SERVICES AGREEMENT BETWEEN THE CITY OF VERNON AND ADMINSURE, INC.
FOR WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION
SERVICES
COVER PAGE
Contractor: AdminSure, Inc.
Responsible Principal of Contractor: Alithia Vargas-Flores, President Notice Information - Contractor: AdminSure, Inc.
3380 Shelby Street
Ontario, CA 91764
Attention: Alithia Vargas-Flores, President
Telephone: (909) 396-5814
Notice Information - City: City of Vernon
4305 Santa Fe Avenue
Vernon, CA 90058
Attention: Lisette M. Grizzelle
Interim Director of Human Resources
Telephone: (323) 583-8811 ext. 166
Commencement Date: January 1, 2025
Termination Date: December 31, 2027
Consideration: Total not to exceed $257,415 (includes all applicable sales tax); and more particularly
described in Exhibit B
Records Retention Period Three (3) years, pursuant to Section 11.20
SERVICES AGREEMENT BETWEEN THE CITY OF VERNON AND ADMINSURE, INC. FOR
WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES This Agreement is made between the City of Vernon, a California charter City and California municipal corporation ("City"), and AdminSure, Inc., a California corporation ("Contractor").
The City and Contractor agree as follows:
1.0 EMPLOYMENT OF CONTRACTOR. City agrees to engage Contractor to perform the services as hereinafter set forth as authorized by the City Council on November 19, 2024.
2.0 SCOPE OF SERVICES.
2.1 Contractor shall perform all work necessary to complete the services set forth in the City's Request for Proposals issued on or about April 25, 2024, and titled Request for Proposals (RFP) Worker's Compensation Third Party Claims Administration Services, and Contractor's proposal to the City ("Proposal") dated May 14, 2024, Exhibit "A", a copy which is attached to and incorporated into this Agreement by reference.
2.2 All services shall be performed to the satisfaction of City.
2.3 All services shall be performed in a competent, professional, and satisfactory manner in accordance with the prevailing industry standards for such services.
3.0 PERSONNEL.
3.1 Contractor represents that it employs, or will employ, at its own expense, all personnel required to perform the services under this Agreement.
3.2 Contractor shall not subcontract any services to be performed by it under this Agreement without prior written approval of City.
3.3 All of the services required hereunder will be performed by Contractor or by City approved subcontractors. Contractor, and all personnel engaged in the work, shall be fully qualified and authorized or permitted under State and local law to perform such services and shall be subject to approval by the City.
4.0 TERM. The term of this Agreement shall commence on January 1, 2025, and it shall continue until December 31, 2027, unless terminated at an earlier date pursuant to the provisions thereof.
5.0 COMPENSATION AND FEES.
5.1 Contractor has established rates for the City of Vernon which are comparable to and do not exceed the best rates offered to other governmental entities in and around Los Angeles County for the same services. For satisfactory and timely performance of
the services, the City will pay Contractor in accordance with the payment schedule set forth in Exhibit "B" attached hereto and incorporated herein by reference.
5.2 Contractor's grand total compensation for the entire term of this Agreement, shall not exceed $257,415 without the prior authorization of the City, as appropriate, and written amendment of this Agreement.
5.3 Contractor shall, at its sole cost and expense, furnish all necessary and incidental labor, material, supplies, facilities, equipment, and transportation which may be required for furnishing services pursuant to this Agreement. Materials shall be of the highest quality. The above Agreement fee shall include all staff time and all clerical, administrative, overhead, insurance, reproduction, telephone, air travel, auto rental, subsistence, and all related costs and expenses.
5.4 City shall reimburse Contractor only for those costs or expenses specifically approved in this Agreement, or specifically approved in writing in advance by City.
Unless otherwise approved, such costs shall be limited and include nothing more than the following costs incurred by Contractor:
5.4.1 The actual costs of subcontractors for performance of any of the services that Contractor agrees to render pursuant to this Agreement, which have been approved in advance by City and awarded in accordance with this Agreement.
5.4.2 Approved reproduction charges.
5.4.3 Actual costs and/or other costs and/or payments specifically authorized in advance in writing and incurred by Contractor in the performance of this Agreement.
5.5 Contractor shall not receive any compensation for extra work performed without the prior written authorization of City. As used herein, "extra work" means any work that is determined by City to be necessary for the proper completion of the Project, but which is not included within the Scope of Services and which the parties did not reasonably anticipate would be necessary at the time of execution of this Agreement. Compensation for any authorized extra work shall be paid in accordance with the payment schedule as set forth in Exhibit "B," if the extra work has been approved by the City.
5.6 Licenses, Permits, Fees, and Assessments. Contractor shall obtain, at Contractor's sole cost and expense, such licenses, permits, and approvals as may be required by law for the performance of the services required by this Agreement. Contractor shall have the sole obligation to pay for any fees, assessments, and taxes, plus applicable penalties and
interest, which may be imposed by law and which arise from or are necessary for the performance of the Services by this Agreement.
6.0 PAYMENT.
6.1 As scheduled services are completed, Contractor shall submit to the City an invoice for the services completed, authorized expenses, and authorized extra work actually performed or incurred according to said schedule.
6.2 Each such invoice shall state the basis for the amount invoiced, including a detailed description of the services completed, the number of hours spent, reimbursable expenses incurred and any extra work performed.
6.3 Contractor shall also submit a progress report with each invoice that describes in reasonable detail the services and the extra work, if any, performed in the immediately preceding calendar month.
6.4 Contractor understands and agrees that invoices which lack sufficient detail to measure performance will be returned and not processed for payment.
6.5 City will pay Contractor the amount invoiced within thirty (30) days after the City approves the invoice.
6.6 Payment of such invoices shall be payment in full for all services, authorized costs, and authorized extra work covered by that invoice.
7.0 CITY'S RESPONSIBILITY. City shall cooperate with Contractor as may be reasonably necessary for Contractor to perform its services; and will give any required decisions as promptly as practicable so as to avoid unreasonable delay in the progress of Contractor's services.
8.0 COORDINATION OF SERVICES. Contractor agrees to work closely with City staff in the performance of Services and shall be available to City's staff, consultants, and other staff at all reasonable times.
9.0 INDEMNITY. Contractor agrees to indemnify City, its officers, elected officials, employees and agents against, and will hold and save each of them harmless from, any and all actions, suits, claims, damages to persons or property, losses, costs, penalties, obligations, errors, omissions or liabilities (herein "claims or liabilities"), including but not limited to professional negligence, that may be asserted or claimed by any person, firm or entity arising out of or in connection with the work, operations or activities of Contractor, its agents, employees, subcontractors, or invitees, provided for herein, or arising from the acts or omissions of Contractor hereunder, or arising from Contractor's performance of or failure to perform any term, provision, covenant or condition of this Agreement, except to the extent such
claims or liabilities arise from the gross negligence or willful misconduct of City, its officers, elected officials, agents or employees.
