code 1, Any Auto).
3. Original and Separate Additional Insured Endorsement for General Liability (ISO Form CG 20 10 11/85 or its equivalent) with primary and non-contributory language.
4. Workers’ Compensation Insurance as required by the State of California including Employer’s Liability coverage.
5. Original and Separate Waiver of Subrogation for Workers’ Compensation insurance.
6. Professional Liability or Errors & Omissions Liability Insurance appropriate to the CONTRACTOR’s profession (if required.)
Required Coverage Minimum Limits
Workers’ Compensation and
Employers’ Liability
Statutory limits as required by the State of California including $1 million Employers’ Liability per accident, per employee for bodily injury or disease.
If CONTRACTOR is self-insured, provide a certificate of Permission to Self- Insure, signed by the California Department of Industrial Relations and Self- Insurance. If contractor is a sole proprietor (has no employees) than contractor must sign “Contractor Release of Liability” found at:
http://www.ci.richmond.ca.us/index.aspx?nid=61.
General Liability
(primary and excess limits
combined)
$2,000,000 per occurrence for bodily injury, personal injury and property damage. If the policy includes a general aggregate, either the general aggregate shall apply separately to this project, service or location or the minimum required aggregate limit shall be twice the per occurrence limit ($4 million aggregate limit).
Policy shall be endorsed to name the City of Richmond as an additional insured per the conditions detailed below.
___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:
Professional Services
Type 2 – Page 2 of 3
Revised: September 2011
Automobile Liability $1,000,000 per occurrence for bodily injury and property damage.
PROJECT COST R EQUIRED LIMIT
$0 - $1 million $1 million p/o
$1 million - $5 million $2 million p/o
Over $5 million $5 million p/o
Professional Liability or Errors &
Omissions Liability –
Required for all professionals
including architects, engineers,
consultants, construction
management, counselors, medical
professionals, hospitals, clinics,
attorneys and accountants, & other
consultants as may be required by
the City.
Required Policy Conditions
Additional Insured Endorsement
Applicable to General Liability coverage.
The City of Richmond, its officers, officials, employees, agents and volunteers are to be named as additional insureds for all liability arising out of the operations by or on behalf of the named insured including bodily injury, deaths and property damage or destruction arising in any respect directly or indirectly in the performance of this contract.
ISO form CG 20 10 (11/85) or its equivalent is required. If the Contractor is supplying their product or providing a service then the endorsement must not
exclude products and completed operations
coverage. If it does, then CG 20 37 (10/01) is also required.
SAMPLE Endorsements can be found at
http://www.ci.richmond.ca.us/index.aspx?nid=61
.
Primary and Noncontributory The contractor’s insurance coverage must be primary coverage as it pertains to the City, its officers, officials, employees, agents and volunteers. Any insurance or self insurance maintained by the City is wholly separate from the insurance of the contractor and in no way relieves the contractor from its responsibility to provide insurance.
Waiver of Subrogation
Endorsement Form
Contractor’s insurer will provide a Waiver of Subrogation in favor of the City for Workers’ Compensation Insurance during the life of this contract.
SAMPLE Endorsements can be found at
http://www.ci.richmond.ca.us/index.aspx?nid=61.
Deductibles and Self-Insured
Retentions
Any deductible or self-insured retention must be declared to and approved by the City. At the option of the City either the insurer shall reduce or eliminate such deductibles or self-insured retention as respects the City or the CONTRACTOR shall procure a financial guarantee in an amount equal to the deductible or self-insured retention guaranteeing payment of losses and related investigations, claims administration and defense expenses.
Contractor is responsible for satisfaction of the deductible and/or self-insured retention for each loss.
A. M. Best Rating A:VII or Better. If the A.M. Best Rating falls below the required rating, CONTRACTOR must replace coverage immediately and provide notice to City.
Umbrella/Excess Liability Policies
If an Umbrella or Excess Liability Policy is used to meet the liability limits, coverage shall be as broad as specified for underlying coverage’s and cover those insured in the underlying policies.
___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:
Professional Services
Type 2 – Page 3 of 3
Revised: September 2011
Claims-Made Policies
If any insurance policy is written on a claims-made form: 1) the retroactive date must be shown, and must be before the date of the contract or the beginning of contract work. 2) Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the contract of work. 3) If coverage is canceled or non-renewed, and not replaced with another claims-made policy form with a retroactive date prior to the contract effective date, the Contractor must purchase an extended period coverage for a minimum of five (5) years after completion of contract work.
Subcontractors
CONTRACTOR
shall include all subcontractors as insured under its policies or shall furnish to the City for review and approval, separate certificates and endorsements for each subcontractor. All coverage for subcontractors shall be subject to all of the requirements stated herein.
CONTRACTOR agrees to defend and indemnify the City of Richmond for any damage resulting to it from failure of either CONTRACTOR or any subcontractor to take out or maintain the required insurance policies.
The fact that
insurance is obtained by CONTRACTOR, and/or CONTRACTOR’s subcontractors, will not be deemed to release or diminish the liability of CONTRACTOR, including, without limitation, liability under the indemnity provisions of this contract. Damages recoverable by CITY from CONTRACTOR or any third party will not be limited by the amount of the required insurance coverage.
Verification of Coverage
All original certificates and endorsements shall be received and approved by the City before work may begin .
The City of Richmond reserves the right to require complete, certified copies of all required insurance policies including endorsements affecting the coverage at any time.
Original insurance certificates and required policy endorsements shall be mailed or delivered to the Designated Project Manager for the City of Richmond.
Insurance certificates and endorsements may be faxed to the Designated Project Manger. However, CONTRACTOR must mail the original certificates and endorsements to Designated Project Manager once faxed.
Continuous Coverage
CONTRACTOR shall maintain the required insurance for the life of the contract. Should the CONTRACTOR cease to have insurance as required during this time, all work by the CONTRACTOR pursuant to this agreement shall cease until insurance acceptable to the City is provided. In the event that CONTRACTOR fails to comply with the City’s insurance requirements, the City may take such action as it deems necessary to protect the City’s interests. Such action may include but is not limited to termination of the contract, withholding of payments, or other actions as the City deems appropriate.
If services or the scope of work extend beyond the expiration dates of the required insurance policies initially approved by the City, CONTRACTOR must provide updated certificates and endorsements indicating that the required coverage, terms and conditions are still in place. Renewal certificates and updated endorsements shall be mailed to the Designated Project Manager.
Cancellation
CONTRACTOR shall ensure that coverage shall not be cancelled, reduced or otherwise materially changed except after thirty (30) days’ prior written notice has been given to the City.
Reporting Requirements
Any failure to comply with reporting or other provisions of the policies including breaches of warranties shall not affect coverage provided to the City, its officers, officials, employees or volunteers.
Consistent with Public Policy
The insuring provisions, insofar as they may be judged to be against public policy shall be void and unenforceable only to the minimum extent necessary so that the remaining terms and provisions herein may be consistent with public policy and thus enforceable.
Request for Proposals
Third Party Workers’ Compensation Claims
Administration and Managed Care Services
Release Date: February 24, 2022
Deadline for Submittal
March 18, 2022
Contact: Laura Marquez, Risk Management
Email: [email protected]
Phone Number: 510-620-6810
City of Richmond
Human Resources Department
Risk Management
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
2 City of Richmond
INTRODUCTION
The City of Richmond is requesting proposals from qualified third-party administrators (TPA) firms to administer the City’s self -insured workers’ compensation claims including bill review and utilization review (collectively called “managed care services”). The City seeks service providers with experience in public entity workers’ compensation self - insurance who promote a proactive approach to manage and administer benefits in accordance with California State laws and statutes with a focus on quality care This request for proposal (RFP) describes the p roject, the required TPA Performance Expectations (Attachment III), the consultant selection process, and the minimum information that must be included in the proposal. Failure to submit information in accordance with the RFP requirements and procedures may be cause for disqualification. It is the City’s intent to enter into a three (3) year contract with one or more experienced firms to provide claims administration and managed care services for all new and existing self -funded workers’ compensation claims beginning July 1, 2022. The City may elect to award separate contracts for claims administration, bill review, and utilization review or may elect to award one contract for all services to one firm, whichever is determined to be in the City’s best interest. Interested bidders are welcome to respond to this entire Request for Proposal (RFP), may respond only to claims administration, or may respond to one or more of the managed care services. Each main service category listed in Scope of Services will be evaluated and awarded independently using the Evaluation Criteria outlined Proposed Evaluation and Selec tion Process. In the event that one or more firms are awarded ancillary support service contract(s), the selected TPA must have the capability to work with these firms.
ABOUT THE CITY
The City of Richmond was chartered as a city in 1909, and is located 16 miles northeast of San Francisco, directly across the San Francisco Bay. Richmond’s population is 103,828.
The mission of the City of Richmond is as follows:
The City of Richmond provides services that enhance economic vitality, the environment and the quality of life of our community.
The City of Richmond provides a full range of municipal services including police and fire protection; construction and maintenance of highways , streets and infrastructure ; library services; storm water and municipal sewer systems ; operation of a wastewater treatment facility; and the administration of recreational activities and cultural events. The City also operates the Richmond Memorial Convention Center and the Port of Richmond.
SCOPE OF SERVICES
The TPA shall perform all services required to supervise and administer the City’s self - insured workers’ compensation claims, and to act as the City’s representative in matters relating to the City’s obligations under the workers’ compensation laws for the State of California.
Program Administration Needs: The City's Risk Management Division, in the Human Resources Management Department, coordinates all aspects of the workers' compensation DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
3 City of Richmond
program including the management of the TPA and its contract.
Permanent Disability: As soon as the TPA receives notice of permanent and stationary status, they shall communicate this information to the City so that permanent accommodation consideration can be initiated.
Fraud Control: The City requires the TPA to aggressively control fraud and pursue restitution in all fraud cases. Risk Management shall be notified of all claims involving potential fraud and initiation of fraud investigation activities.
