MEDREVIEW
P.O. Box 3730 Ontario, CA 91761
Savings by Service Class
Client: Total:Total
Service Class Additional
Bill Count Total Charges Charge Dup Red BR Reg Red OSR Red All Other Red Total Red Total Red % Total Allowance ANESTHESIOLOGY 4 $12,912.00 50.00 $0.00 $10,751.28 $0.00 $0.00 $11,065.42 85.70% $1,846.58 196 $107,274.56 $0.00 $10,786.91 $46,654.57 $163.74 $8.98 $58,077.35 54.14% S49,197.21 DURABLE MEDICAL EQUIPMENT 17 $13,085.72 $0.00 $1,082.92 $3,630.41 $0.00 $117.41 $5,438.54 41.56% $7,647.18 EVALUATION AND MANAGEMENT 380 $145,977.91 $13,988.33 $61,942.08 $0.00 $0.00 $83,988.07 57.53% $61,989.84 12 $0.00 S100,233.47 $0.00 S0.00 $100,938.92 87.53% $14,377.00 FACILITY-INPATIENT HOSPITAL $429,717.45 $599,103.32 $0.00 $0.00 $1,030,196.11 92.42% S84,498.62 FACILITY-OUTPATIENT HOSPITAL 11 $1,538.34 $80,311.86 $0.00 $0.00 $81,892.51 76.86% $24,657.83 HEARING SERVICES 1 $0.00 $6,175.00 $0.00 $0.00 $6,175.00 100.00% $0.00 18 $19,967.64 $0.00 $1,027.80 $0.00 $0.00 $1,027.80 5.15% $18.939.84 88880888 $84.92 $3,162.52 $4.97 64,88%
MEDICAL AND SURGICAL SUPPLIES 11 $5,397.40 $0.00 $3,502.06 $1,895.34 MEDICAL-LEGAL 18 $37,318.86 $9,444.93 ($251.62) $0.00 $0.00 $9,193.31 24.63% $28,125.55 24 $19,032.99 $0.00 $11,878.52 $0.00 $0.00 $12,410.17 65.20% $6,622.82 $1,548.85 $0.00 $0.00 $0.00 $0.00 $0.00 0.00% $1,548.85 ORTHODIC PROCEDURES AND DEVICES $9,541.27 $0.00 $2,169.92 $0.00 $165.56 $3,348.22 35.09% $6,193.05 24 $64,007.92 $1,087.44 $58,162.20 $42.81 $0.00 $59,664.05 93.21% S4.343.87 PHYSICAL MEDICINE AND REHAB 259 $85,310.17 $0.00 $4,161.78 $31,932.24 $0.00 $0.00 $40,825.51 47.86% S44,484.66 35 $25,400.24 $0.00 $1,554.00 $18,083.28 $68.80 $0.00 $20,483.53 80.64% $4,916.71 26 $48,838.32 $0.00 $2,591.13 $29,382.15 $0.00 $0.00 533,963.28 69.54% $14,875.04 TRANSPORTATION 5 $5,657.26 $0.00 53,876.25 $640.28 $0.00 $0.00 $0.00 S4,516.53 79.84% $1,140.73 Unknown 12 $23,713.38 $0.00 $7,500.00 $3,246.23 $0.00 $0.00 $16,151.61 68.11% $7,561.77 Total 1,073 $1,967,720.48 $0.00 $487,414.40 $1,068,235.51 $275.35 $296.92 $1,582,857.99 80.44% $384,862.49 Savings by Service Class Page 1 of 1
MEDREVIEW
P.O. Box 3730 Ontario, CA 91761
PPO/OSR Penetration
Bill. Jurisdiction State PPO/OSR Bill Count Total Charges BR Allowance* Billed To PPO/OSR PPO/OSR Red PPO/OSR Fee PPO/OSR Savings PPO/OSR Penetration PPO/OSR Efficiency PrimeHealth Pend And Transmit $46.90 $9.38 $1.69 20.00% 100.00% 200.00 AZ 20.00% 100.00%
Total $46.90 $9.38 $1.69 200.00
Anthem Blue Cross Pend and Transmit $4,574,189.43 $1,334,886.56 $1,334,886.56 $353,573.92 $84,628.67 26.49% 24.50% 64.90 Coventry Pend And Transmit $114,752.08 $406.09 $101.54 0.35% 2.11% 0.07 HealthSmart Pend And Transmit $697,440.32 $497,226.39 S4,755.56 $1,283.46 0.96% 9.13% 0.88 CA IQ Analysis FS $659,480.04 $221,512.40 $221,512.40 S6,862.63 $1,503.66 3.10% 4.07% 1.26 NO PPO $2,844,808.26 $1,061,182.86 $0.00 $0.00 $0.00