10.0 INSURANCE. Contractor shall procure and maintain for the duration of the Agreement insurance against claims for injuries to persons or damage to property that may arise from or in connection with the performance of the work hereunder by the Contractor, its agents, representative, or employees. The policies shall state that they afford primary coverage.
10.1 Commercial General Liability Insurance - Contractor shall carry General Liability Insurance covering all operations performed by or on behalf of the Contractor providing coverage for bodily injury and property damage with a single limit of not less than one million dollars ($1,000,000) per occurrence and two million dollars ($2,000,000) general aggregate limit written on an Insurance Services Office (ISO) Comprehensive General Liability "occurrence" Form CG 00 01 or its equivalent for coverage on an occurrence basis. The City of Vernon, its directors, commissioners, officers, employees, agents, and volunteers must be endorsed on the policy as additional insureds with respect to liability arising out of the Contractor's performance of this Agreement. The additional insured coverage under the Contractor's policy shall be primary and non-contributory and will not seek contribution from the City's insurance. The policy shall be endorsed to include a waiver of subrogation.
10.1.1 If Contractor intends to employ other contractors as part of the services rendered, the City must approve and will establish the appropriate insurance requirements.
10.1.2 Contractor agrees to subrogate General Liability resulting from performance under this agreement by agreeing to defend, indemnify, and hold harmless, the City, and its respective employees, agents, and City Council from and against all claims, liabilities, suits, losses, damages, injuries and expenses, including all costs and reasonable attorney's fees ("Claims"), which are attributable to any act or omission by the Contractor under the performance of the services.
10.2 Professional Errors and Omissions Coverage in a sum of not less than one million dollars ($1,000,000), where such risk is applicable. Applicable aggregate must be identified and claims history provided to determine amounts remaining under the aggregates. Contractor shall maintain such coverage for at least one (1) year after the termination of this agreement.
10.3 Umbrella Liability Insurance - An umbrella (over primary) may be used to comply with limits or other primary coverage requirements. When used, the umbrella policy shall apply to bodily injury/property damage and personal injury/advertising injury and shall include a
"dropdown" provision providing primary coverage for any liability not covered by the primary policy. The umbrella policy shall have no additional exclusion or coverage difference from the primary policy. The coverage shall also apply to automobile liability.
10.4 Workers' Compensation/Employers Liability - Contractor shall comply with the applicable sections of the California Labor Code concerning workers' compensation for injuries on the job. Compliance is accomplished in one of the following manners:
10.4.1 Provide a copy of the permissive self-insurance certificate approved by the State of California; or
10.4.2 Secure and maintain in force a policy of workers' compensation insurance with statutory limits and Employer's Liability Insurance with a limit of one million dollars ($1,000,000) per accident. The policy shall be endorsed to waive all rights of subrogation against City, its directors, commissioners, officers, employees, and volunteers for losses arising from performance of this Agreement or
10.4.3 If Contractor has no employees, it may certify or warrant to the City that it does not currently have any employees or individuals who are defined as "employees" under the Labor Code, and the requirement for Workers' Compensation coverage will be waived by completing the waiver form provided by the City.
10.5 If Contractor maintains broader coverage and/or higher limits than the minimums shown above, City requires and shall be entitled to the broader coverage and/or the higher limits maintained by the Contractor. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City.
10.6 Each insurance policy included in this clause shall be endorsed to state that coverage shall not be cancelled except after thirty (30) days prior written notice to City.
10.7 Insurance shall be placed with insurers with an A.M. Best rating of no less than A- VIII. Any self-insured retention or deductible in excess of $25,000 must be approved in advance by the City. Any policies written on a claims-based basis must include a minimum of a 3-year tail.
10.8 Prior to the commencement of performance, Contractor shall furnish City with a certificate of insurance for each policy. Each certificate is to be signed by a person authorized by that insurer to evidence coverage on its behalf. The certificate(s) must be in a form approved by City. City may require complete, certified copies of any or all policies upon request.
10.9 Failure to maintain required insurance at all times shall constitute a default and material breach. In such event, Contractor shall immediately notify City and cease all performance under this Agreement until further directed by the City. In the absence of satisfactory insurance coverage, City may, at its option: (a) procure insurance with collection rights for premiums, attorney's fees, and costs against Contractor by way of set-off or recoupment from sums due to Contractor, at City's option; (b) immediately terminate this Agreement and seek damages from the Agreement resulting from said breach; or (c) self-insure the risk, with all damages and costs incurred, by judgment, settlement or otherwise, including attorney's fees and costs, being collectible from Contractor, by way of set-off or recoupment from any sums due to Contractor.
11.0 GENERAL TERMS AND CONDITIONS.
11.1 INDEPENDENT CONTRACTOR.
11.1.1 It is understood that in the performance of the services herein provided for, Contractor shall be, and is, an independent contractor, and is not an agent, officer or employee of City and shall furnish such services in its own manner and method except as required by this Agreement, or any applicable statute, rule, or regulation. Further, Contractor has and shall retain the right to exercise full control over the employment, direction, compensation and discharge of all persons employed by Contractor in the performance of the services hereunder. City assumes no liability for Contractor's actions and performance, nor assumes responsibility for taxes, bonds, payments, or other commitments, implied or explicit, by or for Contractor. Contractor shall be solely responsible for, and shall indemnify, defend and save City harmless from all matters relating to the payment of its employees, subcontractors and independent contractors, including compliance with social security, withholding and all other wages, salaries, benefits, taxes, exactions, and regulations of any nature whatsoever.
11.1.2 Contractor acknowledges that Contractor and any subcontractors, agents or employees employed by Contractor shall not, under any circumstances, be considered employees of the City, and that they shall not be entitled to any of the benefits or rights afforded employees of City, including, but not limited to, sick leave, vacation leave, holiday pay, Public Employees Retirement System benefits, or health, life, dental, long-term disability or workers' compensation insurance benefits.
11.2 CONTRACTOR NOT AGENT. Except as the City may authorize in writing, Contractor and its subcontractors shall have no authority, express or implied, to act on behalf of or bind the City in any capacity whatsoever as agents or otherwise.
11.3 OWNERSHIP OF WORK. All documents and materials furnished by the City to Contractor shall remain the property of the City and shall be returned to the City upon termination of this Agreement. All reports, drawings, plans, specifications, computer tapes, floppy disks and printouts, studies, memoranda, computation sheets, and other documents prepared by Contractor in furtherance of the work shall be the sole property of City and shall be delivered to City whenever requested at no additional cost to the City. Contractor shall keep such documents and materials on file and available for audit by the City for at least three (3) years after completion or earlier termination of this Agreement. Contractor may make duplicate copies of such materials and documents for its own files or for such other purposes as may be authorized in writing by the City.