Claims Reviews: On -site quarterly claim reviews at the City are required and involve participation by City Department representatives. The TPA is expected to send claim staff to attend claim reviews and be prepared to discuss agendized claims.
Loss Reporting and Data: The TPA shall provide basic loss reports electronically that detail payments and check runs, claim frequency, paid and incurred costs, annual OSHA reports, 1099's and the annual SIP report. In addition, the City may need on occasion to obtain other reports for various purposes including, but not limited to, actuarial studies, audits, program and departmental analysis. The City retains the right to select the risk management information system. The TPA shall not change the RIMS without advance written notice to the City and consent by the City.
Claims Personnel: The City maintains the right to interview and review evidence of work experience of all personnel to be assigned to its account and to approve such personnel.
The City shall have a right to request a change of designated acco unt staff. The claims supervisor and senior claims examiner shall possess a self-insured certification. A minimum of 5 years experience shall be required of the claims supervisor, senior claims examiner, and claims examiner.
The TPA will input all new claim reports within 24 hours of receipt.
The City and/or the excess carrier may conduct claims performance audits to measure the TPA's performance and compliance with claims administration standard's and requirements.
The TPA shall provide the results of the SAS70 audit compliance report on an annual basis.
Excess Carrier: Report on all potential excess carrier claims as required to the applicable excess carrier. Provide to the City a copy of each report and pursue, when appropriate, excess reimbursements f rom the carrier. Maintain records on excess re -insurers and reimbursements on behalf of the City. Comply with all State mandated reporting requirements (SIP, DWC, OSHA log, etc.).
Settlement Authorization: Prepare and submit settlement authorization request for approval by the City prior to initiating settlement negotiations. The City may, at its discretion, grant limited authority to the TPA to resolve minor claims; however, settlement authorization request forms must still be submitted to the City. Settlements involving payments of over ten thousand dollars ($10,000) require City Council approval. Provide at least 35 days advance notice of settlement authorization requests for settlement amounts over ten thousand dollars ($10,000).
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
4 City of Richmond
The TPA will provide documentation and information as needed to enable the City to effectively coordinate return to work and the ADA interactive process.
The TPA will maintain an electronic and/or paper file on each claim.
The TPA will provide the City with updates and information on changes or proposed changes in statutes, rules, and regulations affecting the City's responsibility under a self -insured workers' compensation program.
Claims Administration Services
A. Determine liability for claimed injuries and illnesses on a timely basis and in accordance with the California Labor Code.
B. Determine eligibility for and authorize payment of medical and indemnity benefits on a timely basis.
C. Review, compute, and, after approval by the City, pay all informal ratings, f indings and awards, and settlements; arrange for informal disability ratings whenever possible to avoid unnecessary litigation.
D. Pay any and all penalties due in accordance with the California Labor Code. Such penalties shall be paid by the claims administr ator with liability for the action determined by the record unless such penalties were incurred as a result of the City’s action or inaction.
E. Establish files containing medical and factual information on each reported claim, together with complete accounti ng records and maintain in accordance with statutory time requirements.
F. Prepare, file, and maintain all information and reports as required by the State of California, Department of Self-Insurance.
G. Provide the City with information and recommendations for implementation strategies for changes or proposed changes in statutes, rules and regulations affecting the City under the California Labor Code for workers’ compensation.
H. Review with the City the program’s progress, including identification of problem areas and conduct periodic root cause analysis and recommended solutions to reduce claims cost and attend monthly regularly scheduled meetings required by the City relative to the workers’ compensation program.
I. Arrange for and supervise all necessary investig ations to determine eligibility for compensation benefits and liability of negligent third parties.
J. Establish procedures to support the payment of all benefits and allocated expenses together with appropriate documentation necessary to reconcile a trust fu nd checking account provided by the City.
K. Sponsor and pay for a membership in the nationwide Index System on the City’s behalf; submit all claims to the Index System as regular practice.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
5 City of Richmond
L. Provide (at no cost to the City) informational pamphlets in appropriate languages to employees as required by the State of California relative to their workers’ compensation benefits.
M. Refer litigated cases to attorneys approved by the City for the purpose of defending the City’s interest before the Workers’ Compensation Appeals Board and courts of law.
N. Attend, where indicated, trials, hearings, arbitrations, rehabilitation hearings and any and all legal proceedings.
O. Produce computer generated reports as specified by the City; including, comparison reports with data from similar agencies (anonymous) that may be similar in size or in demographic area.
P. Coordinate Medicare and Medicaid set aside agreements in compliance with Section 111 of the MMSEA including required reporting.
Q. Comply with the PRISM claims adjusting requirements dated 7/1/2011.
Bill Review
A. Review all bills in a timely manner for compliance with applicable fee schedules and reduce accordingly, including those that fall outside of a fee schedule or PPO network.
B. Identify and reduce all duplicate billings.
C. Deny charges for all items not required for injury described.
D. Identify all unauthorized charges to ensure billing does not exceed parameters of injured workers’ treatment plan.
E. Maintain contracts with effective PPO organizations (including pharmacie s), that include providers in the City of Richmond area.
F. Provide reports on a monthly and annual basis outlining bill review activity, savings, and costs. Provide ad hoc reports as requested.
G. Provide a computer system that interfaces with both the City’s w orkers’ compensation TPA and utilization review provider.
H. Handle all provider inquiries regarding bill reductions.
Utilization Review
A. Approve or disallow service requests within the applicable time standards and provide medical advice as warranted.
B. Provide timely reports to the City outlining utilization review requests, approvals, denials, and costs/savings.
C. Recommend, for City approval, panels of medical professionals, specialists, and treatment facilities to which injured employees should be referred for long- term or specialized treatment.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
6 City of Richmond
D. Provide medical management of all cases to assure cost -effective and appropriate treatment, including assurance that treatment is related to the compensable injury or illness.
E. Arrange for medical/legal opinions in disputed cases, conferring with medical examiners, professional personnel, the City, and legal counsel where indicated.
F. Provide a computer system that interfaces with the selected TPA and bill review service provider.
PROJECT BACKGROUND / DESCRIPTION
The workers’ compensation claims have been administered by Acclamation Insurance Management Services (AIMS) - California since 2012. This RFP is being issued to comply with public bidding requirements that require the City to competitively bid its contracts every five (5) years. AIMS sister company, Allied Managed Care, currently provides most other managed care services in conjunction with administering the workers’ compensation claims.
RFP SCHEDULE
Date Activity
February 24, 2022 Release RFP
March 8, 2022 Final Day to Submit Questions (1:00 PM)
March 18, 2022 RFP Due Date
April 2022 Short List Interviews
April 2022 Final Selection and Contract Negotiations
April 2022 City Approval Processes
July 1, 2022 Effective Date of Contract
PROPOSAL FORMAT GUIDELINES
The proposal should be concise, well organized, and demonstrate the proposer’s qualifications and experience applicable to the Project. The proposal shall be limited to 15 double-sided pages (8.5 inches x 11 inches), inclusive of graphics, forms, pictures, photographs, dividers, etcetera, but not of cost proposal, resumes, required f orms, certifications, front and back covers, or letters of commitment from sub -consultants. The required font size is 12 point, with minimum left and right margins of one-inch, and top and bottom margins of 0.7 inches.
Each proposal will adhere to the fol lowing order and content of sections. Proposal should be straightforward, concise and provide “layman” explanations of technical terms that are used. Emphasis should be concentrated on conforming to the RFP instructions, responding to the RFP requirements, and on providing a complete and clear description of the offer.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
7 City of Richmond
Proposals, which appear unrealistic in the terms of technical commitments, lack of technical competence or are indicative of failure to comprehend the complexity and risk of this contract, ma y be rejected. The following proposal sections are to be included in the Vendor’s response:
A. Vendor Cover Letter
A cover letter, not to exceed three pages in length, should summarize key elements of the proposal and shall:
• Confirm that all elements of this RFP have been reviewed and understood. • Include a statement of intent to perform the services as outlined. • Express company’s willingness to enter into an agreement under the terms and conditions prescribed by this RFP , insurance requirement s and in the sample City or Richmond Standard Contract (Services Agreement). • Submit a written description and brief history of the company’s experiences, qualifications and successes in providing California services described herein. Please indicate the number of employees, client base and location of offices.
• Indicate the address and telephone number of the vendor’s office located nearest to Richmond, California and the office from which the project will be managed.
• Confirm that vendor has a minimum of three (3) years verifiable California experience.
• Stipulate that the proposal price will be valid for a period of at least 180 days. • Identify a single person for contact during the RFP review process; and • Cover letter shall be signed by an authorized official of the company.
B. Background and Project Summary Section
The Background and Project Summary Section should describe your understanding of the City, the work to be done, and the objectives to be accomplished. Refer to description of services for this RFP.
C. Methodology Section
Provide a detailed description of the approach and methodology to be used to accomplish the Scope of Services of this RFP. The Methodology Section should include:
1) An implementation plan that describes in detail (i) the methods, including controls by which your firm manages projects of the type sought by this RFP; (ii) methodology for soliciting and documenting views of internal and external stakeholders; (iii) and any other project management or implementation strategies or techniques that the respondent intends to employ in carrying out the work.
2) Detailed description of efforts your firm will undertake to a chieve client satisfaction and to satisfy the requirements of the "Scope of Services" section.
3) Detailed project schedule, identifying all tasks a nd deliverables to be performed, durations for each task, and overall time of completion.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
8 City of Richmond
4) Detailed descri ption of specific tasks you will require from City staff.
Explain what the respective roles of City staff and your staff would be to complete the tasks specified in the Scope of Services.
D. Staffing
Describe proposed Project team organization, including iden tification and responsibilities of key personnel. Indicate role and responsibility of prime consultants and all sub-consultants. If applicable, indicate how local firms are being utilized to ensure a strong understanding of state and local laws, ordinances , regulations, policies, requirements, and permitting. Indicate the extent of the commitment of key personnel for the duration of the Project and furnish resumes of key personnel. Provide an indication of the staffing level for the Project. The City of Richmond’s evaluation of the proposal will consider the proposer’s entire team; therefore, no changes in the team composition will be allowed wit hout prior written approval of the City of Richmond. Sub-consultant letters of commitment are required and must be submitted with the proposal.
