8D
Date: June 3, 2025
To: Honorable Mayor and Members of the City Council
From: Ian Dailey, Finance Director
By: Daniel Lee, Workers' Compensation Manager | [email protected] Subject: Finance – Approve First Amendment to Consulting Services Agreement for Workers’ Compensation Claims Management Services. Expenditure: Approximately $817,218 (Non-General Fund: Approximately $408,609 Annually).
RECOMMENDATION
Recommendation of the Finance Director that City Council approve a first amendment to the consulting service s agreement with Sedgwick Claims Management Services ( Sedgwick) of Memphis, TN (C2022 -104), in the amount of approximately $817,218, to provide for workers’ compensation claims management services and to exercise the option to extend the term for a two-year period beginning July 1, 2025 and ending June 30, 2027.
FUNDING
Funding is anticipated to be available in the fiscal year 2025-2026 Self-Insurance Fund Operating Budget and in subsequent fiscal years.
DISCUSSION
In June 2022, City Council approved a consulting services agreement (C2022-104) with Sedgwick through June 30, 2025, with a one-time option to extend the term of the Agreement by two years, to provide workers’ compensation claims administration services for the City’s injured employees.
The contracted services with Sedgwick include:
• Claims Adjusting Services – Intake and triage employee injuries, investigate to determine coverage and administer benefits in accordance with State workers’ compensation laws.
• Medical Case Management – Coordinate effective medical treatment, assign nurse case management for complex injuries and monitor return to work and employee rehabilitation. • Cost Containment & Recovery – Conduct medical bill review and utilization revie w services. Medical bill review is a process where medical bill codes are review ed per the adopted Medical Fee schedule. Utilization review is a process where medical treatment being requested by the treating doctor is reviewed by the adopted medical treatment guidelines. Subrogation services is to recover costs from third parties at fault for causing injuries.
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June 3, 2025
• Regulatory Reporting – Ensure compliance with legally required reporting including Cal/OSHA injury disclosures.
• Analytics and Reporting – Provide custom reports of claim trends, costs and injury root causes.
Based on the services provided by Sedgwick, the workers’ compensation program has achieved the following positive results:
• Saved an estimated $190,000 annually in system fees based on leveraging Sedgwick’s electronic claims system (Juris) and paperless documentation system (SIR). This system also eliminated the need to handle mail manually within the City and physical documents now go to a P.O. box for scanning and the City saved on administrative costs of storage on an ongoing basis.
• Saved $532,099 in medical treatment based on State medical review guidelines. • Resulted in 30.3% decrease in total open claim inventory from 801 claims in the 3rd Quarter of 2022 to a historical low of 558 claims in the 3rd Quarter of 2025. Lower claim inventory helps control overall costs and administrative fees.
• Decreased financial reserves of open claims for Police Department from $46 million in August of 2023 to $42 million in April of 2025 and Fire from $40 million in October of 2023 to $33 million in April of 2025.
• Enhanced ability to run reports on different data points driven from the claim system (Juris) helps us identify trends in claims, finances and injuries. Monthly reports are provided to each City Department for analysis and preventive actions. • Passed the California State Compliance Audit in 2023.
Based on these objective results, Staff recommends exercising the option to extend the term for a two-year period beginning July 1, 2025 and ending June 30, 2027 . By extending the contract with Sedgwick, the City will continue to support the workers’ compensation program goals by providing excellent customer service for the City’s injured employees and help ensure the administration of the workers’ compensation claims are in compliance with State laws.
Based on Staff’s projections of open claims, projected new claims and administrative fees, the estimated total cost over the next two years is $817,218. The reason for estimated total cost over the next two years is due to administrative fees being charged based on a fixed fee per claim basis for new and open claims. The volume of new claims can fluctuate from year to year. Staff recommend City Council approve the first amendment to consulting service s agreements with Sedgwick Claims Management Services.
ATTACHMENTS
1. First Amendment to Consulting Service Agreement
2. Consulting Services Agreement (C2022-114)
3. Sedgwick Proposal
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ATTACHMENT 1
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6 ATTACHMENT 2
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Exhibit B
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ble of Contents
Cover Letter .......................................................................................................................................................................................... 3 Executive Summary .............................................................................................................................................................................. 5 Section 1: RFP Instructions and lnformation ....................................................................................................................................... 9 Section II: Technical Requirements ................................................................................................................................................... 16 Section Ill: Proposal Submittal ........................................................................................................................................................... 41 Performance Standards ...................................................................................................................................................................... 56 Customized Program Design and Pricing Proposal ........................................................................................................................ 128 Appendix Items ................................................................................................................................................................................ 139 SP<l~'wick Copyright (_ 2022
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June 6, 2022
Rebecca Poirier
City Clerk
3031 Torrance Boulevard
Torrance, California 90503
RE: RFP for workers' compensation claims administration services, RFP no. B2022-28 Dear Ms. Poirier and the evaluation committee,
RFP B2022-28
Sedgwick Claims Management Services, Inc. {Sedgwick) would like to thank the City ofTorrance, California {City) for the opportunity to respond to your request for proposal {RFP) to provide workers' compensation third-party claims administration.
Sedgwick is uniquely qualified to serve as the City's partner due to our extensive experience providing claims administration services to California public entitles; our expertise in transitioning and managing public entity programs, including large municipalities with large safety officer populations; our experience assisting self administered, self-insured employers who are outsourcing all or part of their program; our in-depth working knowledge of the PRISM {the City's) claims handling and reporting requirements; along with our flexible approach to using a client's desired claims system - whether it is a client-owned platform, Sedgwick's technology solutions or a combination of both. We have thoroughly reviewed the RFP and are confident in our ability to meet all of the City's requirements.
We understand that managing risk for public entity clients, particularly cities, creates challenges that are unique, both in the breadth of the potential exposure and the diversity of possible claims. Sedgwick's public entity clients represent a broad risk profile that includes schools/higher education, state, county, city and municipal workers, transportation workers and law enforcement. We are proud to serve more than 456 public entities nationally, many of which are in the west, including the County of Los Angeles, Los Angeles Unified School District, University of California and California State University. We are also currently in the implementation stage with the City of Los Angeles.
As a trusted third-party administrator {TPA), we focus on program cost reductions and employee advocacy with our caring counts® approach. Taking care of people and organizations - both public and private employers - is at the heart of everything we do.
Our custom approach uniquely positions Sedgwick to deliver:
" Proactive, measurable solutions that will reduce overall claim costs and the City's total cost of risk {TCOR) through effective claims management
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• A proven program implementation process and an experienced implementation manager to oversee a seamless, successful onboarding of the program
• Innovative technology, mobile access to your claims data and an unparalleled employee experience through our self-service, web-enabled platform, mySedgwick " Benchmarking against the largest employer claims database available • Quality staff development and ongoing training
through Sedgwick University
Sedgwick is committed to delivering a best-in-class program explicitly designed with the City's needs in mind. We look forward to the next steps with you to further the due diligence process.
Philip Cordeiro, Director of Business Development, will serve as the main point of contact for Sedgwick during the procurement process. He can be reached at 858.876.7445 or [email protected]. Please reach out to Philip with any questions you may have.
We look forward to additional discussion regarding how Sedgwick can fulfill the needs of the City.
Sincerely,
Scott Rogers
Chief Client Officer
Sedgwick Claims Management Services, Inc.
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Executive Summary
Sedgwick is recognized as the leading TPA for public entities, handling 9.3 million claims with claim payments greater than $26 billion annually. With more than SO years of experience, no other TPA can deliver the breadth of expertise and resources needed to develop and manage a custom, best-in-class workers' compensation program for the City.
Our approach - caring counts
More employers are beginning to realize and embrace the paradigm shift from volume-based to value-based service models. Employees that feel physically, financially and emotionally supported take pride in their work, interact effectively with peers and deliver the quality of service that is essential for public entities to function. To ensure that we deliver our own brand of value-based services, Sedgwick has developed and implemented our purpose statement - taking care of people is at the heart of everything we do.
Caring counts is the framework for every interaction between Sedgwick colleagues and our clients as well as their employees. Regardless of the circumstances, we are mindful of the trust our clients place in us. Sedgwick claims examiners and case managers provide advocacy-based care that can be a key factor in determining claim outcomes, avoiding unnecessary litigation and keeping costs reasonable.
The Sedgwick difference
Sedgwick is ultimately differentiated by our customized programs, thought leadership, reputation, philosophy of caring, technology and niche expertise in the public sector. Our public entity industry segment is led by Jody Moses, managing director of public entity programs, who has more than 25 years of specialized claims administration experience.
Sedgwick serves 456 public entity clients from more than 257 U.S. locations, ensuring that every program speaks to each client's unique needs. We focus on developing custom programs that offer reliable, financially aware, accessible and scalable claims services that guide our clients, their employees and the members of the community they serve through the claims process. Issues that are significant to our public entity partners, like the City, include:
s Preparing for emerging risks
"' Embracing next-level technology
* Moving forward with healthcare strategies
"' Broadening claims expertise as needs change
We leverage our experience to effectively manage the wide array of issues facing our public entity partners today.
Our comprehensive solutions focus on mitigating and reducing risks and losses, keeping employees and organizations healthy and productive, protecting the public's trust and containing costs that can impact the bottom line.
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California expertise
Sedgwick differentiates itself in California through our unparalleled experience with California workers' compensation claims and our depth of local resources. We have more than 2,000 California colleagues in 22 offices throughout the state handling workers' compensation claims. Scotty Benton, our vice president of workers' compensation practice, is located in California and has 30 years of experience in the jurisdiction. His engagement in legislative and regulatory affairs and overall compliance ensure that we are not only cognizant of and participating in the discussion but are also preparing best practices as to how we approach any changes to ensure continued positive outcomes. Scotty has in-depth knowledge and specializes in the nuances of California workers' compensation laws. This knowledge translates to ongoing training for our California claims colleagues and innovative processes that facilitate compliance and mitigate litigation.
Sedgwick's expert resources include some of the industry's most respected thought leaders who are engaged at the local, state, regional and national levels in the dialogue about key industry issues. The workers' compensation landscape in California is extremely complex, and this state ranks among the most costly for many employers.
Sedgwick has a wealth of experience and intellectual capital in California to ensure that our clients stay abreast of pending regulatory changes and are armed with solutions that can positively impact their overall cost of risk.
Jeff Loeffel man, senior vice president of business development at Sedgwick, is a member of the board of directors of the California Coalition on Workers' Compensation (CCWC). The CCWC is the premier employer-based organization dedicated exclusively to providing leadership and expertise to California's workers' compensation community, and it strives to achieve and maintain a state system that is equitable and efficient for both injured employees and employers. Founded in 1985, the CCWC represents hundreds of employers and trade associations, including a number of Sedgwick's largest clients. As a coalition board member, Jeff is in a unique position to influence legislative changes in California, a state known to be a hotbed for workers' compensation advancements and reform.
Outcomes-driven service
Beyond sound claims management practices, a critical component of a successful claims program is a client services team focused on superior outcomes and continuous improvement. We understand that overall performance must be measured in dollars. Sedgwick's proven infrastructure, program management philosophy and ability to respond quickly to changes in your organization, as well as industry and regulatory changes, facilitate a faster realization of program improvements.
It is important to us that our goals align with the City's overall risk management objectives. Sedgwick provides a proactive, metric-driven partnership via scorecards, and our advanced analytics tool will be used to identify opportunities to focus our attention on areas with the most potential impact. Your Sedgwick client services director (CSD) and the leadership team will leverage these tools to identify areas that require further investigation, attention and intervention to proactively mitigate claim costs and exposures.
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Next-generation thinking
Sedgwick can bring a significant value-added differentiator to the City's program with our investment in our proprietary, multiline claims management system. Sedgwick has 1,700 colleagues supporting our IT and infrastructure, and our technology is used as a tool for continuous improvement. We constantly evaluate data, identify trends and implement innovative strategies to bring about improved outcomes on each claim.
Sedgwick has the largest public entity database in the nation. Armed with an extensive dataset, we leverage our robust analytic tools to benchmark client programs against those similar in scope and complexity. Your client services team will work closely with the City to apply a full complement of predictive modeling resources capable of forecasting results and affecting continuous improvement for the City's program.
Sedgwick uses data to drive decisions that will ultimately lead to smarter outcomes for the City, your employees, customers and other stakeholders. With this analytical approach, we can harness the value of the information we gather to prompt the right action at the right time, resulting in continuous improvement and better overall satisfaction. Using our decision optimization platform, Sedgwick is able to automate the next steps on a claim and direct resources to the appropriate party for exceptional care and service.
Sedgwick's viaOne® web portal serves as our client-facing data access and analytics powerhouse, offering the City's risk management team the ability to view, track and predict the key drivers in your program. In viaOne, the City can view real-time data and access claim activity, including notes, diaries and payment history, as well as monitor claim progress. Users can also create their own notes/diaries and interact with the claims team.
We are responding to the cultural shift toward self-service by reconsidering our technology from the customer's perspective and moving our on line platforms toward a more comprehensive and dynamic user experience. Our web-enabled self-service platform, mySedgwick, delivers on-point functionality for the City's managers, supervisors and employees, who have more capability than ever before to upload and manage data, view claim status and associated notifications, communicate with Sedgwick examiners and choose options for text notifications, banking preferences and more. Our proprietary claims system allows us to remain nimble and continually enhance our capabilities to stay ahead of the needs of our dynamic client base.
Sedgwick also provides flexible OSHA recordkeeping solutions. The City has the option to select one of two levels of service to suit your preferences through our viaOne OSHA tool. viJOne OSHA is able to generate standard reports, such as the OSHA 300, 300A, 301 and sharps logs, as well as other reports, such as DART and BLS surveys.
Sedgwick is also able to support electronic reporting. We will review your structure, the size of your establishments and your NAICS codes to determine which of your locations must report to be in compliance with OSHA's electronic reporting rules.
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Software as a service (SaaS)
At Sedgwick, we understand the need for flexible solutions that help clients meet the challenges in today's dynamic business climate. In addition to out-sourced claim management, we offer the ability for clients to co source, using Sedgwick's Saas. In 2014, Sedgwick acquired Absentys, advancing our Saas solution and building on our position as the leading provider of technology-enabled claims and productivity management solutions. We work with our clients to understand their needs based on our experience and expertise in the marketplace.
Clients can choose to mix and match our software modules and claim services to meet their needs.
Our commitment
At Sedgwick, we leverage our experience to effectively manage the wide array of issues facing our public entity partners today. Our comprehensive solutions focus on mitigating and reducing risks and losses; keeping employees and organizations healthy and productive; protecting the public's trust; and containing costs that can impact the bottom line.
Sedgwick brings a combination of innovation, experience and flexibility that cannot be found anywhere else in the industry. We apply resources to our programs in a way that enables our colleagues to do the right thing for our clients every day. We know that shared knowledge and experience are the key to making each other better and will form the foundation of a true partnership between Sedgwick and the City.
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Section 1: RFP Instructions and l n
Notice is hereby given that sealed proposals will be received in the office of the City Clerk, City Hall, 3031 Torrance Boulevard, Torrance, CA, or via electronic submission until 3:00 p.m. on June 6, 2022. An original and three (3) printed copies of each proposal must be submitted in a sealed envelope and clearly marked: "RFP for Workers' Compensation Claims Administration Services, RFP No. B2022-28" or submitted electronically at https://www.dropbox.com/request/fbVngQUSlxvPCRkwYIMs
The City of Torrance
The City of Torrance is on the western side of Los Angeles County. It is boarded by the Palos Verdes Peninsula on the south, the City of Gardena on the north, the City of Redondo Beach on the north and west boundaries, the City of Lomita on the east and the Pacific Ocean on the west. The City encompasses an area of approximately 21 square miles, 329 miles of Streets, 1870 intersections, 550 miles of sidewalks, 47,000 Street Trees, 6 Public Libraries, a Municipal Airport, Transit System, 46 Parks & Recreation Amenities, 6 Fire Stations, 1 Police Station and 1 Police Community Center, and has an estimated population of approximately 146,115, which makes Torrance one of the top 10 cities in Los Angeles County in regards to population.
Background
The City of Torrance is searching for qualified Workers' Compensation Third-Party Administrators to submit proposals to provide Workers' Compensation claims' administration services per specifications delineated in this request for proposal (RFP) document. The requested proposal and ensuing contract will be for a three (3) year initial term with the possibility to extend for two additional (1) year terms. It is anticipated that the contract period will start on or about July 2022.
The contract will be subject to the successful submittal of required proposal information and documentation, negotiation of terms and conditions and approval of City Management and City Council. If successful, the contract will be subject to regular performance reviews, funding and City appropriations requirements.
Definitions:
City
Vendor, Contractor,
Proposer, Firm, Consultant,
Third-Party Administrator
(TPA)
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The City of Torrance, California
The person, firm, company or corporation providing services to the City, or submitting a proposal in response to this RFP
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. Contract, Purchase Order,
Agreement, Purchasing
Agreement
Proposal Submittal Form:
The agreement between the awarded Vendor and the City as a result of this Request for Proposals
The proposal must be made on the form provided for that purpose, enclosed in a sealed envelope, and marked "RFP for Workers' Compensation Claims Administration Services, RFP No. B2022-28" and addressed to the City Clerk, City of Torrance, 3031 Torrance Blvd., Torrance, CA 90503 or electronically submitted at:
https://www.dropbox.com/request/fbVngQUSlxvPCRkwYIMs
If an individual makes the proposal, it must be signed by that individual, with an address and telephone number. If made by a business entity, it must be signed by an authorized person that executes binding agreements and contracts. A full business address and telephone are required.
Blank spaces in the proposal form must be completed using ink, indelible pencil, or typewriter. The text of the proposal form must not be changed and no additions. Any unauthorized conditions, limitations, or provisos attached to a proposal will render it informal and may cause its rejection. Alterations by erasure or interlineations must be explained or noted in the proposal form over the signature of the Proposer.
Questions
Submit questions in writing via email to Adrian Fajardo, Management Assistant at [email protected] by 12:00 P.M Noon, local Pacific Time on May 20, 2022. No questions via telephone. No questions submitted after deadline. Written answers and any other changes to the RFP will be sent (via email and posted on the City of Torrance website with the RFP document at https://www.torranceca.gov/government/city clerk/request-for-proposals) to all known prospective proposers as an addendum to the RFP.
To ensure fairness and avoid misunderstandings, all communications must be in written format and submitted via e-mail by the due date. Any communications whether written or verbal to any person other than the designated individual listed on page 1, prior to award of a contract/purchase order is strictly prohibited and may cause disqualification.
Errors and Omissions
The proposer will not be allowed to take advantage of any errors and/or omissions in these specifications or in the proposer's specifications submitted with its proposal. Full instruction will always be given when errors or omissions are discovered.
Proposers Examination of Requirements
The Proposer is required to examine carefully the instructions, information, and specifications of this document, investigate the conditions to be encountered, the character, quality, and quantities of work to be performed as required by this document. Submission of a proposal will be considered prima facie evidence that the Proposer has made such examination.
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Reservation
The City reserves the right to revise or amend these specifications prior to the date set for opening proposals.
Revisions and amendments, if any, will be announced by an addendum to this RFP. If the revisions require additional time to enable vendors to respond, the City may postpone the opening date accordingly. In such case, the addendum will include an announcement of the new proposal submittal due date. All addenda must be attached to the proposal. Failure to attach any addendum may render the proposal non-responsive and cause it to be rejected.
The City reserves the right to award a contract to a company solely on the basis of the initial proposal submitted. The City reserves the right to require more information and clarification on information submitted in the proposal to complete the evaluation.
The City Council reserves the right to reject any and all proposals received, to take all proposals under advisement for a period not to exceed ninety {90) days after the date of the opening, to waive any informality on any proposal, and to be the sole judge of the relative merits of the material and or service mentioned in the respective proposals received. The City reserves the right to reject any proposal not accompanied with all data or information required.
This Request for Proposals does not commit the City to award a contract or to pay any cost incurred in the preparation of a proposal. All responses to this RFP document become the property of the City of Torrance.
The City reserves the right to examine all factors bearing on a Proposer's ability to perform the services under the contract. The City reserves the right to reject any proposal not accompanied with all data or information required. The City reserves the right to cancel this solicitation, without penalty, at its sole discretion.
Affidavit:
An affidavit form is enclosed. It must be completed signifying that the proposal is genuine and not collusive or made in the interest or on behalf of any person not named in the proposal, that the Proposer has not directly or indirectly induced or solicited any other proposer to put in a sham proposal or any other person, firm, or corporation to refrain from proposing, and that the Proposer has not in any manner sought by collusion to secure for itself an advantage over any other proposer. Any proposal submitted without an affidavit or in violation of this requirement will be rejected. {Attachment 1) Evaluation of Proposals
The City will be the sole determiner of suitability to the City's needs. Proposals will be rated according to their completeness and understanding of the City's needs, conformance to the requirements of the technical specifications, compatibility with the City's current technology and operations, prior experience with similar scope of work, financial capabilities, delivery, and cost. Cost including any ongoing maintenance and support cost will be reviewed to determine which proposal best meets the needs of the City.
The City will take into consideration a local Torrance vendor sales tax rebate of 1% for proposals submitted by a Torrance vendor that include a material component.
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The City's project evaluation team will evaluate proposals based on the evaluation criteria listed below.
Points will be assigned to each criterion up to a maximum of 100 points. Proposals will be ranked and that ranking will be made public. Subsequently, the City may interview/ request an oral presentation for a qualified Firm, prior to deciding whether to recommend the award of an Agreement.
Ability - Ability to meet the City's current and projected service requirements over the term of the third-party administration agreement.
Pricing - Provide competitive pricing for existing services.
Related Experience & Personnel - Experience and knowledge of working with public agencies. Quality background, certifications of dedicated key personnel on the team.
Communication and Information systems - The systems available to enable the real time access to reports, claim notes, claimant servicing (i.e.: customer service line directly to the vendor)
References - Quality and applicability of references.
Maximum Total Points=
Estimated Timeline of Events (dotes ore subject to change) Oral Presentation (if requested)
Intent to award contract
City Council approval
Effective date of agreement
The Contract
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20 15
10 100
June 17, 2022
Late June-July 2022
Late July 2022
Late July 2022
The vendor to whom the award is made will be required to enter into a written contract with the City of Torrance. Attached is a copy of the City's standardized contract, which will be modified to reflect the awarded RFP. A copy of this RFP and the accepted proposal will be attached to and become a part of the contract.
Sedgwick agrees to enter into a contract with the City that addresses the deal points that the parties have agreed upon. Because of our highly customizable approach to design, develop and implement a unique solution, the final program design will differ from the original proposal and bid documents. Therefore, we do not recommend including any bid documents in the agreement.
We have detailed exceptions to the City's standardized contract below with redlines. 12 29
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6. RETENTION OF FUNDS
CONSULTANT authorizes CITY to deduct from any amount payable to CONSULTANT (whether or not arising out of this Agreement) any amounts the payment of which may be in dispute or that are necessary to compensate CITY for any losses, costs, liabilities, or damages suffered by CITY, and all amounts for which CITY may be liable to third parties, by reason of CONSULTANT's _negligent or willful acts or omissions in performing or failing to perform CONSULTANT's obligations under this Agreement. In the event that any claim is made by a third party, the amount or validity of which is disputed by CONSULTANT, or any indebtedness exists that appears to be the basis for a claim of lien, CITY may withhold from any payment due, without liability for interest because of the withholding, an amount sufficient to cover the claim. The failure of CITY to exercise the right to deduct or to withhold will not, however, affect the obligations of CONSULTANT to insure, indemnify, and protect CITY as elsewhere provided in this Agreement.
15. INDEMNIFICATION
CONSULTANT will indemnify, defend, and hold harmless CITY, the Successor Agency to the Former Redevelopment Agency of the City of Torrance, the City Council, each member thereof, present and future, members of boards and commissions, their officers, agents, employees and volunteers (collectively "City Affiliates") from and against any and all liability, expenses, including defense costs and legal fees, and claims for damages whatsoever, including, but not limited to, those arising from breach of contract, if caused bythf:
Ll§gligence or willful rr1~QQCJl.Jct9f CONSULTANT then bodily injury, death, personal injury, property damage, loss of use, or property loss however the same may be caused-a~~fl-&ibHi-t:y-fBf--flf:cg1igf'ftEe. The obligation to indemnify, defend and hold harmless includes, but is not limited to, any liability or expense, including defense costs and legal fees, arising from the negligent acts or omissions, or willful misconduct of CONSULTANT, its officers, employees, agents, subCONSULTANTs or vendors. CONSULTANT's obligations to indemnify, defend and hold harmless will apply even in the event of concurrent negligence on the part of City Affiliates, except for liability resulting solely from the negligence or willful misconduct of City Affiliates. Payment by CITY is not a condition precedent to enforcement of this indemnity. In the event of any dispute between CONSULTANT and CITY, as to whether liability arises from the sole negligence of City Affiliates, CONSULTANT will be obligated to pay for the defense of City Affiliates until such time as a final judgment has been entered adjudicating City Affiliates as solely negligent. CONSULTANT will not be entitled in the event of such a determination to any reimbursement of defense costs including but not limited to attorney's fees, expert fees and costs of litigation.
Contract Term
The initial contract will be for a period of a three (3) year term (7 /31/22 - 7 /30/25). The City may extend the contract with two additional one (1)-year extensions (7 /31/25-7 /30/26, 7 /31/26 - 7 /30/27). Dates are subject to change.
Fiscal Year Funding
Each payment obligation of the City is conditioned upon the availability of state or local government funds, which are apportioned or allocated for the payment of such an obligation. If the funds are not allocated and 13 30
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available for the continuance of the function performed by the Vendor, the product or service directly or indirectly involved in the performance of that function may be terminated by the City at the end of the period for which funds are available.
Independent Contractor
The successful proposer is, and will at all times remain as to the City, a wholly independent contractor.
Neither the City nor any of its agents will have control over the conduct of the Contractor or any of the Contractor's employees, except as otherwise set forth in the awarded Agreement. The Contractor's agents and employees are not and will not be considered employees of the City for any purpose. The Contractor may not, at any time or in any manner, represent that it or any of its agents or employees are in any manner agents or employees of the City. The City has no duty, obligation, or responsibility to the Contractor's agents or employees under the Affordable Care Act. The Contractor is solely responsible for any tax penalties associated with the failure to offer affordable coverage to its agents and employees under the Affordable Care Act and any other liabilities, claims and obligations regarding compliance with the Affordable Care Act with respect to the Contractor's agents and employees. The City is not responsible and will not be held liable for the Contractor's failure to comply with the Contractor's duties, obligations, and responsibilities under the Affordable Care Act. The Contractor agrees to defend, indemnify, and hold the City harmless for any and all taxes and penalties that may be assessed against the City as a result of the Contractor's obligations under the Affordable Care Act relating to the Contractor's agents and employees.
Payments
Complete payment on the contract price will be made in approximately thirty (30) days from date of delivery, or completion and acceptance, unless otherwise provided for in Proposer's proposal or in these specifications.
Payments will be made upon verification and acceptance by the City of contract services performed and upon the City's receipt of a correct invoice.