11.4 CORRECTION OF WORK. Contractor shall promptly correct any defective, inaccurate or incomplete tasks, deliverables, goods, services and other work, without additional cost to the City. The performance or acceptance of services furnished by Contractor shall not relieve the Contractor from the obligation to correct subsequently discovered defects, inaccuracy, or incompleteness.
11.5 RESPONSIBILITY FOR ERRORS. Contractor shall be responsible for its work and results under this Agreement. Contractor, when requested, shall furnish clarification and/or explanation as may be required by the City, regarding any services rendered under this Agreement at no additional cost to City. In the event that an error or omission attributable to Contractor occurs, then Contractor shall, at no cost to City, provide all necessary design drawings, estimates and other Contractor professional services necessary to rectify and correct the matter to the sole satisfaction of City and to participate in any meeting required with regard to the correction.
11.6 WAIVER. The City's waiver of any term, condition, breach, or default of this Agreement shall not be considered to be a waiver of any other term, condition, default or breach, nor of a subsequent breach of the one waived. The delay or failure of either party at any time to require performance or compliance by the other of any of its obligations or agreements shall in no way be deemed a waiver of those rights to require such performance or compliance.
No waiver of any provision of this Agreement shall be effective unless in writing and executed by a duly authorized representative of the party against whom enforcement of a waiver is sought.
11.7 SUCCESSORS. This Agreement shall inure to the benefit of, and shall be binding upon, the parties hereto and their respective heirs, successors, and/or assigns.
11.8 NO ASSIGNMENT. Contractor shall not assign or transfer this Agreement or any rights hereunder without the prior written consent of the City and approval by the City Attorney, which may be withheld in the City's sole discretion. Any unauthorized assignment or transfer shall be null and void and shall constitute a material breach by the Contractor of its obligations under this Agreement. No assignment shall release the original parties from their obligations or otherwise constitute a novation.
11.9 COMPLIANCE WITH LAWS. Contractor shall comply with all Federal, State, County and City laws, ordinances, rules and regulations, which are, as amended from time to time, incorporated herein and applicable to the performance hereof. Violation of any law material to performance of this Agreement shall entitle the City to terminate the Agreement and otherwise pursue its remedies. Further, if the Contractor performs any work knowing it to be contrary to such laws, rules, and regulations Contractor shall be solely responsible for all costs arising therefrom.
11.10 ATTORNEY'S FEES. If any action at law or in equity is brought to enforce or interpret the terms of this Agreement, the prevailing party shall be entitled to reasonable attorney's fees, costs, and necessary disbursements in addition to any other relief to which such party may be entitled.
11.11 INTERPRETATION
11.11.1 Applicable Law. This Agreement shall be deemed an agreement and shall be governed by and construed in accordance with the laws of the State of California. Contractor agrees that the State and Federal courts which sit in the State of California shall have exclusive jurisdiction over all controversies and disputes arising hereunder, and submits to the jurisdiction thereof.
11.11.2 Entire Agreement. This Agreement, including any exhibits attached hereto, constitutes the entire agreement and understanding between the parties regarding its subject matter and supersedes all prior or contemporaneous negotiations, representations, understandings, correspondence, documentation, and agreements (written or oral).
11.11.3 Written Amendment. This Agreement may only be changed by written amendment executed by Contractor and the City Administrator or other authorized representative of the City, subject to any requisite authorization by the City Council. Any oral representations or modifications concerning this Agreement shall be of no force or effect.
11.11.4 Severability. If any provision in this Agreement is held by any court of competent jurisdiction to be invalid, illegal, void, or unenforceable, such portion shall be
deemed severed from this Agreement, and the remaining provisions shall nevertheless continue in full force and effect as fully as though such invalid, illegal, or unenforceable portion had never been part of this Agreement.
11.11.5 Order of Precedence. In case of conflict between the terms of this Agreement and the terms contained in any document attached as an Exhibit or otherwise incorporated by reference, the terms of this Agreement shall strictly prevail. The terms of the City's Request for Proposals shall control over the Contractor's Proposal.
11.11.6 Construction. In the event an ambiguity or question of intent or interpretation arises with respect to this Agreement, this Agreement shall be construed as if drafted jointly by the parties and in accordance with its fair meaning. There shall be no presumption or burden of proof favoring or disfavoring any party by virtue of the authorship of any of the provisions of this Agreement.
11.12 TIME OF ESSENCE. Time is strictly of the essence of this agreement and each and every covenant, term, and provision hereof.
11.13 AUTHORITY OF CONTRACTOR. The Contractor hereby represents and warrants to the City that the Contractor has the right, power, legal capacity, and authority to enter into and perform its obligations under this Agreement, and its execution of this Agreement has been duly authorized.
11.14 ARBITRATION OF DISPUTES. Any dispute for under $25,000 arising out of or relating to the negotiation, construction, performance, non-performance, breach, or any other aspect of this Agreement, shall be settled by binding arbitration in accordance with the Commercial Rules of the American Arbitration Association at Los Angeles, California and judgment upon the award rendered by the Arbitrators may be entered in any court having jurisdiction thereof. The City does not waive its right to object to the timeliness or sufficiency of any claim filed or required to be filed against the City and reserves the right to conduct full discovery.
11.15 NOTICES. Any notice or demand to be given by one party to the other must be given in writing and by personal delivery or prepaid first-class, registered or certified mail, addressed as follows. Notice simply to the City of Vernon or any other City department is not adequate notice.
If to the City:
City of Vernon
Attention: Lisette M. Grizzelle, Interim Director of Human Resources 4305 Santa Fe Avenue
Vernon, CA 90058
If to the Contractor:
AdminSure, Inc.
Attention: Alithia Vargas-Flores, President
3380 Shelby Street
Ontario, CA 91764
Any such notice shall be deemed to have been given upon delivery, if personally delivered, or, if mailed, upon receipt, or upon expiration of three (3) business days from the date of posting, whichever is earlier. Either party may change the address at which it desires to receive notice upon giving written notice of such request to the other party.
11.16 NO THIRD PARTY RIGHTS. This Agreement is entered into for the sole benefit of City and Contractor and no other parties are intended to be direct or incidental beneficiaries of this Agreement and no third party shall have any right or remedy in, under, or to this Agreement.