PrimeHealth Pend And Transmit $4,740,985.70 $2,218,774.65 $2,218,774.65 S193,643.08 $44,438.25 8.73% 40.72% 35.55 Total $14,283,553.77 $5,448,334.94 $4,387,152.08 $559,241.28 $131,955.58 12.75% 80.52% 102.67 Coventry Pend And Transmit $825.13 $8.25 $2.06 1.00% 100.00% 10.00 ID $2.06 1.00% 100.00% 10.00
Total $825.13 $8.25
MS NO PPO $3,748.00 $1,629.11 $0.00 $0.00 $0.00
Total $0.00 $0.00 $0.00
PrimeHealth Pend And Transmit $1,798.00 51.427.12 $1,427.12 $168.52 $30.33 11.81% 100.00% 118.10 TX
Total $1,798.00 $1,427.12 $1,427.12 $168.52 $30.33 11.81% 100.00% 118.10 Total 10,763 $14,291,322.52 $5,452,263.20 $4,389,451.23 $559,427.43 $131,989.66 12.74% 80.51% 102.57 PPO/OSR Penetration Page 1 of 1
DASHBOARD SAMPLE 1 of 2
Admin Sure
Applied Calendar Year Fiscal Year - Quarter Claim Status Claim Type Organization Location Filters All All Multiple selections All All All
Risk Management
Claim Count # Total Incurred (S) Total Paid (S) Outstanding Reserve (S) @ RM Dashboard
230 $54.83M $23.22M $31.61M
a Loss Stratiication
Demographic Analysis
My Report
Occupation Analysis Claimant Age Analysis (In Years) Employment Tenure (In Years) * Claim Management ~ 99.00 98.00 # 00 0O
97.00 200
100 100
Q Claim Search
60.00 50 100
50 35.00
13.00 7.00 5.00 2.00 2.00 1.00 28.00 10.00 11.00 19.00
7.00 0 5.00 4.00 0
0 Police Depart... Fire Department Public Works Administrative... Community Se... Parks & Recrea... Water and Sew..." Street Mainten Less 1to2 3 to 5 6 to 10 More 18 to 26 to 36 to 46 to 56 to 66 to than 1 than 10
25 35 45 55 65 75 year years
Occupation Claimant Age Employment Tenure
Reporting Statistics
Report Lag Analysis (In Days) Seasonality Trend
•Total Incurred - No of Claims 00
$40M
189 01
100 59.00 64.00 60.00
530.97M
$20M 47.00
38.00 22.00 18.00
13.00 -S1:88M
SOM 0
0107 08 to 15 16 to 30 31 to 60 60 above Spring Summer Fall Winter Soscon
DASHBOARD SAMPLE 2 of 2
AdminSure
Calendar Year Fiscal Year - Quarter Claim Status Claim Type Organization Location Applied
1 Risk Managemert a Filters. All All Multiple selections V All Al @ PM Dashboard Claim Count # Total Incurred (S) Total Paid ($) Outstanding Reserve (S)
& Losa Strailication 230 $54.83M $23.22M $31.61M
• My Repor Injury Analysis
Injury Causes Injury Types Body Parts
* claim Management e
96.00 100 79.00
9 Claim Search 100 83.00
100
50 41.00 50
50 177.00 16.0011.00 9.00 7.00 7.00 7.00 7.00 14.00 13.00 12.00 7.00 20.00 19.00 19.00 17.00 14.00 g.00 6.00
6.00 5.00
0 Ulting Twisting Sirin spain Contuston Fracture cardiat inta. Abrasion WHEE Shoulderis) Camelative Tra.. Repetitive Mot fall on same le... Robbery/Assau Mult-Vehicle A.. Other than Phy... Pasting or Puls... No Physical Inj.. Hearing Less (C.. Multiple Body Hest Lower Back ( Laris) Body Systems Injury Cause Injury Type Body Part
Geographic Analysis and Organization Analysis
Geographic Analysis Organization Analysis
100.00 99.00
100
50 • UNITED STATES
8.00 7:00 6.00 4.00
2.00 2.00 2.00
Police Fire Public Water Comm. Finance City Of Comm. HUMAN do Tamto nons Mirant demoration Taime Works Services Orange Devel. RESOU...