Suspension of Procurement
The City may suspend, in writing all or a portion of the procurement of materials or services pursuant to this RFP and subsequent contract agreement, in the event unforeseen circumstances make such procurement impossible or infeasible, or in the event, City should determine it to be in the best interest of City to cancel such procurement of services or materials.
Notice
Whenever it will be necessary for either party to serve notice on the other respecting the Agreement, such notice will be served by personal delivery or by certified mail to the following addresses, unless and until different addresses may be furnished in writing by either party or the other, and such notice will be deemed to have been served within seventy-two (72) hours after the same has been deposited in a United States Post Office by certified mail or has been delivered personally, and will be valid and sufficient service of notice for all purposes:
CITY:
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City Clerk
City of Torrance
3031 Torrance Boulevard
Torrance, CA 90503
VENDOR: Will be determined upon award of contract.
Notice of Intent to Award
Approximately two (2) weeks prior to the anticipated City Council meeting awarding a contract as a result of the RFP, the City will notify all proposer's of its intent to award. Results will be posted on the City of Torrance Web site at https://www.torranceca.gov/government/city-clerk/request-for-proposals The anticipated City Council meeting date for approval of this contract will take place July 2022.
City of Torrance Bid/RFP Protest Procedures
The City of Torrance Bid/RFP Protest Procedures may be found on the City of Torrance Web site:
https://www.torranceca.gov/ government/ city-clerk/ request-for-proposals Insurance
See the contract template (Attachment 3) for the insurance requirements.
Our exceptions to the insurance requirements are detailed below with redlines.
17. INSURANCE
Sedgwick Ccpyn;ht '!. 2022
B. The insurance provided by CONSULTANT will be primary and non- contributory. Professional iiability insurance is not primary and non-contributory.
E. SJ1qylcJ0qyofthe above described policies be cancelled before the exQiration date thereof, r_,,qti~~' will be delivered in accordance with the policy provisionsf..3th-lns-ur-;;1Rtt"-pell€y+equiH¼f by-tl::1ix; Paragraph must contain a provision that no termination, ca0te4kHior+or-~f E8v,0r-ag-e-E:ilfl-Be--fHae~t-A0t-i0e--t&th0-QT¥.
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82 RFP B2022-28
II: Technical Requirements
Overview
Currently, the City of Torrance (City) open claims count includes 610 indemnity claims, and 306 medical only claims. Of those totals, the open claims count for the Police department is 224 indemnity claims and 86 medical only claims. At this time, the City of Torrance is seeking to outsource claims administration in a phased approach, with the first year outsourcing only those claims from the Police department (the City's largest department), adding the Fire department in the 2nd year, and all claims by year 3. The average counts by department can be found below (as of May 2, 2022):
Police
Fire
All Others
Total City
75 65
155
295
215
162
185
562
2 5
7 14
292
232
347
871
The City also currently employs four (4) full-time employees in the Workers' Compensation Division: one (1) Workers' Compensation Manager, two (2) Claims Examiners, and one (1) Claims Technician. It is the City's intent to retain these employees. Should any employees decide to depart, claims will be distributed amongst the selected third-party administrator and remaining employees.
The City's goal is to ensure timely, adequate medical treatment and issuance of medical benefits for injured employees during the course of employment, and decrease the frequency and severity of workplace injuries and illnesses at the member level.
The responsibilities of the claims adjusting service is divided into five categories:
1) Personnel,
2) Claims administration,
3) Litigation management,
4) Reporting of claims activities, and
5) General/ State requirements.
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83 f<FP B2022-28
Section 2 .1 - scope of work
1. Establish claims-handling and investigation protocols for the City. Please provide a copy of the claims management program if there is already one in place.
Sedgwick agrees to comply with this requirement. We focus on optimal claim outcome from day one, achieving the best overall result for injured employees. We base our philosophy on these key elements:
The advocacy approach
Delivering appropriate, expedient care
Engaging the right resources at the right time
Acting in partnership with employers
Holding ourselves accountable
Providing creative solutions for complex claims
Our team members function as advocates for injured employees. They strive to demonstrate empathy and compassion, while understanding that receiving accurate information and appropriate, timely care are crucial to an outcome that benefits all stakeholders. We educate the injured employee on the claim process, answer questions and help set realistic expectations for recovery. While statutes, regulations and best practices provide a claims management framework, we believe that expedient access to benefits facilitates an injured employee's return to health and peace of mind.
Great outcomes result from providing quality medical care. We work to match the injured employee with a physician who delivers the best possible care, based on prior outcomes. We couple our outcomes-based networks with evidence-based medicine to ensure the right treatment is provided. Our expert resources work with our claims team in understanding the injured employee's optimal path to health and productivity and help to enlist the correct resources to achieve recovery.
Sedgwick understands that appropriate use of medications is critical to the injured employee's well-being.
Pharmacists with our complex pharmacy team help examiners by ensuring injured employees are using suitable medicc1tions. In the event the injured employee needs assistance with opioid overuse, this team works closely wrth all stc1keholders in adopting a care plan.
Our relc1tionship with employers is critical in securing successful outcomes. Sedgwick works closely with our clients to understand their culture, values c1nd mission. We customize our program to tacilitate a claims process that is unique to each client's needs. A CSD serves JS a steward for the program ,rnd continuously evaluates the program to determine how we can add value and improve results. 1 i
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RFP 82022-28
It is important to measure and ensure compliance with best practices, unique client service instructions (CSI) and regulatory requirements. However, Sedgwick understands that quality must go beyond standard auditing. Our Performance 360® program measures how our examiners drive outcomes. In every facet of claims handling, we facilitate productive discussions with our colleagues on enhancing their skills in securing the best possible result.
A copy of our claims management best practices is included in the appendix.
2. Conduct a thorough investigation of all new claims.
Sedgwick agrees to comply with this requirement. Once a workers' compensation claim is reported, a team lead reviews the claim and determines if there are any red flags, subrogation opportunities or special requirements based upon the reported information. The team lead then will assign the claim to an examiner based upon the complexity of the claim and dedication/designation requirements with instructions, where appropriate.
We have outlined the investigative process by line of coverage below:
* Incident only claims are set up within the claims system, but no further investigation is performed. * Medical only claims may include one-point contact with the employer, depending upon the completeness of the information reported or questions regarding the information presented. We review medical bills and reports upon receipt to eliminate inconsistencies with the reported mechanism of injury and the injury type, as well as to ensure appropriate treatment protocols, etc. 4 Indemnity claims require a minimum three-point contact with the claimant, employer and medical provider. Additional contacts may be necessary based upon the details of the accident, presence of witnesses, potential for subrogation, etc. When appropriate, we obtain recorded statements or conduct on-site investigations. We review medical information for appropriateness of treatment and other actions.
3. Review all "open" files individually to determine claim status and develop plan of action regarding claim closure.
Sedgwick requires claims examiners to place thorough, complete notes in the claim record. Documents and pertinent information obtained through investigation and other activities are added to the claim file as notes.
Specific to resolution strategies, the initial action plan on all the City's cases will document the steps required to bring the claim to a conclusion. Each time the action plan is updated, the resolution strategy also will be updated.
The team leads for the City's program will focus on technical quality by performing ongoing reviews of all open indemnity claims at various points in their life span. Sedgwick requires standard reviews at 30 days after receipt and every 90 days thereafter ( or sooner if needed or required by the client) throughout the life of the claim.
Additional reviews are scheduled based upon the individual merits of the claim. We see this first-level quality as a critical element in the process. Team lead reviews focus on coverage, action plan, reserves, evaluation and appropriateness of the investigation. In addition, the team lead verifies the prevailing state negligence standard and other legal considerations as well as the timeliness and accuracy of our decision and outcomes.
All supervisory reviews are documented in the claim notes. 18 35
85 RFP B2022-28
4. Ensure claims-handling based on best practices of PRISM Standards of Performance (Attachment 2).
Sedgwick agrees to comply with this requirement. Our workers' compensation best practices for all areas of claims management are included in the appendix. Additionally, Sedgwick has over 25 years of experience working with PRISM and are deeply familiar with the PRISM Standards of Performance.
As part of our guiding principles, we will:
"' Maintain high-quality customer service through regular and effective communication with our clients and adhere to applicable service agreements
" Resolve cases as expeditiously and cost effectively as possible while achieving optimal results for our clients
" Handle claims in accordance with the designated service expectations Document file activities, facts, action plans and reserve rationales concisely and on a timely basis " Use team leads to ensure that cases are assigned to appropriate claims handlers, provide instruction and oversight to claim examiners and ensure that cases are resolved on a timely and cost-effective basis.
We have responded to the City's Standards of Performance (attachment 2) on the following pages.
5. Apply accepted claims management practices and City protocols consistently.
Sedgwick agrees to comply with this requirement. To provide consistency in individual claim files, we have created and continually manage our claims management best practices. Specific areas covered in the best practices include investigation, reserving, development of action plans, managing medical costs, resolution, litigation management, recovery and client communication. These written standards provide a roadmap for our colleagues regarding specific file-level direction. Team leads provide technical and jurisdictional direction, mentor examiners and maintain diaries on all claims. Quality colleagues perform compliance and performance reviews on claims to measure compliance with audit requirements, client and carrier service instructions, outcome results and Sedgwick's best practice standards.
6. Promptly create a claim file within twenty-four (24) hours of receipt of the claim form or accident report from the City and make contact with claimant.
Sedgwick agrees to comply with this requirement. Whether new claims are reported from our contact center or directly from the client, the process is the same once the information reaches Sedgwick. The data is loaded into the claims system, where it is validated and routed to the appropriate servicing office based on the location identified for the claim. Examiners receive new claim information within one business day after the claim has been reported.
Sedgwick requires examiners to complete or attempt three-point contact on every new indemnity claim within one business day.
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7. Establish monetary reserves reasonably adequate for the expected value of the claim in coordination with the City Risk Management Division.
Sedgwick agrees to comply with this requirement. Our examiners set reserves to reflect the most probable outcome of each claim based on the available facts at that time. We establish appropriate initial reserves on all new claims based on information available at the time of file creation. We subsequently review and recalculate as developments impact the total incurred. Our examiners must set initial reserves within five days, although the majority of claims have an initial reserve set within two days. We review initial reserves within 30 days after the investigation is complete and adjust as necessary.
8. Handle claim to conclusion and obtain all appropriate releases and W9 forms. Authority for settlements must be obtained from the City prior to settlement resolutions with claimant.
Sedgwick agrees to comply with these requirements. Our goal is to conduct a timely and thorough investigation to direct the file to a successful conclusion. It is critical for the City to be involved in the settlement process. We will work with the City on all issues of claim settlement analysis and recommendation.
9. Report losses to City's Excess Insurance Carrier as required in their reporting requirements.
Sedgwick agrees to comply with these requirements. Excess notification is part of our claims handling standards.
Client-specific parameters are entered into the claims system, which triggers the examiner to complete the required reporting. The CSD also receives an automatic email notification so that the file can be reviewed for proper reporting requirements.
10. The TPA shall promptly initiate investigation of issues identified as material to potential litigation. The City shall be alerted to the need for special outside investigation or appraisal services as soon as possible and before the investigation and/or surveillance is initiated. Authorization for surveillance shall be obtained from the Workers' Compensation Manager. The City shall be kept informed on the scope and results of all investigations. All activities shall be clearly documented in the claim file.
Sedgwick agrees to comply with this requirement.
Once a workers' compensation claim is reported, a team lead reviews the claim and determines if there are any red flags based upon the reported information. Sedgwick's predictive models run continuously throughout the life of the claim and flag claims for potential action by our claims team when they hit specific data elements. These flags can predict when a claim may become a large loss, might be complex and require additional intervention or could be at risk for litigation or attorney involvement. This assists the examiner and Sedgwick's special investigation unit (SIU) with identifying suspicious claims that may require further investigation.
In addition to our SIU services, Sedgwick has a long-standing partnership with RJN Investigations in California and would be pleased to work with them on claims investigations for the City.
We will only refer cases to an investigator with the consent of the City.
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Oua!ity assurance
We are committed to delivering excellence. Our quality assurance program captures quality metrics in real time at multiple checkpoints throughout the process. We measure video quality, report turnaround time and invoice accuracy. Our team conducts random file audits and provides feedback on individual investigation efforts. We also track the quality of red flag indicators to ensure suspicious findings are brought to the forefront. Quality scores and averages are reviewed quarterly to ensure accountability Jnd drive service improvements. Sedgwick's customers have full visibility of our performance metrics for their program and work with the team to determine providers that fit best.
ond teturn on investrner.1t
Sedgwick's SIU offers the most complete reporting Jlong with claim insight that sets us apart from others in our industry. We provide customized outcome reporting on 100% of the cases we investigate, including:
,, Client stewardship
"' Quality performance metrics
Claim impact survey results
ROI on closed claims
Aggregated red flag characteristics
ActionJble information helps customers examine their organizations' vulnerabilities Jnd risk mJnagement strategies and see the savings resulting from our claim investigations.
Sedgwick's SIU is integrated with viaOne, allowing customers to view investigation notes in real time within our viaOne suite of services.
B,
1. TPA shall refer all litigated claims to the City's approved defense Counsel firms unless otherwise directed by the City.
Sedgwick agrees and will refer cases to counsel with our client's approvJI when we arc unable to reach disposition by settlement or if a case is defensible under the appropriate state workers' compensJtion act. We welcome the City to use their preferred counsel, with consideration of any carrier requirements.
2. The TPA shall maintain an open case file and ensure loss runs accurately report claims that become litigated including legal fees, legal costs, settlements, and judgements.
NOTE: There are currently approximately 342 open litigated claims {Citywide).
Sedgwick agrees to comply with this requirenwnt.
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RFP B2022-28
One key aspect of expense management is legal bill review. Our examiners are responsible for the review of all legal bills in accordance with the criteria outlined in our litigation management guidelines. Any overcharges or discrepancies are resolved with the law firm, and any trends identified are elevated to management and client services to either meet with the firm to correct the billing trend or to recommend alternative counsel to our customer.
As an alternative, Sedgwick partners with Mitratech for third-party legal bill review services. The advantage of this service is primarily the data capture that comes from a detailed review of legal bills, which allows Sedgwick and the client to measure law firm and attorney activities compared with outcomes. This enables clients to make informed business decisions about the continued use of firms and to gravitate to those that provide the best service and results. Sedgwick also would work to partner with any other legal bill review solution you may select.
In addition to legal bill review, other key aspects of our litigation management guidelines contribute to legal expense management:
" Our examiners maintain control of the claim file and continue to perform the duties of a claim handler while ensuring defense counsel only performs those tasks requiring an attorney. " Within 30 days of referral, we require counsel to provide an initial case evaluation as well as a corresponding legal budget.
" At a minimum of every 60 days, examiners discuss the legal strategy with counsel to ensure it remains current .
., Budgets and legal strategies are updated as litigation develops and changes. & Our examiners continually review the claim to weigh the costs and benefits of ongoing litigation versus settlement of the case to achieve the best possible outcome Section 2.2 - general requirements and :-esponsibiiities To be considered for selection, proposing Third-Party Administrators must meet following requirements:
,t:... Personnel requirements
1) The claims adjusting firm shall provide the City with sufficient qualified personnel to efficiently and effectively meet the responsibilities as defined below and any other duties incidental, or in addition, to those responsibilities.
Assistant vice president of operations, Alicia Badillo, and claims team lead, Bernadette Bates, will provide operational leadership and oversight for the City's program. We have included bias for Bernadette and Alicia in the appendix for your reference.
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89 The Sedgwick account team includes the following key positions:
Claims director
(Operations manager)
Client services director
(Account manager)
Claims team lead
(Supervisor)
Claims examiner
Claims associate
Baccalaureate degree from an
accredited college or university
preferred. ARM, AIM, and/or
AIC designations preferred.
Licenses as required or
appropriate.
Baccalaureate degree from an
accredited college or university
preferred
ARM, AIM, and/or AIC
designations preferred
Licensed if required or
appropriate
Baccalaureate degree from an
accredited college or university
preferred
Licensed if required
by management
Professional designations as
applicable to line of business
preferred
Baccalaureate degree from an
accredited college or university
preferred
licensed if required
Professional designation as
applicable to line of business
preferred
High school diploma or GED
RFP B2022-28
Five years prior claims
experience with two years prior
management experience.
Five years prior claims
experience with two years prior
managerrientexperience
Six years or more of claims
management experience
required
Four years of claims
management experience
One year of claims industry
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Licenses asrequired
Claims assistant High school diploma or GED
RFP B2022-28
experience
Six months customer service
experience preferably in claims
operations
The following organizational chart shows a typical claims department structure and the positions that may be assigned to your account. Staffing models vary by Sedgwick office and by client-specific needs. The average ratio of examiners to team leads is 5:1, with one support person for every six to eight colleagues.
Sedgwick's best practice is to work with our clients during implementation to select team members that best fit your culture and your needs. We welcome the City's input in creating the service team during implementation and agree to provide resumes of all key staff during the initial assignment as well as during any proposed staff changes. While we believe this involvement from the City is critical, it is also important that Sedgwick reserves the right to make all final hiring and personnel decisions. 5-edi:,wick ( opyr ii;ht ,, ,' /022
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RFP B2022-28
2) The claims adjusting firm must have a minimum of five (S) years demonstrated experience as a TPA in California providing services as required by this RFP. Please include a description of all personnel along with their experience, certificates, designations, and licenses for this review. Respondents must also provide this information for each of its major subcontractors, if any.
Sedgwick differentiates itself in California through our unparalleled experience with California workers' compensation claims and our depth of local resources. Over 2,000 California colleagues in 22 offices throughout the state handled nearly 118,000 new workers' compensation claims in 2019 - that represents 18.2% of Sedgwick's new claim inventory. Scotty Benton, our vice president of workers' compensation practice, is located in California and has 30 years of experience in the jurisdiction. His engagement in legislative and regulatory affairs and overall compliance ensure that we are not only cognizant of and participating in the discussion but also preparing best practices as to how we approach any changes to ensure continued positive outcomes. He has in depth knowledge and specializes in the nuances of California workers' compensation laws. This knowledge translates to ongoing training for our California claims colleagues and innovative processes that facilitate compliance and mitigate litigation.
Sedgwick proposes our Rancho Cucamonga, California, servicing office for handling the City's claims. Assistant vice president of operations, Alicia Badillo, and claims team lead, Bernadette Bates, will provide operational leadership and oversight for the City's program.
Alicia Badillo, assistant vice president, operations:
Alicia is assistant vice president of operations and claims director located in Sedgwick's Riverside, California, office. She has more than 25 years of experience in the workers' compensation industry, working with insured and self-insured clients. Alicia is responsible for the technical and operational functions within our Riverside and Rancho Cucamonga offices, including compliance with company standards and industry best practices. She ensures consistent delivery of quality services to Sedgwick's clients and has direct responsibility for more than 90 colleagues.
Prior to joining Sedgwick, Alicia was the director of complex claims for a major insurance carrier. She was responsible for staffing and training technical examiners managing cases with high-dollar exposure with complex medical and legal issues. She was also accountable for the disposition of complex cases in the California region.
Alicia earned a master's degree in international business at San Diego State University. She also holds a workers' compensation claims professional designation.
Bernadette Bates, claims team lead:
Bernadette has worked in the claims and insurance industry for more than 25 years. Throughout her time in the industry, she has worked with both insured and self-insured employers, including CKE Restaurants, EDCO Disposal, Garnet Captive Program - to name a few. Bernadette has also worked with a number of school district clients.
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As an examiner, Bernadette focused on settling claims early for a nominal amount to avoid further litigation. She also assisted in training new employees to help them become familiar with the claims system and the industry.
Bernadette participates in conference calls clients, attorneys and adjusters to ensure action plans are addressed and that the claim is headed toward a timely resolution. She also participates in regular claim file reviews and attends regular training sessions to ensure the laws, rules and regulations for California claims are being adhered to.
Bernadette is dedicated to continuing professional growth. She was promoted to team lead in July 2021 and currently oversees a team of five examiners, consisting of individuals with up to 30 years of experience in the industry, as well as trainees.
We have also included bios for Bernadette and Alicia in the appendix for your reference.
We intend to hire and assign claims examiner(s) to the City's program that meet all education and licensing requirements as well as the City's approval.
a. Self-Insurance Certificate strongly desired
Team members handling claims for the City will have Jn active qualified self-insurance administrator certificate. 3) The City must approve any change of an adjuster working on the City's account. The City has the right to request a change of adjuster and be involved in the selection and/or replacement of the adjuster. The City will not interfere with any progressive discipline and/or personnel issues that may warrant a change of adjusters. When the adjuster is off on an extended leave, the City must be notified of who will cover the workload. In the event of a same day absence, the City must be notified of the absence by 9:00 AM the same day.
Sedgwick agrees to comply with these requirements; however, please note, our best practice is to work with our clients to select team members that best fit your culture and your needs. We welcome the City's input and agree to provide resumes of all key staff during the initial assignment as well as during any proposed staff changes.
While we believe this involvement from the City is critical, it is also important that Sedgwick reserves the right to make all final hiring and personnel decisions.
4) Please describe if the adjusting firm has experience with Alternate Dispute Resolution processes.
We work with our clients to understand their preference on alternative dispute resolution (ADR). If they are open to this approach and it makes sense for a particular case, we will recommend it.
From the beginning, the ADR process differs from the statutory process. In the statutory process, the employee is not helped through the workers' compensJtion system. In comparison, with ADR Jn assigned nurse Jdvocate helps with JII aspects of the employee's claim. This limits frustration and helps with the employee's morale. If any disputes arise during the process, the employee is referred to a panel of ombudsmen, chosen specifically to be neutral and capable of working with the employer, the employee and the union. If the dispute progresses past thrs point, it goes through a mediation process. If the dispute still remains unresolved, the employee goes through arbitration. Only ill thilt point is the statutory system involved. In the traditional workers' rnmpensation system, the problem goes immediately from the dispute during the injury into litigation. 43 93
RFP B2022-28
ADR does not alter any benefits; all statutory benefits remain the same. Rather, ADR allows employers and unions to work together to improve the system by using the help of the nurse advocates, ombudsmen, mediation and arbitration to cut down on the number of cases that go to litigation and to improve the process for the employees.
5) All outside vendors (if any) such as Return to Work Coordinator, Nurse Case Manager, Utilization Review, etc. shall be approved by the City.
Sedgwick will comply with this requirement in the event that the City chooses to use Sedgwick's fully integrated managed care and ancillary services. We perform core managed care services internally with Sedgwick colleagues. Our in-house managed care services include:
0 24/7 nurse triage/clinical consultation with guidelines-supported treatment direction for self-care, telemedicine or in-person care
~ Behavioral health solutions
~ Telephonic case management (TCM)
,. Surgery nurse program
Field and catastrophic case management
,. Utilization review (UR), including pharmacy UR
,. Medical director/physician advisor review
,. Complex pharmacy management
" Return to work (RTW) case management
Medical bill review (MBR) and medical state reporting
National provider benchmarking
Medical provider and specialty networks
We complement our core in-house managed care services with customized private label programs we co-created with national preferred partners. Through this approach, we are able to offer our clients streamlined access, top quality outcomes and significant discounts. For all of our private label partnerships, we maintain management oversight, quality control and ownership for state reporting and cost savings. 44 94
RFP B2022-28
Our private label services include:
$ Field case management {FCM) and catastrophic case management, and vocational rehabilitation - Sedgwick has an on-staff team of certified rehabilitation managers that support our in-house vocational services. If cases exceed our FCM (coverage area, cannot be managed virtually/telephonically or require specialty review, with the client's approval, services may be supplemented by Sedgwick's vendors available through nationwide partnerships. Partners include: The Windham Group, GEN EX and Paradigm Complex Care Solutions. R3 Continuum provides on-site behavioral health through our crisis care program.
" Sedgwick pharmacy benefit management (PBM) - supported by Optum or myMatrixx, an Express Scripts company
" Sedgwick physical medicine network - supported by Med Risk or One Call Care Physical Therapy 0 Sedgwick diagnostic network - supported by One Call Care Management and Homelink " Sedgwick physician advisor network - supported by MES Solutions, ExamWorks and Dane Street
8. General/state requirernents
1. Customer Service Phone Line
The City requires that the TPA provide exceptional customer service to all claimants. TPA shall establish a customer service phone number and email address to be able to address claimant inquiries. Replies will be within three (3) business day and all inquiries made by Risk Management staff on the same day, preferably, but no later than within one {1) business day.
The City will be assigned a dedicated, toll-free number and email address that are used to specifically identify the City to the contact center customer service representative (CSR). The client-defined greeting is contained within our IVR. Our intake software guides the CSR to capture all of the specific information needed, as defined during our client implementation process.
Sedgwick requires all communications to be returned within one business day and documented in the claim file upon occurrence.
2. Customer Complaints
The TPA shall document and respond to all complaints and inquiries received from claimants, defense counsel, and/or City Workers' Compensation/Risk Management staff and bring about resolution of such within three {3) business days. Please attach any policies or procedures you may have regarding customer escalation to your proposal. TPA shall provide City with monthly reports of all complaints received, resolution, and documentation of follow-up with claimants.
Sedgwick agrees to comply with this requirement.
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95 RFP B2022-28
Each complaint is handled individually by the assigned claims examiner, their team lead, the operations manager or the CSD. The claims team lead and CSD are jointly responsible and accountable for monitoring and managing the performance of the claims colleagues. The Sedgwick CSD is the coordinator of all efforts to resolve issues and will deploy other departments and management to escalate the effort appropriately while following an agreed upon action plan to resolution.
When a complaint arises, the appropriate party works directly with the source of the complaint to resolve the issue. Individual claims are escalated to management or the client level for resolution assistance as necessary.
Sedgwick has a complaint reporting process that will track and trend any escalated complaint to resolution. We will work with the City during implementation to set up a tracking and reporting process and will provide quarterly reporting to the City, including the corrective action plan and resolution status.
We will provide a dedicated phone number that the City's employees can call to leave a message with any concerns. An office assistant plays all Helpline voicemails and sends out an acknowledgement letter, then logs the complaint in the spreadsheet within Share Point. From there, the issue goes to the claims director for final review and closure. Once closed, a resolution letter is sent to the complainant informing the issue has been resolved. The spreadsheet in SharePoint can be generated as an excel or printed at the City's request.
We have provided a copy of our complaint resolution and complaint acknowledgement letters in the appendix.
Also included is a copy of our escalation policy.
3. Settlements
The TPA shall make claims recommendations and obtain the City's authorization on all settlements prior to taking action to settle. The TPA shall forward settlement proposals to the City in a form acceptable to the Workers' Compensation Manager. All requests for settlement authority shall be clear and concise and include a written claim analysis, estimate of liability and examiners recommendations. If the settlement exceeds the City's self-insured retention, the written settlement proposal shall also be directed to the excess carrier or designated representative to provide authority in addition to the City's authority.
Sedgwick agrees to comply with this requirement. It is critical for the City to be involved in the process. Our examiners have specific settlement and payment authority levels based on their experience. The City can customize these levels as appropriate. In the event the settlement exceeds their authority, examiners will supply their team lead and you with a timely and complete evaluation of the claim exposure, recommendations and settlement range. Our reserve philosophy requires that the examiner set a projection that encapsulates the probable outcome of the claim. This helps ensure the reserve is adequate and in line with the settlement proposal.