11.17 TERMINATION FOR CONVENIENCE (Without Cause). City may terminate this Agreement in whole or in part at any time, for any cause or without cause, upon fifteen (15) calendar days' written notice to Contractor. If the Agreement is thus terminated by City for reasons other than Contractor's failure to perform its obligations, City shall pay Contractor a prorated amount based on the services satisfactorily completed and accepted prior to the effective date of termination. Such payment shall be Contractor's exclusive remedy for termination without cause.
11.18 DEFAULT. In the event either party materially defaults in its obligations hereunder, the other party may declare a default and terminate this Agreement by written notice to the defaulting party. The notice shall specify the basis for the default. The Agreement shall terminate unless such default is cured before the effective date of termination stated in such notice, which date shall be no sooner than ten (10) days after the date of the notice. In case of default by Contractor, the City reserves the right to procure the goods or services from other sources and to hold the Contractor responsible for any excess costs occasioned to the City thereby. Contractor shall not be held accountable for additional costs incurred due to delay or default as a result of Force Majeure. Contractor must notify the City immediately upon knowing that non-performance or delay will apply to this Agreement as a result of Force Majeure. At that time Contractor is to submit in writing a Recovery Plan for this Agreement. If the Recovery Plan is not acceptable to the City or not received within 10 days of the necessary notification of Force Majeure default, then the City may cancel this order in its entirety at no cost to the City, owing only for goods and services completed to that point.
11.19 IERMINATION FOR CAUSE. Termination for cause shall relieve the terminating party of further liability or responsibility under this Agreement, including the payment of money, except for payment for services satisfactorily and timely performed prior to the service of the notice of termination, and except for reimbursement of (1) any payments made by the City for service not subsequently performed in a timely and satisfactory manner, and (2) costs incurred by the City in obtaining substitute performance. If this Agreement is terminated as provided herein, City may require, at no additional cost to City, that Contractor provide all finished or unfinished documents, data, and other information of any kind prepared by Contractor in connection with the performance of Services under this Agreement. Contractor shall be required to provide such document and other information within fifteen (15) days of the request.
11.19.1 Additional Services. In the event this Agreement is terminated in whole or in part as provided herein, City may procure, upon such terms and in such manner as it may determine appropriate, services similar to those terminated.
11.20 MAINTENANCE AND INSPECTION OF RECORDS.
The City, or its authorized auditors or representatives, shall have access to and the right to audit and reproduce any of the Contractor's records to the extent the City deems necessary to insure it is receiving all money to which it is entitled under the Agreement and/or is paying only the amounts to which Contractor is properly entitled under the Agreement or for other purposes relating to the Agreement.
The Contractor shall maintain and preserve all such records for a period of at least three (3) years after termination of the Agreement.
The Contractor shall maintain all such records in the City of Vernon. If not, the Contractor shall, upon request, promptly deliver the records to the City of Vernon or reimburse the City for all reasonable and extra costs incurred in conducting the audit at a location other than the City of Vernon, including, but not limited to, such additional (out of the City) expenses for personnel, salaries, private auditors, travel, lodging, meals, and overhead.
11.21 CONFLICT. Contractor hereby represents, warrants, and certifies that no member, officer, or employee of the Contractor is a director, officer, or employee of the City of Vernon, or a member of any of its boards, commissions, or committees, except to the extent permitted by law.
11.22 HEADINGS. Paragraphs and subparagraph headings contained in this Agreement are included solely for convenience and are not intended to modify, explain or to be
a full or accurate description of the content thereof and shall not in any way affect the meaning or interpretation of this Agreement.
11.23 ENFORCEMENT OF WAGE AND HOUR LAWS. Eight hours labor constitutes a legal day's work. The Contractor, or subcontractor, if any, shall forfeit twenty-five dollars ($25) for each worker employed in the execution of this Agreement by the respective Contractor or subcontractor for each calendar day during which the worker is required or permitted to work more than 8 hours in any one calendar day and 40 hours in any one calendar week in violation of the provisions of Sections 1810 through 1815 of the California Labor Code as a penalty paid to the City; provided, however, work performed by employees of contractors in excess of 8 hours per day, and 40 hours during any one week, shall be permitted upon compensation for all hours worked in excess of 8 hours per day at not less than 1½ times the basic rate of pay.
11.24 EQUAL EMPLOYMENT OPPORTUNITY PRACTICES. Contractor certifies and represents that, during the performance of this Agreement, it and any other parties with whom it may subcontract shall adhere to equal employment opportunity practices to assure that applicants, employees and recipients of service are treated equally and are not discriminated against because of their race, religion, color, national origin, ancestry, disability, sex, age, medical condition, sexual orientation or marital status. Contractor further certifies that it will not maintain any segregated facilities. Contractor further agrees to comply with The Equal Employment Opportunity Practices provisions as set forth in Exhibit "C". [Signatures Begin on Next Page].
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Commencement Date stated on the cover page.
City of Vernon, a California charter City AdminSure, Inc., a California corporation and California municipal corporation
or Mitia danger Hai
By:
Daniel E. Calleros, Interim City Name: Alithia Vargas-Flores Administrator
Title: President
ATTEST:
While ell
By:
Yonnie Parker, Deputy City Clerk Name: Ashley Sells
Title: Corporate Secretary
APPROVED AS TO FORM:
-
Zaynah N. Moussa, City Attorney
EXHIBIT A
CONTRACTOR'S PROPOSAL
Admin Sure
Workers' Compensation
Third Party Claims Administration Services
-RFP RESPONSE-
OR VERNO
CAUFORNIA
FOUNDED
USIVELY
May 14, 2024
Third Party Administrators of Workers' Compensation and Liability Self-Insurance Programs in California since 1982
3380 Shelby Street
Ontario, California 91764
Alithia Vargas-Flores
909.396.5814
3380 Shelby Street
Ontario, California 91764
Admin Sure
Telephone (909) 861-0816
Fax (909) 978-1131
May 14, 2024
Lisa Wirtz
Human Resources Analyst
City of Vernon
[email protected]
Re: Request for Proposal Response
Workers' Compensation Third Party Claims Administration Services Cover Letter
Dear Lisa Wirtz:
AdminSure Inc., a California Corporation, is submitting a proposal response to provide for Workers' Compensation Claims Administration Services, Utilization Review Services, and Bill Review Services for the City of Vernon. Our services are both comprehensive and flexible, which will allow us to conform to the City's specific and overall needs as described in the Request for Proposal (RFP).
Since 1982 we have been a leading service provider of performance-based Workers' Compensation Program Services for numerous full-service cities with Police Departments (safety members) like the City of Vernon. This is truly our specialty as nearly 100% of our client base is comprised of full- service cities with safety members - Police and Fire. We have a very longstanding and secure client base as we have administered many of our municipality clients, specifically cities, Workers' Compensation Programs for more than 20 years. Please refer to Attachment 1 for our Workers' Compensation Program Client List.