Describe the experience of the proposer’s Project team in detail, including the team’s Project Manager, and other key staff members, on projects of similar size, capacity, and dollar value. For each similar project, in clude the client’s name and correct telephone number. It is the City of Richmond’s policy to interview proposers’ references as well as references identified by the City of Richmond.
E. Qualifications
The information requested in this section should describe the qualifications of the firm, key staff and sub‐contractors performing projects within the past five years that are similar in size and scope to demonstrate competence to perform these services.
Information shall include:
1) Names of key staff that part icipated on named projects and their specific responsibilities with respect to this scope of service. 2) A summary of your firm’s demonstrated capability, including length of time that your firm has provided the services being requested in this Request for Proposal.
3) Provide at least three (3) references that received similar services from your firm. The City of Richmond reserves the right to contact any of the organizations or individuals listed. Information provided shall include:
a) Client Name and contact info
• Telephone & e-mail address
• Address
b) Description of services provided including contract amount c) Project start and end dates
F. Cost Information
Provide the total direct and indirect costs to complete all tasks identified in the scope of services. Even if the method of payment to proposer will be fixed fee, a detailed cost breakdown shall be provided identifying: (1) the number of staff hours and DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
9 City of Richmond
hourly rates for each professional and administrative staff person who will be committed to this Project ; (2) all other direct costs, such as materials and reproduction costs; and (3) sub-consultant services, if needed. These rates will also be used to negotiate rates for other projects (including optional tasks) that ma y be assigned. No additional funds will be paid above and beyond the original quote given by the selected Vendor.
Proposers will be paid at the same rates set forth in their cost proposal unless further negotiated in writing and agreed to by the City of Richmond.
G. Value Added Services
Please provide any additional services of benefit not specifically required herein, which the Offeror offers to provide.
H. Contractor Assignment of Sub-Contract
The resulting contract shall not be assigned, transferred, or sublet, in whole or in part, without the prior written approval of the City of Richmond. If Offerors intend to subcontract any portion of the resulting contract, they must describe their process for selecting such subcontractor(s) and the quality control measures that the Offeror will employ to ensure that any subcontractor complies with the provisions of Offeror’s contract with the City.
I. Previous Contracts with the City of Richmond
The proposer shall submit a list which indicates all prime contracts and/or amendments awarded to the proposer by the City of Richmond for the last three (3) years. The list shall include a short description of the Project, the Project scope of work, award date, completion date, name of City of Richmond ’s assigned Proje ct Manager, and contract value.
J. Exceptions to this Request for Proposals
The proposer shall state whether or not it takes exception(s) to this RFP, including but not limited to the City of Richmond’s Standard Services Agreement – RFP. If the proposer does take exception(s) to any portion of the RFP or contract, the specific portion to which exception(s) is taken must be identified by section number and explained. Requests for changes or additions to sections of City of Richmond’s Standard Services Agreement must be shown by requesting deletion of specific words and/or by providing new requested contract language. Requests for complete replacement of the City of Richmond’s Standard Services Agreement for another contract will not b e granted. Failure to make exceptions to the RFP or Standard Services Agreement within the proposal will be deemed a waiver of any objection.
Exceptions will be considered during the proposal evaluation process.
K. Statement of Impartiality and Disclosure
The nature of this Project requires an impartial unbiased approach on the part of the proposer’s team. This proposal shall include a statement declaring that the proposer’s and sub -consultants are not currently, and will not, during the performance of these services, participate in any other similar work involving a third- party with interests currently in conflict or likely to be in conflict with City of Richmond’s interests. Additionally, proposer is required to disclose any pending or DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
10 City of Richmond
active investigations or litigation that may affect the reputation or ability of the proposer to carry out the Project.
PROCESS FOR SUBMITTING PROPOSALS
Questions Concerning Request for Proposals
All questions must be submitted via the electronic BidsOnline system on the Q&A tab by 1:00 p.m. on March 8, 2022 . If the City finds it necessary to issue an addendum, prospective Offerors will receive e -mail notification of addendum. Otherwise, answers to questions received will be provided on the Q&A tab and notification will be sent by March 11, 2022. It is the prop oser’s responsibility to periodically check the BidsOnline w ebsite www.ci.richmond.ca.us/bids for any possible Addenda to the RFP that may have been posted.
Any party submitting a proposal shall not contac t or lobby any City Council member, City official, employee (except those specified for contact) or agent regarding the RFP. Any party attempting to influence or circumvent the RFP, bid submittal, and review process may have their proposal rejected for violating this provision of the RFP.
Interested parties may download copies of the above-mentioned proposal by visiting the City's web site, www.ci.richmond.ca.us/bids. To download RFP, new vendors will be required to register. Once the vendor downloads any documents relative to a solicitation, that vendor's name will appear on the Prospective Bidders list for that project and will receive any addenda or notifications relating to the RFP.
Submission of Proposals
Electronic Proposals shall be submitted via the City’s secure online bidding system. All required sections of the proposal must be submitted via the website. Contractor is solely responsible for “on time” submission of their electronic proposal. The Bid Management System will not accept late proposals and no exceptions shall be made. Contractors will receive an e-bid confirmation number with a time stamp from the Bid Management System indicating that their bid was submi tted successfully. The City will only receive those proposals that were transmitted successfully.
The proposal must be received no later than 5:00 p.m., local time, on March 18, 2022.
The proposal and any required certifications shall be signed by an individual or individuals authorized to execute legal documents on behalf of the proposer.
GENERAL GUIDELINES
This RFP does not commit the City of Richmond to award a contract, to defray any costs incurred in the preparation of a proposal pursuant to this RFP, or to procure or contract for work. The City of Richmond may reject a proposal without providing the reason(s) underlying the declination. A failure to award a contract to the proposer with the lowest cost proposal shall not constitute a valid cause of action against the City of Richmond. The City DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
11 City of Richmond
shall not be responsible for work done, even in good faith, prior to final approval of the proposed contract. The City may investigate the qualifications of any respondent under consideration, require confirmation of information furnished by the respondent, and require additional evidence or qualifications to perform the Services described in this RFP.
The City reserves the right to:
1. Reject any or all proposals.
2. Issue subsequent Requests for Proposal.
3. Postpone opening for its own convenience.
4. Remedy technical errors in the Request for Proposal process.
5. Negotiate with any, all, or none of the Respondents.
6. Solicit best and final offers from all or some of the Respondents.
7. Select one or more Respondents.
8. Accept other than the lowest proposed fees.
9. Waive informalities and irregularities in proposals.
Public Records
All proposals submitted in response to this RFP become the property of the City of Richmond and public records and, as such, may be subject to public review. Documents protected by law from public disclosure will not be disclosed by the City of Richmond if clearly marked with the word "confidential" on each applicable page. Trade secrets may be marked as confidential only to the extent they meet the requirements of California Government Code section 6254.7. Only information claimed to be a trade secret at the time of submittal to the City of Richmond and marked as "confidential" will be treated as a trade secret.
Insurance Requirements
The City of Richmond requires consultants doing business with it to obtain insurance, as shown in RFP insurance requirements. The required insurance certificates must comply with all requirements of the st andards as shown and must be provided within fifteen (15) days of issuance of the Notice of Intent to Award and prior to the commencement of any work on the Project.
Business Licenses
The successful Contractor and all subcontractors used in the work will be required to hold or to obtain a City of Richmond business license for which the fee will not be waived.
Compliance with City Ordinances
The contractor and all subcontractors shall comply with the City of Richmond Nondiscrimination Clauses in City Contracts Ordinance (Richmond Municipal Code (RMC) Chapter 2.28), Business Opportunity Ordinance ( RMC Chapter 2.50), Local Employment Program Ordinance (RMC Chapter 2.56), Living Wage Ordinance (RMC Chapter 2.60) and Ordinance Banning the Requiremen t to Provide Information of Prior Criminal Convictions DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
12 City of Richmond
on all Employment Applications (“Ban the Box”) ( RMC Chapter 2.65 ), which are incorporated into the Contract Documents by this reference.
Sanctuary City Contracting Ordinance (SCCO)
The Richmond Sanctuary City Contracting Ordinance No. 12 -18 prohibits the City from granting and or retaining contracts with any person or entity that provides Data Broker or Extreme Vetting services to the U.S. Immigration and Customs Enforcement Division of the United States Department of Homeland Security (“ICE”). Bidders/Proposers must submit the attached Sanctuary City Compliance Statement with their Bid or Proposal.
Collusion
By submitting a proposal, each r espondent represents and warrants that its proposal is genuine and not false or collusive or made in the interest of, or on behalf of any person not named therein; that the r espondent has not directly or indirectly induced or solicited any other person to submit a false proposal, or any other person to refrain from submitting a proposal; and that the respondent has not, in any manner, sought collusion to secure any improper advantage over any other person submitting a proposal.
Withdrawal of Proposals
A respondent may withdraw their proposal before the expiration of the time for submission of proposals by delivering to the Finance Department a written request for withdrawal signed by, or on behalf of, the respondent.
Ownership of Documents
All reports, studies, information, data, statistics, forms, designs, plans, procedures, systems, and any other materials produced for the Project shall be the sole and exclusive property of the City. No such materials or properties produced in whole or in part for the Project shall be subject to private use, copyrights, or patent rights by Respondent in the United States or in any other country without the express written consent of the City. The City shall have unrestricted authority to publish, disclose (except as may be limited by the provisions of the Public Records Act), distribute, and otherwise use, copyright, or patent, in whole or in part, any such reports, studies, data, statistics, forms or other materials or properties produced for this project.
PROPOSAL EVALUATION AND SELECTION PROCESS
All proposals will be reviewed for responsiveness to this RFP. Those proposals deemed responsive will be further screened by a selection committee using five criteria outlined below. Firms submitting the highest rated proposals may be invited for interviews.