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96 RFP 82022-28
4. Subrogation
The TPA will pursue all subrogation submitted by the City involving responsible third parties and work closely with City staff to resolve subrogation issues. The TPA is not authorized to file litigation without first receiving consent from the City. TPA will consult with the City if there is deemed the need for subrogation counsel. The City must approve all settlements. The City will provide specific language to incorporate in any subrogation settlement. TPA is responsible for protecting any and all statutes of limitation and must notify City staff in writing no later than sixty (60) days prior to expiration of statute.
The City retains the right to handle any subrogation issue it deems appropriate. The City requires copies of all subrogation correspondence.
Sedgwick agrees to comply with these requirements.
We identify subrogation opportunities during the initial investigation, and throughout the life of the claim, as we obtain additional information. The pursuit of subrogation will be coordinated with the appropriate representatives of the City to determine the extent you want us to pursue this on your behalf and to assist in the determination of any waiver of subrogation or other contractual agreements that may exist. When a client wants us to pursue subrogation, we will refer the claim to Sedgwick's centralized subrogation unit that will put the liable parties on notice, actively manage and continue to monitor the claim until all subrogation recoveries have been secured.
5. Records Retention
All claim files shall be maintained indefinitely, in accordance with statutory time requirements and the City of Torrance's Record Retention Policy. The City shall be notified prior to any destruction of files to determine if the City wishes to retain the claim file.
Sedgwick agrees to comply with these requirements.
Claim records are the property of our client partners. The client has the right to review all files at any time, as well as the right to determine if the files should be retained or destroyed. In the event that the City chooses to utilize Sedgwick's proprietary claims system, all claim file data can be viewed by the City through our· via One web-based suite of services.
All claim data (i.e., payment and reserve transactions, file notes, etc.) is retained in the claims system for the life of the claim. We will continue to retain this information unless otherwise obligated by stated contract provisions for distribution of claims data upon termination of services. There are no additional charges for file storage while Sedgwick is under contract to the City. At the termination of the contract, however, the City may be charged the prevailing rate for storing paper files at a storage facility or for the transfer of imaged files.
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6. Computer Access
All data, records, products, and claim files shall be the property of the City.
Sedgwick agrees to comply with this requirement. Claim records are the property of our client partners. The client has the right to review all files at any time, as well as the right to determine if the files should be retained or destroyed.
The City of Torrance prefers that the TPA have access, and manage claims in the City's workers' compensation system. City will maintain its own bank account and process checks.
Sedgwick agrees to comply with this requirement but also offers the option to leverage Sedgwick's proprietary claims and RMIS solutions with fully supported check processing and bank account reconciliation.
In addition to Sedgwick colleagues working in the Sedgwick technology solutions, we have also offered a Saas solution for the City's examiners to use in the event that the City retires its current system.
Sedgwick has experts currently working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our experts and dedicated analyst, Sedgwick can provide the information requested within SIMS.
Additionally, our internal team of SIMS experts can support training for any new colleagues hired on to the City's program.
Sedgwick regularly provides and receives data to and from other RMIS vendors. All data transfers are secured through SFTP, PGP or secure VPN tunnel. An alert protocol is in place to ensure the success of the interfaces for both inbound and outbound transmissions. Additionally, our standard interface procedures use header and trailer records to ensure completion of all data processing for interface exports and loads.
Sedgwick's proprietary, multiline technology platforms are supported by a team of 1,700 IT professionals, which includes colleagues dedicated to application development, infrastructure, network and hardware management, local technology coordination and tech/support help desk operations. Our experienced senior programmers/analysts are dedicated to ensuring that successful transmissions occur on behalf of our clients.
We have included a case study in the appendix demonstrating our success with a current California public entity client's workers' compensation program along with our ability to interface with other RMIS vendors.
Sedgwick will support a client-established relationship with various banks. This option allows you to maintain your existing banking relationship. This arrangement is fully managed by the client; however, Sedgwick provides full assistance on implementation and working with your designated bank. Sedgwick will pay claims directly from the account on behalf of the client. No escrow is required for this option.
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Please note if TPA requires use of their own system, TPA shall provide online access to the TPA's claims management system, at no additional charge, to the City of Torrance and/or designated representatives. Such data shall be in a format accessible from the TPA's servers and will permit the City to print copies of the data on its printers. The City shall have the ability to input notes in the notes area of each claim. The TPA shall provide training for use of the computer system at no additional charge.
Sedgwick will not require the use of our system but is offering it as a viable option both for the Sedgwick team as well as the City's internal claims team. We would recommend that the program begin by leveraging the City's current system with a plan to explore the functionality of Sedgwick's system and develop a transition plan for all departments in partnership with the City that will minimize any disruption to the injured employees, create a seamless experience for the City and offer an alternative to the current system on a city-wide basis.
In the event that the City chooses to leverage Sedgwick's system for only the claims managed by Sedgwick, we will be able to comply with the access, printing and training requirements noted above at no additional charge.
Our proprietary claims management system provides our clients with direct access to their claim data through our web-based suite of services, viaOne, which gives a comprehensive, platform-independent, secure view of real time claims information. System access includes:
Secure, real-time information from Sedgwick's proprietary claims information systems, including notes, correspondence and other data
Customizable dashboards with drill-down capabilities, allowing users to customize how they view metrics and data
* Detailed information about the incidents, claimant work status and time tracking information "' Financial information about an event, including claim payment history and available reserves The creation of client diaries and customized alerts sent via text or email " Easy access to a number of customizable reports with user-specified fields and filters Access to Sedgwick's advanced analytics platform that offers reporting on data at multiple levels from summary trending to fine data elements and enables users to set up recurring reports and push completed reports to other recipients via email
In addition to viaOne, our mySedgwick self-service portal provides claim status, payment history, absence history and more. Users can also report a new claim, upload documents, assign delegates, turn on/off push notifications, report a RTW date, communicate securely with an examiner or nurse, view and complete medical authorization and medical history release forms and use direct deposit from mySedgwick. Users can view claims via PC, tablet or smartphone.
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We employ a dedicated training team to assist in all client user training at no additional charge. There are several options available for training, depending on the type of application. For viaOne, we typically use webinar-based training. We will work with the City to better define a live training plan, which may be provided on-site, at a centralized location or at a Sedgwick service office. viaOne users have system support available 24 hours a day, seven days a week. We also provide documentation and offer post-training support through our viaOne support team. Additionally, Sedgwick support colleagues are available after hours by mobile phone.
Sedgwick has recent experience transitioning self-administered clients to our claims management system. In addition, we have several current clients leveraging our JURIS® system for self-administration.
7. Employer Services
The City requires coordination between the TPA and Risk Management and Workers' Compensation Divisions of the Finance Department.
Sedgwick agrees to comply with this requirement.
Each client relationship is managed by a Sedgwick CSD. This model ensures that each client receives the full benefit of our services, and that services are tailored and delivered with respect for the individual client's needs and culture. Sedgwick's CSDs oversee all critical aspects of the program, including performance and quality assessment; staff recruitment, retention and training; cultural alignment; issue resolution; strategic direction and program evolution; and outcomes reporting.
Your CSD will serve as the City's single point of contact and liaison with broader Sedgwick resources. They will disseminate the City's objectives to all functional and strategic areas of Sedgwick, including claims administration, customer service, systems, communication and program analysis, as needed. This approach has yielded optimal results and ensures that our clients' needs and program objectives are communicated properly.
The TPA will provide in-person quarterly claims review presentations. Presentation material will be reviewed by the Workers' Compensation Manager at least fourteen (14) days prior to the scheduled presentation.
We will provide in-person quarterly claim reviews to ensure that Sedgwick and the City are meeting their agreed objectives.
Periodic claim reviews facilitate regular communication and ensure that we are working with the City to resolve cases promptly, with the best outcomes. Each claim is reviewed in a number of categories including, but not limited to, reserving, reporting and the development of a claim action plan. Reviewing the action plan allows us to discuss how we plan to move the claim toward resolution.
Quarterly meetings are scheduled to review program results and obtain client feedback on our performance. As part of our standard procedures, we track this information as well as our actions resulting from the client response. We also document specific feedback on a routine basis and take appropriate actions to resolve outstanding issues. We use this information to develop best practices and process improvement opportunities. 33 50
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In the event of termination of the contract, the TPA will furnish all claim files, computer files, and financial information at no cost to and at a location identified by the City. At the termination of the contract the Contractor will transfer all data immediately and permanently destroy all copies of the data in its possession.
Sedgwick agrees to comply with this requirement.
Claim records are the property of our client. The City is responsible for storage of claim files closed at the time that Sedgwick begins claims administration. All claims data (payment and reserve transactions, file notes, etc.) is retained in the claims system for the life of the claim. We will continue to retain this information unless otherwise obligated by stated contract provisions for distribution of claims data upon termination of services. There are no additional charges for file storage while we are under contract to the City. At contract termination, the City may be charged the prevailing rate for storing paper files at a storage facility or for the transfer of imaged files.
The final transfer of the claims data includes a preliminary data extract and a final data extract delivered in Sedgwick's standard format. Both extracts will be all-time extracts valued as of the nearest month-end to the requested delivery date of the extract (e.g., if data is requested for April 1, the data extract would be valued as of March 31). Sedgwick will push this data via Pretty Good Privacy (PGP)-encrypted file transfer protocol (FTP) to the receiving entity, which requires the receiving entity share their PGP public key information as well as the FTP directory the files should be delivered.
For a client that is leaving Sedgwick where we store images on SIR through Xerox/ACS, Sedgwick will also provide an interim data extract and a final data extract (including read and unread). Documents can be transferred by Xerox/ACS using DVD, external hard drive, or electronic transfer. All images from Xerox/ACS will be encrypted regardless of the transfer protocol. Once the transfer is complete and confirmation has been made that the images and index file can be accessed, Xerox/ACS will delete all images for the client off of their systems, both production and DR.
For a client that is leaving Sedgwick and that has been using our bill review services, we will also provide up to two years of historical data (as applicable) in our standard format. This will be provided via an agreed upon FTP site at no additional cost.
8. Right to Audit or Review
Every claim file is subject to audit by the City representatives. Notice of audit by the City's representative will be provided at least ten (10) calendar days prior to an audit. The City retains the right to audit any file with 24-hours' notice.
We welcome independent audits as directed by the City; however, all costs associated with a third-party audit for the independent review team are the responsibility of the City. Sedgwick will provide on-site or electronic access to requested file information for audit purposes.
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9. Conflict of Interest
The TPA shall avoid all conflicts of interest and/or appearance of conflicts of interest in performance of the agreement. If, during any given year, the TPA receives compensation, in any form, from any party for services included in the agreement, such as bill review services, managed care or investigations, the TPA shall disclose total compensation received in the prior year. Such disclosures shall be in the form of a letter mailed to the Workers' Compensation Manager and shall be received by the City no later than April 1 of each year.
Sedgwick agrees to comply with this requirement.
10. Performance Evaluation
As part of the contract, upon request by Risk Management, the TPA will agree to be evaluated annually by the City using criteria outlined in an agreed upon Performance Evaluation.
Sedgwick agrees to comply with this requirement.
Sedgwick's quality program befits the leading TPA. Performance 360 - named to convey its mission to measure and improve quality from multiple vantage points - is truly a differentiator in the industry. fnterrial oudit,;
Within our Performance 360 program, compliance audits focus on regulatory and carrier requirements as well as best practices. One group of auditors on the quality team complete the compliance audits, while a separate team of colleagues completes activities which focus on claim outcomes.
The compliance team evaluates essential criteria including investigation, accurate data and reserves, clear documentation, timely state filings, effective action plans, litigation management, medical management and team lead engagement. As a part of this compliance process, we complete jurisdiction-specific assessments for state regulations as needed.
In contrast to our compliance audit teams, our perform,rnce review team focuses on strategies to promote the best possible outcomes. Key claim segments are the forns, including investigation, injured employee/claimant experience, reserving, supervision, medical/disability management, RlW, recovery, litigation management and resolution.
Results are disseminated to each examiner and tearn lead for their review and comment. An appropriate training and development plan is then determined based upon the r-esuits of the audits/reviews. Training can be provided on an individual basis or within a team training environment dependent upon the developmental needs. This unique approach has yielded excellent results for our colleagues and focuses our attention on having training where it is necessary.
Quality is not only measured at the claim level, but by mea\w ir1g the business at the office level As part of Performance 360, business operational assessnwnts are completed to fill the gaps that are not always addressed by claim level or internal audit activities.
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Operational assessment drives excellence through the active review, evaluation, measurement and training of several specific areas within the individual offices. Our operational assessment team, in conjunction with the appropriate departments, assists in the support of each office to ensure they are engaged in the quality process and have the direction and ability to improve overall performance.
Meeting our goals
Our goal is to consistently meet or exceed the expectations of our clients. Performance 360 will provide consistent alignment of our clients' objectives at the desk and program level, which drives improved outcomes and overall client satisfaction. Embedded in the program is a continual performance review process to make ongoing enhancements and to ensure we are delivering the best possible services to our clients.
Continuous irnprovement and customer .sutisfoctiun
We will work closely with the City to identify areas of improvement using metrics and analytics to identify areas of opportunity. City data is reviewed monthly by the CSD to identify any trends or jurisdictional needs. Using this information, they communicate with the claims operations team for immediate action.
Sedgwick also produces comprehensive monthly scorecards that track claim and financial trends. Scorecards are invaluable for managing the program internally and providing the City with actionable information. We also provide litigation and other specialty scorecards to drive claims to the best service providers that generate the best outcomes for our clients.
We measure and report our performance against comprehensive quality metrics to ensure we are delivering excellent customer service and expeditiously resolving any employee concerns. We also conduct injured employee surveys throughout the course of the claim.
11. Confidentiality
All data, or other information developed or received, verbally or in writing, in performance of the agreement between the TPA and the City are confidential and not to be disclosed to any person except as authorized by the City, the TPA, or as required by law. It is the TPA's responsibility to develop and implement processes and procedures relating to the protection of the City's electronic data, including a suitable security and back-up system for all stored data and a written policy with respect to disaster recovery, physical and electronic data security, and electronic data retention.
Sedgwick agrees to comply with this requirement.
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Security
Sedgwick maintains security procedures to restrict access to confidential information, limit authority by function and protect against fraud and theft. We have safeguards and precautions in place for the confidentiality of covered information about ill/injured employees. Additionally, colleagues undergo mandatory annual security and privacy awareness training. We created and maintain an electronic information security policy that directs all colleagues in matters of security and data protection. The policy requires strong, complex passwords and that all passwords be changed routinely. In the case of the operational systems, logons/passwords control the user's access to the system, which includes levels of access to specific client databases. Individual colleagues further restrict access by placing system-generated authorities on reserves and payments. Further, all employees and individual contractors undergo a pre-hire background review by an independent third party.
Additionally, Sedgwick has defined a sensitive personally identifiable information {SPII) policy and potential breach reporting procedure that identifies data elements and groupings Sedgwick considers being SPII. Sedgwick's best practice for clients is to ensure encryption of SPII data during any transmissions outside of Sedgwick (including interfaces and correspondence) by use of PGP encryption and/or secure FTP services. Sedgwick encourages its clients to implement transport layer security (TLS) email encryption for all involved domains, which Sedgwick supports on its mail servers.
All Sedgwick laptops are fully data encrypted prior to deployment. The encryption cannot be overridden by users.
All Sedgwick colleague workstations and servers are equipped with virus protection. Updates are centralized and workstations are automatically subscribed to updates and monitored for compliance.
The security of Sedgwick's wide area network {WAN) is ensured through firewalls and additional levels of password security as defined in the security policy. Access to operational systems via the web is securely protected and fully encrypted by the industry standard SSL encryption from a certified provider.
Virtual private network {VPN) access allows connections to only Sedgwick's dedicated network when VPN services are in use, preventing rogue network intrusions. Access to other wireless or hardware connections is shut down when VPN is activated. Sedgwick's network undergoes a network penetration test from a third-party reviewer at least once annually.
Security incidents, including potential security breaches as defined by our potential security breach policy, are reviewed by both directorship and senior management-level Sedgwick colleagues. Colleagues of this level, along with other senior contributors, are also involved in our annual risk assessment conference held to assess the company's risk status across all disciplines of the company. All policies are approved by directors and/or senior management prior to deployment. The chief information officer reports to the chief operating officer. 37 54
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Business continuity/disaster recovery
The Sedgwick business continuity plan (BCP) includes procedures to be performed by both corporate and field office colleagues to provide immediate response and subsequent recovery from any unplanned business interruption to a field office. An unplanned business interruption can result from a loss of a critical service (e.g., computer processing, telecommunications), a loss of building access (e.g., contamination, etc.), or physical facility catastrophe (e.g., fire, sabotage, etc.). A centralized corporate group oversees response and recovery activities and provides support for the recovery of affected field offices.
The BCP provides the requirements, strategies and proposed actions necessary to rapidly yet effectively recover business operations following such an event. Specific details on incident response and subsequent business recovery actions and activities are included.
The BCP was developed to meet the following objectives:
"' Provide an organized and consolidated approach to managing response and recovery activities following any unplanned incident or business interruption, avoiding confusion and reducing exposure to error
" Provide prompt and appropriate response to any unplanned incident, thereby reducing the impacts resulting from short-term business interruptions
" Recover essential business operations in a timely manner, increasing the ability of the organization to recover from a damaging loss to the facility
Sedgwick's BCP coordinates field office (operational) and information technology (IT) protocols and is expressed through two complementary plans:
" An operational disaster recovery plan (OP-DRP) to document specific actions and procedures to be executed in response to a disruption to the day-to-day operations of a Sedgwick field office and/or the corporate headquarters.
" A coordinated but separate information technology disaster recovery plan (IT-DRP) to document specific actions and procedures that are to be executed in response to a disruption to primary application or business technology support systems related to key claims system or corporate administrative or communications systems.
The IT-DRP plan categorizes all data center applications and services into three categories:
Core systems - Systems necessary for emergency real time communication and infrastructure necessary for restoration of base systems and secondary systems * Base systems - Critical and client-sensitive transaction processing services Secondary systems - Internal corporate and "back office" services whose use can be deferred briefly to allow a focus on client and critical systems
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In the event of a disaster declaration, base and core systems are the first to be restored and are done so within 48 hours of the disaster declaration. This is the recovery time objective (RTO). Base and core systems will be restored to the data state that existed no greater than 24 hours prior to the event occurrence, which constitutes our recovery point objective (RPO).
System restoration is tested in large-scale exercises at least annually at Sedgwick's secure offsite disaster recovery (DR) facilities. This testing is performed in an environment that accurately simulates the DR environment and circumstances of most statistically significant business interruption scenarios.
Mission-critical base and core systems are backed up via multiple data replication technologies both on-site and off-site to assure high statistical probability of successful and accurate restoration.
Sedgwick deploys multiple and redundant backup strategies depending on the environment, such as cloud, on prem or hybrid environments. New requirements in our data centers require air gap and encrypted technology across diverse networks with role-based access controls. Firewalls are used to isolate backup networks and anti virus protection is utilized. Replication strategies (e.g., storage replication, log transfers, DB replication) are also employed as a redundant measure on critical data sets.
Additionally, backup offices are available for each of our field offices. In the event of a business interruption to a field office requiring implementation of our BCP, telephone calls and critical claims activity can be rerouted to a backup office or an alternative site. Sedgwick can also use secure web-based applications, VPN connections and Citrix servers to provide our colleagues access to business-critical applications from alternate sites with internet connectivity following a business interruption. This allows for a great degree of flexibility in recovering from business interruptions to our field offices.
Loss data
Upon request of a prospective TPA, an electronic version on claim loss data will be provided in Excel format.
This loss data can be used to estimate future claim frequency and types of claims. Any claim data submitted as part of the RFP process is for informational purposes only. The City shall not be responsible for the complete accuracy of said data.
Sedgwick understands and acknowledges the above.
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Termination for non-performance
If the TPA refuses or fails to perform services as required to provide the City with efficient claims administration including furnishing properly trained personnel, or if the firms should be adjudged as bankrupt, or if a receiver should be appointed on account of insolvency or should repeatedly or persistently refuse or fail to provide service as required, or TPA persistently disregards laws, ordinances, or instructions of the City, or is otherwise guilty of a substantial violation of the agreement, then the City may, without prejudice to any other right or remedy, serve written notification of intention to terminate the agreement.
Such notice shall contain the reasons for such intentions to terminate, and unless within fifteen (15) days after service of such notice the condition or violation shall cease and satisfactory arrangements for the correction thereof be made, the agreement shall upon the expiration of the fifteen (15) days cease and terminate. The foregoing provisions are in addition to and not in limitation of any other rights or remedies available to the City.
Sedgwick understands and acknowledges the above.
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I 1 ,.,,,_ ··--· ...... .
i : RFP No. 82022-28 i:
SECTION Ill PROPOSAL SUBMITTAL
=====--=·--.= ....... :::: ..... -=· ... :=. ::::::::::::::::::== FAILURE TO COMPLETE ALL ITEMS IN THIS SECTION MAY INVALIDATE PROPOSAL.
In accordance with your "Request for Proposals (RFP}", the following proposal is submitted to the City of Torrance.
RFP Submitted By:
8125 Sedgwick Way
Street Address
858.876.7445
Telephone Number
Scott Rogers, Chief Client Officer
Printed Name!Title
Signature
Memphis, Tennessee
City
Fax Number
[email protected]
E-Mail Address
June 6, 2022
Date
Form of Business Organization: Please indicate the following (check one); 38120
Zip Code
00 Corporation □ Partnership □ Sole Proprietorship □ Other: ___________ _ Do you have a Parent Company?: □ No 00 Yes, ________ s_ed_g_w_i_ck_L_.P_. ______ _ (Name of Parent Company)
Do you have any Subsidiaries?: □ No 00 Yes, Please refer to the proposal for a list of our 193 subsidiaries and affiliates. (Name of Subsidiary Company)
Business History:
Years in business under your current name and form of business organization? 26 Years If less than three (3) years and your company was in business under a different name, what was that name? Sedgwick is a privately owned corporation.
Primary Contact for Proposal Submittal:
Please provide the name of the individual at your company to contact for any additional information:
Director of Business Deveiopm2nt
Printed Name Title
858.876.7445 Ph1lip.Corde1ro@sedgw,ck.co,n
Telephone E-Mail Address
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Proposal Submittal (continued):
Vendor Name: ______ s_e_d_g_w_ic_k_C_la_i_m_s_M_a_n_a_g_e_m_e_n_t_S_er_v_ic_e_s,_l_nc_. _______ _ Addenda Received: Please indicate addenda information you have received regarding this RFP:
Addendum No. Date Received Addendum No. Date Received
1 May 31, 2022
2 June 1, 2022
D No Addenda received regarding this RFP.
Payment Terms: The City of Torrance Payment terms are Net 30. The City does not make pre-payments, or pay upon receipt.
Do you offer any discounted invoice terms? Sedgwick is willing to consider and negotiate discounts on invoice terms with the City.
Project Start and Completion: Per the City's terms below, Sedgwick agrees to establish mutually agreed upon start and completion dates following award of contract.
The City requires the project to start as soon as possible from the award of a contract and the project completed as soon as possible. Specific time frames that are mutually agreed upon will be established after award of a contract.
Renewal Option:
Please state, if requested by the City, if your company would agree to a renewal of this contract with price, terms and conditions unchanged.
Yes _X_ we would agree to add two (2) additional years after initial three (3) year term.
No __ we would not be interested in renewing this contract. 13 59
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Proposal Submittal (continued):
Vendor Name: __ S_e_dg_w_ic_k_C_la_im_s _M_a_n_a_g_em_e_nt_S_e_r_vi_c_es_,_ln_c_. ___________ _ Background and Recent Experience with Similar Projects: (Please attach additional sheets if more space is needed.)
In the space below, please provide a narrative explaining your background and recent experience with similar projects as the scope of work identified in this RFP. (Please attach additional sheets if more space is needed.) We have provided several case studies on the following pages that detail our background and experience with similar clients.
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C!TY OF I.OS ANGEi.ES
County of Los Angeles
Sedgv✓ ick began partnership with the County of Los Angeles (County), handling V,/Orkers' compensation for t\,vo of the County's four units on January 1, 2014. On July 1, 2019, Sedgwick assumed an additional 16,00o+ open claims and is nmv responsible for administering claims for all four County units, encompassing the entire workers' compensation program for all County departments from four Sedgwick offices located 1.vithin the County.
Throughout the implementation process and to date, we have accomplished the follmving:
Fife
❖ Sorted and filed hundreds of boxes of loose mail received from prior TPAs ❖ All 16,000+ assumed claims were alphabetized and re-organized before July 1, 2019 Service team established
❖ Hosted multiple open houses and successfully recruited over 200 colleagues, bringing the total colleague count for the County's program to 371 colleagues ❖ All 200+ new Sedgwick colleagues were hired and readv to start work on the Countv program when new units went live on July 1, 2019
" Hosted a one-week orientation of aH new hires at the Ontario Convention Center with subject matter experts and key County personnel
.., 99% of Sedgwick examiners earned the SIP certificate by the first year of the program " Maintained staff at 94% as of October 2020
❖ Claims reviews and disability status meetings for every County department on a monthly or quarterly basis for 32 departments
"' Established monthly management meetings with County CEO-Risk Management Branch "' To promote quicker closures, Sedgwick obtained D\VC audit approval in writing to forego stipulated a1.vards on 0% PD with future medical c1aims. The County approved Sedgv..-ick's proposal for issuing a PD denial and closing the file immediately " Establishment of an independent medical exam (lt,iiE) appointment desk to set a!! initial appointments and track sequential dates leading to reso!ution of disputes for monitoring the effectiveness of the fire carve-out program for Unit C, fife departrnent Establishment of a three-point contact desk to ensure timeiy initial contacts and prepare the files with an ISO claims index, EAMS check and prior County claims check for Units C and D
Establishrnent of fraud interdiction program that combines the capture of surveiilance results on a master spreadsheet with prompt 5,U roundtable str·ategy sessions, plus fraud 61 111
CITY OF LOS ANGELES
questionnaires for claimants
• Establishment of IMR desk to timely process and log all !MR requests for Units C and D • Developed paperless mail process with revised workflows to accommodate paperless file management
" Creation of a COVID-19 secure portal for client reporting of positive cases to determine outbreaks
management
" Estabnshment of centralized tracking tools to manage time sensitive items in the paper environment, including the following office wide documents: master hearing log, LC4850 and salary continuation tracking log, claims assistant task assignment log, LC4850 and salary continuation tracking log and roundtable discussion tracking log -0 Testing of new iVOS claim system and development of nev; value-added system tools " Initiated a helpline dedicated number for tracking comp!aints, featuring the tracking of incident and resolution details to assess customer service " On-demand injured employee surveys to assess customer service " Quality assurance team to supervise an accurate calculation of av,1ards and commutations, claims coding, timely initial owe benefit notices and compensabi1ity determinations
,, Monthly self-audits in line with Sedgv,ick and the County's best practices ,. Bi-weekly in-house staff training on the elements of workers' compensation claims best practices
" Established monthly training topics on the County·'s best practices and expectations " In-house industry advancement program (IAP) to generate a pipeline of well-trained, SIP certified college graduates to fill speciaf proJect needs and immediate back-fill for claims desk vacancies
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CITY OF LOS ANGELES
" Sedgwick's claim administration for the fire department is experiencing year-over-year reductions in personnel receiving LC4850 benefits. During the first 18 months, the number of firefighters on LC4850 dropped 13%. Sedgwick's aggressive early investigation, combined with strong
coordination of return-to-work strategies, has produced excellent cost savings
" During the first year on the program Sedgwick recovered $1,762,000 in subrogation reimbursement (excluding
subrogation credit). Our continued focus on subrogation training has heightened the claims examiner's awareness of subrogation potential and improved recovery strategies.