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
Transition Plan
Sample Start Date: July 1, 2024
TASKS TIMEFRAME DATE OF COMPLETION KEY PERSONNEL
Begin the data conversion and discuss with Approximately 2 Hours The day after, AdminSure (IT/IS and City Contacts the transition and timelin or within the same week, Claims Team), City's approval of our Services current RMIS, and
City Contacts
Begin and complete the setup process for the Approximately 2 Weeks By July 1, 2024 he City, AdminSur City's Workers' Compensation Trust ITS Department
Account, and Positive Pay Services, if and the City's choice applicable of Bank
Provide the City with a sample letter for their Less than 1 Hour By June 1, 2024 AdminSure current employees that advises them of the (WC Directors) change and the contact information of their
new Claims Adjuster (our direct contact info)
Meet with City Contacts to discuss reporting Approximately 2 Hours By June 15, 2024 AdminSure requirements, forms, workflow, expectations, (Claims Team) goals, et cetera
Schedule Orientation and/or Training Approximately 1 Hour for By August 1, 2024 AdminSure Sessions with each Department, and may each Department (Claims Team) include certain/all City employees (optional)
Meet with designated City Clinics/Facilities Approximately 1 Hour for By June 15, 2024 AdminSure to discuss protocols, expectations, goals, et each Clinic/Medical (Claims Team) cetera Facility
Complete the Notice of Change of Less than 1 Hour Before July 1, 2024 AdminSure Administrator (Regulations §15402- (WC Directors)
§15402.4) to the State, SIP Manager
Receive/pick up all hard open/closed files 1 Day By July 1, 2024 AdminSure from the City, if applicable
Complete the City's "Client Profile" Approximately 2 Hours By July 1, 2024 AdminSure (Claims Team)
Mail all injured workers with open claim files Approximately 4 Hours By August 1, 2024 AdminSure a letter reminding them of the change and (IT/IS and Claims their new Claims Adjuster's direct contact Team, if applicable) information. We will also send a similar
letter to all interested parties involved in the
claim files
Data Conversion and Software Training This is a collaborative By July 15, 2024 for The City's current effort between the City's Software Training and by RMIS provider and current RMIS provider and July 31, 2024 for the fully AdminSure AdminSure executed Data Conversion.
Both are dependent on the
date we receive the final
(exit) data
Admin Sure
ID % Complete Task Name Responsible Duration| Start Finish Actual Finish 1 0% Collect data from City's RMIS Provider City's RMIS 7 days Mon 06/17/24 Sun 06/23/24 2 0% Data Mapping / Creation of Scripts AdminSure 7 days Mon 06/24/24 Sun 06/30/24 3 0% Upload Data into Test Environment / Data Validation AdminSure 7 days Mon 07/01/24 Sun 07/07/24 4 0% Receive Final (Exit) Data / Exit Reports City's RMIS 7 days Mon 07/08/24 Sun 07/14/24 5 0% Run Scripts & Upload Data into Test / Data Validation AdminSure 7 days Mon 07/15/24 Sun 07/21/24 6 0% Upload Data into Production / Final Data Validation AdminSure 10 days Mon 07/22/24 Wed 07/31/24 Prepared by AdminSure Page 1 of 2 Draft
Admin Sure
June 2024 July 2024
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 % Complete MTwIE|S|SMT|WTF|S|SMT|WTF|sMT|WTF|S|SM/TWE|S|SM/TW#F|S|SMT|WTFS/SMT|WTFIssMT|WIF 1 2 0%
3 0%
4 0%
5 0%
6 0%
Prepared by AdminSure Page 2 of 2 Draft
Admin Sure
Transition
Implementation Plan
(Data Conversion)
F ER
FORNIA
PrOUNDED.