Proposals for claims administration, bill revie w, and utilization review will be evaluated separately using the following criteria:
A. Ability to provide services as outlined in the RFP.
B. Experience and qualifications of the firm and proposed service team DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
13 City of Richmond
members.
C. Quality of the references.
D. Responsiveness to the RFP including completeness and thoroughness of proposal.
E. Proposed cost.
The City reserves the right to reject any or all proposals, or to make no award. The City also reserves the right to require modifications follow ‐up with requests for additional information, including, but not limited to, follow ‐up interviews. The City may request Best and Final offers based upon improved understanding of the offers or changed scope of service. The City will negotiate with that vendor to determine final pricing, and contract form. Because this proposal is negotiable, all pricing data will remain confidential until after award is made, and there will be no public opening and reading of Proposals. Overall responsiveness to th e RFP is an important factor in the evaluation process. The criteria upon which the evaluation of the proposals will be based include, but are not limited to, the following:
Experience/Past Performance/References/Proposer Qualification– 50% Consideration will be given based upon the firm’s experience, years in business, past and current client references; technical expertise and professional competence in areas directly related to this RFP; number of years of experience in performing similar work. This category will also evaluate the ability to provide services as outlined in the RFP and the proposer’s demonstrated knowledge of the work required. Respondent should demonstrate that all key personnel have been successfully involved with projects of similar sc ope and magnitude. This category will evaluate the firm’s:
• Qualifications and relevant individual experience
• Unique qualification of key personnel
• Staff Availability / Time commitment of key members
• Organization chart
Proposer Qualifications –
Claims Administration
A. Firm’s s: Describe the firm and provide a statement of qualifications for performing the requested scope of services as outlined in Scope of Services-Claims Administration Services. Identify the firm’s primary service office for the City’s account. Provide a company -wide organizational chart with reference to the proposed service office and proposed service team.
B. Service Team Qualifications: Provide an organizational chart outlining your proposed service team including names, titles, and length of service in your organization. For each proposed team member, provide a summary of qualifications including claims handling experience, indemnity case load, experience working with public entity self- insured entities, education, and any professional designations and awards. Include DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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full resumes for each member of your proposed service team. If you have not designed staff to service the City’s account, provide the selection qualifications for any staff necessary to service the City’s account.
C. Claims Administrative Services: Describe your firm’s claims administration policies, procedures, and best practices that ensure superior service to City employees while maintaining economic and administrative control over claims costs. Discuss your claims reserving philosophy and indicate the maximum number of indemnity files handled by your proposed claims examiners.
D. Ancillary Services: Identify any company-owned and affiliated ancillary services to include, but not limited to, bill review, and utilization review. Provide a description of each ancillary service including an organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. List all outside vendors you currently work with including the services they provide. If such services were awarded to one or more vendors not owned by or affiliated with your company, describe how your firm would work with such outside providers to ensure effective and efficient service to the City. Include any limitations you may have in working with outside vendors.
E. Claims Management System: Describe in detail how your computer system is utilized to provide workers’ compensation services. Discuss the capabilities of the system including whether the system tracks lost time, temporary modified duty and temporary partial disability. Provide samples of standard and customized computer- generated reports you prepare for your clients (Note: limit 1 - 2 pages per sample).
F. SAS 70 Audit Compliance: Indicate your firm’s compliance with SAS70 annual audit compliance reporting and indicate the date of the most recent completed audit report.
G. Client References: Provide a list of five (5) clients (including full contact information) from which similar types of claims-related services are provided by your proposed service team office. Include the length of your contract with each client including the approximate number of indemnity claims annuall y. The City will contact these references to discuss the bidder’s performance.
Bill Review
A. Firm’s Qualifications: Describe the firm and provide a brief statement of qualifications in providing bill review services. Describe your experience doing business with self- insured public entities in California. Discuss what distinguishes your company from other bill review providers. Provide a company -wide organizational chart with reference to the proposed service office and proposed service team.
B. Service Team Qualifications: Provide a brief summary of the qualifications and experience of each proposed team member, including their length of service with your firm and their resume. Provide an organization chart representing your staff and identify any sub-consultants you plan to utilize to supplement your proposed staff.
C. Services: Describe your bill review services, features of your system, unique DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
15 City of Richmond
capabilities, and ability to customize the delivery of your services. Provide an organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. Discuss your ability to work with TPAs in delivering bill review services and provide a list of three (3) you currently work with. Include your average monthly bill volume processed by your office.
D. Client References: Provide three (3) client references for your firm for which you provide bill review services including full contact information.
Utilization Review
A. Firm’s Qualifications: Describe the firm and provide a brief statement of qualifications in providing utilization review services. Describe your experience doing business with self -insured public entities in California. Discuss what distinguishes your company from other utilization review providers. Provide a company-wide organizational chart with reference to the proposed service office and proposed service team.
B. Service Team Qualifications: Provide a brief summary of the qualifications and experience of each proposed team member, including their length of service with your firm and their resume. Provide an organization chart representing your staff and identify and sub-consultants you plan to utilize to supplement your proposed staff.
C. Services: Describe your utilization review services including standards and guidelines you use to review treatment requests. Describe any unique capabilities or approaches your firm has for reviewing medical treatment requests. Discuss any methods you employ to help clients reduce utilization review costs. Provide an organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. Discuss your ability to work with TPAs in delivering utilization review services and provide a list of three (3) you currently work with.
D. Client References: Provide three (3) references for your firm for which you provide utilization review services including full contact information.
Cost Proposal – 25%
For all services offered in your written proposal, complete the appropriate cost proposal worksheet in Attachment I A, B, and/or C of this RFP and include them in a separate section of your written proposal. In addition, indicate on this cost proposal a schedule of rates for additional related services, if any, which the City may consider, at its sole option.
Interview/Presentations – 25%
Upon request of the City of Richmond, vendors may be requested to give an oral presentation/demonstration on vendor’s proposal, which would include a detailed analysis of how each of the RFP requirements would be addressed should Offeror receive the award. A presentation by video conference will be arranged. The demonstration shall be DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
16 City of Richmond
conducted at no cost to the City.
Vendors are not guaranteed an opportunity to demonstrate. Vendors may be eliminated from consideration based solely on inability to meet minimal requirements and/or review of written proposals. The City shall be the sole judge of the acceptability of the system in conformance with the specifications and its decision shall be final.
Offerors will be given at least 1-week advance notice if required to make a presentation. If required these presentations will take place at the following location:
City of Richmond
450 Civic Center Plaza
Richmond, CA 94804
If special accommodations are required in order to attend a site visit, contact Laura Marquez at [email protected] , no later than three (3) days before the event.
Pre-Award Negotiations
After the proposals are opened, but prior to award, the City may elect to conduct negotiations with the highest ranked respondent for purposes of:
• Resolving minor differences and information
• Clarifying necessary details and responsibilities
• Emphasizing important issues and points
• Receiving assurances from respondents
• Cost/budget clarifications
If the City cannot successfully negotiate a contract with the highest ranked respondent, the City may begin negotiations with the second highest ranked respondent.
Selection may be made without further discussion, negotiations, or Offeror’s presentations; therefore, Offeror shall offer the most favorable terms in response to this RFP. Offeror must demonstrate an understanding of the scope of service to be provided and the ability to accomplish the tasks set forth. Offeror shall include information that will enable the City to determine the Offeror’s overall qualifications. The City reserves the right to request additional information or clarification on any matter included in the proposal response, to enable the City to arrive at the final award decision.
Award - When the Review Panel has completed its work, City staff will then recommend a select number of Third Party Workers’ Compensation Claims Administration and Managed Care Services firm in order to develop a recommendation to be submitted to the City Manager and City Council. The services provided by the successful bidder shall be governed by a Standard Services Agreement.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT I A
CLAIMS ADMINISTRATION COST PROPOSAL
Claims Administration Cost Proposal
Complete and include this cost proposal worksheet if you are proposing workers’ compensation claims administration services. Proposals which do not contain this cost proposal may be rejected. If non-company owned vendors are used for any services proposed, attach their proposal to you for such services.
1. Claims Administration Services
Proposed fixed sum for Workers’ Compensation Claims Administration Services to include assumption of all open claims, new indemnity, new medical only, new first aid, and all future medical claims for the proposed THREE (3) year contract period:
$
Other costs (if any) related to claims administration for the proposed THREE (3) year contract period:
Standard reports: $
Customized reports: $
Computer access fee: $
Data transfer/conversion: $
Other: $
(Please specify):
2. Performance-Based Compensation Alternatives: The City is willing to consider performance-based compensation alternatives. If offering such alternatives, please outline the options below and indicate the standards that would used to qualify:
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT I B
BILL REVIEW SERVICES COST PROPOSAL
Bill Review Services Cost Proposal
Complete and include this cost proposal worksheet if you are proposing bill review services. Proposals which do not contain this cost proposal may be rejected. If non- company owned vendors are used for any services proposed, attach their proposal to you for such services.
1. Bill Review
Flat fee per bill: $
Flat fee per line item: $
Percentage of Savings: $
Maximum Cap: $
2. Other Services Associated with Bill Review (Specify service and cost, if any:)
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
17 City of Richmond
ATTACHMENT I C
UTILIZATION REVIEW SERVICES COST PROPOSAL
Utilization Review Services Cost Proposal
Complete and include this cost proposal worksheet if you are proposing utilization review services. Proposals which do not contain this cost proposal may be rejected. If non- company owned vendors are used for any services proposed, attach their proposal to you for such services.