Success identified for all units V✓ ith reimbursements
includes:
" Unit A: $738,000
" Unit B: $24,000
" Unit C: $531,000
" Unit D: $469,000
During the first 18
months, the number
of firefighters on
LC4850 dropped
13~/o
• In the first 12 months of the newly assumed programs, Sedgwick achieved a net claim reduction of 1,836 claims for Unit B Mental Health and Unit C Fire, between July 1, 2019 and June 30, 2020
"' Sedgv;lck implemented a County-specific COVID-19 business continuity plan to ensure Sedgwick's response to the COVID-19 pandemic was s·.vift and effective; in addition, we transitioned 164 claims examiners to work from home within seven days 63 113
CITY OF LOS ANG6LES
Californi~ Joint Powers lnsunm~e Authority (CJPIA)
In 1978, 33 cities formed the California Joint Powers Insurance Authority (UPIA) to till an immediate need and to develop a long-term strategy for mitigating the growing risks of their public agencies. Today, more than 120 public agencies have parinered with the CJPIA to address their risks and implement best practices. Member agencies vary from small, sing!e purpose entitles to cities to special districts.
At the inception of the partnership bet\veen CJPIA and Sedgwick in 2001, we assumed administration of 550 open claims spanning the membership of 67 agencies. As of July 2020, Sedgi,vick provides administration for over 1,800 \Vorkers' compensation claims from 108 member agencies pat1iclpating in the CJPIA's \'iorkers' compensation prograrn. The long-term partnership between CJPIA and Sedgv,1ick has supported desired pool grmvth efforts, increasing membership by nearly 40%.
Throughout the implementation process and to date, •.ve have accornpiished the following:
" On July 1, 2001, Sedgwick started handling new· and takeover claims for CJPIA " An average of 1,500 nev.r losses have been reported annually since July 2019 " Hired and trained dedicated program staff
0 In 2008, we implemented a nev.,· incurred loss position designed to investigate and intake all incoming new losses
$ Collaborated with the client and implemented a program designed to determine the root causation of injury and !itigatlon. This v;-as supported by an enhanced interview process at claim intake to determine the root cause of injury occurrence. Utigat1on causal factors are determined by the examiner at the time of litigation based on experience and case facts
~ Partnered with UPIA on the development of a member retention level (excess) program for poo[ members. This opened new program growth opportunities for CJPIA, resulting in the addition of eight new agencies to the pool since 2017 " Implemented an afternative dispute resolution (ADR) program specific to the fire department of a CJPIA member agency effective January 1, 2020 ,, Average closing ratio of 109% over the tast five fiscal ,,,ears Our proactive claims handling approach has produced a year-over-year drop of 2.5% in average examiner caseloads annually since FY 2016-2017
" The average lifespan cf ciairns reported and closed in the same fiscal year is 50 days The successful impiementaton of a first aid program has resulted in an average reduction 64 114
of 280 claims reported to the Office of Self Insurance Plans annually
" Enhanced services focused on return-to-work efforts realized average annual savings of $3.3 million in temporary disability and Labor Code section 4850 benefits and represents over 22,000 workdays saved by providing transitional duties
., Over the past five years, we resolved 1,698 claims (C&R, stipulated awards, dismissals and findings and award)
" The number of settlements vla compromise and release have increased year-over-year since FY 2014-2015 by a yearly average of 17.5%
., We have obtained over $7.6 miWon ln recoveries over the last five years
" Through management of the pharmacy benefits, opioid
classified medications have decreased in both utilization and overall spend in calendar year 2019 by 27.2% and 0.6%,
respectively
" We have achieved annual claims audit scores ln the 90th percentile since 2009 as determined by an independent
auditor on 56 ratable categories
amn if §Ill I§
$3.3 million
in annual savings in
temporary disability
and Labor Code
section 4850
benefits through
enhanced services
focused on retum
to-work efforts
22,000
vvorkdays saved
by providing
transitional duties
65 115
CITY OF LOS ANGELES
California State University (CSU}
On July 1, 2003, Sedgwick began administering new and takeover claims for CSU. During the implementation process,. \Ve:
,. Received 2,100 open claims from the prior administrator • Opened and staffed three regional offices in Oakland, Rancho Cordova and Long Beach !?esults tu date
• 47% decrease in open claims
,. 33% decrease in annual cash flmv
64% decrease in pharmacy spend, resulting from a
combination of the 2013 implementation of our pharmacy
benefits net\vork (PBN), monthly clinical roundtables to develop strategies for serious cases where over-utilization is an issue, and the use of drug utilization review
• The implementation of a high exposure desk combined with formal settlement strategy roundtables has resulted in $9.9 miHion in net reserve salvage on high exposure claims, as well as the closure of 22% of aged pending greater than five years old
• 18% reduction in defense attorney spend
47%
decrease in
open claims
• The number of open claims as of June 30, 2020 .. is 1,109, the lowest inventory since program inception
66 116
University of California (UC)
In April 1980, Sedg\vick v.ias selected as the administrator for the University and began hand!lng v,;orkers' comepnsation claims. Today, Sedgv,;ick provides workers' compensation, general ilability (began in 1995) and professional liability (began in 1983) claims management for the UC.
After deploying a creative, multi-faceted settlement strategy in partne,ship with the UC. v;e were able to achieve the follcwing:
38% reduction in open ,ndemnity inventory since 2005
Reduced ultimate loss expense by more than $48M
The UC deve!oped an employee \Nellness program tied to
their workers' compensation prngram in an effort to r·educe claims as vvell as ultimate loss costs. Sedgwick has
administered this program since inception {nine years) •,vith the follmving results:
, There have been over 2,000 graduates o· ,he program
The VVorkStrnng progran1 has resulted in a 25'% reduction in ultimate loss expense, a potential savings of $7fv1 since the onset of the program
reduction in open
indemnity inventorv
since 2005
67 117
Proposal Submittal (continued):
Vendor Name: __ s_e_d_g_w_ic_k_C_la_i_m_s_M_ar_1a_g_e_m_e_n_t_S_er_v_ic_e_s,_l_n_c. ___________ _ References:
Please supply the names of companies/agencies for which you recently supplied comparable goods/services as requested in this RFP. A minimum of three (3) references is required; additional references are optional.
References from public agencies are preferred. Don't include the City of Torrance as a reference for this RFP.
Name of Company/Agency: California Joint Powers Insurance Authority Street Address: 8081 Moody Street
City:
La Palma, California 90623 State, Zip Code:
What ProducUService did you provide to
1 this Company/Agency?
Workers' compensation
Name of Person to Contact: Jeff Rush, Workers' Compensation Program Manager Phone Number of Contact: 562.467.8707
Email Address of Contact: [email protected]
t< . ·t-fii'. i/;' ; ... •:y,:< ·,o;:(- : . /:: .. _ ' tf:ii ..... .:
Name of Company/Agency: City of Santa Cruz
Street Address: 809 Center Street, #7
City, State Zip Code: Santa Cruz, California 95060
2 What ProducUService did you provide to
this Company/Agency? Workers' compensation
Name of Person to Contact: Dilia Schulz, Principle H.R. Analyst Phone Number of Contact: 831.420.5043
Email Address of Contact: [email protected]
... .. '·< .;;'
Name of Company/Agency: City of Ridgecrest
Street Address: 100 West California Avenue
City, State Zip Code: Ridgecrest, California 93555
What ProducUService did you provide to
3 this Company/Agency?
Workers' compensation
Name of Person to Contact: Ms. Ricca Charlon, City Clerk Phone Number of Contact: 760.499.5002
Email Address of Contact: rcha [email protected]
15 68
118
RFP B2022-28
Proposal submittal (continued):
Cost and pricing proposal:
In the space below or in the main proposal document, please provide both an annualized cost proposal and per claim proposal that includes a summary of all fees detailing services related to such fees. Include any pricing changes over the course of the service agreement and if you offer a multi-year flat rate guarantee. If there are any optional services not required in the current scope but the vendor is recommending, list those and label as optional.
(Please attach additional sheets if more space is needed.) Per c!aim optwn
Required services
Per claim fees
New indemnity/
lost time
New medical only
New incident only
Indemnity/
lost time takeover
Medical only takeover
Future medical only
Program management
fee
Program implementation
fee (one-time)
Sedgwick Copyright X.. 2012
Ci:,Year . Year -z';:c '
· (pblice only) (police and fir.,t. _, ---~:o:r:·~
''.<.'.'/(,YJ:
$1,575 $1,622
$165 $170
$40 $41
$290 $299
$85 $88
$270 $278
$30,000 $30,900
$11,000 NA
$1,671 $1,721
$175 $180
$42 $43
$308 $317
$91 $94
$286 $295
$31,827 $32,782
NA NA
Soption
<allr.tepartments> ,f··· ,, , ,,f,fV'; '"'""
$1,773
$185
$44
$327
$97
$304
$33,765
NA
52 69
119
RFP B2022-28
Optional services 1
Optional services 2
*Per claim rates were
multiplied by the
number of claim counts
(by category) provided in
the RFP when calculating
the total annual price
Total estimated annual
price
Flot fee
Saas
Please see
the
narrative for
specific
details
concerning
this optional
service
$462,110 $464,654 $478,655 $493,011 $507,937
*Please note that with the flat-fee option, only one year can be provided. This is due to the fact that pending claim figures are subject to change for fire and other public safety claims, and this may have a material impact for the following years' pricing. For subsequent years, the flat-fee will have to be recalculated based on the current pending claims, with the addition of fire and other public safety claims.
Required services
Flat fee
.xear1
(police only)
$451,000
•· ,,,vear,option Years option
; 1Jii11 de~rtments) (all departments)
53 70
120
Program management
fee
Program
implementation fee
(one-time)
Optional services 1
Optional services 2
Total annual price
NA
$11,000
Saas
Please see
the
narrative for
specific
details
concerning
this optional
service
$462,000
RFP B2022-28
54 71
121
ATTACHMENT 1
STATE OF CALIFORNIA
COUNTY OF LOS ANGELES
PROPOSER'S AFFIDAVIT
_____ s_c_ot_t_R_o_ge_r_s ____ being first duly sworn deposes and says:
1. That he/she is the Chief Client Officer
(Title of Office)
of Sedgwick Claims Management Services, Inc.
(Name of Company)
Hereinafter called "proposer," who has submitted to the City of Torrance a proposal for RFP B2022-28 for Workers' Compensation Claims Administration Services (Title of RFP)
2. That the proposal is genuine; that all statements of fact in the proposal are true;
3. That the proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not named or disclosed;
4. That the Proposer did not, directly or indirectly, induce solicit or agree with anyone else to submit a false or sham proposal, to refrain from proposing, or to withdraw his proposal, to raise or fix the proposal price of the Proposer or of anyone else, or to raise or fix any overhead, profit or cost element of the Proposer's price or the price of anyone else; and did not attempt to induce action prejudicial to the interest of the City of Torrance, or of any other Proposer, or anyone else interested in the proposed contract;
5. That the Proposer has not in any other manner sought by collusion to secure for itself an advantage over the other Proposer or to induce action prejudicial to the interests of the City of Torrance, or of any other Proposer or of anyone else interested in the proposed contract;
6. That the Proposer has not accepted any proposal from any subcontractor or materialman through any proposal depository, the bylaws, rules or regulations of which prohibit or prevent the Proposer from considering any proposal from any subcontractor or material man, which is not processed through that proposal depository, or which prevent any subcontractor or materialman from proposing to any contractor who does not use the facilities of or accept proposals from or through such proposal depository;
7. That the Proposer did not, directly or indirectly, submit the Proposer's proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative thereto, to any corporation, partnership, company, association, organization, proposal depository, or to any member or agent thereof, or to any individual or group of individuals, except to the City of Torrance, or to any person or persons who have a partnership or other financial interest with said Proposer in its business.
8. That the Proposer has not been debarred from participation in any State or Federal works project.
Dated this _2 _ day of June , 20B__.
~ud-r.?or
(Proposer Signature)
Chief Client Officer
(Title)
17 72
122
Rr P B2022-28
Attachment 2
The following performance standards establish the minimum requirements and level of service to be provided by the third-party claims administrator {TPA) in delivering claims adjusting services and related activities to the City. The TPA agrees that all duties and responsibilities contained within the performance standards will be provided to the City at no additional cost unless otherwise specifically noted herein and agreed to by both parties. The performance standards and expectations below shall be in conjunction with PRISM's Addendum A Claims Administration Standards, whichever is more stringent for each criterion.
1. Caseload
Each examiner shall have a caseload not to exceed one hundred and twenty-five (125) open indemnity claims, which includes future medical claims (weighted as 2:1). The supervisor shall not carry a caseload.
Sedgwick agrees to comply with the City's caseload requirement of 125 (maximum) open indemnity claims with weighted future medical claims 2:1.
Our teJm leads are part of our management structure and do not carry a caseload.
The TPA shall provide a computer-generated monthly caseload report to Worker's Compensation Manager for all examiners handling the City's claims. The report shall include all clients and claims each examiner is handling and shall be provided to the Worker's Compensation Manager electronically within ten {10) business days of closure of the previous month.
Sedgwick agrees to comply with this requirement. We will provide the client with reports that show the caseload for each ot the examiners assigned to the client's account. In the event that the City opts to use Sedgwick's system, the City also can run reports using via One to confirm that caseloads are within the con tr c1ctual range.
Caseload monitoring starts at case assignment and includes the team lead tracking new assignments by examiner.
The team lead can track pending caseloads in our system at all times, and we can print caseload reports as often as daily for each operational leader. Our managers use these reports and an office scorecard to 1nonitor and ensure the integrity of caseload benchmarks and the quality and timeliness of our service to clienls.
Please note that reports including specific client names and claims will have names redacted for confidentiality purposes. We can give an accounting of cases by client and would redact the other client's namv(,) or we would need to obtain client approval to release the names.
SC
73 123
RFP B2022-28
2. Claim File Set Up
Upon receipt of the Employer's Report of Occupational Injury or Illness or Application for Adjudication of Claim, the TPA will prepare an individual claim file within one (1) business day for each claim. Preparation of the claim file shall include entering each new claim into the computer system and establishing appropriate initial reserves. Initial reserves will be set based on the facts known at the time the case is entered into the computer and clearly documented in the computer notepad. The file shall be available to the City, including their representatives, claims auditors, and agents, for inspection and contain all medical and factual information on each reported claim.
Sedgwick agrees to comply with this requirement.
If we are working within the City's system, then we will develop, in partnership, the most efficient and accurate method of imputing new claims into the City's system along with the reserves and supporting rationale. In the event that the City ops to use Sedgwick's intake platform and claims system - whether new claims are reported from our coI1tact center, through smartly, or directly from the City - the process is the same once the information reaches Sedgwick. The data is loaded into the claims system, where it is validated and routed to the appropriate servicing office based on the location identified for the claim. Our clairns system checks for and routes new transmissions every 20 minutes so that new claims arrive in the servicing offices withrn 30 minutes of their receipt by Sedgwick.
Team leads review all claims and assign them to the appropriate resource based on the type of claim. The examiner will be notified of the new claim assignment through the system-generated claim file diary. We complete claim assignment within one business day of receipt along with the appropriate reserves and supporting rationale.
3. Coverage
The TPA shall verify coverage was provided to the City by The City on the date of injury or illness in accordance with the City program dates and governing documents. If applicable, the TPA shall exercise due diligence in joining applicable co-defendants. All activity to verify coverage and join co-defendants shall be clearly documented in the computer notepad.
Sedgwick agrees to comply with these requirements. All claim related activity is documented in the electronic claim file.
4. Index Bureau and EDEX
The TPA shall subscribe to the Index Bureau, EDEX, and other recommended organizations in order to obtain background history on individual claims. Costs to subscribe to these services shall be included in the pricing structure. The examiner shall request a report from the Index Bureau, EDEX, or other recommended organizations on all new indemnity claims. Subsequent requests should be made every six (6) to twelve (12) months thereafter on all active indemnity claims.
Sedgwick agrees to comply with these requirements.
Sedgwick Copyri1;ht '< ?022
74 124
RFP B2022-28
Sedgwick participates in the ISO Universal Format indexing system for workers' compensation and liability bodily injury claims. Claims are automatically indexed within five days of receipt. The initial index record provides a historical look at a claimant's reportable events as well as 12 months of future updates. As all subsequent searches are historic in scope, claims are re-indexed at the 18-month life of claim and every six months thereafter as long as the claim remains open. Our best practice requires examiners to review index search results immediately if a potential match is identified.
Indexing fees and costs to subscribe to the services above are included in the program pricing.
5. Employer Contact
The TPA shall request the Employer's Report of Occupational Injury or Illness form within one (1) business day when or if notification of any injury or illness by any source is received first.
Sedgwick agrees to comply with this requirement. Sedgwick can produce the Employer's First Report of Injury for all U.S. states. We file these reports with the state either via paper or electronically, depending upon the requirements of the state. We can also provide a copy of the Employer's First Report of In Jury to the City via email immediately following intake of the new claim.
If the DWC Form 1 has not been received by the TPA within two (2) business days after receiving the Employer's Report of Occupational Injury or Illness, the examiner will contact the City to ensure the DWC Form 1 was given to the employee within one (1) business day of knowledge of the injury. If a DWC Form 1 has not been given to the injured employee, the TPA shall immediately send the DWC Form 1 directly to the employee.
Sedgwick agrees to comply with these requirements.
The TPA shall contact the City within one (1) business day of receipt of notice of a claim by any source to conduct an initial and meaningful investigation. Such contact with the City shall be clearly documented in the computer notepad.
Sedgwick agrees to comply with this requirement. Our best practice is to provide our clients with notification of a new claim no later than one business day from receipt of the claim. All communication is documented in the claim file {located in our claims management system) upon occurrence.
When a claim reaches or exceeds $100,000 in total incurred value, the TPA shall report to the City every ninety {90) calendar days regarding the status of the claim. A copy of the claim status report will be provided to the City's Workers' Compensation Program Manager. Such report shall include a current status of the claim, the examiner's plan of action for the future handling of the claim, and the current paid to date and total incurred amounts listed by indemnity (broken down by TD and PD), vocational rehabilitation, medical, and expense categories.
Sedgwick agrees to comply with these requirements.
58 75
125
RFP B2022-28
In the event that the City opts to leverage Sedgwick's claims system, we can provide preprogrammed claim status reports. We generally use these reports for clients who require written status reports at regular intervals, usually quarterly, for serious or complex cases. These reports provide the most recent claim examiner, team lead and medical management notes, as well as reserve payment and any excess information. We recommend development of a cumulative report that could provide updated claim information in a condensed format.
There are many data filtering options available to clients when requesting this report including, but not limited to:
the status of a claim, the type of claim, range of dates, as of reporting and pay categories. Additional options are available on a number of fields such as litigation, subrogation, excess, rehabilitation and finance ranges.
A sample claim status report is included in the appendix.
Sedgwick also offers alert features as part of our viaOne web-based suite of services. Clients can create customized alerts in viaOne sent via text or email. viaOne alerts gives users convenif'nt access to real-time claims information and the user-controlled data management and reporting capabilities of our proprietary claims management system. viaOne alerts increases the value of claims information by expanding user-defined parameters regarding notifications of new developments affecting individual claims and facilitating accelerated analysis of claim trends. The notification utility includes information tracking points and comprehensive sequencing options. These capabilities enable system users to establish an unlimited number of alert triggers based on factors such as the duration, severity and processing status of claims. Users can also create alert-nesting routines that integrate combinations of contingencies into a single alert trigger. Other functionalities include a variety of options for the delivery of notifications, links to full files for claims associated with an alert, and customization of the duration of the alert and data retention timeline.
The examiner will provide on-site file reviews with each district as outlined below:
• More than 5 open claims - 2 times a year
• 2-5 open claims - Annually
• Less than 2 open claims - Teleconference
• Other periodic on-site file reviews will be scheduled based upon the needs of the City Sedgwick agrees to comply with this requirement.
Return phone calls to the City will be accomplished within one (1) business day.
Sedgwick agrees to comply with this requirement. Sedgwick requires all communications to be documented in the claim file and calls to be returned within one business day.
6. Employee Contact
In all non-litigated, lost time cases, where the employee has not returned to work, telephone or personal contact will be established with the injured employee within one (1) business day of receipt of notice of claim.
Such contact will continue as often as necessary, but at least monthly. Such contact with the employee shall be clearly documented in the computer notepad.
76 126
RFP B2022-28
Return phone calls to employees will be accomplished within one (1) business day.
All correspondence from employees will be responded to within five (5) calendar days of receipt.
Sedgwick agrees to comply with these requirements.
Establishing contact and communication with the employee is critical in securing a successful outcome. While best practices establish a framework and expectations, Sedgwick is working to drive a culture of caring. Our caring counts philosophy empowers examiners to offer compassionate, personalized care for injured employees. We maximize opportunities to communicate with empathy and urgency. This advocacy-based approach helps build rapport with injured employees, facilitating their return to health. reducing the chance of litigation and resulting in better overall outcomes.
Examiners currently communicate with parties based on the following criteria:
Incident only claims - are set up in our claims system but no further investigation is performed.
Medical only claims - may include a one-point contact to the employer depending upon the completeness of the information reported or if there are questions based on the information presented. Medical bills and reports are continuously reviewed upon receipt to ensure there are no inconsistencies with the reported mechanism of injury and the injury itself, as well as to ensure appropriate treatment protocols, etc.
Indemnity claims - require a minimum three-point contact with the employee, employer and medical provider. Additional contacts may be necessary based upon the details of the accident, presence of witnesses, potential for subrogation, etc. When appropriate, recorded statements or on-site investigations will be obtained. Medical information will co11tinue to be reviewed for appropriateness of treatment and other actions on a continual basis.
Communication with employees: Following receipt of an accident report, Sedgwick contacts employees based on the claim type and the criteria outlined above. Our goal will be to review the facts of the accident with the employee and explain the claim process. The examiner will offer a medical panel if one has not already been offered. Examiners communicate with employees by telephone, email and formal letter delivered by the U.S.
Postal Service. The examiner makes follow-up contacts based on the developments of the claims. This will primarily involve contact before and after physician appointments to confirm the employee's work status and address any benefit questions the employee may have. Follow-up communication with the employee may involve the examiner, the telephonic nurse or both.
We understand that continued voice-to-voice contact is not always possible with in Ju red employees at critical points in the claim. With our mySedgwick tool, employees can view clain1 or case status and information, including payment history. We provide instructions regarding mySedgwick access in the initial information packet.
Sedgwick also developed the ability to push importa11t communirdt1or1s to rnJured employees through text and/or email. For example, the injured employee will receive a text or email explaining the details each time we make an rndemnity payment. We find that knowing when to expect payrnl'nt helps ease the inJured employee's a11x1ety.
GO
77 127
RFP 82022-28
Sedgwick's standards require that all forms of communication be returned within one business day. All communication is documented in the claim file upon occurrence.
7. Compensability
The compensability determination (accept claim, deny claim, or delay acceptance pending the results of additional investigation) and the reasons for such determination will be made and clearly documented in the file within five (5) business days of the receipt of the notification of the loss.
Delay of benefit notices shall be mailed in compliance with the Division of Industrial Relations' guidelines.
Copies of benefit notices will be maintained in the applicable claim file. The TPA shall obtain authority from the City to delay or deny a claim. The City's authorization shall be clearly documented in the applicable claim file or in the computer notepad.
In no case shall a final compensability decision be extended beyond ninety (90} calendar days from the City's knowledge of the claim.
We understand the importance of conducting a thorough investigation of each claim. We work with compassion and expediency when completing our investigation and making an appropriate compensability determination.
Sedgwick claims examiners use the applicable workers' compensation statutes, appropriate investigation practices and additional clinical evaluation to determine causation. When addressing compensability, the examiner considers whether:
" The person seeking compensation is a covered employee as defined by law 11e The employee sustained an injury or exposure to an occupational disease as defined by law o The injury or exposure happened during and in the course of their employment (AOE/COE) " The accident or exposure resulted in an injury or occupational disease as defined by law and not the result of outside activities or a concurrent nonindustrial medical condition 11e The employee incurred a need for treatment or disability related to the injury or exposure as defined by law
11e A statutory defense does not exist that would prohibit the claim from being determined work-related Each state has variations on the above tests, which form the basis of compensability determinations. We follow jurisdictional requirements for a timely and accurate compensability determination. Generally, we make compensability determinations within 14 calendar days of the date the claim is reported to Sedgwick; however, we agree to make a determination and file documentation within five business days if all information necessary to make an informed decision is obtained. If we do not have the information needed to make a determination by the fifth business day, then a note explaining the need for additional information will be documented in the claim file.
Based on the compensability/coverage evaluation, the claim status will be established in the system as accepted, denied, deferred or compromised.
Sedgwick Copvright :L 2022
61 78
128
RFP 82022-28
We will communicate all recommended claim denials and the basis for the decision to the City via telephone or email. In some cases, a legal review may be indicated, and we would obtain proper authorization from the City prior to making a referral.
The investigation screen housed in our claims system provides a framework for examiners to articulate the results of their contacts, facts of the claim and the justification for their compensability decision.
8. Investigations
The TPA shall promptly initiate investigation of issues identified as material to potential litigation. The City shall be alerted to the need for an outside investigation as soon as possible and the examiner shall appoint an investigator who is acceptable to the City. The City shall be kept informed on the scope and results of all investigations. All activities shall be clearly documented in the computer notepad.
Sedgwick agrees to comply with these requirements.
Our initial investigation includes the appropriate use of recorded statements and witness interviews and vigilance in identifying discrepancies throughout the life of the case. When suspect claim factors are identified and further investigation is warranted, the Sedgwick claims examiner will submit a referral to Sedgwick's internal SIU.
Sedgwick created the SIU to support employers and claims teams with integrated solutions for effective claim investigation and fraud mitigation. Sedgwick's SIU prevention program uses state-of-the-art detection techniques, varied interventions for fraud and consultative advice on the pursuit of fraud on an individual basis. Key elements of the program include red flag analytics, focused investigations, expert analysis, vendor management, quality assurance and impact and ROI reporting.
Generally, Sedgwick examiners refer cases to the SIU for a specific task assignment, such as comprehensive backgrounds, social media searches, medical canvasses, witness locates/skip traces, activity and wellness checks, recorded statements, surveillance and other investigations based on the specific issues, facts and needs of the file.
Referrals are triaged, and details are entered into Sedgwick's SIU case management system (FACTS) and assigned to the appropriate teams or vendor partners for handling. Throughout the course of the assignment, details, correspondence, investigative reports, video evidence and invoices are documented and archived in the system.