We administer claims in a professional, proactive and consistent manner, and we are very knowledgeable with regard to all aspects involved with the Workers' Compensation system.
Specifically, we are extremely well versed in the Workers' Compensation Laws of California (Labor Codes, California Code of Regulations (CCRs), Government Codes, Case Laws, and Senate Bills (SB), et cetera) that govern Workers' Compensation claims. We are also very knowledgeable of the presumptions for safety members and their impact on CaPERS Retirement Benefits (Industrial Disability Retirement (IDR) Benefits) as well as matters involving the coordination of State and Federal disability benefits, i.e., Americans with Disabilities Act (ADA).
Our services are performed with a clear purpose in mind - to see that claims are handled properly, quickly, and economically. At the same time, we pride ourselves in maintaining strong lines of communication with our clients, their injured workers, and all other interested parties. Our goal is to provide the City's injured workers with all the benefits they are entitled to that is specific to the City's approach; this is our core competency.
In addition, we believe our following approaches/services are key elements in order to maintain a successful Workers' Compensation Program:
Third Party Administrators of Workers' Compensation and Liability Self-Insurance Programs in California since 1982
Workers' Compensation Third Party Claims Administration Services Request for Proposal Response - City of Vernon
May 14, 2024
• Goals: Results-based; timelines are set and met; progress is followed; outcomes are reviewed. • Claims Handling Approach: We are assertive and professional; we communicate and document. • App - Injured Worker and Claims Adjuster Advocacy Solution: The App will help injured workers return to health and work, while increasing our productivity. The App is in addition to our voice-to-voice communications as it is not meant to dehumanize the claims process or take the place of telephone calls with injured workers. Specifically, in addition to their assigned claims adjuster, the App will also guide injured workers throughout their entire Workers' Compensation claim - from inception to closure. Injured workers will also be able to securely communicate with their assigned claims adjuster in over 100 different languages through in-App messaging/texting, and email, et cetera. Moreover, the App is very user friendly and ideal for injured workers who prefer to obtain quick answers to their questions, provide us with information, and for those injured workers who are not able to easily communicate through telephone calls during their workday (anticipated to be finalized by 7/31/24). • Efforts: We are proactive not reactive; specifically, our experience assists us in anticipating when certain occurrences are truly a forewarning, example: A non-litigated injured worker fails to attend a scheduled doctor's appointment (exam) that we initially reminded them about; we immediately contact the injured worker to discuss why they failed to attend the exam and will reschedule the exam. Our immediate contact with the injured worker is a proactive effort to remind them that the City and we care about them, their health, et cetera, and bottom line - we take their claim file very seriously.
• Return-to-Work Program: When applicable, we will work as a team with the City and each individual department to ensure a "not-able-to-accommodate" response is the exception, not the rule.
• Investigations: With prior City notice and approval, we investigate all "red flags" and clearly document our computer notes in a very timely manner to ensure the City is completely aware of the investigation aspect of each claim file.
• Customized Training: We will offer ongoing training in all areas such as technology, data, and reports, as well as industry best practices and State of California requirements, industry standards, et cetera. Per the City's discretion, training may be extended to certain or all City employees on a quarterly or yearly basis. We will offer our assistance with creating policies specific to Workers' Compensation, and we will coordinate training in other areas such as safety, ergonomics, ADA, et cetera, which may arise out of or impact a claim file. • File Reviews and Meetings: Accurate, timely and consistent communication is vital. We offer to meet with our City clients along with all Department Heads to provide a current status of each Admin Sure
Workers' Compensation Third Party Claims Administration Services Request for Proposal Response - City of Vernon
May 14, 2024
claim file and to ensure everyone is "on the same page." We also recommend the financial component of the claim files be discussed with each department as we have found that most City Department Heads have little to no idea as to what their department's costs are relative to the City's overall Workers' Compensation costs. We have found that there is a larger "buy in" from them when they are aware of the associated costs.
• Reports: We will provide the City with unlimited standard, ad hoc, customized, et cetera reports that provide current claims' statuses on a monthly basis to reports that provide decades' worth of data. Our reports are purposeful, accurate and timely; thereby ensuring that all parties are well informed.
We have found that these approaches and services streamline the Workers' Compensation claims process for all interested parties as they are both comprehensive yet flexible. We have proven success in tailoring each of our clients' Workers' Compensation Programs to meet their individual needs; therefore, we are very capable of conforming to the City's specific and overall needs as described in the RFP.
In addition to providing Workers' Compensation Claims Administration Services, we provide Utilization Review Services and Bill Review Services through our wholly owned subsidiary, MedReview Inc. - which is located in-house, on AdminSure's premises. It is important to note that nearly 100% of our clients have selected us to provide them with Utilization Review Services and Bill Review Services in addition to Claims Administration Services as they have found that tightly integrating these services results in greater cost savings, timeliness, efficiency, and reliability. This is particularly important in view of the deadlines, penalties, and Electronic Data Interchange (EDI) requirements associated with these activities.
We are able to ensure we are in full compliance with the Workers' Compensation Laws of California and the Workers' Compensation industry's best practices by adhering to our Workers' Compensation Claims Administration Standards (Attachment 2) and our State of California approved Utilization Review Plan (Attachment 3), as well as other client-specific and pool/excess standards, i.e., Excess Standards. It is important to note that City/Excess Standards shall supersede any/all other Standards.
Adhering to the above-noted Standards has resulted in our following most recent 2023 State of California Audit Scores:
• Our Workers' Compensation Department's score is over three times better than the passing score
• Our Utilization Review Department's score is 100%
Please refer to Attachment 4 for our 2023 State of California Audit Scores/Findings.
Admin Sure
Workers' Compensation Third Party Claims Administration Services Request for Proposal Response - City of Vernon
May 14, 2024
It is important to note that the cost of administering the City's Workers' Compensation Program and the handling of the City's existing open files is included in our proposed Workers' Compensation Claims Administration fee. In addition, we considered the City's caseload volume and the economic challenges the public sector continues to experience when quoting our proposed fee. Therefore, our proposed guaranteed fee is guaranteed throughout the term of the Contract Agreement.
We believe these good faith gestures demonstrate our ability to provide professional services for a competitive fee as well as our commitment to creating and maintaining a long-term business relationship with the City of Vernon. Please refer to Attachment 5 for our Fee Proposal, thank you.
Closing
Given the opportunity, we believe the City of Vernon will find that we have the overall experience, technical expertise, and qualifications in order to administer the City of Vernon's Workers' Compensation Program in a very professional and cost-effective manner.