1. Utilization Review
Flat fee per review (nurse): $
Flat fee per review (Dr. peer review) $
2. Other Services Associated with Utilization Review (Specify service and cost, if any:)
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT II
LOSS HISTORY REPORTS
Loss History Reports
City of Richmond Loss Stratification
Report
Total Incurred and Claim Count by Fiscal Year
Incurred
Range
Fiscal Yr
17/18
Fiscal Yr
18/19
Fiscal Yr
19/20
Fiscal Yr
20/21
Fiscal Yr
21/22*
$0 - $5,000
$120,427
-----------
106
$77,070
----------
69 $80,187
----------
70 $90,209
----------
68 $39,078
---------
29 $5,001 -
$20,000
$160,883
---------
14 $112,915
----------
9 $207,857
----------
19 $280,268
----------
22 $317,082
----------
27 $20,001 -
$50,000
$256,557
---------
7 $487,476
---------
13 $413,163
----------
12 $691,868
----------
21 $340,501
----------
9 $50,001 -
$100,000
$1,223,908
--------
17 $1,222,610
---------
16 $1,173,340
----------
16 $606,964
----------
8 $465,960
----------
6 $100,001 -
$200,000
$1,814,920
----------
13 $1,191,992
---------
8 $2,070,421
-----------
15 $1,681,110
-----------
12 $0
----------
0 + $200,000
$4,046,851
----------
14 $1,368,914
-----------
5 $2,977,549
----------
11 $958,717
----------
3 $0
-----------
0 Total
Incurred
$7,623,546
$4,460,977
$6,922,517
$4,309,136
$1,162,621
Number
Claims
171
120
143
134
71 * as of 01/31/2022
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT II
LOSS HISTORY REPORTS
City of Richmond
Loss Stratification Report
Total Incurred and Average Incurred By Range
7/1/2017 - 1/31/2022
Incurred Range Total Incurred Average Total # Claims
$0 - $5,000 $406,972 $1,190 342
$5,001 - $20,000 $1,079,005 $11,857 91
$20,001 - $50,000 $2,189,565 $35,316 62
$50,001 - $100,000 $4,692,783 $74,489 63
$100,001-$200,000 $6,758,444 $140,881 48
+ $200,001 $9,352,031 $283,395 33
Total $24,478,800 $38,308 639
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT III
TPA PERFORMANCE EXPECTATIONS
The following are minimum performance standards under this contract. The City reserves the right to adopt additional standards with the selected third-party administrator.
****************************************************************************************************
CITY OF RICHMOND
TPA PERFORMANCE EXPECTATIONS
CASE LOAD
The claims examiners assigned to the City's files shall handle a caseload of no more than 125 claim files. This caseload may include future medical cases. For purposes of calculating caseloads, two future medical claims will equal one indemnity claim.
Supervisory personnel should not handle an active caseload although there may be situations that arise where a Supervisor is assigned a highly sensitive claim for handling.
CLAIM REVIEW AND DOCUMENTATION
Documentation should reflect any significant developments in the file. Each file will contain a current plan of action.
The examiner shall review every open, active claim every 30 calendar days, except the future medical files shall be reviewed no less than every 90 calendar days.
Claims staff will distinguish between (a) regular diary and (b) routine file documentation in the computer notepads.
The supervisor shall monitor significant activity on the file every 120 cale ndar days. File contents shall be kept in a neat and orderly fashion.
COMMUNICATION
Telephone Inquiries: Return calls shall be made within one (1) working day of the original telephone inquiry. All documentation shall reflect these efforts.
Return Correspondence: A correspondence requiring a written response shall have such response completed and transmitted within five (5) working days of receipt.
FISCAL HANDLING
Indemnity benefits on active cases shall be balanced with appropriate documentation on a semi-annual basis to verify that statutory benefits are paid appropriately.
Proof of file balancing or reconciliation will remain in the file and documented in computer notepad.
In cases of multiple losses involving the same person, payments shall be mad e on the appropriate claim file.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT III
TPA PERFORMANCE EXPECTATIONS
THREE POINT CONTACT
The claims examiner shall complete "three-point contact" with the injured worker, City and treating physician within two business days of receipt of the notice of the claim.
The triage nurse may make the initial contact with the physician and the injured worker.
In the event a party is non-responsive, there should be evidence of at least three documented attempts to reach the individual.
Each new claim will be set up within two business days of notice of the claim from any source.
COMPENSABILITY DETERMINATIONS
The initial compensability determinatio n (accept claim, deny claim or delay acceptance pending the results of additional investigation) and the reason for such a determination shall be made and documented in the file within fourteen (14) calendar days of the filing of the claim with the employer.
For SEIU Local 1021 (aka 790) general class employees, the TPA shall be required to delay or deny a claim within 14 days from the date the employee returns the DWC-l claim form. The TPA must send BOTH a notice of delay of claim as well as a notice of delay of salary continuation payments. The TPA understands that if the notices are not timely sent to the employee, salary continuation payments must be paid so long as an employee is unable to work; up to 26 weeks regardless if the claim is later denied.
Delay of benefits letters shall be mailed in compliance with the Department of Industrial Relations' guidelines.
The final compensability determinations shall be evaluated by the claims examiner or supervisor with a recommendation to the City in advance o f the 90 day determination date.
SETTING AND MAINTAINING CLAIM RESERVES
An initial reserve shall be established at the most probable case value.
Reserve projections will be in compliance with the California rules and regulations.
Reserves shall be reviewed every 90 days. Such review will be documented in the computer notepad.
PAYMENTS AND PENALTIES
Indemnity and medical benefits will be provided in a timely manner.
Late payment of indemnity benefits must include a self -imposed penalty. Penalties shall be coded so as to be identified as a penalty payment.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT III
TPA PERFORMANCE EXPECTATIONS
In accordance with the section on compensability determination, if notices to SEIU Local 1021 general class employees are not sent within 14 days from the date the DWC-1 claim form is returned by the employee and the City must make salary continuation payments, and the delay is caused by the TPA, then the TPA will reimburse the City for the salary continuation payments incurred due to the late notices.
Penalties caused by the TPA will be reimbursed on a monthly basis.
Payments on undisputed Awards, Commutations, or Compromise and Releases shall be issued with ten (10) calendar days following receipt of the appropriate document.
Medical treatment billings shall be reviewed for correctness.
MEDICAL TREATMENT
The TPA shall maintain contact with the injured workers' treating physician. Such contact will be documented in the computer database.
The TPA shall arrange medical evaluations as needed.
A triage nurse will review all new claims. If the employee returns to full duty the nurse will not continue on the case. If the employee remains off work or is on modified duty the triage nurse will remain on the case until the employee returns to full duty or becomes permanent and stationary.
All utilization review requests are given to the triage nurse for authorization. If unable to authorize, the utilization review will be forwarded to the Medical Director.
All medical treatment bills are reviewed by the claims examiner for approval and then the bills are directed to bill review where the fee schedule is applied and the bill is paid.
In regard to the use of selected vendors for the Triage Nurse, Utilization Review, and Bill Fee Review, the City reserves the right to implemen t alternate providers for these services.
SETTLEMENT AUTHORITY
Settlement value shall be documented in the claim file utilizing all relevant information.
No agreement shall be authorized without the advance consent of the City.
LITIGATED CASES
The TPA shall, in consultation with the City, assign defense counsel from a list approved by the City.
Settlement proposals directed to the City shall be in a clear and concise written form with a reasoned recommendation. Settlement proposals shall be presented to the City as to ensure receipt in sufficient time to process the proposal.
SUBROGATION
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
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ATTACHMENT III
TPA PERFORMANCE EXPECTATIONS
In all cases where a third party is responsible for the injury to the employee, attempts to obtain information regarding the identity of the responsible party shall be made within ten (10) calendar days of recognition of subrogation potential.
Once identified, the third party shall be contacted within ten (10) calendar days with notification of the City's right to subrogation and the recovery of certain claim expense s.
If the third party is a governmental entity, a claim shall be filed with the governing board (or State Board of Control as to State entities) within six (6) months of the injury or notice of injury.
Periodic contact shall be made with the responsible p arty and/or insurer to provide notification of the amount of the estimated recovery to which the City shall be entitled.
The file shall be monitored to determine the need to file a complaint in Civil Court in order to preserve the statute of limitations.
If the injured worker brings a civil action against the party responsible for the injury, the claims administrator shall consult with the City about the value of the subrogation claim and other considerations. Upon City authorization, subrogation counsel shall be assigned to file a Lien or a Complaint in Intervention in the civil action.
Whenever practical, the TPA shall aggressively pursue recovery in any subrogation claim.
The TPA should attempt to maximize the recovery for benefits paid and assert a cr edit against the injured workers' net recovery for future benefit payments.
EXCESS INSURANCE
Claims meeting the definition of potential excess workers' compensation claims shall be reported within 10 working days on which the excess criteria is met, and as required by the City's excess insurance carrier.
DocuSign Envelope ID: 0038F51D-A7F3-44CA-8428-876933777298
December 6, 2022
Human Resources
DATE: December 6, 2022
TO: Mayor Butt and Members of the City Council
FROM:
Sharrone Taylor, Interim Director of Human Resources
Nickie Mastay, Deputy City Manager
Subject:
Resolution Approving Side Letters to Implement a City
Curtailment Plan from December 27 through and
including December 30.
FINANCIAL IMPACT: There is no financial impact.
PREVIOUS COUNCIL
ACTION:
Not Applicable
STATEMENT OF THE
ISSUE:
City Council approval is required to formalize the side letter agreement between the City and SEIU 1021
General Employees Union and IFPTE Local 21 Mid-
Management and Executive labor units regarding holiday
curtailment for 2022
RECOMMENDED ACTION:
ADOPT a resolution approving the Side Letters between
the City of Richmond and Service Employees
International Union (SEIU) Local 1021 and International Federation of Professional and Technical Engineers
(IFPTE) Local 21 (Mid-Management and Executive
Management units) regarding holiday curtailment for
2022 (Sharrone Taylor/Nickie Mastay 510-620-6602).
AGENDA
REPORT
December 6, 2022
DISCUSSION:
City offices will be on curtailment from December 27 – 30, 2022. Sworn Police and Fire departments and critical services provided by the Community Services and Public Works departments, as well as other services deemed critical by the City Manager and department directors, will also be in operation. In addition, Department Heads were directed to identify essential and critical services that will remain open with minimal staffing through January 3, 2023.