Additionally, the notes from our SIU investigators would be documented in the claim file within our claims management system and would be accessible to the City through viaOne.
The services provided by the SIU are specialized and performed on a large, national scale. Sedgwick SIU has internal investigators and a contracted vendor panel to offer an extensive national footprint and specialized service coverage. Our vendor partners are thoroughly vetted to meet stringent data security, insurance and licensing requirements.
In addition to our SIU services, Sedgwick has a long-standing partnership with RJN Investigations in California and would be pleased to work with them on claims investigations for the City.
Investigative services will only be used with the City's approval. 62 79
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RFP B2022-28
9. Reserves
Reserves shall be established based on the facts of the claim and the probable cost of each claim in accordance with OSIP Regulation §15300. A reserve rational for each reserve change shall be clearly documented in the file notes. All reserve categories shall be reviewed on a regular basis but not less than at least every thirty (30) calendar days. The use of a paper or electronic reserve worksheet is required on all claims and a hard copy shall be maintained in the applicable claim file.
Sedgwick agrees to comply with these requirements.
We base our philosophy on the idea that each claim is unique, with exposures particular to that loss depending upon the injured employee or claimant, the client, the facts of the accident and the injuries or damage sustained.
Our examiners set reserves to reflect the most probable outcome of each claim based on the available facts at that time.
We establish appropriate initial reserves on all new claims based on information available at the time of file creation. We subsequently review and recalculate as developments impact the total incurred. Our examiners must set initial reserves within five days, although the majority of claims have an initial reserve set within two days. We review initial reserves within 30 days after the investigation is complete and adjust as necessary.
If the most probable outcome changes as a claim evolves, our examiners increase or decrease the reserves accordingly. If material changes to the claim facts affect the most probable outcome, our service expectations require the examiner to review and adjust the reserves within five business days. Examiners review reserves a minimum of every 90 days for the life of the claim.
We set reserves for each individual category ~ indemnity, medical and expense. Our reserve worksheet, which is contained on line in our claims system, breaks the reserve into detailed categories within each major category. For example, for workers' compensation, the indemnity reserve would include temporary total disability, permanent total and partial disability, and vocational rehabilitation.
For workers' compensation, indemnity reserve calculations take into consideration many factors, including but not limited to the extent and credibility of the in Jury; jurisdiction; the Official Disability Guidelines (ODG); availability of modified duty employment; permanent partial disability where applicable; and the demeanor of the claimant and witnesses. Medical reserve calculations consider jurisdiction; the nature and extent of the injury; medical provider; the need for physical therapy, prescription medication or durable medical goods; surgery and hospitalization, etc.
We calculate expense reserves based upon the anticipated investigative costs to take the claim to resolution.
These analyses assist the examiner in projecting the City's financial exposure based on the most probable outcome.
The reserve rationales and amounts documented by the examiner in the reserve worksheet download automatically into the claim notes. In addition, we retain all prior reserve worksheet adjustments to provide a historical record of the reserve changes on the claim. We have included a sample reserve worksheet in the appendix.
63 80
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RFP B2022-28
Through viaOne, the City may view real-time claims data, including examiner notes, reserve history and payment history, and may monitor the progress and activity on individual claims. During implementation, Sedgwick will establish the specific procedures to ensure the City is involved in the process. The claims system establishes automatic email notifications of reserve changes at levels specified during implementation.
10. Payments
The TPA is authorized to make payments of claims, allocated loss expenses, and other amounts on behalf of the City, on a weekly basis. The TPA shall electronically submit a detailed statement of payments and reverse ACH funds from the City's bank account.
Sedgwick agrees to comply with these requirements.
For loss funding, Sedgwick offers ACH debit, ACH credit and federal wire credits as funding options for the replenishment of the required escrow for Sedgwick-owned and -managed accounts, depending on the frequency method selected. If ACH debit is the chosen funding method, the client would execute an agreement with their bank allowing Sedgwick to request their bank to debit their specified account for the debits and/or issuances drawn on the Sedgwick-managed account. A detailed summary of the debits and/or issuances for the funding request are provided to the client.
We offer a variety of funding options including daily, weekly, semimonthly or monthly replenishment cycles.
11. Collections
All collections will be logged and posted to the file but will be sent to the City's office with accompanying support for deposit. The support will list that date the collection was posted to the claim file. No City refunds or other collections will be deposited by the TPA in any TPA or client accounts.
Sedgwick agrees to comply with these requirements.
12. Provision of Benefits
The TPA shall provide all compensation and medical benefits in a timely manner and in compliance with the statutory requirements of the California Labor Code. The TPA shall compute and pay temporary disability benefits to injured employees based upon earnings information and authorized disability periods. The TPA shall review, compute, and pay all informal ratings, death benefits, Findings and Awards, life pensions, or Compromise and Release settlements. All such benefits shall be paid by TPA. TPA shall electronically submit a detailed statement of payments and reverse ACH funds from the City's bank account.
Sedgwick agrees to comply with these requirements.
Sedgwick's team leads work with our examiners to ensure accurate and timely benefit delivery that is in compliance with the California Labor Code. The accurate payment of indemnity benefits is one of the most important functions of a claims examiner. Sedgwick's claims system allows our examiners to pay benefits in accordance with the work status entered. This guarantees accurate benefit payments and supplies the City with an outline of the work status history from claim creation to resolution. Our examiners maintain system automated benefit approval diaries throughout the life of the claim, ensuring timely payments. 64 81
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In accordance with our payment processing procedures, examiners will:
" Initiate indemnity payments within 14 days of the onset of disability or as required by state statute "' Process subsequent checks on a timely basis in accordance with jurisdictional requirements " Schedule long-term payments in the system, to be produced within the system as appropriate to their due date
" Issue payments required due to awards, judgments or orders within five days of receipt "' Pay all substantiated bills within 21 days of receipt. If the bill is not to be paid, we notify the vendor of the reason for nonpayment
13. Initial Indemnity Payment
The initial indemnity payment or voucher will be issued and mailed to the injured employee together with a properly completed DWC benefit notices within fourteen (14) calendar days of the first day of disability.
Copies of benefit notices will be maintained in the applicable claim file.
Late payments must include the self-imposed 10% penalty in accordance with Labor Code Section 4650.
Sedgwick agrees to comply with these requirements. Our best practices require initial indemnity payment within 14 calendar days of disability or sooner if jurisdiction requires. Appropriate benefit notices are sent, the claim file is documented, and copies are maintained in the claims file.
Sedgwick is responsible for any fines and penalties that are a result of noncompliance with the California Labor Code, or the workers' compensation rules and regulations of the state, that are the fault of Sedgwick and/or our vendors.
We operate openly and honestly with our clients in penalty assessments on claims. All penalty payments are transparent on the claim file, whether by the client or by Sedgwick. We have an automated process to reimburse the client for any TPA penalties that is reviewed for accuracy by the CSD.
Sedgwick uses different payment codes to ensure proper processing of these payments. Penalties that are determined to be our responsibility are reimbursed to the client on a monthly basis, or whatever time interval the client deems appropriate based on the coding.
14. Subsequent Indemnity Payments
All indemnity payments or vouchers subsequent to the first payment will be verified, except for those payments where permanent disability is expected beyond ninety (90) calendar days in which case those payments will be verified in ninety (90) day increments. All disability payments will be issued in compliance with Labor Code Section 4651.
Sedgwick agrees to comply with this requirement.
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Our examiners maintain benefit approval diaries throughout the life of the claim to ensure timely payments. Our claims team leads review the benefit approval diaries to confirm that the payments are going out as required by the state jurisdiction. In addition, each claims examiner can schedule future payments based on the medical period of disability and can modify or terminate this cycle at any time. Managers or team leads review and approve a report listing each check, sorted by claimant name, number and payee name, prior to releasing the checks for payment.
Late payments must include the self-imposed 10% penalty in accordance with Labor Code Section 4650.
Sedgwick agrees to comply with this requirement. Sedgwick is responsible for any fines and penalties that are a result of noncompliance with the California Labor Code, or the workers' compensation rules and regulations of the state, that are the fault of Sedgwick and/or our vendors. Sedgwick uses different payment codes to ensure proper processing of these payments. Penalties that are determined to be our responsibility are reimbursed to the client on a monthly basis, or whatever time interval the client deems appropriate based on the coding.
Copies of benefit notices issued with subsequent benefits will be maintained in the applicable claim file.
Sedgwick agrees to comply with this requirement.
15. Medical Administration
The TPA, absent a Medical Provider Network (MPN), shall select a panel of general practitioners, specialists, hospitals, and emergency treatment facilities to which injured employees should be referred and regularly review and update the panel.
Sedgwick agrees to comply with this requirement.
A dedicated medical provider network {MPN) management team, based in Rancho Cucamonga, California, leads the implementation of the MPN for our clients. We will collaborate on the required documentation and provider panel postings and support the City's training as required. Sedgwick's California MPN is accessible through our provider benchmarking and search tool, which is continually updated with provider benchmarking and validated demographics.
Sedgwick's California MPN focuses on provider outcomes and offers several key benefits, including:
" Cost savings - claims in Sedgwick's MPNs show a 25% reduction in total costs versus claims not operating within an MPN. Clients changing to the outcomes-based MPN model experienced 15% a reduction in the average cost per claim during their first year in the program. " Tighter focus on medical control and medical outcomes - this allows for greater savings on temporary total disability, reduced claim expenses and lower litigation rates; medical care is directed within the MPN for the life of the claim regardless of the number of diagnoses, recidivism (re-opening of old claims) or subsequent additional claims for the same employee. * Improved employee satisfaction with care - this helps reduce rates of litigation.
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The physician's office will be contacted within three {3) calendar days of notice of all new claims to conduct an initial investigation as to the medical aspects of the claim and discuss the City's return-to-work goals. Such contact will continue as needed during the continuation of temporary disability to assure that treatment is related to a compensable claim and clearly documented in the computer notepad.
Sedgwick agrees to comply with this requirement.
Establishing contact and communication with the physician(s) is critical in securing a successful outcome.
Sedgwick requires examiners to complete or attempt three-point contact on every new indemnity claim within one business day.
Our examiners contact medical providers based on claim type - incident only, medical only or indemnity. Our goal is to confirm accident history, diagnosis, causal relationship and disability status. Examiners communicate with medical providers by telephone, email, fax and formal letter delivered by the U.S. Postal Service. Medical providers are also able to communicate with Sedgwick's claims colleagues using viaOne for providers. Follow-up communication with medical providers takes place both before and after physician appointments, to confirm the employee's work status. Follow-up communication may involve examiners or telephonic nurses Sedgwick's standards require that al/forms of communication be returned within one business day. All communication is documented in the claim file upon occurrence.
The TPA shall maintain contact with treating physicians to ensure employees receive proper medical treatment and are returned to full or modified employment at the earliest possible date.
Sedgwick agrees to comply with this requirement. The claims examiner or assigned nurse case manager contacts the treating physician after each medical examination when an injured employee is off work to confirm the treatment status, compliance with care and progress toward RTW.
The TPA shall maintain direct contact with medical providers to ensure their reports are received in a timely manner.
Sedgwick agrees to comply with this requirement. Our best practices require examiners to follow up with the medical provider after each doctor's visit or at least monthly to obtain a medical report.
The TPA shall arrange medical evaluations when needed, reasonable, and/or requested in compliance with the current California Labor Code.
Sedgwick agrees to comply with this requirement. We use all our tools and resources to make sure that we are providing proactive medical management to bring each claim to the best possible outcome. 67 84
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The TPA shall ensure that medical bills are reduced to the Official Medical Fee Schedule (OMFS) and recommended rates established by the Administrative Director of Workers' Compensation. The use of a service contractor is acceptable provided approval is first obtained from the City s Administrator. The City shall pay for the use and benefits of the services provided; however, fees charged by the service contractor shall have been approved by the City's Workers' Compensation Manager prior to the provision of and payment for services. The City's Workers' Compensation Manager will approve the service contractor's fees on a monthly basis prior to payment by TPA to the service provider. Such fees will be charged to the applicable claim file and will be paid from the medical category.
Sedgwick agrees to comply with these requirements. Sedgwick performs MBR services in house.
The TPA shall provide, at the City's expense, utilization review and/or professional managed care services on an as-needed basis to injured employees, provided The City and/or the City's approval is obtained prior to the provision of such service. The use of a service contractor to provide this service is acceptable provided the City's approval is first obtained. Such fees will be charged to the applicable claim file and will be paid from the medical category. Establishment of the UR referral criteria shall be approved by the City prior to implementation and submission to the state as part of the City's UR Plan.
Sedgwick agrees to comply with these requirements. Approved vendor partners agree to best pricing for Sedgwick customers and may agree to pay administrative fees for the cost of technical connectivity, administrative and compliance oversight and vendor management. There are no vendor fees charged to our customers.
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16. Medical Payments
Medical bills will be reviewed by the assigned claims examiner, assistant, or supervisor for correctness, approved for payment, and paid within time limits established by Labor Code Section 4603.2. If all or part of the bill is being disputed, the TPA will notify the medical provider, on the appropriate form letter, within time limits established by Labor Code Section 4603.2.
Sedgwick agrees to comply with these requirements. We comply with all jurisdictional regulations, including Labor Code Section 4603.2. Sedgwick's bill review process starts with the claims examiner's review of the bill to ensure it is compensable. Upon the examiner's initial approval, our electronic bill review system reviews the bill using the most automated and accurate re-pricing available. Our system reviews each bill for all possible savings, checking for fee schedule/UCR reductions, UR treatment plans and clinical edits. The structure and workflow ensures the greatest savings possible within the established state agency rules/regulations and fee schedules. After this compete review, we apply contracted preferred provider organization (PPO} discounts either directly in the platform or via an electronic bridge to the PPO network. The bill review system sends the bill electronically back to the claims system. Sedgwick's total turnaround time is 16 days from receipt of the medical bill to payment of the provider. All bills entered into the system are released with an explanation of review (EOR} that documents the reasons for the recommended payment, partial payment or denial. The EOR also advises the provider of next steps (address to send information or phone number to call) should they have questions or disagree with the recommendation.
17. Transportation Expense
Transportation reimbursement will be mailed within five (5) calendar days of the receipt of the claim for reimbursement. Advance travel expense payments will be mailed to the injured employee at least ten (10) calendar days prior to the anticipated date of travel.
Sedgwick agrees to comply with this requirement.
18. Return-to-Work
The TPA shall provide assistance to the City in coordinating return-to-work program information that is appropriate for injured employees while recovering and prior to their return to regular duties.
Sedgwick agrees to comply with this requirement.
Sedgwick starts coordinating an injured employee's RTW immediately after an illness or injury, and because the circumstances surrounding each claim are unique, so is our RTW management strategy. We match injured employees with the right plan based on their condition and restrictions, the employer's culture and industry standards on recovery times. Our claims examiners use proprietary technology tied to the ODG to electronically track RTW, restricted duty, intervals between lost workdays and on/off workdays.
With our holistic RTW services, we focus on eliminating RTW barriers. By combining our multidisciplinary team, personalized RTW plans and powerful technology, we help employees recover sooner - so they can get back to health and work after an illness or injury, and employers can reduce their overall claim costs.
Our team of experts facilitate a safe and healthy RTW, through:
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" Early intervention - within the first 30 days for non-complex medical claims "' Custom RTW plans
Case management for complex RTW scenarios, including those involving the claim, or functional, environmental and job-related challenges
" Full workplace accommodation support - from the initial inquiry through accommodation implementation and tracking
Completion/submission of required jurisdictional forms
Review and completion of functional job descriptions
" Modified-duty options
~ Transitional work placements with local nonprofits
Specialized vocational services - including on-site job analysis, ergonomic evaluations and skills analysis
The TPA shall notify the City immediately upon receipt of an employee's permanent work restrictions so that the City can determine the availability of permanent modified or alternative work. Notification shall clearly be documented in the computer notepad within one (1) business day.
Sedgwick agrees to comply with this requirement. All communication is documented in the claim file upon occurrence.
The TPA shall consult with the City on a bi-weekly basis in those cases where the injury residuals might involve work restrictions and assist the City in the provision of modified duty when appropriate.
Sedgwick agrees to comply with this requirement.
When accommodating light or modified duty requirements is a challenge, our RTW experts can help design programs and strategies that allow injured employees to RTW sooner. They can help with issues including extensive restrictions and durations, lack of on-site modified or light duty jobs or providers not following the ODG related to returning to work. By recognizing possible barriers and developing a plan to address them, a RTW specialist can significantly impact a claim and often resolve it in an expedited manner.
RTW experts tailor their approach to each client's culture, environment, industry and location. Our specialists can design light and modified duty assignments with local nonprofit organizations to meet the needs of the local community, the injured employee and the client. Our expert team works with treating providers to determine the employee's capabilities, coordinates job placement options and addresses complicated RTW issues. They use multiple assessment tools, such as labor market surveys, transferable skills analysis, job analysis and vocational evaluation and testing. Our RTW experts are master's-level certified rehabilitation counselors with expertise in transitional duty programs, job accommodations and requirements of the Americans with Disabilities Act (ADA). 70 87
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Should the City contract with a vendor to assist with return-to-work, the TPA shall cooperate with the assignment of cases or the provision of information in order to help facilitate a successful return-to-work program.
Sedgwick agrees to comply with this requirement.
19. Permanent Disability
The TPA shall provide information and assistance to injured employees in completing the necessary forms to obtain a permanent disability rating.
Sedgwick agrees to comply with this requirement. Our examiners are trained regarding the utilization of the American Medical Association Guides as well as other jurisdictional methods. Upon maximum medical improvement (MMI}, they explain to injured employees how the physician or medical legal evaluator established a whole person impairment (WPI} rating and how this WPI is altered based on the employee's age and occupation, or any jurisdictional variations. In cases where the injured employee may want a second opinion, we find it helpful to advise them that any rating established is double-checked for adequacy by an arbitrator or administrative law judge upon reviewing settlement documents for approval.
The TPA shall determine the nature and extent of permanent disability and arrange for an informal disability rating whenever possible to avoid Workers' Compensation Appeals Board (WCAB) litigation. The TPA shall take advantage of any potential apportionment potential to prior claims, disabilities, and impairments. The TPA shall also advise the City of potential credits and penalties to permanent disability benefits should the City accommodate permanent/alternative work for at least twelve (12) months.
Sedgwick agrees to comply with these requirements.
Permanent Disability benefits shall be provided in accordance with Labor Code Section 4658. All permanent disability benefit notices shall be sent to the employee as required by the California Labor Code. Copies of benefit notices will be maintained in the applicable claim file.
Sedgwick agrees to comply with these requirements. All claim-related information (claim payment history and reserve transactions, file notes, benefit notices, etc.) is retained in the claims system for the life of the claim.
20. Vocational Rehabilitation
A. In accordance with all applicable California laws in place at the date of injury, the TPA shall:
B. Determine the Qualified Injured Worker/Non-Qualified Injured Worker status; C. Advise the injured worker of his/her right to rehabilitation benefits; Provide appropriate vocational rehabilitation benefits;
D. Control rehabilitation costs;
E. Attempt to secure the prompt conclusion of vocational rehabilitation benefits; and F. Provide notification to the City should work restrictions require a permanent or modified accommodation.
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Sedgwick agrees to comply with 20 (A- F} above.
Recognizing RTW barriers and engaging a vocational rehabilitation counselor can significantly impact claim outcome. For injuries that require field vocational rehabilitation, Sedgwick engages a master's degree-level vocational counselor.
The vocational rehabilitation counselor uses multiple assessment tools and techniques to develop a RTW plan for the injured employee that is in line with limitations defined by the medical provider. These assessment tools include, but are not limited to, job analysis, job placement, job modification, labor market surveys, transferable skills analysis and vocational evaluation and testing. Together, with our client and the injured employee, we will collaboratively develop an action plan for job modification, job placement or retraining.
21. Diary Review
All claim files shall be reviewed at least every thirty (30) calendar days for active claims and at least every three (3) months for claims that have settled but are open for the employee's future medical care. The examiner shall distinguish the regular diary review from routine file documentation in the computer notepad.
Sedgwick agrees to comply with these requirements.
We require every open claim to have a computer diary. Diaries are system-generated based on client instructions and can be entered by the examiner and team lead to remind them of critical dates for the claim. The system allows for examiner, team lead and other diaries on the same claim. The claims system assists the examiner by automatically documenting critical activities with system-generated diaries and file notes and by performing extensive data validation and edits throughout the claims management process.
The team lead for the City's program will focus on technical quality by performing ongoing reviews of all open indemnity claims. We require standard reviews at 30 days after receipt and at minimum every 90 days thereafter (or sooner if needed or required by the client} throughout the life of the claim. Additional reviews are scheduled based upon the individual merits of the claim.
All supervisory reviews will be documented in the claim notes, which are made available to the client through viaOne.
Note coteyorizuUon
Notes are organized, or filtered, to display the notes needed for the examiner. The notes recorded on a given claim accumulate chronologically beginning with the day a claim is opened. Besides the examiner's notes, the system also stores team lead, legal, nurse, client and other note categories. All notes are coded for easy viewing on any specific note category, or all notes can be viewed (or printed} chronologically providing a complete history of the claim.
Nurse notes are interfaced and coded by type. This electronic exchange of information between the nurse and examiner occurs hourly from 7 a.m. until 9 p.m., Monday through Friday. These notes are available to clients for viewing through viaOne.
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Users with the proper security have the ability to record notes on the individual claim files. When a client enters a note, the system will generate a diary to the examiner advising them to review the client created note. These notes are stored with the examiner's notes and are available to the examiner for review. Client notes are documented in the claim file.
A plan of action will be included and separately labeled in the file notes during a diary review. The plan of action shall include, but not limited to, the employee's current work status, medical status, review of reserves, and future activity to move the claim towards resolution.
Sedgwick agrees to comply with this requirement. The action plan includes all items listed above and can be further customized to meet the individual client's needs.
The TPA shall monitor the diary reviews by printing a "No Activity" report each month to identify any files that have fallen off the diary system. The TPA will provide to the City's administrator a copy of the "No Activity" report referenced in Section 38, "loss Runs", of this document by the 10th calendar day of each month.
Sedgwick agrees to comply with these requirements.
S!tv/5
Sedgwick has experts currently working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our experts and dedicated analyst, Sedgwick can provide the information requested within SIMS.
Additionally, our internal team of SIMS experts can support training for any new colleagues hired on to the City's program.
Our internal control reports identify cases that are open without a diary and management reviews the reports to ensure that claims do not remain open without a diary.
The controls we have in place to ensure examiners promptly follow up on supervisory direction include supervisory diaries, interactive claim exception reports (ICERs) and internal audits. With regard to audits, our quality team colleagues review the quality of guidance provided by the team lead to examiners and confirm that examiners address and follow up on those instructions.
Examiner diaries are set for no more than a 30-day interval. The examiner may set diaries at more frequent intervals if needed, especially on deferred cases undergoing investigation.
22. Plan of Action
Each claim file shall contain the examiner's plan of action for the future handling of that claim. Such plan of action shall be clearly stated including the reasoning for the plan. The plan of action will be updated at least every forty-five (45) calendar days and clearly identified in the computer notepad. The initial plan of action will be clearly documented in the computer notepad within fourteen (14) calendar days of the initial claim set-up.
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Sedgwick agrees to comply with these requirements.
Our standards require that a plan of action be documented in the claims system on all indemnity claims within 14 calendar days from the claim open date. If a material change occurs or we receive new information that would alter the action plan, examiners are required to update the plan within five business days. We will update ongoing action plans every 45 calendar-days.
The action plan will be problem- and goal-focused and will identify steps needed to remove barriers to medical and disability issue resolution. As circumstances change with the employee's medical treatment and case management, the examiner will revise the plan to reflect those circumstances.
23. Claim Supervision
The TPA shall provide supervisory staff that will regularly review the work product of the examiners. The supervisor shall review at least ten percent (10%) of each examiner's caseload, Ind 120 days and FM 180 days, to ensure each examiner is following the performance standards outlined in this AGREEMENT.
Sedgwick agrees to comply with these requirements.
The team lead (supervisor) for the City's program will focus on technical quality by performing ongoing reviews of all open indemnity claims at various points in their life span. Sedgwick requires standard reviews at 30 days after receipt and every 90 days thereafter {or sooner if needed or required by the client) through the life of the claim.
Additional reviews are scheduled based upon the individual merits of the claim.
All team lead reviews will be documented in the claim notes In addition, the supervisor shall conduct a regular quarterly review of all open indemnity claims with reserves in excess of $100,000 and all problem or complex claims. Such reviews shall be labeled as "Supervisor Review" and clearly documented in the computer notepad.
Sedgwick agrees to comply with this requirement.
We will provide in-person quarterly claim reviews to ensure that Sedgwick and the City are meeting their agreed objectives.
Periodic claim reviews facilitate regular communication and ensure that we are working with the City to resolve cases promptly, with the best outcomes. Each claim is reviewed in a number of categories including, but not limited to, reserving, reporting and the development of a claim action plan. Reviewing the action plan allows us to discuss how we plan to move the claim toward resolution.
Quarterly meetings are scheduled to review program results and obtain client feedback on our performance. As part of our standard procedures, we track this information as well as our actions resulting from the client response. We also document specific feedback on a routine basis and take appropriate actions to resolve outstanding issues. We use this information to develop best practices and process improvement opportunities.
Supervisor reviews and supervisor diaries are labeled as "SR". Supervisor notes can be titled/labeled as "SR" in the notepad area.
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24. Status Reports
Other than the reports identified in Section 38, "Loss Runs" of this document, claim status reports requested by the City, in addition to the regular ninety (90} day status reports referenced in Section 5, "Employer Contact" of this document, shall be provided by the TPA to the City within ten (10} business days. Verbal status reports requested by the City shall be provided by the TPA to the City within two (2) business days.
Computer generated loss data reports requested by the City's shall be provided within twenty (20) business days.
Sedgwick agrees to comply with these requirements.
C!o/n; stotr1s
Our claim system provides for preprogrammed claim status reports, which can be scheduled daily, weekly, monthly, quarterly, semiannually and annually. These reports provide the most recent claim examiner, team lead and medical management notes, as well as reserve payment and any excess information. We recommend development of a cumulative report that could provide updated claim information in a condensed format.
There are many data filtering options available to clients when requesting this report, including, but not limited to, the status of a claim, claim type, range of dates, as of reporting and pay categories. Additional options are available on a number of fields such as litigation, subrogation, excess, rehabilitation and finance ranges.
Verboi st.utus
A verbal status report will be provided to the City within two business days when requested.
During implementation, Sedgwick will work with the City to determine the frequency and medium of reporting for their program. Our claims system provides a wide variety of standard reports, which can be generated for any level of the City's organization on a regular basis.
Standard reports that are available to be pulled by Sedgwick for the City include - accumulative loss analysis, lag report, allocation/transaction report, loss and claim experience report, cause code analysis report, loss analysis II, claim report, loss summary report, claim status history report, loss run summary report, claims log report, miscellaneous client field report, cost range analysis report, pay-code analysis report, experience rating report, payment and reserve progression, hard copies by client report, repeaters list report, indemnity report, reserve change report, stewardship report, specific excess report and many more.