We promise to provide the City with customized "boutique" care and attention - wherein everyone and everything matters. We will be adaptable and flexible to the City's needs and requests. We will also provide a high level of service, responsiveness, and communication with our City contacts, injured workers, and all interested parties.
Based on our entire proposal response, our proposed cost for services, our years of experience related to successfully administering complex claims for Cities with Police Departments, we are confident that AdminSure will provide the City of Vernon with the greatest overall cost-benefit advantages for its Self-Insured Workers' Compensation Program.
Should you have any questions or would like to further discuss our services, please contact me directly at (909) 396-5814, or by way of e-mail at [email protected] as I am fully authorized to bind our proposal, execute a Contract Agreement, and act on behalf of AdminSure Inc.
Our proposal response shall remain valid for a period of not less than ninety (90) days from the date of submittal.
Thank you for your time and consideration.
Respectfully submitted,
Heither Darzas: Hore
Alithia Vargas-Flores, President
MBA, SIA, WCCP, WCCA
Admin Sure
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
TABLE OF CONTENTS
Page
Introduction.. ....1
General Scope of Work & Work Plan... ...3
Financial Management & Positive Pay Services .. ...12
Loss Prevention Services - IDR & ADA ...13
Client Training.... ....13
Medical Provider Network (MPN) Services. ...14
Pharmacy Card (Benetit) Network Services. ...15
Utilization Review Services. ..15
Bill Review Services (Medical Billing Services) .. ..15 Risk Management Information System (RMIS) ..16
Data Conversion - Transition & Implementation Plan..... ..18 Data Integrity & Confidentiality - Disaster Recovery Plan ...18 Fees and Costs ..18
Ability of the Proposer to Perform ...18
Client References ...20
Affidavit of Non-Collusion.. .20
Closing
ATTACHMENTS
Attachment 1 Workers' Compensation Client List
Attachment 2 Workers' Compensation Claims Administration Standards Attachment 3 Utilization Review: Plan, Claims Authorization Criteria, and Workflows Attachment 4 2023 State of California Audit Scores/Findings Attachment 5 Fee Proposal
Attachment 6 Reports and Analytics: Summary and Samples Attachment 7 Data Conversion - Transition & Implementation Plan Attachment 8 Resumes
Attachment 9 Affidavit of Non-Collusion
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
Introduction
Since 1982, AdminSure Inc., a California Corporation, has been a leading service provider of performance-based Workers' Compensation Program Services for numerous cities with police and/or fire departments (safety members). In addition to providing Workers' Compensation Claims Administration Services, we provide Utilization Review Services and Bill Review Services.
Administering Workers' Compensation Program Services for Southern California cities with police and/or fire departments is truly our specialty as the great majority of our client base is comprised of cities like the City of Vernon. Specifically, our public entity/sector clients are comprised of Cities, Fire Districts, and one County - of which, the great majority have public safety (police and/or fire); therefore, we are a proven service provider.
We are a financially strong and stable company with a very longstanding and secure client base as we have administered many of our clients' Workers' Compensation Programs for more than 20 years. Please refer to Attachment 1 for our Workers' Compensation Program Client List.
We are able to achieve the objectives of this project as we currently provide the exact services described in the City's Request for Proposal (RFP). We are a top-tier service provider with decades' worth of experience in City - public entity/sector - Workers' Compensation Self- Insurance Claims Administration, and we also promote a proactive approach to manage and administer benefits in accordance with applicable laws and City-specific policies. Therefore, we have very current, on-point experience to achieve all of the City of Vernon's RFP objectives.
We are able to meet each specified timeline as described in the RFP by establishing City-approved standards and protocols. We will assign qualified, best-fit Claims Adjusting Staff (with prior City approval), as well as all necessary support Staff. We will also dedicate the required resources during the transition period and throughout the entire business relationship in order to meet and exceed the City's needs and expectations.
It is important to reiterate that for nearly 42 years, our focus has been and remains to provide performance-based Workers' Compensation Program Services for California cities with Police and/or Fire Departments (safety members). This is truly our specialty as the great majority of our client base is comprised of cities - like the City of Vernon. Our continued focus and commitment to this sector specifically - California Cities with Police and/or Fire Departments - significantly differentiates us from our competitors.
The following are key attributes and additional areas of our focus that collectively distinguish us from our competitors and also point as to why we are the best qualified TPA to partner with the City of Vernon:
• Our most recent 2023 State of California Audit Scores:
• Workers' Compensation Department: over three times better than the passing score • Utilization Review Department: 100%
• We encourage City involvement, whatever is possible and practical for the City
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
• We provide tailored training sessions and assistance on the claim submission process, forms, Risk Management Information System (RMIS), industry standards and best practices, etc. We are also able to assist with creating policies specific to Workers' Compensation and assist with coordinating training in other areas such as ergonomics, ADA, etc. • The City's Claims Team will customize their claims handling approach to meet the City's requirements and needs so that they are specific to the City's approach • Quality assurance and professionalism - we truly humanize the claims process by treating each injured worker as a "person," not a "problem"
• Communication and documentation - we will establish and maintain a professional relationship and effective communication process with our City contacts) and injured workers; as well as all interested parties (physicians, attorneys, etc.) • We are assertive. We communicate and document. We are mindful of the genuine injured worker and maintain the integrity of the claims process by utilizing both our heads and hearts when making informed decisions
• Return-to-Work (RTW Program) - with prior client review and approval, we will ensure a "not-able-to-accommodate" response is the exception not the rule • Claim notes - "If it's not in writing, it never happened," we will document all interactions and efforts - and a plan of action towards settlement/closure will be noted • File Reviews and meetings - on a quarterly basis and along with all Client Department Heads - should our City Contacts) agree, we will discuss and provide a current status of claim files to ensure everyone is "on the same page"
• Real-time software and City access - everyone (City contacts) and Claims Staff) works on the same system, at the same time, sharing information in real-time. The City will be provided access for an unlimited number of authorized read-only users • Reports, Analytics, and Data - if "it" is captured, we can create it. We are able to provide the City with an unlimited number of reports as well as analytics and data • Results based - timelines are set and met, progress is followed, outcomes are reviewed. We will provide kind customer service while focusing on extending cost-effective services • App - Injured Worker and Claims Adjuster Advocacy Solution. The App will help injured workers return to health and work, while increasing our productivity. The App is in addition to our voice-to-voice communications as it is not meant to dehumanize the claims process or take the place of telephone calls with injured workers. Specifically, in addition to their assigned claims adjuster, the App will also guide injured workers throughout their entire Workers' Compensation claim - from inception to closure. Injured workers will also be able to securely communicate with their assigned claims adjuster in over 100 different languages through in- App messaging/texting, and email, etc. Moreover, the App is very user friendly and ideal for injured workers who prefer to obtain quick answers to their questions, provide us with
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
information, and for those injured workers who are not able to easily communicate through telephone calls during their workday (anticipated to be finalized by 7/31/24) We promise to provide the City with customized "boutique" care and attention - wherein everyone and everything matters. We are adaptable and flexible to the City's needs and requests. We will provide a high level of service, responsiveness, and communication with our City contacts), injured workers, and all interested parties.