Employees will be permitted to use available vacation, floating holidays, administrative leave, or compensatory time accruals for December 27, 28, 29, and 30, 2022. In addition, employees have the option to take a leave of absence without pay or report to work during this period. If employees opt to come to work, department heads must ensure that adequate supervision is provided.
NEXT STEPS:
City Council’s approval is required to formalize the side letter agreement between the City and SEIU 1021 General Employees Union and IFPTE Local 21 Mid-Management and Executive Unions.
DOCUMENTS ATTACHED:
Attachment 1 – Resolution approving City curtailment agreement between the City and SEIU 1021 General Employees and IFPTE Local 21 Mid-Management and Executive Management Unions
Attachment 2 – SEIU 1021 Side Letter
Attachment 3 – IFPTE Local 21 Mid-Management Side Letter Attachment 4 – IFPTE Local 21 Executive Management Side Letter
RESOLUTION NO. _____
RESOLUTION OF THE COUNCIL OF THE CITY OF RICHMOND, CALIFORNIA
APPROVING THE SIDE LETTERS BETWEEN THE CITY OF RICHMOND AND SERVICE EMPLOYEES INTERNATIONAL UNION (SEIU) LOCAL 1021 AND INTERNATIONAL FEDERATION OF PROFESSIONAL AND TECHNICAL ENGINEERS (IFPTE) LOCAL 21 (MID-MANAGEMENT AND EXECUTIVE MANAGEMENT UNITS) REGARDING HOLIDAY CURTAILMENT FOR 2022
WHEREAS, the City has negotiated in good faith with SEIU 1021 and IFPTE Local 21, regarding a holiday curtailment for 2022; and
WHEREAS, the parties have executed a Side Letter on term for a holiday curtailment for 2022; and
WHEREAS, the Side Letter shall not bind the parties until they are ratified by a majority of both the SEIU Local 1021 and IFPTE Local 21 membership and ratified by the City Council; and
WHEREAS, the Side Letter will establish a holiday curtailment for 2022; and
WHEREAS, the adoption of these Side Letters will support a stable and amicable labor relations environment in the City.
NOW THEREFORE, BE IT RESOLVED, that effective December 6, 2022, the City Council of Richmond approves the Side Letters between the City of Richmond and Service Employees International Union (SEIU) Local 1021 and International Federation of Professional and Technical Engineers (IFPTE) Local 21 (Mid-Management And Executive Management units) regarding holiday curtailment for 2022 among the City of Richmond, SEIU Local 1021, and IFPTE Local 21 (Mid-Management and Executive Management units) regarding holiday curtailment for 2022, the terms of which are set for and marked as Exhibits A, B, and C to the agenda report in support of this resolution.
-----------
I hereby certify that the foregoing Resolution was passed and adopted by the Council of the City of Richmond at a regular meeting thereof held by the following vote:
AYES:
NOES:
ABSTENTIONS:
ABSENT:
_____________________________
CLERK OF THE CITY OF RICHMOND
(SEAL)
Approved:
____________________
Mayor
Approved as to form:
____________________
City Attorney
EXHIBIT A
EXHIBIT B
EXHIBIT C
December 6, 2022
Human Resources
DATE: December 6, 2022
TO: Mayor Butt and Members of the City Council
FROM:
Sharrone Taylor, Interim Director of Human Resources
Nickie Mastay, Deputy City Manager
Subject:
Amend Position Control and Salary Schedule to Add
Director of Economic Development. Amend Position
Control to add Deputy City Manager, Finance Manager
and Management Analyst I/II or Senior Management
Analyst.
FINANCIAL IMPACT: Director of Economic Development: Fiscal impacts will be determined when the candidate is hired, and salary and
benefits are determined.
Deputy City Manager: Fiscal impacts will be determined
when the candidate is hired, and salary and benefits are determined.
Finance Manager: Fiscal impacts will be determined once the incumbent is retitled, and salary and benefits are
determined.
Management Analyst I/II or Senior Management Analyst:
There is no fiscal impact due to the reallocation of two existing positions – Project Coordinator and Accounting Assistant I/II.
PREVIOUS COUNCIL
ACTION:
Click or tap here to enter text.
STATEMENT OF THE
ISSUE:
The City Council’s authorization is required to amend
position control and establish equitable salary ranges for general classifications..
AGENDA
REPORT
December 6, 2022
RECOMMENDED ACTION:
ADOPT a resolution amending position control and the
salary schedule to add Director of Economic
Development and APPROPRIATE the required wages,
salaries, and benefits; and AMEND position control
reallocating Deputy City Manager to oversee the
Department of Children and Youth and Community
Services, reallocating the Community Services
Department Senior Accountant to Finance Manager, and
reallocating the Office of Neighborhood Safety Division Project Coordinator and Accounting Assistant I/II to
Management Analyst I/II or Senior Management Analyst
– Human Resources (Sharrone Taylor/Nickie Mastay
510-620-6803).
DISCUSSION:
DIRECTOR OF ECONOMIC DEVELOPMENT
The Director of Economic Development position will be within the City Manager’s Office.
This is a newly established executive position and will oversee the Richmond Housing Authority, and direct and manage economic development, marketing, real estate, and Port operations. The department head classifications that were assigned to these divisions have been vacant for over a year. With the hiring of the Senior Business Assistance Officer and the current recruitment for a Management Analyst, the division has the foundation to rejuvenate the City’s economic development efforts. It is imperative that the City has a dedicated Director of Economic Development position to lead and oversee these critical, revenue generating divisions.
The Human Resources Department is bringing forth a proposed revision to amend the City’s salary schedule by adding the Director of Economic Development and establishing the grade 5.1z ($15,114 – $18,893/monthly) and amend the City’s position control by adding the position of Director of Economic Development.
DEPUTY CITY MANAGER
With the establishment of the Director of Economic Development classification, the City Manager desires to reassign the Deputy City Manager position, that previously oversaw Economic Development, to oversee the Department of Children and Youth, Community Services, and special projects. Per the City’s Charter, Article XV - Richmond Fund for Children and Youth, the Department of Children and Youth fund administrator must be within the City Manager’s Office. The reallocated Deputy City Manager will be in the City’s Manager’s Office and thus comply with the City Charter.
The Human Resources Department is bringing forth a proposed revision to position control to reallocate the Deputy City Manager position to oversee the Department of
December 6, 2022
Children and Youth, Community Services, and special projects. There is no salary range change nor fiscal impact since a Deputy City Manager position is within the adopted FY 2022-2023 budget.
COMMUNITY SERVICES DEPARTMENT POSITION CONTROL
The Community Services Department consists of: Employment and Training, Library/LEAP, Recreation, and Office of Neighborhood Safety. Currently, the financial functions are siloed in the respective divisions. While this model has worked for several years, there are some areas of inconsistency in the application of proper finance management. The Interim Director of Community Services would like to create a Finance Manager position that will oversee all the finance-related positions for the Community Services department. This change will ensure that there is adequate oversight, quality control, coordination, and consistency in financial management across all the divisions. Therefore, the Human Resources Department is requesting the reallocation and retitle of the current Senior Accountant to Finance Manager.
In addition, the Office of Neighborhood Safety experienced the recent retirement of a tenured Project Coordinator and the loss of an Accounting Assistant. These positions oversaw grant management and fiscal reporting, as well as administrative oversight and management of the day-to-day operations of the department. The Human Resources Department is requesting the reallocation of the Project Coordinator and Accounting Assistant to a Management Analyst I/II or Senior Management Analyst classification.
FISCAL IMPACT:
Below is a table that illustrates the comparison of the proposed salary for the Director of Economic Development (not including benefits) and the fiscal impact for the third and fourth quarter of FY 2022-2023 (January – June).
Annual Cost at Top of
Range Cost in FY 2022-23
Job Class Proposed Proposed
Director of Economic
Development $226,716 $113,358
Below is a table that illustrates the fiscal impact of reallocating the Senior Accountant to Finance Manager, by comparing the current and proposed salaries (not including benefits). The total cost of salary and benefits will be budgeted in the current and subsequent budgets.
Annual Cost at Top of Range
Senior Accountant
Annual Cost at Top of Range
Finance Manager
Job Class Current Proposed Difference
Finance Manager II $103,994 $120,984 $16,990
December 6, 2022
There is no fiscal impact for the reallocation of the Project Coordinator and Accounting Assistant to Management Analyst I/II or Senior Management Analyst. This reallocation will generate a cost savings.
NEXT STEPS:
City staff recommends the addition of the Director of Economic Development and reallocation of Deputy City Manager, Finance Manager II, and Management Analyst I/II or Senior Management Analyst in position control. Also, amend the salary schedule to include the wages and salaries for the Director of Economic Development classification and the appropriation of the required wages, salaries, and benefits.
Accordingly, the attached resolution will adjust the salary ranges for th is classification in the following manner:
Classification New Grade New Range Unit
Director of Economic
Development 5.1Z $15,114 - $18,893 IFPTE Local 21
Executive Management
Note: The salary numbers are rounded in both tables
DOCUMENTS ATTACHED:
Attachment 1 – Resolution Amending the Salary Schedule
Attachment 2 – Resolution Amending Position Control
RESOLUTION NO. _____
RESOLUTION OF THE COUNCIL OF THE CITY OF RICHMOND, CALIFORNIA
AMENDING THE SALARY SCHEDULE
WHEREAS, the Department of Human Resources maintains the classification and salary schedule on behalf of the City; and
WHEREAS, the City wishes to amend the salary schedule and such amendments are supported by the City Manager.
NOW THEREFORE, BE IT RESOLVED, that effective December 6, 2022, the Salary Schedule is hereby revised as follows and the Director of Human Resources shall publicly post the revised Salary Schedule.
Job Classification Range Step 1
or Min.
Step 2 Step 3 Step 4 Step 5
or Max.