LUSIVELY
June 2024 - July 2024
Third Party Administrators of Workers' Compensation and Liability Self-Insurance Programs in California since 1982
Admin Sure
Transition & Implementation Plan
(Data Conversion)
We have found that when a realistic transition and implementation plan (data conversion) timeline and plan is in place, transferring claim files and data/documentation by a specific Contract Agreement start date is possible. Our following Transition and Implementation Plan (data conversion) summarizes the necessary actions required for an efficient transition with a sample start date of July 1, 2024.
We understand the importance of a seamless transition for you and your injured workers (employees) while undergoing a transition and data conversion. Our proven, detailed and comprehensive approach to conducting transitions and data conversions ensures completion in such a manner that causes the least amount of disruption or delay for all parties involved.
The entire data conversion process is accomplished through a proven, very well-thought-out plan that involves the following main six steps:
1. We obtain/collect sample data from the City's current Risk Management Information System (RMIS) provider
2. Data is analyzed; field and code mapping scripts are compiled
3. Data is uploaded into our test environment and scrutinized for accuracy
4. We receive final (exit) data and final (exit) reports from the City's current RMIS provider
5. Final (exit) data set is uploaded to our test environment; accuracy and consistency with final (exit) loss runs are verified
6. Final (exit) data set is moved into production; final (exit) data validation is conducted Collecting Sample Data
At least 30-45 days before the takeover date (ideally), we obtain test data and record layouts from the City's current RMIS provider. It is absolutely necessary that we receive data in CSV format only.
Data Analysis
Data integrity is valued with the utmost importance as it is vital to the success of a Risk Management Information System (RMIS). With this in mind, data mapping and code scripts are carefully compiled. The data mapping process will identify all the data elements that are to be Prepared by AdminSure Page 2 of 3 June 2024 - July 2024 Admin Sure
converted. We then assign each data element to a specific database field and govern/set rules and/or logic that applies to the data.
Initial Data Testing
The sample data will be uploaded to our test environment and scrutinized for accuracy. All day- to-day functions are tested and executed. Reports are generated and compared to the sample data received. If any anomalies are discovered, they are corrected and documented. The data validation and testing of the sample data will continue until we are confident we are ready to proceed with the final (exit) data set.
Collecting Final (Exit) Data Set
On/about the date the City's hard claim files, if any, are transferred from to us, or no later than on our first day of our Contract/Agreement effective date with the City, we obtain the final (exit) data set. At this point, it is imperative that any and all fundamental changes that may have been made to the data structure that we previously received in the sample data be communicated to us.
The final (exit) data set is uploaded into our test environment and validated for accuracy and consistency by comparing same with the final (exit) loss runs. This data validation and testing will continue until we are confident we are ready to move this into our live production database.
"Going Live" with Final (Exit) Data Set
The final (exit) data set will then be uploaded into our production database and made available to the Claims Adjusting Staff assigned to your Workers' Compensation Program. A final (exit) data validation will take place while both the Information Systems/Technology (IS/IT) and Claims Adjusting Staff review the imported claims information. Once the data is verified, we will notify all interested parties of the completion of the data conversion/implementation project and provide an unlimited number of City users (City contacts) and our assigned Claims Adjusting Staff with their online user account credentials (login/password).
We will also provide our City contacts training at no additional cost.
Closing
We are very confident in our proven ability to successfully complete the proposed Transition and Implementation Plan (data conversion) within the timeline provided (30 workdays or sooner).