Truly, our ultimate goal is to provide considerate and consistent services in order to positively impact claim outcomes. Given the opportunity, we are confident the City will experience that we have the knowledge and qualifications in order to professionally administer its Workers' Compensation Program in both an effective and cost-benefit sensitive manner.
Therefore, it would merely be a matter of continuously working closely with our City Contacts to perfect the desired claims handling approach and process that is specific to the City's requirements and expectations. We are also able to adjust our internal standards accordingly to meet the City's needs so that we provide the City and all of their injured workers with the services they expect and deserve.
General Scope of Work & Work Plan
The following is a detailed description of our approach when providing services based on the City's Scope of Work and service requirements as noted/discussed within the Request for Proposal (RFP). We have found that explaining exactly how we will comply is best answered by summarizing what can be expected of us, in general, when administering a Workers' Compensation claim on behalf of the City of Vernon. In doing so will concisely demonstrate that we have a unique understanding of the City's needs based on the RFP.
We strive to respond to the City's and injured workers' questions, requests, etc. within one workday by way of e-mail, telephone, etc. Specifically, phone calls, faxes and electronic transmissions (e-mails) will be responded to within one workday from when they were received, and all mailed correspondence will be responded to within five workdays of receipt.
Specific to injured workers, as previously shared, the App will help injured workers return to health and work, while increasing our productivity. The App is in addition to our voice-to-voice communications as it is not meant to dehumanize the claims process or take the place of telephone calls with injured workers. Specifically, in addition to their assigned claims adjuster, the App will also guide injured workers throughout their entire Workers' Compensation claim - from inception to closure. Injured workers will also be able to securely communicate with their assigned claims adjuster in over 100 different languages through in-App messaging/texting, and email, etc.
Moreover, the App is very user friendly and ideal for injured workers who prefer to obtain quick answers to their questions, provide us with information, and for those injured workers who are not able to easily communicate through telephone calls during their workday (anticipated to be finalized by 7/31/24).
We operate in a paperless environment wherein all mail, documents, etc. received/created is scanned/saved in our computer system on a real-time basis so that the City has access to review all claims information on a real-time basis. Correspondence will be electronically date stamped on the day received and will be "matched" to the appropriate claim file and given (assigned) to the
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
assigned claims adjusters. Claims Staff will review unmatched mail, if any, and appropriate action will be taken.
Claims are reported to us in various ways depending on client preference. We prefer claims to be electronically reported to us by way of our on-line 5020 reporting module (real-time) which allows for the proper electronic forms to be attached (system entries: Employer's Report of Occupational Injury or Illness (Form 5020), Workers' Compensation Claim Form (DWC 1), Supervisor's Report of Injury or Illness, etc.). Specifically, at no additional cost, the City is able to directly and securely report new claims (and pertinent new claim information) to us in a completely electronic (paperless) manner through our company website utilizing our On-Line Services Module.
Upon receipt of an Employer's Report of Occupational Injury or Illness (Form 5020) and/or a Workers' Compensation Claim Form (DWC 1), we will open/prepare a claim file. We will contact the City and request the appropriate forms from both the injured worker and the City be provided to us when notification of an injury/illness or incident by any source is first received in our office, i.e., Application of Adjudication, Notice of Legal Representation, Doctor's First Report of Injury (DFR, Form 5021). We will document said contact in our computer notepad after the claim has been created in our Risk Management Information System (RMIS).
If there is no evidence that the DWC 1 Form was provided to the injured worker, we will provide the injured worker with the DWC 1 Form within one workday of knowledge of the injury. Should we receive a request for a DWC 1 Form, we will advise the sender (if the sender is a non-litigated injured worker) to notify the City and we will also immediately contact the City to advise that the documentation provision of the DWC 1 Form is maintained within our RMIS.
Once a claim file is opened and/or we have knowledge of a possible or imminent claim, we make immediate 3-point contact with the City, the injured worker, and the treating medical facility (physician) - all communications are documented in our computer notepad. In the event a party is non-responsive, there will be evidence of at least three documented attempts to reach the individual by phone, email or in writing (mail). Medical-Only claim files will also have this three- point contact requirement as well. Contact with opposing counsel will also be made when an Application is our first notice.
On all non-litigated, lost time cases where the injured worker is temporarily disabled (has not returned to work), telephone contact will be established with the injured worker upon receipt of notice of a claim and will continue as often as necessary, but not less than twice a month until the injured worker returns to work. We will also provide ongoing information, guidance, and assistance to injured workers at every stage of the claims process: compensability, the delay process, conditional denial process, all statutory benefits, permanent disability ratings (potential apportionment, modified/alternative/permanent work, etc.), the Qualified/Agreed Medical Examiner (QME/AME)/Independent Medical Review (IMR) process, and settlement of claims, etc. All contact will be documented in our computer notepad.
When making the initial phone contact, we will ask the injured worker to make contact with us as well whenever they may have any questions, concerns, comments, etc. We will maintain contact with all non-litigated injured workers from the inception to disposition (closure) of their claim file(s). All contact will be documented in our computer notepad. Our goal is to provide exceptional, timely, and appropriate services for the City and their injured workers as in doing so will assist us
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
in developing and maintaining a professional and trusting rapport with the City and their injured workers.
Within 14 calendar days of receipt of a claim form (DWC 1), a proper notice will be sent to the injured worker notifying them of the decision reference their claim (acceptance, delay or denial), and their rights under the Workers' Compensation Laws of California. If a decision is made to delay a claim file (benefits), an AOE/COE (arose out of employment/in the course of employment) investigation will be initiated with prior City approval.
Based on all the information present at that time, we determine which medical facility and/or physician will be best to examine and/or provide medical treatment to the injured worker. A Qualified Medical Examination (QME), Agreed Medical Examination (AME), or Independent Medical Examination (IME), etc. may also be options depending on the facts/specifics of each claim.
We also have many investigative techniques in place to identify and investigate questionable or fraudulent industrial injury claims. We will work closely with the City and their injured workers/employees to obtain all pertinent information on each claim file so that the most appropriate decisions are made in a timely manner. Based on all the information present at that time, we determine whether or not investigation, surveillance, fraud, litigation, and/or subrogation efforts are necessary or applicable.