FLSA Unit
TBD Director of
Economic
Development
5.1Z $15,114 $18,893 Exempt IFPTE Local
21 – Exec-
Management
-----------
I hereby certify that the foregoing Resolution was passed and adopted by the Council of the City of Richmond at a regular meeting thereof held by the following vote:
AYES:
NOES:
ABSTENTIONS:
ABSENT:
_____________________________
CLERK OF THE CITY OF RICHMOND
(SEAL)
Approved:
____________________
Mayor
Approved as to form:
____________________
City Attorney
RESOLUTION NO. _____
RESOLUTION OF THE COUNCIL OF THE CITY OF RICHMOND, CALIFORNIA AMENDING THE CITY’S POSITION CONTROL LIST
WHEREAS, pursuant to Article IV Section 1(b)(1) of the City Charter, the City Manager has the responsibility to manage all affairs of the City's operations, and appoint employees when necessary for the good service of the City; and
WHEREAS, pursuant to City Resolution No. 148-20, the City Manager has the authority to make appropriate administrative changes to the City’s position control list; and
WHEREAS, the City Manager has determined that certain amendments to the position control list are necessary to meet the operational needs of the City.
NOW THEREFORE BE IT RESOLVED, that the Richmond City Council authorizes the City Manager to modify the position control in order to meet the operational needs of the City; and
BE IT FURTHER RESOLVED, that, effective December 6, 2022, the City’s position control is hereby revised as follows:
Classification Unit
Director of Economic Development IFPTE Local 21 Executive Management
Deputy City Manager IFPTE Local 21 Executive
Management
Finance Manager IFPTE Local 21 – Mid Management
Management Analyst I/II IFPTE Local 21 – Mid Management Senior Management Analyst IFPTE Local 21 – Mid Management
-----------
I hereby certify that the foregoing Resolution was passed and adopted by the Council of the City of Richmond at a regular meeting thereof held by the following vote:
AYES:
NOES:
ABSTENTIONS:
ABSENT:
_____________________________
CLERK OF THE CITY OF RICHMOND
(SEAL)
Approved:
____________________
Mayor
Approved as to form:
____________________
City Attorney
December 6, 2022
Human Resources
DATE: December 6, 2022
TO: Mayor Butt and Members of the City Council
FROM:
Sharrone Taylor, Interim Director of Human Resources
Nickie Mastay, Deputy City Manager
Subject:
Resolution to Adopt the IFPTE Local 21 Side Letter for
Sworn Executive Management Personnel Sick Leave
Cash-out
FINANCIAL IMPACT: Fiscal impact is determined once executive sworn personnel separates from City service.
PREVIOUS COUNCIL
ACTION:
n/a
STATEMENT OF THE
ISSUE:
City Council approval is required to adopt the resolution approving the Side Letter agreement between the City
and IFPTE Local 21 Executive Management Unit.
RECOMMENDED ACTION:
ADOPT a resolution approving the Side Letter agreement
between the City and IFPTE Local 21 Executive
Management Unit regarding sick leave cash-out at
retirement for Sworn Executive Management Personnel –
Human Resources (Sharrone Taylor/Nickie Mastay 510-
620-6602).
AGENDA
REPORT
December 6, 2022
DISCUSSION:
It was brought to the attention of Human Resources that a key benefit that allows Sworn Executive Management personnel (Police Chief, Assistant Police Chief, Fire Chief, and Deputy Fire Chief) to receive a payout of a percentage of their sick leave balance upon retirement from the Richmond Police Management and Richmond Fire Management Memorandums of Understanding was not carried forward to the IFPTE Local 21 – Executive Management Memorandum of Understanding that was adopted by City Council with an effective date of July 1, 2021.
The Human Resources Department and IFPTE Local 21 – Executive Management Unit negotiated in good faith and agreed via Side Letter agreement to incorporate this benefit in the IFPTE Local 21 Executive Management Memorandum of Understanding.
Therefore, the Human Resources Department is bringing forth the Side Letter for City Council approval that permits Sworn Executive Personnel who retire from City service for reasons other than disability to be entitled to receive pay for their accumulated sick leave at the same rate and terms afforded to police and fire management employees represented by the Richmond Police Management and Richmond Fire Management Associations, respectively.
NEXT STEPS:
City staff recommends that the City Council approve the resolution adopting the Side Letter agreement Sick Leave Cash-out between the City and IFPTE Local 21 Executive Management Bargaining Unit.
DOCUMENTS ATTACHED:
Attachment 1 – Resolution approving Sworn Executive Personnel Sick Leave Payout Upon Separation
Attachment 2 – IFPTE Local 21 Executive Unit Side Letter – Sworn Executive Personnel Sick Leave Cash-out
RESOLUTION NO. _____
RESOLUTION OF THE COUNCIL OF THE CITY OF RICHMOND, CALIFORNIA
APPROVING THE SIDE LETTER REGARDING SICK LEAVE CASH OUT FOR SWORN
EXECUTIVE MANAGEMENT PERSONNEL UPON RETIREMENT BETWEEN THE CITY
OF RICHMOND AND SERVICE EMPLOYEES INTERNATIONAL UNION (SEIU) LOCAL 1021 AND INTERNATIONAL FEDERAION OF PROFESSIONAL AND TECHNICAL ENGINEERS (IFPTE) LOCAL 21
WHEREAS, the City has negotiated in good faith with IFPTE Local 21, regarding sworn executive management personnel sick leave cash out upon retirement; and
WHEREAS, the parties have executed a Side Letter on term for sworn executive management personnel sick leave cash out upon retirement; and
WHEREAS, the Side Letter shall not bind the parties until they are ratified by a majority of the IFPTE Local 21 membership and ratified by the City Council; and
WHEREAS, the Side Letter will establish sworn executive management personnel sick leave cash out upon retirement ; and
WHEREAS, the adoption of this Side Letter will support a stable and amicable labor relations environment in the City.
NOW THEREFORE, BE IT RESOLVED, that effective December 6, 2022, that the City Council of Richmond approves the Side Letter among the City of Richmond and IFPTE Local 21 (Executive Management) regarding sworn executive management personnel sick leave cash out upon retirement, the terms of which are set for and marked as Exhibits A to the agenda report in support of the resolution.
-----------
I hereby certify that the foregoing Resolution was passed and adopted by the Council of the City of Richmond at a regular meeting thereof held by the following vote:
AYES:
NOES:
ABSTENTIONS:
ABSENT:
_____________________________
CLERK OF THE CITY OF RICHMOND
(SEAL)
Approved:
____________________
Mayor
Approved as to form:
____________________
City Attorney
Alan M. Cohen for
December 6, 2022
Library and Community Services
DATE: December 6, 2022
TO: Mayor Butt and Members of the City Council
FROM:
LaShonda White, Interim Director of Community Services
Diana Lopez, Deputy Director of Community Services –
Library
Abigail Sims-Evelyn, Literacy Program Manager
Subject:
Accept and Appropriate the Grant Award Notification:
Workforce Innovation and Opportunity Act, Title II (WIOA II)
FINANCIAL IMPACT: Project expenditures will be funded by the Workforce Innovation and Opportunity Act, Title II. There isn’t a net additional expense to the General Fund.
PREVIOUS COUNCIL
ACTION:
Not applicable
STATEMENT OF THE
ISSUE:
The Richmond Public Library – Literacy for Every Adult
Program has been awarded $50,945 for adult literacy
and family literacy services.
RECOMMENDED ACTION:
ADOPT a resolution to ACCEPT and APPROPRIATE the
Workforce Innovation and Opportunity Act, Title II grant award of $50,945, to support educational programming
offered at the library’s literacy services program, Literacy for Every Adult Program – Library and Community
Services Department (Diana Lopez 510-620-5452/Abigail
Sims-Evelyn 510-307-8084).
AGENDA
REPORT
December 6, 2022
DISCUSSION:
The Richmond Public Library has been awarded a Workforce Innovation and Opportunity Act, Title II (WIOA II) grant in the total amount of $50,945, which will provide funds to support the Literacy for Every Adult Program’s adult learner and family literacy services. The services include one-on-one and small group instruction to adult learners who desire to develop literacy skills.
DOCUMENTS ATTACHED:
Attachment 1 – Grant Award Notification
Attachment 2 – Grant Award Notification (continued) Section 225, 231, and 243 Attachment 3 – California Department of Education Program and Accountability Requirements
Attachment 4 – California Department of Education Guidelines for Coalition Submission Attachment 5 – Resolution
December 6, 2022
Library and Community Services
DATE: December 6, 2022
TO: Mayor Butt and Members of the City Council
FROM:
LaShonda White, Interim Director of Community Services
Lori Reese-Brown, Project Manager II
Subject:
North Richmond Waste and Recovery Mitigation Fee
Expenditure Plan amendments
FINANCIAL IMPACT: There is no fiscal impact to the City’s General Fund.
PREVIOUS COUNCIL
ACTION:
7/6/2021 and 6/21/2022
STATEMENT OF THE
ISSUE:
The amended North Richmond Waste and Recovery
Mitigation Fee Expenditure Plans require approval by the Richmond City Council and the Contra Costa Board of
Supervisors for continued North Richmond cleanup
efforts and initiatives support efforts of blight reduction and cleanliness.
RECOMMENDED ACTION:
APPROVE the Amended 2021/2022 and 2022/2023
North Richmond Waste and Recovery Mitigation Fee
Expenditure Plans, identifying the activities authorized to be funded with Mitigation Fee revenue and respective
funding allocations for the period of July 1, 2021, to June 30, 2022, and July 1, 2022, to June 30, 2023, as
recommended by the North Richmond Waste and
Recovery Mitigation Fee Joint Expenditure Planning
Committee – Library and Community Services
Department (LaShonda White/Lori Reese-Brown 620-
6869).