Thank you for your time and consideration and we truly look forward to having the opportunity to partner with the City of Vernon.
AdminSure Inc.
Prepared by AdminSure Page 3 of 3 June 2024 - July 2024 Nerissa Burnside, SIA, WCCP, WCCA
Senior Workers' Compensation Claims Director
Professional 2017-Present AdminSure Inc. - Senior WC Claims Director Experience
2004-2017 AdminSure Inc.
Workers' Compensation Claims Supervisor/Manager
• Performs an extensive range of claims services which includes supervising nanagement staff; communication with employers, injured workers nedical providers (medical management and return-to-work program management), and attorneys (litigation and subrogation
management); oversees managers' coordination of lost time/monetary benefis (i.e. TD, LC4850, CaPERS, SJDB/vocational rehabilitation, and settlements) and medical benefits (benefit administration as well as excess reporting; utilization review and bill review management), as well as the investigation of questionable claims, and when required, attends various meetings WCAB conferences, etcetera.
Assists with conducting claims reviews, training sessions, and educational seminars; and coordinates various outside expert service providers reference ADA accommodation meetings, MSA reviews, ergonomic assessments, et cetera.
2001-2004 AdminSure Inc.
Workers' Compensation Senior Claims Adjuster
• Performed an extensive range of claims services including communication with employers, injured workers, medical providers, and attorneys; coordinated accurate and timely delivery of benefits; investigated questionable claims, and when required, attended various WCAB conferences.
1997-2001 Liberty Mutual Insurance Company
Case Manager/Senior Case Manager
• Responsible for assisting team members with claims administration education and achieving office objectives. Performed an extensive range of claims services including communication with employers, injured workers, nedical providers, and attorneys; coordinated accurate and timely deliver of benefits; investigated questionable claims, and when required, attende Education • Graduated from California Polytechnic University, Pomona with a Bachelor's Degree in Business Administration.
• State Certified Self-Insurance Workers' Compensation Administrator. • Workers' Compensation Claims Professional Designation (WCCP).
Workers' Compensation Claims Administration Certification (WCCA).
References Please refer to our Client List.
Nicolas Bowers, SIA, WCCP, WOCA
Workers' Compensation Claims Director
Professional 2022-Present AdminSure Inc.
Experience
• Performs many of the Supervisor/Manager tasks and assists with an 2020-2021 AdminSure Inc.
Workers' Compensation Claims Supervisor/Manager
Performed an extensive range of claims services which included supervising accounts and claims staff; communication with employers, injured workers, medical providers (medical management and return-to-work program management), and attorneys
(litigation and subrogation management); coordinated accurate and timely delivery of lost time/monetary benefits (i.e. TD, LC4850 benefits, CaPERS, SJDB/vocational rehabilitation, and
settlements, et cetera) and medical benefits (benefit administration as well as excess reporting; utilization review and bill review management); investigated questionable claims, and when required, attended various meetings, WCAB conferences, et cetera.
• Assisted with conducting claims reviews, training sessions, and educational seminars; and coordinated various outside expert service providers reference ADA accommodation meetings, MSA reviews, ergonomic assessments, et cetera.
2011-2019 AdminSure Inc.
Workers' Compensation Senior Claims Adjuster
Performed an extensive range of claims services including communication vith employers, injured workers, medical providers, and attorney:
oordinated accurate and timely delivery of benefits: investigate questionable claims, and when required, attended various WCAB conferences.
Education State Certified Self-Insurance Workers' Compensation Administrator.
Bachelor of Science Degree, Business Management and HR.
Workers' Compensation Claims Professional Designation (WCCP).
Workers' Compensation Claims Administration Certification (WCCA).
AFFIDAVIT OF NON-COLLUSION BY CONTRACTOR
STATE OF CALIFORNIA )
) SS
COUNTY OF LOS ANGELES )
Alithia Vargas-Flores _ being first duly sworn deposes
and says that he/she is President
(Insert "Sole Owner", "Partner", "President, "Secretary", or other proper title) of_ AdminSure Inc.