Sedgwick's standard month-end report package includes:
Adjustment report
Loss analysis I report
Claim and expense report
Transaction report
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There are no additional fees for Sedgwick's standard reports.
25. Claim Reconciliation
All claim files shall be reconciled to ensure all indemnity payments have been made correctly. The reconciliation should verify that payments were made in the correct amount and from the correct claim file.
The physical file should be verified with the computer information. All open claim files shall be reconciled semi-annually and at the time of submission for closure. Proof of the reconciliation should remain in the claim file and clearly documented in computer notepad.
Sedgwick clients have the option of using either a client-owned and -managed account or one owned and managed by Sedgwick. The latter gives clients complementing support resources for reconciliation and account management as well as real-time reporting and information.
If the City selects an option where Sedgwick will establish a loss fund account on behalf of the City, Sedgwick will provide a detail report denoting check number, claimant name and amount for each bank account.
Sedgwick will reconcile the claims disbursement bank account on a monthly basis. Per the City's request, a monthly reconciliation package can be mailed with the results of such monthly reconciliation. The bank reconciliation will be mailed within 30 days after the end of a month.
All claim information, including financials, are documented in the electronic claim file and can be viewed by the City in real time.
26. Settlements
The TPA shall obtain the City's authorization on all settlements. The TPA or defense counsel shall forward settlement proposals to the City in a format approved by the City's Workers' Compensation Manager. All requests for settlement authority shall be clear and concise and include a written claim analysis, estimate of permanent disability, and the defense counsel's comments and recommendations. If the settlement exceeds an amount established by the City's established guidelines, the written settlement proposal shall also be directed to the City's Workers' Compensation Manager to provide authority in addition to the City's authority.
Sedgwick agrees to comply with these requirements.
It is critical for the City to be involved in the settlement process. We will work with the City on all issues of claim settlement analysis and recommendation.
Sedgwick's examiners have specific settlement and payment authority levels based on their experience. The City can customize these levels. In the event the settlement exceeds their authority, examiners will supply their team lead and you with a timely and complete evaluation of the claim exposure, recommendations and settlement range.
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Our examiners are trained in mitigation and resolution techniques and may not wait for a determination of MMI to begin settlement discussions. In the event that nature and extent issues exist, the examiner will conduct a critical analysis on the impact of further litigation on the ultimate outcome and may provide settlement recommendations early in the process. It is our charge to work through all possible scenarios and their ultimate outcomes to secure the best possible resolution for the City.
We have had great success settling claims through compromise and release. In California, Sedgwick has reduced our public entity clients' future medical claims inventory to an average of 33% by means of compromise and release.
In addition, we were able to achieve the following results for claims involving a public safety officers for one of our large public entity clients in California:
• Sedgwick reduced the future medical inventory of safety officers from 30% of open indemnity files to 12% of open indemnity files
These results were achieved through strategic settlement efforts that increased the number of safety officer claims settled by compromise and release from 5% to 63% versus those settled by stipulation
27. Award Payment
Payments on Awards, computations, or Compromise and Release agreements will be issued within ten (10) business days or sooner if necessary, to ensure payment within twenty (20) calendar days of the WCAB approval date, following receipt of the appropriate document.
Sedgwick agrees to comply with this requirement.
In accordance with our payment processing procedures, examiners will:
• Initiate indemnity payments within 14 days of the onset of disability or as required by state statute 11 Process subsequent checks on a timely basis in accordance with jurisdictional requirements a Schedule long-term payments in the system, to be produced within the system as appropriate to their due date
11 Issue payments required due to awards, judgments or orders within five days of receipt $ Pay all substantiated bills within 21 days of receipt. If the bill is not to be paid, we notify the vendor of the reason for nonpayment
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28. Future Medical Claims
Claims that remain open to monitor future medical care shall remain open for two (2) years from the last payment of benefit in accordance with OSIP Regulations §15400.2. Reviews shall be documented in the claim notes to include settlement information, future medical care outline, last date and type of treatment, name of excess carrier, excess carrier reporting level, and excess carrier reporting history. Reserves for future medical treatment will be reviewed every six (6) months and adjusted for use over a three (3) year average and the injured employee's life expectancy based on the latest version of the U.S. Life Table in accordance with OSIP Regulations §15300. The reason(s) and calculation(s) for the adjustment(s) shall be clearly documented in the computer notepad.
Sedgwick agrees to comply with these requirements.
We will use all our tools and resources to make sure that we are providing proactive medical management on all cases, including future medical cases. Our examiners work closely with medical providers to bring each claim to the best possible outcome.
29. Subrogation
In all cases where a third party is responsible for the injury to the employee, the TPA will consult with the City to determine if subrogation should be pursued. The TPA will send a letter to the City indicating they will pursue subrogation unless instructed otherwise by the City. When subrogation is to be pursued, the third party shall be contacted within ten (10) business days with notification of the City's right to subrogation and the recovery of certain claim expenses. If the third party is a governmental agency, a claim shall be filed with the governing agency within six (6) months of the injury or notice of injury.
Sedgwick agrees to comply with these requirements.
The pursuit of subrogation will be coordinated with the City's appropriate representatives to determine the extent you want us to pursue this on your behalf and to assist in the determination of any waiver of subrogation or other contractual agreements that may exist.
Sedgwick has developed a dedicated subrogation unit to increase the opportunity for ROI for our client partners.
This unit also provides the following benefits:
" Utilization of staff experienced in recovery work
" Ability to maximize the City's returns
" Solidify ongoing relationships with our client partners " Free up examiners to concentrate 100% on management of "mainstream" claims versus recovery claims, thereby maximizing efficiencies
We provide datamining services at no cost to clients that are enrolled in our subrogation program. We continually scan files to identify opportunities for subrogation pursuit. We identify mined files using a number of cause/mechanism of injury codes, which have a higher likelihood of containing a subrogation component, including:
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" Slip/trip/fall
.. Auto accident
" Equipment/product liability
" Assault
Vendor /contract
If a third-party is involved, our best practice is to have the third-party formally notified within five business days of gaining knowledge of the tortfeasor.
Periodic contact shall be made with the responsible third party and/or insurer to provide notification of the amount of the estimated recovery to which the City will be entitled.
Sedgwick agrees to comply with this requirement.
In accordance with Sedgwick's best practice, updates are provided to the parties involved at least every 90 calendar days.
If the injured worker brings a civil action against the party responsible for the injury, the TPA shall consult with the Workers' Compensation Program Manager about the value of the subrogation claim and other considerations. If subrogation rights are waived, TPA shall obtain written authority from the City's Workers' Compensation Manager or Executive Director. Upon the City's authorization, subrogation counsel shall be assigned to file a Lien or a Complaint in Intervention in the civil action. Upon assignment of the case to an authorized subrogation attorney, the TPA shall request a "not to exceed" estimate of fees for such representation. The fees shall be authorized by the City prior to commencement of work by counsel. Should the "not to exceed" fees be reached, the TPA shall be responsible for obtaining continuing authority prior to incurring additional costs. Such contact with the City shall be documented in the computer notepad. Should the costs exceed the estimated fees without proper verbal authority from the City, the TPA may be responsible for reimbursement to the City for the additional cost(s).
Sedgwick agrees to comply with these requirements.
Whenever practical, the TPA should take advantage of any settlement in a civil action by attempting to settle the workers' compensation claim by means of a Third Party Compromise and Release. If such attempt does not succeed, then every effort should be made through the WCAB to offset claim expenses through a credit against the proceeds from the employee's civil action.
Sedgwick agrees to comply with this requirement.
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30. Litigated Cases
TPA shall promptly initiate investigation of issues identified as material to potential litigation. The City shall be alerted to the need for an outside investigation as soon as possible and the examiner shall appoint an investigator who is acceptable to the City. The City shall be kept informed on the scope and results of all investigations.
Sedgwick agrees to comply with this requirement.
Once a workers' compensation claim is reported, a team lead reviews the claim and determines if there are any red flags based upon the reported information. Sedgwick's predictive models run continuously throughout the life of the claim and flag claims for potential action by our claims team when they hit specific data elements. These flags can predict when a claim may become a large loss, might be complex and require additional intervention, investigation or could be at risk for litigation or attorney involvement.
When defense counsel is not necessary, the TPA shall work closely with the applicant's attorney in informal disposition of litigated cases. All assignments to outside counsel will be done with the City's authorization and consent. The TPA shall prepare clear and concise litigation referrals to outside counsel outlining the issues of the claim and duties that will be handled by defense counsel. Such referral will be documented in the TPA's computer notepad. In conjunction with the City, the TPA shall monitor the outside counsel's progress. The TPA shall audit all defense counsel's bills before payment is authorized. Defense counsel shall provide to the TPA, with a copy to the City, an initial case analysis and a plan of action within ten (10) business days of the assignment.
Sedgwick agrees to comply with this requirement.
Sedgwick will refer cases to counsel with our client's approval when we are unable to reach disposition by settlement or if a case is defensible under the appropriate state workers' compensation act. Sedgwick has established litigation management guidelines that provide defense counsel with direction for budgeting, reporting, billing and handling the legal issues included in the assignment. The guidelines also provide our claims examiners with requirements for reporting claims to counsel and expectations for litigation management. We believe that direction of defense counsel remains the responsibility of the handling examiner.
Our examiners partner with defense counsel through timely communication and strategy sessions. As required by the demands of each individual claim, the examiner will continue to complete any investigative task and will not abandon the file to defense counsel. Our examiners work hand-in-hand with counsel to develop and implement a strategy for resolution or prepare for defense. We promptly convey ongoing developments to our client as required. Additionally, the examiner generally is responsible for settlement negotiations and is charged with keeping both the client and defense counsel updated on the discussions with plaintiff counsel. As ongoing communication with defense counsel is necessary to keep the case on track, we require that defense counsel provide us with a status report at a minimum of every 60 days or as material facts change on the case.
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One key aspect of expense management is legal bill review. Our examiners are responsible for the review of all legal bills in accordance with the criteria outlined in our litigation management guidelines. Any overcharges or discrepancies are resolved with the law firm, and any trends identified are elevated to management and client services to either meet with the firm to correct the billing trend or to recommend alternative counsel to our customer.
As an alternative, Sedgwick partners with Mitratech for third-party legal bill review services. The advantage of this service is primarily the data capture that comes from a detailed review of legal bills, which allows Sedgwick and the client to measure law firm and attorney activities compared with outcomes. This enables clients to make informed business decisions about the continued use of firms and to gravitate to those that provide the best service and results. Sedgwick also would work to partner with any other legal bill review solution you may select.
In addition to legal bill review, other key aspects of our litigation management guidelines contribute to legal expense management:
Our examiners maintain control of the claim file and continue to perform the duties of a claim handler while ensuring defense counsel only performs those tasks requiring an attorney.
Within 30 days of referral, we require counsel to provide an initial case evaluation as well as a corresponding legal budget.
" At a minimum of every 60 days, examiners discuss the legal strategy with counsel to ensure it remains current.
" Budgets and legal strategies are updated as litigation develops and changes. ,. Our examiners continually review the claim to weigh the costs and benefits of ongoing litigation versus settlement of the case to achieve the best possible outcome.
All preparation for a trial shall involve the City so that all material evidence and witnesses are utilized to obtain a favorable result for the defense.
Sedgwick agrees to comply with this requirement.
The manager, supervisor, or the examiner shall attend WCAB hearings, rehabilitation hearings, other court proceedings, meetings with defense counsel, and meetings with the City's staff, departments, and employee groups as necessary and as requested to do so.
Sedgwick agrees to have a member of our claims team attend meetings with defense counsel as well as with the City's staff, departments and employee groups as necessary and as requested.
We usually use an outside vendor such as defense counsel to attend any mediations, arbitrations or trials on our behalf. However, in some circumstances an examiner could attend a hearing. Any additional cost would be considered an allocated expense and discussed with the City prior to proceeding. The examiner assigned to the claim file will notify the City of any hearing or trial immediately. 81 98
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31. Fraudulent Claims
The TPA shall consult with the City regarding any claim believed to be fraudulent prior to referring to TPA's in house special investigation unit for further investigation and potential referral to the District Attorney. If TPA does not have an in-house special investigation unit, the claim will be referred to an investigator, with the City's prior approval, to conduct further investigation.
Sedgwick agrees to comply with these requirements.
We recognize that the identification, investigation and pursuit of suspicious claims or fraudulent elements of claims are an integral part of our responsibility as a TPA. Sedgwick created an internal SIU to support employers and claims teams using state-of-the-art detection techniques and technology for the evaluation of red flags, varied interventions for investigations, fraud identification and consultative advice on the pursuit of fraud on an individual basis.
When suspect claim factors are identified and further investigation is warranted, the Sedgwick claims examiner will submit a referral to Sedgwick's SIU. These suspect claim factors could be any industry red flag, or combination of red flags, that raise articulable suspicion and the need for investigation such as exaggerated symptoms, malingering, or conflicting statements regarding the injury.
Our SIU fraud analysts work with examiners and clients to determine the proper path to resolution for any suspicious claim. These experts will conduct claim reviews, analyze red flags, recommend services and work with state agencies as necessary to ensure compliance for claims with reasonable suspicion.
Our program is fully compliant with all state reporting of individual fraudulent claim situations. Pursuit of fraud with state agencies is done only with client approval and in conjunction with the appropriate authorities and cooperate with state agencies to help drive prosecution efforts.
In addition to our SIU services, Sedgwick has a long-standing partnership with RJN Investigations in California and would be pleased to work with them on claims investigations and in the pursuit of fraudulent claims for the City.
32.Excesslnsurance
Cases that have the potential to exceed the City's self-insured retention shall be reported in accordance with the reporting criteria established by the excess insurance policies. All cases that meet the established reporting criteria are to be reported within five (5) business days of the day on which it is known the criterion is met. A copy of the submission to the excess carrier shall be forwarded to the City's Workers' Compensation Program Manager until such time the TPA is instructed otherwise. Any related excess reimbursements will be posted to the file and the payment will be forwarded to the City for deposit.
Sedgwick agrees to comply with these requirements.
Excess notification is part of our claims handling standards. Client-specific parameters are entered into the claims system, which triggers the examiner to complete the required reporting. The CSD also receives an automatic email notification so that the file can be reviewed for proper reporting requirements.
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33. Penalties
Late payment of all benefits must include the self-imposed penalty in accordance with California law. The TPA will provide the City a quarterly listing of any administrative penalties paid the quarters ending March 31, June 30, September 30, and December 31, which were the responsibility of the TPA, and a check from the TPA payable to the City for reimbursement. The check and report shall be submitted to the City by the 20th of the following month after the quarter ends. Evidence of the penalty reimbursement shall be noted within the claim file and posted within the payment detail as a recovery/reimbursement.
Sedgwick agrees to comply with these requirements.
We are responsible for any fines and penalties that are a result of noncompliance with the California Labor Code, or the workers' compensation rules and regulations of the state, that are the fault of Sedgwick and/or our vendors.
We operate openly and honestly with our clients in penalty assessments on claims. All penalty payments are transparent on the claim file, whether by the client or by Sedgwick. We have an automated process to reimburse the client for any TPA penalties that is reviewed for accuracy by the CSD.
Sedgwick uses different payment codes to ensure proper processing of these payments_ Penalties that are determined to be our responsibility are reimbursed to the client on a monthly basis, or whatever time interval the client deems appropriate based on the coding.
34. Case Closure
The supervisor must review all medical only claims open beyond ninety (90) calendar days from the date of entry by the TPA for potential closure or conversion to indemnity claim status. Claims with $3,000 or more paid-to-date on any claim open beyond one hundred eighty (180) calendar days from date of entry shall be converted to indemnity status and a reasonable, precautionary indemnity reserve placed on the claim. All indemnity cases, where permanent disability is not an issue, will be closed within sixty (60) calendar days of the final financial transaction or final correspondence to the injured worker as required by law. All indemnity claims, where permanent disability is an issue but no settlement, will remain open for two (2) years from the last payment of benefit and then closed within sixty (60) calendar days of that date.
Sedgwick agrees to comply with these requirements.
Sedgwick's claims management system has prompts that alert a claims team lead to the need for review at customized intervals, such as $3,000 or more paid-to-date on an open claim and more. 100
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35. Forms
The TPA shall provide all forms necessary for the processing of benefits or claims information including the Employer's Report of Occupational Injury or Illness, DWC Form 1, medical service orders, return-to-work slips, lost time information reports, vouchers, checks, and other related forms. The cost of providing these forms shall be included within the contract price set forth in this AGREEMENT.
We create client-specific forms from our best practice templates. Sedgwick is responsible to provide all required correspondence to administer and adjudicate qualified claims. Some forms may be the City's responsibility, but we will assist where possible. We will complete and file state individual claim and annual reports as required.
Sedgwick agrees to comply where there is a state requirement or agreement that the TPA will perform this function.
36. Computer Access
Depending on the claims system used to handle claims, the TPA shall provide online access at no additional charge to the City's Administrator. Such data shall be in a format accessible from the City's Administrator's computers and will permit the City's Administrator to print copies of the data on its printers. The TPA shall provide training for use of the computer system for the City's Administrator. If the City's Administrator, under the TPA's guidance, is not able to maintain online interface with data maintained by the TPA, the TPA may be required to provide a copy of all data processed during the previous month to the City's Administrator's office on a disk by the tenth (10th) calendar day following month end.
Sedgwick agrees to comply with these requirements.
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Sedgwick regularly provides and receives data to and from other RMIS vendors, including SIMS. We currently have experts working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our experts and dedicated analyst, Sedgwick can provide the data requested within SIMS. Additionally, our internal team of SIMS experts can support training for any new colleagues hired on to the City's program.
All data transfers are secured through SFTP, PGP or secure VPN tunnel. An alert protocol is in place to ensure the success of the interfaces for both inbound and outbound transmissions. Additionally, our standard interface procedures use header and trailer records to ensure completion of all data processing for interface exports and loads.
Sedgwick's proprietary, multiline technology platforms are supported by a team of 1,700 IT professionals, which includes colleagues dedicated to application development, infrastructure, network and hardware management, local technology coordination and tech/support help desk operations. Our experienced senior programmers/analysts are dedicated to ensuring that successful transmissions occur on behalf of our clients.
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Claims management and client access in JURIS/viaOne
We provide our clients with direct access to their claim data through our web-based suite of services, viaOne, which gives a comprehensive, platform-independent, secure view of real-time claims information. System access includes:
,. Secure, real-time information from Sedgwick's proprietary claims information systems, including notes, correspondence and other data
c Customizable dashboards with drill-down capabilities, allowing users to customize how they view metrics and data
., Detailed information about the incidents, claimant work status and time tracking information ,. Financial information about an event, including claim payment history and available reserves The creation of client diaries and customized alerts sent via text or email " Easy access to a number of customizable reports with user-specified fields and filters Access to Sedgwick's advanced analytics platform that offers reporting on data at multiple levels from summary trending to fine data elements and enables users to set up recurring reports and push completed reports to other recipients via email. Every report from is available in comma-separated values (CSV) for easy data manipulation in most Word processing and spreadsheet software. Our system allows for exporting into Microsoft Excel and PDF for ease of sharing and printing. Clients can also view, print and save images for faxing and emailing.
In addition to viaOne, our mySedgwick self-service portal provides claim status, payment history, absence history and more. Users can also report a new claim, upload documents, assign delegates, turn on/off push notifications, report a RTW date, communicate securely with an examiner or nurse, view and complete medical authorization and medical history release forms and use direct deposit from mySedgwick. viaOne and mySedgwick are web enabled for use with PCs, tablets or smartphones; users will need a modern version of Microsoft Edge, Google Chrome, Mozilla Firefox or Safari.
We employ a dedicated training team to assist in all client user training. There are several options available for training, depending on the type of application. For viaOne, we typically use webinar-based training. We will work with the City to better define a live training plan, which may be provided on-site, at a centralized location or at a Sedgwick service office.
Sedgwick provides global technical support from our systems support team in Memphis, Tennessee, from 7 a.m. - 6 p.m. EST. Support analysts work directly with callers to resolve issues to their satisfaction and provide status updates as long as the issues are outstanding. Urgent and after-hours calls are directed to support analysts who are on call during non-business hours. There are no fees for technical support.
The City also will have access to on line help files and quick reference guides within viaOne and mySedgwick. 85 102
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37. Reporting Services and Record Retention
Provide the City with regular monthly and quarterly reports in the format and number requested. The reports may be provided in hard copy, excel accessible or via online access format.
Such reports include, but may not be limited to, the following:
• Loss Experience Reports
• Location Report
• Growth Analysis and Loss Narrative Report
• Management Summary Reports
• Weekly Claims Register
• Monthly Claims Summary Reports
• Monthly Claims Register Reports
• Annual Report to the State
• Annual Tax Statements, including Federal Form 1099 and State form 599 as appropriate • Large Loss Reports - Over $25,000 and $100,000
Sedgwick agrees to comply with this requirement.
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Sedgwick has experts currently working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our experts and dedicated analyst, Sedgwick can provide the reporting services requested within SIMS. Additionally, our internal team of SIMS experts can support training for any new colleagues hired on to the program.
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Sedgwick can provide all of the reports listed above, and we will automate the vast majority of them so that your people have the data needed as soon as possible. We typically create all custom reports during the implementation process prior to go-live so that they are ready to go once the claims are in the system. In addition to these reports, we have a number of other advanced reports available to give you even more actionable insight into the City's program.
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In addition to the reports we can create and push to your stakeholders, we offer a wide variety of self-service reports that can be pulled by Sedgwick for the City in our claims management system, JURIS. These reports include accumulative loss analysis, lag report, allocation/transaction report, loss and claim experience report, cause code analysis report, loss analysis II, claim report, loss summary report, claim status history report, loss run summary report, claims log report, miscellaneous client field report, cost range analysis report, pay-code analysis report, experience rating report, payment and reserve progression, hard copies by client report, repeaters list report, indemnity report, reserve change report, stewardship report, specific excess report and many more.
Sedgwick's standard month-end report package includes the following:
,. Adjustment report
,. Loss analysis I report
"' Claim and expense report
,. Transaction report
The month-end package can be customized during implementation. There are no additional fees for standard reports; copies of these are included in the appendix.
In addition to the reports of above, Sedgwick provides electronic data feeds to a wide range of states supporting such transmissions. Sedgwick is compliant in all lAIABC mandated states as well as a number of proprietary states.
Interface files already exist for all states using the various IAIABC formats (release one, two and three). Sedgwick has been reporting electronically in most of these states since they began accepting IAIABC submissions.
Moreover, for many of these states, we are their largest contributor of state EDI information. In addition to these agencies, we have worked with a number of other states before their roll-out of state-mandated electronic data reporting. Sedgwick is a currently an EDI council member at the IAIABC and participates regularly in various conferences and forums to ensure our subject matter experts remain aware of new mandates and changes.
We use a combination of methods to gather information for workers' compensation state reporting. The most common is to pull the information from the claim. For example, date of injury and description, claimant information, cause codes and accident site information can be pulled from the claim. We also gather information from our claims system's parameters (information such as insurer FEIN must be specific to the contract) and office records (claim administrator address and FEIN). One of the more complex ways to gather information is to look at information on the claim and to apply specific logic, depending upon the entries listed. Our programs look for certain triggers for each state on a daily basis and automatically create a flat file that we send to our vendor, Mitchell Workers' Compensation Solutions (Mitchell). Mitchell then sends the information on to each state in the format required. Acknowledgements are processed each day upon receipt from the various EDI states and loaded into the JURIS system. Examiners and team leads receive EDI errors or rejections daily via email so they can review and resolve outstanding issues.
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Through viaOne, our clients have access to an extensive reporting module that can be easily customized using filters, data sorting, subtotals and page-break options. Reports are preformatted but offer multiple levels of detail from summary to fine data elements by line of business, claim type, date range and payment allocations based on the City's reporting needs. The flexible module allows users to set up recurring reports and push completed reports to other recipients via email.
Every report from viaOne is available in comma-separated values (CSV) for easy data manipulation in most word processing and spreadsheet software. via One report and via One advanced analytics allow for exporting into Microsoft Excel and PDF for ease of sharing and printing. Clients also can view, print and save images for faxing and emailing.
Additional reports and lists that must be available include:
• List of Providers -Including the data in the correct format for the City to prepare the IRS 1099s. • Litigated Claims
• Investigated Claims
• Claims involving subrogation
• Vocational Rehabilitation Claims
• Medical Case Management Claims
• First Aid Claims
• Excess Insurance Claims
• Total Incurred for open and closed claims
Sedgwick agrees to provide the reports listed above. We can also provide examples of our best practice reports and can tailor them to the needs of the City, and we can also create custom reports if there are specific formats or criteria that are needed.
Annual Report - Prepare the Public Entities Self-Insurer's Annual Report as required by the Department of Industrial Relations Office of Self-Insurance Plans; and submit it to the City no later than 30 days prior to the due date.
Sedgwick agrees to comply with this requirement.
The TPA shall maintain all loss information as required by the Workers' Compensation Insurance Rating Bureau.
Sedgwick agrees to comply with this requirement.
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The TPA shall assist in the preparation of all reports that are now, or will be, required by the State of California or other government agencies with respect to self-insurance programs. The TPA will also assist in the preparation of all reports for other statistical database organizations or excess coverage provider as requested by the City.
Sedgwick agrees to comply with this requirement. We are also equipped to help keep our California clients in compliance with California Senate Bill 1159 (SB1159). In response to the state-mandated requirements of SB1159, Sedgwick developed a proprietary COVID-19 case reporting system to identify and track outbreaks. 111 Clients have multiple intake options for reporting their positive test results to us. Clients can submit positive results using our on line COVID-19 reporting portal, or they can email or fax positive results using a spreadsheet template we provide to them. Clients must report positive results within three business days of knowledge.
111 Sedgwick will use reported information to determine if an outbreak has occurred. " We will notify the employer if an outbreak has occurred . ., Sedgwick will manage and make determinations around workers' compensation claims that occur during an outbreak assuming a presumption.
38. Records Retention
All claim files shall be maintained in accordance with statutory time requirements and the City's Record Retention Policy. The City shall be notified prior to any destruction of files to determine if the City wishes to retain the claim file.
All records, products and all claim files shall be the property of the City. TPA shall be responsible for providing program tapes, data tapes and system documentation to the City upon request for data from the data system at TPA's expense. TPA shall make claim files available to the City upon request and shall be delivered to the City upon termination of the agreement.
Sedgwick agrees to comply with these requirements.
Claim records are the property of our client partners. The client has the right to review all files at any time, as well as the right to determine if the files should be retained or destroyed. All claim file data can be viewed by the City through our viaOne web-based suite of services.
All claims data (i.e., payment and reserve transactions, file notes, etc.) is retained in the claims system for the life of the claim. We will continue to retain this information unless otherwise obligated by stated contract provisions for distribution of claims data upon termination of services. There are no additional charges for file storage while Sedgwick is under contract to the City. At the termination of the contract, however, the City may be charged the prevailing rate for storing paper files at a storage facility or for the transfer of imaged files.
The City is responsible for storage of claim files closed at the time that Sedgwick begins claims administration.
Sedgwick has included one monthly data file to a single carrier or RMIS system in our proposal. Any requirements outside the scope of our normal layout would be customized and subject to fees.