AGENDA
REPORT
December 6, 2022
DISCUSSION:
The North Richmond Waste and Recovery Mitigation Fee Joint Expenditure Planning Committee (Committee) reviews and recommends approval of the annual North Richmond Waste and Recovery Mitigation Fee Expenditure Plan (Expenditure Plan) for North Richmond community clean-up projects and services. The purpose of the Committee is to provide the City of Richmond (City) and County of Contra Costa (County) with recommended Expenditure Plans that describe the annual activities and/or strategies for keeping North Richmond clean and reducing blighted conditions.
The Expenditure Plan governs the use of funding at the end of each fiscal year (July 1st through June 30th) granting the City and County the authority to utilize allocated funding amounts of actual expenditures for services and activities.
On October 21, 2022, the Committee recommended amendments to both expenditure plans represented in Attachment 1 (FY 2021-22 Amended Expenditure Plan), and Attachment 2 (FY 2022-23 Amended Expenditure Plan). As required, both the Richmond City Council, and the County Board of Supervisors must approve the recommendation. On November 11, 2022, the County Board of Supervisors approved the recommendation. Upon the City Council’s approval, North Richmond projects may commence.
DOCUMENTS ATTACHED:
Attachment 1 – FY 2021-2022 Amended North Richmond Waste & Recovery Mitigation Fee Expenditure Plan
Attachment 2 – FY 2022-2023 Amended North Richmond Waste & Recovery Mitigation Fee Expenditure Plan
Amended North Richmond Waste & Recovery
Mitigation Fee 2021/22 Expenditure Plan
The Waste & Recovery Mitigation Fee was established as a result of the Draft Environmental Impact Report (EIR) dated November 2003 for the WCCSL Bulk Materials Processing Cent er (BMPC) and Related Actions (Project). The Project involved new and expanded processing and resource recovery operations on both the incorporated and unincorporated area of the Project site, which the EIR concluded would impact the host community. To m itigate this impact Mitigation Measure 4-5 called for a Mitigation Fee to benefit the host community, described as follows:
“
Mitigation Fee. The facility operator shall pay a Mitigation Fee of an amount to be determined by the applicable permitting author ity(ies) to defray annual costs associated with collection and disposal of illegally dumped waste and associated impacts in North Richmond and adjacent areas. The mitigation fee should be subject to the joint-control of the City and County and should be co llected on all solid waste and processible materials received at the facility consistent with the existing mitigation fee collected at the Central IRRF.”
I
n July 2004, the City of Richmond and Contra Costa County entered into a Memorandum of Understanding (MOU) agreeing to jointly administer Mitigation Fee monies collected from the BMPC for the benefit of the incorporated and unincorporated North Richmond area. This North Richmond Waste & Recovery Mitigation Fee Joint Expenditure Planning Committee (Committee) was formed pursuant to the terms of the MOU for the specific purpose of preparing a recommended Expenditure Plan. This Expenditure Plan provides a means to jointly administer the Mitigation Fee funding for the benefit of the host community, as des cribed in the EIR. The Expenditure Plan is subject to final approval of the Richmond City Council and the Contra Costa County Board of Supervisors.
B
y approving this Expenditur e Plan, the Cit y Council and Board of Supervisors authorize the use of Mitigation Fee f unding for only the purposes and in the amounts specified herein. The City and County have each designated their respective staff persons responsible for administering the development and implementation of the approved Expenditure Plan, which includes responsibility for drafting and interpreting Expenditure Plan language. However, the City and County have not delegated to the Committee or to staff the authority to expend funding for purposes not clearly identified in the Expenditure Plan document officially approved by their respective decision-making bodies.
A
ctivities which can be funded in this Expenditure Plan period with the Mitigation Fee amounts specified within this Expenditure Plan are described herein as “Strategies” or “Staff Costs ”.
Strategies are categorized as either “Core Services” or “Supplemental Enhancements”. Core Services includes the higher funding priority strategies that most directly address the intended purpose of this City/County approved Mitigation Fee, “to defray annual costs associated with collection and disposal of illegally dumped waste and associated impacts in North Richmond”.
All references to the “Mitigation Fee Primary Funding Area” or “Mitigation Fee Funding Area” pertain to the geographic area shown in the attached map (Attachment 4).
Expenditure Plan Period: July 1, 2021 - June 30, 2022
(unless otherwise specified herein)
2021/2022 Expenditure Plan - North Richmond Waste & Recovery Mitigation Fee
- Page 2 of 13 -
BUDGET
The funding allocation amounts included in this document apply to the Expenditure Plan Period specified on the first page unless otherwise specified herein. The total amount of funding allocated in the Expenditure Plan Budget is based on revenue projections provided by the BMPC operator, Republic Service, which are dependent upon multiple variables (e.g. number of tons of recovered materials vs. solid waste, per ton gate rate charged and amount of CPI - adjusted per t on Mitigation Fee). Actual Mitigation Fee revenue may deviate from revenue projections provided by Republic and used to prepare this Budget. A “Contingency” line item is included in the Budget to help accommodate variations between projected and actual r evenue.
Excess funding allocated to strategies and not expended by the end of each Expenditure Plan period is treated as “roll-over” funding for reallocation in a subsequent Expenditure Plan period.
The Budget includes some line items that are based on fixed costs, however there are other line items which are scalable and/or dependent on utilization thereby providing flexibility to reallocate amounts if and when a significant need is identified. Allocated funding may remain unspent due to under -utilization of a particular program. If the amount allocated to a particular line item is determined to exceed needs based upon usage, the remaining funding can only be reallocated by officially amending the Expenditure Plan. This Expenditure Plan may only be adjusted upon official action taken by both the City and County. Although there has been some interest in allowing flexibility for staff to adjust funding allocations under specific circumstances, the authority to approve or modify the Expenditure Plan rests solely with the City Council and Board of Supervisors.
Annual fiscal year Expenditure Plan cycle is expected to reduce margin of error of Mitigation Fee revenue projects, streamline financial reconciliation/budgeting process and minimize need to amend Ex penditure Plans mid -cycle. Amending Expenditure Plans involve administrative burden and costs due to the joint approval needed from both the Richmond City Council and County Board of Supervisors. In order to minimize the amount of funding needed to cover staff costs incurred to amend the Expenditure Plan, s taff will only recommend changes to the Expenditure Plan when necessary to address a significant and time-sensitive need.
NORTH RICHMOND MITIGATION FEE EXPENDITURE PLAN BUDGET
# Expenditure Plan (EP) Strategy
Amended
Budget
Allocations for
2021/2022
1 Bulky Item Pick-ups & Disposal Vouchers 1,000.00$
2 Neighborhood Clean-ups 30,000.00$
3 Prevention Services Coordinator 50,726.75$
4 City/County Right-of-Way Pick-ups 38,442.91$
5 Code Enforcement - County 91,850.60$
6 Illegal Dumping Law Enforcement 175,814.30$
7 Surveillance Cameras -$
8 Code Enforcement - City 26,666.67$
9 Community Services Coordinator $ 90,909.09
10 Community Clean-Up Projects (See Attachment 2) 75,750.00$ 11 North Richmond Green Community Service Programs 20,042.00$ 12 North Richmond Green Campaign 10,500.00$
13 Garden Projects (See Attachment 4) 48,179.79$
14 Mobile Tool Lending Library 35,540.00$
Contingency (9% of Projected Revenue) 68,105.45$
Subtotal (without Committee Staffing) 763,527.56$
X Committee Administration/Staffing 100,000.00$
Total Projected Revenue in 2021/22 (July 1, 2021 thru June 30, 2022) 756,440.00$ 107,087.56$
863,527.56$
Core ServicesSupplemental
Enhancements
Roll-over Funding from Prior EP Cycle(s)
Total 2021/22 Expenditure Plan Budget
- Page 3 of 12 -Page 477 of 1565
2021/2022 Expenditure Plan - North Richmond Waste & Recovery Mitigation Fee
- Page 4 of 13 -
DESCRIPTION OF STRATEGIES RECOMMENDED FOR FUNDING
Funding allocation amounts for each strategy are specified in the Budget table on page
3. The following Strategies describe the activities allowed to be funded with the amounts allocated to each in the Budget (associated allowable agency staff costs are described in the Staff Costs section). Strategies are grouped based on relative funding priority levels and the “Core Services” category contains higher priority Strategies than the “Supplemental Enhancements” category. Higher funding priority Strategies are those which best address the Fee’s intended purpose, “to defray annual costs associated with collection and disposal of illegally dumped waste and associated impacts in North Richmond”) and “Supplemental Enhancements”.
Level 1 Priority - PRIMARY CORE SERVICES STRATEGIES
• 1 - Bulky Item Pick-ups & Disposal Vouchers
• 2 - Neighborhood Clean-up Events
• 4 - City/County Right-of-Way Trash & Tagging Removal
• 5 - Code Enforcement - County
• 6 - Illegal Dumping Law Enforcement
• 8 - Code Enforcement – City
Level 2 Priority - SECONDARY CORE SERVICES STRATEGIES
• 3 - Prevention Services Coordinator
• 7 - Surveillance Cameras
Level 3 Priority - PRIMARY SUPPLEMENTAL ENHANCEMENTS STRATEGIES • 9 - Community Services Coordinator
• 11 - North Richmond Green Community Services Program
• 12 - North Richmond Green Campaign
• 13 - Garden Project
• 14 - Mobile Tool Lending Library
Level 4 Priority - SECONDARY SUPPLEMENTAL ENHANCEMENTS STRATEGIES • 10 - Community Clean-up Projects
CORE SERVICES
1. Bulky Item Pick-ups & Disposal Vouchers
Provide residents in the Mitigation Fee Primary Funding Area, who prove eligibility consistent with City/County procedures, with the option of choosing to:
o Request up to one on-call pick-up service per household per calendar year for bulky items that are not accepted in the current on-call clean-ups through Richmond Sanitary Service (RSS), only available to those with an active account with RSS; or
o Request up to twelve $5 vouchers per household for disposal at Republic’s transfer station on Parr Blvd. per calendar year (vouchers expire after six months, Mitigation Fees only pay for vouchers that are actually redeemed).