(Insert name of bidder)
who submits herewith to the City of Vernon a bid/proposal; That all statements of fact in such bid/proposal are true; That such bid/proposal was not made in the interest of or on behalf of any undisclosed person, partnership, company, association, organization or corporation; That such bid/proposal is genuine and not collusive or sham; That said bidder has not, directly or indirectly by agreement, communication or conference with anyone attempted to induce action prejudicial to the interest of the City of Vernon, or of any other bidder or anyone else interested in the proposed contract; and further That prior to the public opening and reading of bids/proposals, said bidder:
a. Did not directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal;
b. Did not directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from bidding or withdraw his/her bid/proposal;
c. Did not, in any manner, directly or indirectly seek by agreement, communication or conference with anyone to raise or fix the bid/proposal price of said bidder or of anyone else, or to raise or fix any overhead, profit or cost element of his/her bid/proposal price, or of that of anyone else; d. Did not, directly or indirectly, submit his/her bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative thereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof, or to any individual or group of individuals, except the City of Vernon, or to any person or persons who have a partnership or other financial interest with said bidder in his/her business.
I certify under penalty of perjury that the above information is correct By: _Alithia Vargas-Flores flittia Vargas -flores Title: President Date: 5/14/24
March 2013
EXHIBIT B
SCHEDULE
Fee Proposal
Claims Administration Services • Year 1: $6,940 per month. (Includes Internal Support Staff) • 3% anmual increase.
Flat Fee
Bill Review Services • $10 per bill for all Official Medical Fee Schedule (OMFS), In- Flat Fee
partial bill review services.
• When applicable, up to 25% Preferred Provider Organization (PPO)/Negotiated Savings fee, if there are no applicable savings, there are no fees.
• No additional fees for transmitting medical billing information on behalf of the City to the Workers' Compensation Information System (WCIS) as required by State Law, i.e., Medical Bill Review EDI (Electronic Data Interchange) Reporting and
Services.
• 3% annual increase.
Utilization Review Services
Flat Fee approximately 4% of total charges; $85 adjuster/$125 utilization review.
• 3% anmial increase.
Transition Fee • No fee.
Data Conversion Fee • No fee.
CMS/MMSEA - Internal Services • No fee.
City On-Line Access (All Data) • No fee for City read-only users; at-cost fee for read and write.
All Reports: Standard & Custom/Ad • No fee. At-cost when data is not captured.
Hoc Reports
Index Claim Search & 1099s • No fee.
Training & Development of Special • No fee. Reference amy "Banking" fees, if any, please make note Account Instructions/Procedures & that any fees charged by the bank shall be at cost as we will not Banking add on any feed for our internal services.
Trainings. Meetings. Quarterly Claim • No fee.
Reviews, Forms, Posters &
Pamphlets
EXHIBIT C
EQUAL EMPLOYMENT OPPORTUNITY
PRACTICES PROVISIONS
A. Contractor certifies and represents that, during the performance of this Agreement, the contractor and each subcontractor shall adhere to equal opportunity employment practices to assure that applicants and employees are treated equally and are not discriminated against because of their race, religious creed, color, national origin, ancestry, handicap, sex, or age. Contractor further certifies that it will not maintain any segregated facilities.
B. Contractor agrees that it shall, in all solicitations or advertisements for applicants for employment placed by or on behalf of Contractor, state that it is an "Equal Opportunity Employer" or that all qualified applicants will receive consideration for employment without regard to their race, religious creed, color, national origin, ancestry, handicap, sex or age.
C. Contractor agrees that it shall, if requested to do so by the City, certify that it has not, in the performance of this Agreement, discriminated against applicants or employees because of their membership in a protected class.
D. Contractor agrees to provide the City with access to, and, if requested to do so by City, through its awarding authority, provide copies of all of its records pertaining or relating to its employment practices, except to the extent such records or portions of such records are confidential or privileged under state or federal law.
E. Nothing contained in this Agreement shall be construed in any manner as to require or permit any act which is prohibited by law.