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39. Loss Runs
The TPA shall, at its expense, by the tenth (10th) calendar day of the following month, unless otherwise specified below:
A. Provide the following information monthly to the City's, as it pertains to their respective claims, electronically, on diskette, or in written format:
SIMS - Sedgwick has experts currently working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our SIMS experts and dedicated analyst, Sedgwick can provide the information below electronically, on disk or in hardcopy. Additionally, our internal team of SIMS experts can support training for any new colleagues hired on to the program.
JURIS/viaOne - The City can pull reports by logging into viaOne and downloading the results. viaOne will send an email notification when the report has finished processing. Sedgwick's claims management system can also push reports to receiving parties by entering the receiving parties email address when the report is scheduled. When the report is finished, results are automatically emailed to the receiving parties. Depending on the need, the user can download reports into CSV, PDF, text or Excel formats for printing. i. A listing of all open claims showing the employee's name, claim number, date of injury, paid amount, future liability, total incurred, and any amounts recovered; Sedgwick agrees to comply with this requirement.
ii. OSHA 300 and 300A logs or a listing of all information needed for the City's to complete the OSHA 300 and 300A logs. The logs or report shall include claims where temporary disability benefits were paid during the applicable month showing the paid-to-date amounts, from and through dates of temporary disability benefits paid, claim number, and date of injury; and Sedgwick agrees to comply with this requirement.
We provide flexible OSHA record keeping solutions. The City has the option to select one of two levels of service to suit their preferences through our via One OSHA tool. via One OSHA is able to generate standard reports such as the OSHA 300, 300A, 301 and Sharps logs as well as other reports such as DART and BLS surveys.
Our service levels include:
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For the basic level, Sedgwick provides initial and ongoing demographic data updates to the application. The City retains responsibility for other record keeping decisions, including time tracking, privacy case designation and recordability. Fees are $6,600 for implementation, $460 per user per year and $15 per incident set up in viaOne OSHA.
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Advanced
With the advanced level, Sedgwick's trained OSHA analysts assume responsibility for all recordkeeping updates, including time tracking, recordability, injury type designation and privacy. Fees are $6,600 for implementation, $460 per user per year and $31 per incident set up in viaOne OSHA.
Sharps fog
Within viaOne OSHA, we also have sharps capabilities. Sharps logs allow employers to easily track all work-related needle stick injuries and cuts from sharp objects that are contaminated with another person's blood or other potentially infectious material, ensuring compliance and helping avoid fines. Sharps logs are available for an additional fee. The additional fee only applies to recordable sharps cases.
Electronic reporting
Sedgwick is also able to support electronic reporting. We will review your structure, size of your establishments and your NAICS codes to determine which of your locations must report to be in compliance with OSHA's electronic reporting rules.
iii. A summary listing by fiscal year to include, but not limited to, paid to date amounts, future liability or reserve amounts, total incurred amounts, number of open claims, number of closed claims, and average cost per claim.
Sedgwick agrees to comply with this requirement.
SIMS - Sedgwick has experts currently working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our SIMS experts and dedicated analyst, Sedgwick can provide the requested information within the SIMS system.
JURIS/viaOne - Our claim and expense report chronicles monthly loss data, provides our clients with detailed claims information for all open claims at each level of the corporate structure and lists closed claims with current activity during the month. The report provides current period financials, as well as total incurred, future reserves and paid to date amounts. It also tracks new claims and closures for the period and contains important recovery financials broken out into the appropriate categories. The claim and expense report also provides summary financial and claim count data at each level of the City's structure.
We also offer the following additional loss run reports:
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Loss run summary report - provides a quick summary of the City's losses as a whole for each policy year. It includes data for the current period defined in the request, summary activity for the year to date and all-time experience on the report end date. The report also features a line breakout as well as recovery blocks for actual and estimated recoveries.
Loss analysis I - report provides our clients with a quarterly top 10 breakdown of injury/loss codes for cause, result/nature, and part/ target within each line of coverage and it subtotals at each level of the corporate structure.
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® Loss analysis II - report displays claims information for either claims opened or claims with loss dates during the reporting period. An excellent supplement to our client's safety data, the report considers each cell and calculates that cell's percentage of the total inventory for the reporting period.
In addition, the City can generate their own monthly loss run per location through their viaOne access.
B. Provide the following information monthly to the City's Administrator electronically in Excel format:
i. All open and closed claims run by fiscal year and then alphabetically by the City, to include the employee's name, claim number, date of injury, occupation, text description of the injury, number of days temporary disability benefits were paid, future liability or reserves separated by type, any amounts recovered for subrogation or excess insurance, free form text description of the claim and descriptions of cause, site, and nature;
ii. A summary listing run alphabetically by the City and then by program year showing paid to date amounts, future liability or reserve amounts, total incurred amounts, number of open claims, number of closed claims, and average cost per claim;
iii. A summary listing run by program year showing paid-to-date amounts, future liability or reserve amounts, total incurred amounts, number of open claims, number of closed claims, and average cost per claim;
iv. A check register, excluding vouchers, in check number order, including any voids, refunds, and recoveries received with a page showing the total payments for the month by fiscal year; v. A check register, including all activity, in check number order, including any voids, refunds, and recoveries received with a page showing the total payments for the month to be run by the City and then fiscal year;
vi. A voucher register run by fiscal year and then by the City; and vii. A "No Activity" report listing the claims that have had no activity during the previous six (6) months. The report components should include no reserve changes, no payments, no recoveries, no refunds, and/or no computer notepad activity.
Sedgwick agrees to comply with 39 (B)(i -vii).
SIMS - Sedgwick has experts currently working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our SIMS experts and dedicated analyst, Sedgwick can provide the information above electronically in Excel format.
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JURIS/viaOne - The City can pull reports by logging into viaOne and downloading the results. viaOne will send an email notification when the report has finished processing. Sedgwick's claims management system can also push reports to receiving parties by entering the receiving parties email address when the report is scheduled. When the report is finished, results are automatically emailed to the receiving parties. Our clients have several options available to them to download reports and other claim data from our viaOne web-based suite of services, including Excel format.
C. Provide the following quarterly reports, in addition to the regular monthly reports, to the City's Administrator electronically in Excel format:
i. A listing of any administrative penalties paid during the quarter that were the responsibility of the TPA.
Sedgwick agrees to comply with 39 (C){i).
SIMS - Sedgwick has experts currently working within the SIMS system that can act as a resource and provide system support to the City. Among these experts is our dedicated IT analyst, Juan Rangel, who has worked in SIMS since 2015. Using our SIMS experts and dedicated analyst, Sedgwick can provide the information above electronically in Excel format.
JURIS/viaOne - The City can pull reports by logging into viaOne and downloading the results. viaOne will send an email notification when the report has finished processing. Sedgwick's claims management system can also push reports to receiving parties by entering the receiving parties email address when the report is scheduled. When the report is finished, results are automatically emailed to the receiving parties. Our clients have several options available to them to download reports and other claim data from our viaOne web-based suite of services, including Excel format.
D. Provide a report to the City's Administrator annually in written format as of June 30, in addition to the regular monthly and quarterly reports, a year-end report. The report shall include all open and closed claims run by fiscal year and then alphabetically by the City, to include the employees' name, claim number, date of injury, occupation, text description of the injury, number of days temporary disability benefits were paid, future liability or reserves separated by type, and any amounts recovered for subrogation or excess insurance; and
Sedgwick agrees to comply with this requirement.
Our claim system provides for preprogrammed claim status reports. We use these reports for clients who require written status reports at regular intervals, usually quarterly, for serious or complex cases. These reports provide the most recent claim examiner, team lead and medical management notes, as well as reserve payment and any excess information. We recommend development of a cumulative report that could provide updated claim information in a condensed format. Reports can be scheduled annually.
There are many data filtering options available to clients when requesting this report, including but not limited to the status of a claim, the type of claim, range of dates, as of reporting and pay categories. Additional options are available on a number of fields such as litigation, subrogation, excess, rehabilitation and finance ranges.
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A sample claim status report is included in the appendix.
E. Provide other special reports required of the City or its Administrator including, but not limited to, loss trend reports, claim abstract reports, reports required by actuaries, excess insurance carriers, etc., provided that such reports do not require data elements that have not previously been collected by the TPA on behalf of the City. If new programming is required in order to provide such reports, the TPA shall pay at its own expense for new or special programming costs.
Sedgwick agrees to provide the reports by the required timeline. Our best practice is to provide key monthly reports by the fifth business day. For reports we are able to completely automate, we can provide those as soon as the morning of the first day of the month. Any programming customization requests outside the scope of our normal layout would be subject to additional fees.
Any corrections to the loss runs shall be made within thirty (30) calendar days of the request for correction.
Sedgwick agrees to comply with this requirement.
40. Availability of Personnel
The TPA shall maintain at all times, one (1) or more of the examiners assigned to the City's claims, or in their absence, the supervisor or management above the supervisory level, to be available by telephone for emergencies through a 24-hour emergency telephone number. The TPA shall provide a toll free telephone number at no additional charge to the City.
Sedgwick agrees to comply with these requirements.
Our standard hours of operation are 8:30 a.m. to 5 p.m. However, to meet customer needs, we can assign team members to work non-core hours.
In addition, Sedgwick has resources available 24/7 year-round in the event of a serious incident. We will customize the catastrophe work plan to meet the City's needs. Should the City have a catastrophic claim, the contact center will initiate City-specific procedures including contacting designated City team members. Our staff, including nurses specializing in catastrophic claims, will be deployed to the field so immediate discussions can be held with the family and care team. The appropriate parties from the City will also be contacted immediately.
Sedgwick's complex claims resources are engaged in all catastrophic claims upon intake to help the examiner set the proper foundation, enlist the appropriate resources, set an adequate reserve and form an effective resolution plan. Our organization has developed care paths for most catastrophic conditions such as traumatic brain injury, paralysis, amputation, burns and blunt-force trauma. These care paths help our colleagues know what to expect and contemplate when dealing with catastrophic injuries and assist in having discussions with family and forming expectations and projections around recovery and resolution. Sedgwick's medical director and team of clinicians established and maintain a network of centers of excellence for severe injuries, such as traumatic brain injuries and spinal cord injuries. Centers of excellence have the world's best specialists and facilities to ensure the patient receives the best care at the earliest opportunity. The accurate and exhaustive care approach involves using the most highly skilled and most experienced specialists at the best facilities to mitigate long-term illness and permanent damage.
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Our general criteria to classify an injury as catastrophic include death, serious disfigurement, paraplegia, quadriplegia, serious burns, amputations, head trauma or inpatient hospitalizations involving trauma to multiple body parts. This list will be modified to suit the City's expectations.
Sedgwick offers toll-free claim intake 24 hours a day, seven days a week for all lines of business through our national contact centers. This is provided at no additional charge.
The TPA shall ensure at least one (1) or more of the examiners assigned to the City's claims are available to the City and/or on-site every business day throughout the term of this AGREEMENT.
Sedgwick agrees to comply with these requirements.
41. The City Services
The TPA shall provide special on-site training services annually to the City's staff to ensure that the City's staff that process workers' compensation claims are effectively carrying out the procedures required for a successful program. A copy of the City's Workers' Compensation Claims Procedures Manual should be readily available for review by the City's' staff or representative.
Sedgwick agrees to comply with these requirements.
Sedgwick will partner with the City to develop training and communication resources for your employees and management staff that will outline the claim procedures and other pertinent areas of workers' compensation and liability. Sedgwick is committed to meeting the ongoing educational needs of both our internal colleagues and the City's risk management staff members. We would be happy to partner with the City to develop suitable on-site training as required.
Sedgwick routinely provides training to our partners on an overview of workers' compensation, MPN management, forms employers must provide and time frames they must meet, and new jurisdictional requirements.
Below are some examples of our commitment to providing training and communication to our clients:
Statutory reforms - When California Senate Bill 863 was passed, Sedgwick held a one-day client forum in Los Angeles to review Senate Bill 863. This one-day forum included an outline regarding the genesis of the bill, what was contained in the bill, potential financial impact and an expert panel Q&A session.
The director of the Department of Industrial Relations, Christine Baker, spoke regarding the legislative intent and implementation. We also provided detailed communications to our clients due to reforms in Oklahoma, Illinois and Tennessee.
* Managed care strategies - States like California, Oklahoma and Texas have enacted pharmacy formularies. Our managed care practice team provides resources to our clients so injured employees are provided quality and appropriate care. Upon Illinois enacting their Preferred Provider Program (PPP), Sedgwick held a series of WebEx presentations notifying our clients of Sedgwick's plan for implementation and an outline of how the PPP works, including notification requirements. 95 112
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" Spotlights - We supply spotlights on issues important to the industry. Recent spotlights include our approach to marijuana utilization, same sex marriage, a national legislative summary and how to manage workers' compensation claims when narcotics are supplied. " Case decisions - Our workers' compensation practice group provides updates on important case decisions. For example, Florida and Oklahoma have recently published very impactful decisions, and these were shared with our clients. Sedgwick provided summaries, analysis and our plan going forward. * State expert website - We maintain a state expert portal page for all jurisdictions. State experts work alongside our workers' compensation practice group to update each site with important developments.
This provides a comprehensive resource for all Sedgwick colleagues regarding specific jurisdictional issues.
Healthcare forums - On a quarterly basis, we have a healthcare forum with our clients and review substantive legislative and industry changes.
The TPA shall require its examiners or other TPA personnel, as necessary, to attend the City's meetings, if requested by the City to report on the general state of the program since the last meeting and on any particular cases of interest to the City. The TPA may require the supervisor or other TPA personnel, as necessary, to attend the City's meetings to report on the general state of the program since the last meeting and on any particular cases of interest to the City.
Sedgwick agrees to comply with these requirements.
Sedgwick believes in the importance of regular stewardship meetings and reviewing statistical information on a program's results with the goal of continuous improvement. Sedgwick will provide a detailed analysis that will include all pertinent performance metrics as well as periodic review against industry trends that may impact the City's program. We will also review the effectiveness of specific programs as they relate to the City's overall loss information. The CSD will work in collaboration with the City to determine the appropriate metrics to report on an annual and ongoing basis.
The TPA shall consult annually with the City on the establishment and coordination of necessary procedures and practices to meet the needs of the City with respect to the administration and processing of claims.
Sedgwick agrees to comply with this requirement.
The City's CSD will work with you to develop detailed custom CSls, that are integrated into our claims management system so that all claims professionals have immediate access to City's policies and instructions as they work on the claims management program. These are embedded in our claims system and are authored solely by your CSD. Any updates made to the City's CSls are immediate for all designated team members once entered and updated.
Sedgwick uses SMART panel, a rules-management solution designed to automate operational client-specific instructions as the claim is being handled. This provides additional agility, consistency and precision in client interactions. As specific information is added to or updated in the claims system, it automatically notifies the examiner of client-specific handling requirements.
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Compliance is met through a myriad of techniques. The claims system provides alerts to the examiner based on client-specific handling instructions to remind them proactively of necessary items. The examiner's team lead is notified if these items are not completed in a timely manner. Our team leads review the claim at regular intervals to measure compliance with instructions and ensure the claim is headed to a timely and equitable resolution.
Sedgwick's quality team also reviews a sample of claims to measure compliance and outcomes. Training, mentoring and coaching is developed based on the results of these reviews.
Sedgwick will work with the City to create claim handling best practices specific to your needs.
Our CSI template is included in the appendix.
The TPA shall require one of the examiners or supervisory staff to meet with each the City's personnel, at the City's location, at least once annually to review program procedures regarding workers' compensation reporting requirements and other program matters that require the timely participation of the City's personnel.
Sedgwick agrees to comply with this requirement.
The TPA shall require an examiner to be available and readily respond to the City's request for assistance with problem cases, including on-site visits to the City.
Sedgwick agrees to comply with this requirement.
The TPA shall provide the City with information regarding statutes, proposed changes to statutes, and changes to the rules and regulations affecting the City and its responsibility as a legally uninsured workers' compensation authority.
Sedgwick agrees to comply with this requirement.
Compliance with statutory and regulatory changes is an integral part of any successful benefit administration program. Our workers' compensation practice lead oversees the workers' compensation practice assisted by regional representatives from specific geographic regions and approximately 30 state experts from our claims offices. Training sessions are also developed if the particular jurisdictional change warrants.
The local experts track regulatory changes and communicate them to our regional representatives and national practice lead. We also use numerous regulatory tracking resources to identify pending and recently enacted legislation throughout the country. Sedgwick subscribes and publishes legislative and regulatory publications, and we are members of such organizations as the SIIA, WCRI, NCSI, UWC and IAIABC.
These groups send subscription updates that are summarized and provided to the field offices. We also attend local, regional and national seminars and meetings hosted by these organizations.
In addition, Sedgwick encourages all of our clients to maintain memberships in local associations in order to be directly involved in the legislation process. When necessary, the CSD is available for training related to regulatory changes.
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Sedgwick is committed to meeting the ongoing educational needs of both our internal colleagues and the City's risk management staff members. Sedgwick routinely provides training to our partners, including an overview of workers' compensation, MPN management, forms employers must provide and time frames they must meet. We would be happy to partner with the City to develop suitable training.
As an example of our commitment to providing training and communication to our clients, Sedgwick held a one day client forum in Los Angeles to review California Senate Bill 863. This one-day forum included an outline regarding the genesis of the bill, what was contained in the bill, potential financial impact and an expert panel Q&A session. The director of the Department of Industrial Relations, Christine Baker, spoke regarding the legislative intent and implementation. We also provided detailed communications to our clients in a similar manner due to reforms in Oklahoma, Illinois and Tennessee.
The TPA shall assist in developing and recommending policies and procedures in areas as required by the City.
Sedgwick agrees to comply with this requirement.
We believe in the importance of regular stewardship meetings and reviewing statistical information on a program's results with the goal of continuous improvement. Sedgwick will provide a detailed analysis that will include all pertinent performance metrics as well as periodic review against industry trends that may impact the City's program. We will also review the effectiveness of specific programs as they relate to the City's overall loss information. Your CSD will work in collaboration with you to determine the appropriate metrics to report on an annual basis.
42. Employee Services
As required, the TPA will develop, for review by the City, materials which will provide information and guidance to the City's' employees regarding workers' compensation and the self-insurance program.
Sedgwick agrees to comply with this requirement.
As part of the implementation process, our team works with you to fully understand your company's communication philosophy and will work with you on recommended communications for your injured employees.
As part of our change management plan, Sedgwick has best practice templates to ensure all stakeholders are notified of the transfer of services, key dates and the appropriate contact information for Sedgwick. Our goal is to fully support employees, supervisors and HR resources to ensure an optimal transition. Sedgwick can assist in developing education materials that the City can use in providing an overview of Sedgwick's services and policy administration to employees, all of which we will discuss and mutually agree upon during implementation.
As required, the TPA will meet with and assist injured employees in resolving problems that arise from injury or illness claims.
Sedgwick agrees to comply with this requirement.
We have found that one of the most successful ways to address complex issues with an unrepresented employee as they pertain to the claims settlement process, is to schedule an in person meeting in coordination with the City.
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Additionally, Sedgwick's managed care solution is built around our philosophy that caring counts and often involves meeting virtual or on some occasions in person with the inured employee. We offer a breadth of managed care services, all with one common goal: helping the injured employee recover and RTW quickly and safely. Sedgwick provides a full suite of medical management services. Sedgwick colleagues across multiple disciplines, including claims examiners, nurse case managers, pharmacists, physicians and behavioral health specialists work together in one claims management platform with a single leadership team, shared goals and accountability. This integrated approach creates a collaborative care environment and shared accountability that consistently fosters excellent service and outcomes for injured employees.
Sedgwick offers tools to support every claim scenario.
Clinical consultation/24/7 nurse triage to assess and provide treatment direction for self-care, telemedicine or in-person care
* Behavioral health solutions to identify and address psychosocial barriers to ease the RTW process TCM to screen claims, evaluate injuries and manage RTW efforts, speeding recovery and controlling costs
Surgery nurse program to engage injured employees in prehabilitation/rehabilitation using an innovative app and an experienced nurse
" Field and catastrophic case management to provide short-term task assignments, long-term on-site medical and vocational services and catastrophic services depending on the needs of the case UR, including pharmacy UR, to review treatment requests, where allowable by law, and validate or negotiate the necessity, setting, frequency, intensity and duration of care " Medical director/physician advisor review to enhance the UR process, and provide medical and pharmaceutical expertise to ensure clients and their injured employees continue on the right path to achieve the best possible outcomes
$ Complex pharmacy management to control the use of narcotics, opioids and other inappropriate drugs prescribed to treat work-related injuries
RTW case management to assess functional capabilities and provide strategies for modified duty that match individual claim circumstances and complexity
Medical bill review and medical state reporting by experts, backed by customized technology, allowing us to achieve the highest possible savings for our clients National provider benchmarking to build superior networks and ensure quality care from providers who drive positive results for clients
,, Medical networks of high quality providers including Outcomes, quality-based
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PPO, managed care organization (MCO), MPN and HCN
* Specialty networks including
PBM
Medical equipment and supplies
Physical medicine and rehabilitation
Radiology and diagnostics
Home health
Rideshare transportation solution
Translation
We deliver all of this with an emphasis on the consumer experience, always remembering that at the center of what we do is an injured employee who deserves the best care possible.
43. Examiner Training
The TPA shall annually certify to the City that each claims examiner handling the City's' claims is in compliance with all legal and regulatory licensing and continuing educational requirements as presently or in the future shall be promulgated and required by the State of California. Such certification for the prior year shall be in the form of a letter to be received no later than April 1 of each year.
Sedgwick agrees to comply with this requirement.
We maintain a fully licensed team and our best practice is that our examiners are licensed and credentialed as required by state law. We are dedicated to full compliance with licensing requirements nationwide. A team of regional license coordinators are assigned to assist the individual professionals in obtaining and maintaining examiner license types and required continuing education. Sedgwick maintains and tracks individual examiner licenses in a licensing management system called RegEd. Sedgwick maintains and tracks TPA licensing in a management system called LicenseHQ.
Requirements for licensing or certification of examiners vary by jurisdiction, by governing agency (Department of Insurance and Workers' Compensation agency), by lines of business and funding type, by corporate firm and by the individual examiner level. Sedgwick corporate holds the required Department of Insurance and Workers' Compensation agency-level approvals where required for insurance and self-insurance claims handling.
Approximately 45,000 examiner licenses are held with Departments of Insurance. In addition, hundreds of training certifications are held with workers' compensation agencies as required (for example states such as Washington, Oregon, California and Alabama).
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California-specific training - Because California has unique workers' compensation laws, we have a dedicated training facility in Orange, California, that focuses on training our examiners for both claims handling and California-specific workers' compensation statutes.
44. Right to Audit or Review
The City or its designated representative is authorized to visit the TPA's processing and/or storage premises, for purpose of performing a claims audit or review, and have access to all data, including paper documents, microfilm, microfiche, and magnetically stored data which relate to payments or non-payments made by the City. Additionally, TPA will undergo claims audits by PRISM or their contracted auditor. Any assistance or service provided in response to a claims audit described above will be rendered at no additional cost to the City.
We welcome independent audits as directed by the City; however, all costs associated with a third-party audit for the independent review team are the responsibility of the City. Sedgwick will provide on-site or electronic access to requested file information for audit purposes.
44. Legislative and Judicial Activity
TPA shall keep the City informed as to recent changes or proposed changes in statutes, rules, laws and judicial decisions affecting the City's responsibility and the responsibilities of its personnel under a self-insured Workers' Compensation program.
Sedgwick agrees to comply with this requirement.
Compliance with statutory and regulatory changes is an integral part of any successful benefit administration program. Our workers' compensation practice lead oversees the workers' compensation practice assisted by regional representatives from specific geographic regions and approximately 30 state experts from our claims offices. Training sessions are also developed if the particular jurisdictional change warrants.
The local experts track regulatory changes and communicate them to our regional representatives and national practice lead. We also use numerous regulatory tracking resources to identify pending and recently enacted legislation throughout the country. Sedgwick subscribes and publishes legislative and regulatory publications, and we are members of such organizations as the SllA, WCRl, NCSl, UWC and lAlABC.
These groups send subscription updates that are summarized and provided to the field offices. We also attend local, regional and national seminars and meetings hosted by these organizations.
In addition, Sedgwick encourages all of our clients to maintain memberships in local associations in order to be directly involved in the legislation process. When necessary, the CSD is available for training related to regulatory changes.
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Sedgwick will partner with the City to provide training and communication resources for your employees and management staff that will outline the claim procedures and other pertinent areas of workers' compensation.
Sedgwick is committed to meeting the ongoing educational needs of both our internal colleagues and the City's risk management staff members. Sedgwick routinely provides training to our partners, including an overview of workers' compensation, MPN management, forms employers must provide and time frames they must meet. We would be happy to partner with the City to develop suitable training.
As an example of our commitment to providing training and communication to our clients, Sedgwick held a one day client forum in Los Angeles to review California Senate Bill 863. This one-day forum included an outline regarding the genesis of the bill, what was contained in the bill, potential financial impact and an expert panel Q&A session. The director of the Department of Industrial Relations, Christine Baker, spoke regarding the legislative intent and implementation. We also provided detailed communications to our clients in a similar manner due to reforms in Oklahoma, Illinois and Tennessee.
45. Conflict of Interest
The TPA shall avoid all conflicts of interest or appearance of conflicts of interest in performance of this AGREEMENT. If, during any given year, the TPA receives compensation from any party for services included in this AGREEMENT, such as bill review services, managed care, or investigations, the TPA shall disclose total compensation received in prior year. Such disclosure shall be in the form of a letter and shall be received by the City no later than April 1 of each year.
Sedgwick agrees to comply with this requirement.
These performance standards may be modified, or additions made prior to execution of a contract, and re evaluated throughout the term of the contract. All claims handling services shall comply with statutory requirements.
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Request for Proposals (RFP) Addendum #1
City of Torrance 13031 Torrance Blvd, Torrance CA 905031 www.TorranceCA.Gov RFP No. 82022-28 RFP for Workers' Compensation Claims Administration Services The City of Torrance has received several queries from vendors who are interested in the Request for Proposals (RFP) for Workers' Compensation Claims Administration Services The City of Torrance has decided to make the following exceptions/modifications to this RFP process:
1) This Addendum serves as Addendum #1 to the RFP, and answers questions received by the question deadline of May 20, 2022 at 12:00 noon PST.
No email submissions will be accepted.
The submittal information for this RFP is listed below.
RFP SUBMITTAL INFORMATION
Proposals may be mailed, hand delivered, or submitted via DropBox. No faxed Proposals will be accepted.
Late bids will not be accepted.
Location: Office of the City Clerk
3031 Torrance Blvd.
Torrance, CA 90503
Date: Monday, June 6, 2022
Time Deadline: 3:00 P.M. Local (Pacific) Time
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Questions Received as of May 20, 2022. All responses provided by the City of Torrance.
QUESTION 1: Please provide the pending/open Medical Only and Indemnity claim counts for the Fire and for all other departments.
DEPARTMENT INDEMNITY MEDICAL ONLY Grand Total
CITY CLERK 3 3
CITY MANAGER 1 1 2
COMMUNITY DEVELOPMENT 5 6 11
Community Srv 29 15 44
ENGINEERING 3 3
FINANCE 5 4 9
FIRE 155 63 218
FLEET SERVICES 2 2
GENERAL SERVICES 26 13 39
INFORMATION SYSTEMS 2 5 7
POLICE 214 77 291
PUBLIC WORKS 49 47 96
RECREATION 6 1 7
Transit 57 56 113
Grand Total 554 291 845
QUESTION 2: Please provide the pending future medical claims for each department (Police, Fire and all other departments.)
There are approximately 350 pending future medical claims (all departments included).
QUESTION 3: Do you have a caseload requirement per adjuster? Per PRISM - Each claims examiner assigned to the Member should handle a targeted caseload of 125 claims. In situations where caseloads include future medical and medical only claims, these claims shall be counted as 2:1 in the caseload limit.
QUESTION 4: Are future medical claims weighted differently than IN claims? Per PRISM - In situations where caseloads include future medical and medical only claims, these claims shall be counted as 2: 1 in the caseload limit.
QUESTION 5: What system is the program currently administered on? The system currently used for program administration is SIMS w/lnsurity version - 18.2.0.19789.
QUESTION 6: What vendors currently provide Managed Care Services to the City? The following vendors provide Managed Care Services to the City of Torrance:
• Field Nurse - IWCC; ISYS
• Bill Review - Conduent
• RTW coordinator/Interactive Facilitators - Dickerson Consulting; Shaw Consulting • UR - Professional Dynamics, Inc;
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QUESTION 7: Are you looking for the TPA to provide Managed Care Services (Bill Review, Utilization Review, Nurse Case Management) on the claims that get outsourced? If so, can you provide a copy of the contract and/or fee arrangement for all services being provided currently by the vendor(s).
The City would prefer current vendors continued to be utilized.
QUESTION 8: The City states that it will "maintain its own bank account and process checks" - does this mean that the City will be printing all checks in connection with their Workers' Compensation Program? If so, will the selected TPA have to enter all the payments into the current City's Claim Management System if the TPA is utilizing their own system?
If the TPA will be utilizing their own system, the preference would be for the TPA to ""reverse wire"" or draw from the City's bank account the needed amount of funds and process the checks themselves. The TPA will need to provide the City with the journal entries to be recorded (template to be provided by City).
If the TPA is using the City's system, check printing will be handled by City.
QUESTION 9: What is the inventory breakdown of Future Medical Files? Are they included in the Indemnity numbers? If they are not included in the table below, is the City going to retain those files? Approximately 350 (all departments included) and they are included in both indemnity if payments were issued to the claimant and MO if there were no claimant payments issued.
QUESTION 10: When the City outsources all its claims in year 3, will the City still prefer the TPA to use the City's SIMS system or would the City prefer the TPA to use their own system? Also, if the City prefers the TPA to use its own system to handle all claims beginning in year 3, will the City transition to having a trust account so that the TPA can issue all payments with approval of the City? The current contract with the system provider is due to expire 06/30/2023 and there is a RFP award pending for the next vendor. There is a possibility we will not 100% outsource by year 3. It is anticipated that this will be re-evaluated in year 2. As such the City prefers the use of the City's system. However if not acceptable by TPA, see answer to Question #8.
QUESTION 11: In reference to the City's Indemnity Claim Count, how many are Future Medical only claims? Please provide a breakdown for Police, Fire & All Other Departments.
There are approximately 350 pending future medical claims (all departments included).
QUESTION 12: What is the City's process for approving vendors to provide services for Bill Review, Nurse Case Manager, Utilization Review, etc.?
The City would prefer current vendors continued to be utilized.
QUESTION 13: What is the process for approving investigative firms? The chosen Third-Party Administrator (TPA) will obtain City's approval for timeframe and vendor.
QUESTION 14: Does the City have a panel of preferred investigators? For Panels, the City currently utilities Digistrearn and R.J.N. Investigations. 3 122
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QUESTION 15: Is there a process to approve whether or not to assign an investigator on a case by case basis? If so, what is the process? If not, are you looking for a partner to help the City establish some protocols?
\fl/ILL BE ADDRESSED IN APOJ;f\JQl,JM#2
QUESTION 16: Does the City currently have an ADR program in place? If not, is the City looking to implement an ADR? If so, can the City provide some insight as to when and why? The City isn't currently utilizing an ADR process but may be interested in the near future.
QUESTION 17: What is the City's record retention policy? Specifically, for physical claim files.
According to the City's record retention policy, physical claim files should be held indefinitely.
QUESTION 18: What claims management system is the City utilizing? What version? The system currently used for program administration is SIMS w/lnsurity version - 18.2.0.19789.
QUESTION 19: Please provide a detailed loss run (in excel) for the past three years. {If it includes Employee Dept. codes, NCCI Cause of Loss codes and accident descriptions, we can run and include within our response a loss analysis into the City's loss trends and problem departments which will allow us to suggested a risk service plan to lower the City's total cost of risk.} View attached Excel file for detailed loss run report.
QUESTION 20: On page 7 of the RFP, Overview, it includes a chart of the average counts by department. Are these the annual estimates of NEWLY reported claims?
The count provided on page 7 of the RFP are the open claims as of 5/2/22.
QUESTION 21: Of the Police department's 224 open indemnity claims, how many are future medical claims? Approximately 50% of the Police Department's open indemnity claims are future medical claims.
QUESTION 22: How many "Report Only" claims are submitted annually? Approximately 50 "Report Only" claims are submitted annually.
QUESTION 23: Please provide the last three years (fiscal years 2018-19, 2019-20, 2020-21) of the City's CA Dept. of Industrial Relations Public Self Insures ER Annual Report. \/1/Jlc_L BE APQRESSED IN AQDENDUMft_2
QUESTION 24: Who are the City's current managed care vendors (bill review, utilization review, NCM, TCM, etc.)?
The City would prefer current vendors continued to be utilized.
QUESTION 25: How many medical bills were processed in 2018, 2019, 2020? There are approximately 5500-6000 medical bills processed each year. 4 123
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QUESTION 26: What are the total medical costs paid/incurred in 2018, 2019, 2020? WILL BE ADDRESSED IN ADDENDUM #2
QUESTION 27: Is the City currently utilizing the ADR process? If so, who is the Ombudsman utilized? The City isn't currently utilizing an ADR process but may be interested in the near future.
QUESTION 28: Which workers' compensation (RMIS) system does the City currently utilize? The system currently used for program administration is SIMS w/lnsurity version - 18.2.0.19789.
Addendum Issued By Order Of,
Adrian Fajardo
Management Assistant
May 26, 2022
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Request for Proposals (RFP) Addendum #2
City of Torrance I 3031 Torrance Blvd, Torrance CA 90503 I www.TorranceCA.Gov RFP No. 82022-28 . RFP for Workers' Compensation Claims Administration Services The City of Torrance has received several queries from vendors who are interested in the Request for Proposals (RFP) for Workers' Compensation Claims Administration Services The City of Torrance has decided to make the following exceptions/modifications to this RFP process:
1) This Addendum serves as Addendum #2 to the RFP, and answers questions received by the question deadline of May 20, 2022 at 12:00 noon PST and not answered by Addendum #1.
No email submissions will be accepted.
The submittal information for this RFP is listed below.
RFP SUBMITTAL INFORMATION
Proposals may be mailed, hand delivered, or submitted via DropBox. No faxed Proposals will be accepted.
Late bids will not be accepted.
Location: Office of the City Clerk
3031 Torrance Blvd.
Torrance, CA 90503
Date: Monday, June 6, 2022
Time Deadline: 3:00 P.M. Local (Pacific) Time
1 125
175
Questions Received as of May 20, 2022. All responses provided by the City of Torrance.
QUESTION 15: Is there a process to approve whether or not to assign an investigator on a case by case basis? If so, what is the process? If not, are you looking for a partner to help the City establish some protocols?
Assignment of investigation is a case by case basis which will be determined by the Workers' Compensation Manager. The City is open to discussion of protocols with partners.
QUESTION 23: Please provide the last three years (fiscal years 2018-19, 2019-20, 2020-21) of the City's CA Dept. of Industrial Relations Public Self Insures ER Annual Report.
See attachment below.
QUESTION 26: What are the total medical costs paid/incurred in 2018, 2019, 2020? The amounts represented below are the medical paid/incurred that were reported for years 2018-2020.
Year Sum of Paid Medical
2018 $ 655,848.03
2019 $ 973,787.61
2020 $ 1,817,073.13
Grand Total $ 3,446,708.n
Sum of Medical Incurred
$
$
$
$
1,573,894.71
2,290,064.94
7,025,593.14
10,889,552.79
Addendum Issued By Order Of,
Adrian Fajardo
Management Assistant
May 27, 2022
2 126
176
State of California
Public Self Insurers
Claim Liability - Amended Report
For Period: 07/01/2020 - 06/30/2021
127
177
State of California
Amendment:
Amendment Reason Number of Cases Reported is incorrect (indicate which line i.e. 2a all cases reported or cases open} Report Location Number: Identification of Location
7110·01·099 A CITY OF TORRANCE at TORRANCE
Certificate Holder
City of Torrance
[···~~~E~:~D ~E~~~ITS (to the nea~est.~~llar\~-------------~\,_F_ro_m_D_a_te_~...c.~id To Date ·----·- - ............ ·+······ . ····-·· ·- .... .
Claim Liability
Future Liability
Date # Indemnity Medical , Medical lndemni!y Medical
1) Cases open as of 06/30/2021 ·;135l{~~-$22.764,028)f'.' $4~;29~;244)~ $17,407,412]{ _$:2i'.o~.~3~3T[~. .. ss.3s6.616"c ;~Pi~=~ ~~:rc::::d
1 ~:::ilities ,- 171 *: ··--~---d-----~-J~-----
A) All Cases reported in 2016117 I -·-~-' •• SJ33~.t4iN'• $t:1J~,,5~,~r $1,185,130f .. $709,334p 2016/17 Cases open . ······ -41l : $98!l;J~]· ,$,1'~1~~6pjf $835,17211 ___ $_4_60.374{ B)All Cases reported in 2017/18 ,. ····;;;~,.:==::$1.1ll;;~ij1:~ -).~~~~~4~, $1,247,460){-- --$~37.334 . 2017/18 Cases open .••.. 58Jt .. $1 $1,052,368)( $505.733' C) All Cases reported in 2018/19 ----'--......,....., s1.24·4·.~?:1C sns.9as. 2018/19 Cases open ;:..:===·:::::-:;:::;::j ~---i $1,148,935f . $605.916[:
it_ 1111[ $t68J;!l9,.2- '.< ~;Ei6.Q;76?' $1,319,46_~.1 .. .. $1,408,4281\ D) All Cases reported in 2019/20 2019/20 Cases open :: - . ll5J,/ .. ,$.l.$i •'. $1,205,090'L.
E) All Cases reported in 2020/21
2020/21 Cases open
J ii;slf - $1,,11;t,;a $764,3591! s219. ,ao ,;
:1~ J1:,~,$Q'i~ $685.73a,;·-- $212.25al
S Indemnity
3) Estimate Future Liability (Indemnity Plus Medical)
SUBTOTAL I
TOTAL
$7,620.84~ .
4) Total Benefits Paid During 2020/21 (Including all case expenditures). The indemnity amount includes the amount of LC § 4800/4850 benefits paid for the year (total or Lines 11 and 12)
S Indemnity
$2,757.977
5) Number o! MEDICAL•ONL Y Cases Reported in 2020/21
6) Number of INDEMNIIY Cases Reported in 2020/21
7) Total of 5 and 6 (Also entered in 2F above)
8) Total Number of open Indemnity Cases (All Years)
9) Number of Fatality Cases Reported In 2020/21
10) (a) Number of FY 2020/21 claims for which the employer or administrator was notified of representation by an attorney or legal representative in 2020/21
10) (b) Number of non·FY 2021 claims for which the employer or administrator was notified of representation by an attorney or legal representative in 2020/21
11) Amount from salary continuation payments made pursuant lo LC § 4800/4850 that is in excess of the ar;pi,cab!e temporary disability rate for the period paid. 12) Amount from salary continuation payments made pursuant to LC§ 4800/4850 capped at the temporary c1isability r21e for the period paid.
FilesJJo!oaded
ALL Opcr. Indemnity Claims (by reporting and by year) reported and with claims: SIP._Public .. L,st. fJf_ Open_ Cases xisx $153,011 f
$153,011
$515,889!;
$515.889)'
$549.386 e'.
$362,431
$683.512
$683.512 !
s?o6:~-4~)
$706,2~
sj1a.s11]
$778.511J
s_1 ~01 ,698 J
$1,007,6981
.. ..•. )
-·- ·---- ·--·- -·-----..
$1:?5.:.?3~
S1,152,194J
s 1,152.194]
S Medical
$21, 130,837]
$21)'. 751,68:!J
S Medical
S2.925,333j
·'
-····· .. ··::,
305.[
6oJ
36s·l
siii! ___ J
856.026
128
178
State of California
Dual Jurisdiction Claims
Please note that California Labor Code Section 3702.2(b) requires that" ... the annual report of a self-insured employer who has self-insured both state and federal wor1«crs· C<)mpensation liability snau nlso be, set forth (1) amount of all compensation liability incurred, paid-lo-date. the estimated future liabihl.y under both this chapter and under the feder;;,J longshore and H.~rbor Worke(s Compensation Act {33 U.S.C Sec. 901 et seq.). -ind (2) the identity and the amount of the security depos,t
secunng the employer's liability under state and federal self-insured programs." Accordingly, please mdicate all California exposure on your Self lnsure(s Annual Repcrt, and, in addition identify each Claim with dual jurisdiction on Separate List of Open ldemnity Claims. For those claims. imJicate the incurred, paid-lo-date. and estimated future liabil,ties for federal expo,ure. Please also •ndicate the amount and the type of security deposit securing those claims.
Instructions To Claims Administrator For Soociflc: Excess Insurance The TPA should provide a sum of the unpaid excess carrier excess liability under ·calculation of Specific Excess Coverage Entry for the Annual Reports· In addition. provide a list of claims for which specific excess credit is being claimed. This may be provided as a spreadsheet Indicate ;n the list of claims the following information:
The list shall include the name of the claimant. claim number, date of injury, description of injury, carrier name and policy number. policy coverage period. retention level of policy and paid to date in indemnity or medical benefits, and the estimated future liability of the claim minus the total unpa,d employer retention, which equals the total unpaid carrier liability, whether the claim has been reported to a c-.anier, if the claim has been accepted by the c-.arrier. if the carrier has denied any part of the liability of the claim.
Refer to OSIP website for sample format of the Excess Credit Calculation form.
Calculation Of Soecitic Excess Coverage Entry For Annual Reports:
Enter the sum of the total unpaid carrier excess liability claimed from the "Specific Excess Insurance Policy Coverage" If none enter "O".
Files Uploaded
Certification
Administrating Agency's Certificate Number 099
[Z] Or Self Administered
$ [o
I declare under penalty of perjury that I have prepared or caused this report to be prepared and I have examined this liabilities report to be prepared and I have examined this liabilities report of this self insurer's worker's compensation liabilities. To the best of my knowledge and belief this report is true. correct and complete with respect to the worker's compensation liabilities incurred and paid. I further declare under the penalty of perjury that the estimates of future liability of worker's compensation claims made in this report reflect the administrator's best judgement as to !he future liability of claims. using prevailing industry standards, and the signatory intends Self Insurance Plans to rely upon the representation.
Agency Name
Name
Phone
Email Address
Address 1
Address 2
City
CITY OF TORRANCE
Kimberly Thompson
(310) 618-2950
[email protected]
3031 Torrance Blvd
Name of Person Legally Responsible for this Electronic Signature:
Kimberly Thompson ( Dateff1me of Signature j -10/12/2021 11:18 Fax
State CA Zip 90503
129
179
State of California
STATE OF CALIFORNIA
OFFICE OF SELF INSURANCE PLANS
Public Self Insurers
ER Annual Report
Eor Fiscal Year 2019-20
'
er 1,2020
Torrance
3 Torr;-:m::r1 Hlvd
-rJJance, CA 90503 5013
>;
FORM AR-2 (1-2016)
130
180
State of California
Employer
General Information:
Certificate Number
(Period) From
7110
07/01/2019
Master Certificate Holder:
Name
Address 1
Address 2
City
State of Incorporation
City of Torrance
3031 Torrance Blvd
Torrance
Period Of Report
(Period) To
Annual
06/30/2020
FTIN 95-6000803
State CA Zip 90503 5013
131
181
State of California
During the reporting period of this report, has there been any of the following with respect to the Master Certificate Holder for any affiliate?
None
Any additions to the Self Insurance Program?
None
Employment and wages paid in current fiscal year:
Number of Employees 1,834
Total Wages and Salaries Paid $140,842,116
The variance between Prior Year and This Year is greater than +I- 20%. Please select an explanation:
Reduction in workforce
Addressed Correspondence For Related Self-Insurance Matters:
Company Name
Name
Phone
Email Address
Address 1
Address 2
City
Web Site
City of Torrance
Kimberly Thompson
(310) 618-2950
[email protected]
3031 Torrance Blvd
Torrance
Title Claims Manager
Fax (310) 618-2927
State CA Zip 90503
132
182
State of California
TPA Adjustinq LocatiQns:
Has there been a change in TPA Adjusting Locations during this reporting period that has not yet been reported to OSIP? Have you added any new TPA Adjusting Locations during this reporting period that has not yet been reported to OSIP? Record Storage:
Are there open and closed claims stored at a location other than the adjusting location? Yes Storage Name Phone Number Address
1) Williams Data Management (888) 478-3453 1925 E. Vernon Ave #26 Los Angeles. CA 90058 Insurance Coverage:
No
No
1) During this reporting period, does your company maintain a standard workers' compensation insurance policy to cover any No of your California liabilities?
2) During this reporting period, does your company have a specific excess workers' compensation policy in force to cover any Yes of your California liabilities?
1)
Insurance Company Name
CSAC Excess Insurance Authority
Attachment
Retention Limit
CSAC Excess Insurance f'olicy.pdf
2,000,000.00
3) Do you carry an aggregate(stop loss) workers' compensation insurance policy? Policy Number Policy Issue Date
EIA-PE 19 EWC-19 07/01/2019
No
133
183
State of California
Certification By Authorized ReQresentative:
Company Name
Name
Phone
Email Address
Address 1
Address 2
City
City of Torrance
Kimberly Thompson
(310) 618-2950
[email protected]
3031 Torrance Blvd
Torrance
Name of Person Legally Responsible for this Electronic Signature:
Kimberly Thompson ( Datemme of Signature) - 10/01/2020 14:39 Title Claims Manager
Fax (310) 618-2927
State CA Zip 90503
134
184
State of California
Report Location Number:
7110-01-099A
Identification of Location
CITY OF TORRANCE at TORRANCE
CASES AND BENEFITS (to the nearest dollar)
Incurred Liability
Dale Indemnity Medical
Certificate Holder
City of Torrance
06/30/2020
Future Liability
Medical
1) Cases open as of 06/30/2020
reported prior to 2015/16
450 $22,183,628 $4.781,458 $14,858,311
2) Open and closed Liabilities
A) All Cases reported in 2015/16
2015/16 Cases open
B) All Cases reported in 7016/17
2016/17 Cases open
C) All Cases reported in 2017118
2017/18 Cases open
D) All Cases reported in 2018119
2018/19 Cases open
E) All Cases reported in 2019/20
2019/20 Cases open
167
48 171
1721
61'
158
81 171
124,
3) Estimate Future Liability (Indemnity Plus Medical)
$2,659,242
$1,913,727
$1,312,064
$1,393,632
S 1,201.750
'.li1 ,512,536
$1,489,466
$836,233
$816,581
$2,208,205 :,
$1,910,036
$1.436, 798
$1,234,872\,
$1,242,022
$1,113,019
s, .-1ss.s10;,
$2,3~4.413
$2,320,372
4) Total Benefits Paid During 2019/20 (lncluaing all case expenditures). r,10 indemnity amount includes the amount of LC§ 4800I48:iO benefits pai,J for the year (total of Lines 11 and 12)
5) Number of MEDICAL-ONLY Cases Heported in 2019/70
6) Number of INDEMNITY Cases Reporte,j in 2019/20
7) Total of 5 and 6 (Also entered in 2E above)
8) Total Number of open Indemnity Casns (All Years)
9) Number of Fatality Cases Reported In 2019/20
$423,783
$404,131
SUBTOTAL
TOTAL
$237,87511'
$213,834l;
$ Indemnity
$6,886,4771
$ Indemnity
$1,956,121,
10) (a) Number of FY 2019120 claims for which the erri;,loyc;r or adrnnist,;,lor was notified of represer.tation by an attorney or legal representative in 2019/20
10) (a) Number of non-F-Y 2019/2::J cl;,irns for which lne er'JCllu1er or 2dm1n'strcnor w;,;s nc'.i'led of representation by an attorney or legal representative rn 2019/20
11) Amount from salary continuation payments made pur su,int to LC § '180014850 that is in excess of the ;ipp!icable temporary disability rate for trw period pard. 12) Amount from salary continuation payments rnade pursuan'. to LC § 4800/4850 caoped a~ the ternporar; disability rate for the period pa,cl
Files Uploaded
$567,0181!
$412,450 \
$412,450
$1,010,294
51,010,294
$674,871
$9?9,833
$2,106,538
$2,106,538
$ Medical
$20,341,150'
··'
$27,227,627'
$ Medical
$2,233,005
125
46 523
0 10
28 $286,407
':;fp "'ub,ic List Of Open Cases _Uld0.2020.x,sx
135
185
State of California
Dual Jurisdiction Claims
Please note that California Labor Code Section 3702 2(b) requires that" ... the annual report of a self-insured employer who has self-insured beth state and federal workers· compensar,on li;,bility shall also be set forih ( 1 J amount of all compcnsahon hab1My ,ncurred, paid-to-date, the estimated future tiab1~ly under both 111,s chapter and vnder the federal longshow cind Harbor Wor~.er'•, Compnsation Acl (}3 U.S C Sec. 901 el seq.). and (2) lhe identity and lhe amount of the security deposit securing the emptcyer·s liability under state and f~deral self-insured µrGgran~s." Accordingly, plcaso indicate all California <3~posure on your Self Insurer's Annual F<eport, and, in addition identify ei>Ch Claim w,th dual jurisdicl1on on Soparate Lisi of Open ldemnitv Claims. For those claims, 1ndiCil!e the incurred, paid-to-dale, and estimated future liabilities for federal exposure. Please also indicate lhe amourl and the type of security deposit securing those claims
Instructions To Claims Administrator For Specific E!<cess Insurance The TPA should provide a sum of the unpord excess carrier excess liability under "Calculation of Spec1fir. Excess Coverage Entry for the Annual Reports". 111 addifion, provide a list of claims for which specific excess credit is being claimed. This mny be provided as a spreadsheet. Indicate in the list of claims the following information:
The Ust shall include the name cf the claim~nt. cl:iim number. date of ,niury, deccnplion of injury, carrier name and policy number, policy coverage period. retant,on level of po!icy and p~id to di)te in indemnity or medical benqft:s. {md :he estirn;i:ed fu!ure _liability of the claim minus the tolal u~paid emplovor rt?.tentton. which equ.:ils the total unpaid earner liabihty. whether the claim has been reported lo a earner. if the c1a,rn has been accepted by the carrier. rf the carrier has den;ed any part of the liability of the clarm
Refer to OSIP website for sample format of the Excess Credit Calculation form.
Calculation Of Speciljc Excess Coverage Entry For Ann.\!i!l.Beports:
s ;,o Enter ih: sum of the total unpaid car,,er excess liability clairne,J 'rom the "Spec1f,c Excess Insurance Policy Coverage". If none , enter O.
Files Uploaded
Certification
Administrating Agency's Certificate Number 099
2j Or Self Administered
I declare under penalty of perjury ihat I have prepared er caused th,s re;,01 to be prepared and I have examined this liabilities report to be prepared and I have examined this liabilities report of this self insurer's worker's compensation liabilities. To the best of my knowledge and belief this repori is true, correct and complete with respect lo the worker's compensation liabihlies incurred and paid. I further declare under the penalty of perjury that the estimates of future liability of worker's compensation claims made in lhis report reflect the administrator's best judgement as to the future liability of claims, using prevailing industry standards. and lhe s,gnato:y inlcnds Self Insurance Plans lo rely upon the representation.
Agency Name
Name
Phone
Email Address
Address 1
Address 2
City
CITY OF TORR/\NCE
Kimberly Thompson
(310) 618-2%0
[email protected]
3031 Torrance Ellvd
Torrance
Name of Person Legally Responsible for this Electronic Signature:
Kimberly Thompson ( Date1Time of Signature), 1010112020 · I 4/i Fax
State CA Zip 90503
136
186
State of California
STATE OF CALIFORNIA
OFFICE OF SELF INSURANCE PLANS
Public Self Insurers
ER Annual Report
For Fiscal Year 2018-19
September 30, 2019
City of Torrance
3031 Torrance Rlvd
Torrance, CA 90503 5013
FORM AR-2 (1-2016)
137
187
State of California
Employer
General Information:
Certificate Number
(Period) From
7110
07/01/2018
Master Certificate Holder:
Name
Address 1
Address2
City
State of Incorporation
City of Torrance
3031 Torrance Blvd
Torrance
Period Of Report
(Period) To
Annual
06/30/2019
FTIN 95-6000803
State CA Zip 90503 5013
138
188
State of California
During the reporting period of this report has there been any of the following with resp!;lct to the Ma~Jer Certificate Holder for any affiliat~.1
None
!:illy_ additions to the Self Insurance Program?
None
Employment and wages paid 1n current fiscal year:
Number of Employees 1,959
Total Wages and Salaries Paid $14'1,208,009
Addressed Correspondence For Related Self-Insurance Matters Company Name
Name
Phone
Email Address
Address 1
Address 2
City
Web Site
City of To mince
Kimberly Thompson
(310) 618-2950
[email protected]
3031 Torrance Blvd
Torrance
Title Claims Manager
Fax (310) 618-2927
State CA Zip 90503
139
189
State of California
TPA Adiusting Locations:
Has there been a change in TPA Adjusting Locations during this reporting period that has not yet been reported to OSIP? Have you added any new TPAAdjusting Locations during this reporting period that has not yet been reported to OSIP? Record Storage:
Are there open and closed claims stored at a location other than the adjusting location? Yes Storage Name Phone Number Address
1) Williams Data Management (888) 478-3453 1925 E. Vernon Ave #26 Los Angeles, CA 90058 Insurance Coverage:
No
No
1) During this reporting period, does your company maintain a standard workers' compensation insurance policy to cover any No of your California liabilities?
2) During this reporting period, does your company have a specific excess workers' compensation policy in force to cover any Yes of your California liabilities?
Insurance Company Name
CSAC Excess Insurance Authority
Policy Number Policy Issue Date
1)
Attachment
Retention Limit
WC Excess lnsurance.pdf
2,000,000.00
3) Do you carry an aggregate(stop loss) workers' compensation insurance policy? EIA-PE 18 EWC-14 07/01/2018
No