We obtain Index Claim Searches on all lost time claims and all claims wherein any disability benefit is due, as well as when it is appropriate (i.e., all new claims, and at necessary intervals on continuing active claims). The purpose of an Index Claim Search is to obtain a history of any previous (or current) claim filings the injured worker may have that may impact the claims) against the City and/or wherein the City may be in a position to receive a credit (apportionment).
All index searches are at no additional cost to the City.
In addition, with prior City authorization, we immediately assign (refer) an investigator to a claim when any identified issue arises that may impact the nature, extent, or scope of the City's liability.
Referrals will include specific instructions regarding the scope of the investigation and the City will be kept informed of the costs and results of all investigations. Also, when a claim is believed to be fraudulent ("red flags" are identified), we will refer the claim to the appropriate law enforcement agency for further investigation - of course, with prior authorization from the City.
For all denied and contested (delayed) claims, we will contact the City to discuss the claim in its entirety, including "red flags," etc., before any notice is sent or communication is made with the injured worker. The claims adjuster will document the factual, medical, and/or legal basis for the delay or denial that is in accordance with the Workers' Compensation Laws of California.
Reference questionable claims that should be or may be accepted, we will contact the City to discuss claims such as these in their entirety.
Once a claim is entered into our system and the decision to accept, delay or deny the claim has been made, we set appropriate reserves and place the claim on an appropriate diary cycle.
Compensability determination and reasons for same will be clearly documented in our computer notepad upon receipt of the claim. It is important to reiterate that we will discuss our recommendation to delay or deny a claim with our City contacts) prior to sending any notices, and we will also discuss acceptance of any questionable claims prior to sending notices.
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
All open claim files will have an assigned diary date on an ongoing basis until the date of closure.
Our regular diary reviews are clearly distinguished in our computer notepad from routine file documentation. All open claim files are on an active diary for review of current work status, medical status, review of reserves, investigation/litigation/subrogation status, and plan of action towards claim resolution and closure, etc.
The initial plan of action will be clearly documented in our computer notepad within 14 calendar days of the initial claim set-up. Lost time claims are reviewed at least every 14 days, medical-only claims are reviewed at least every 30-45 days, and Awarded Future Medical claims are reviewed for Compromise and Release (C&R) settlement potential (with prior City approval) and/or administrative closure no less than twice a year. We will also monitor the diary reviews by utilizing a "No Activity" report every month to identify any files that have fallen off diary, if any.
Initial claim reserves will be posted electronically and will reflect the most probable value of the claim file (life of the claim). Reserves are based on the information available at the time of the claim opening and are adjusted accordingly based on medical, legal, etc. facts that develop as the claim file matures, as well as per Self-Insurance Plan (SIP) Regulations, Labor Codes, California Code of Regulations (CRs), etc. Initial claim reserves and subsequent reserve changes will be reviewed and approved by the assigned claims manager.
As claim values increase and decrease, claim reserves will be reviewed and adjusted, if necessary, on a regular basis and on each diary date (at least every 45 workdays). Future medical claim reserves are reviewed at least every 180 days. The rationale for reserves will be documented in our file notes and the amounts allocated to each reserve category will be documented. We also establish and maintain indemnity, medical, and allocated expense reserves as separate line items to ensure each expense is being properly reserved and paid.
Physicians' offices will be contacted within one to two workdays of notice on all new indemnity claims. Such contact will continue as needed during the continuation of temporary disability (lost time benefits) to ensure that treatment is related to the compensable injury or illness. All contact will be documented in our computer notepad. On all non-litigated, lost time cases where the injured worker has not returned to work, telephone contact will be established with the injured worker within one to two workdays of receipt of notice of a claim and will continue as often as necessary, but no less than twice a month until the injured worker (employee) returns to work.
We will also proactively obtain work restrictions and/or a release to work/duty on all cases in order to facilitate a return to temporary modified work/hours, full duty work, etc. All efforts will be documented in our computer notepad. In cases where an injured worker's restrictions are permanent, we will immediately contact the City so that a determination can be made as to the availability of alternative, modified, or regular work (different position), etc.
If we do not receive a response from the City within one to two weeks, we will follow up with the City. We will work as a team with the City in order to comply with laws preventing disability discrimination, including Government Code Section 12926.1. We will also assist our City contacts to the fullest extent to ensure they are meeting their obligations under State and Federal Disability Laws, etc.
With regard to disability benefit payments, we will determine eligibility for disability benefits through medical documentation and City confirmation. The following is our process for issuing
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
benefit payments (both live checks and vouchers (paper transactions) reference salary continuation, if any), including settlements: accurate and timely indemnity benefit payments; notices (including Division of Workers' Compensation (DWC) benefit notices) and Awards will be calculated, processed, and transmitted (mailed) to injured workers as required by California Labor Codes, California Code of Regulations (CCRs), etc.
Initial indemnity benefit payments and/or notices will be processed and mailed to injured workers within 14 days of the first day of compensable disability. Payments reference undisputed Awards, computations, or Compromise and Release agreements, etc. will be issued within 10 workdays or sooner if necessary to ensure payment is made within 20 calendar days of the WCAB's approval date (following receipt of the appropriate documentation).
All subsequent and final indemnity benefit payments and notices will be verified and issued in compliance with the Workers' Compensation Laws of California. Settlements will be approved by the City's claims manager prior to payment being issued and will be documented in our computer notepad. Late payments, if any, will include a self-imposed penalty in accordance with the Labor Code. All benefit notices, notices, correspondence, etc. are saved in our computer system and may be accessed at any time by the City.
Any and all fines/penalties incurred as a result of our failure to comply with statutory laws and/or administrative regulations, if any, shall be our sole responsibility. We will reimburse the City no later than 30 days from the event causing the penalty assessment. We will also provide the City with a Penalty Report every month, if any. Reference overpayments, we will request reimbursement of overpaid funds from the party that received the funds. If necessary, a credit will be sought as part of any resolution of the claim.
We also balance all benefits paid in our computer system whenever a benefit ends, a new benefit begins, receipt of an Award, when there is a change in benefit type or benefit rate, etc., and we will also balance each applicable claim file on a semi-annual basis.
With regard to litigation management, in the event the claims adjuster and the City determine a claim warrants legal service/referral, the claims adjuster will retain primary responsibility of the claim file. Defense Counsel will not be used to perform routine activities that are the responsibility of the claims adjuster. The claims adjuster will also carefully evaluate and monitor the attorney's aggressiveness in resolving claims, ability to identify issues, responsiveness, timeliness, and billing practices. The claims adjuster will also provide the City with advance notice of depositions, hearings, trials, etc., so they may attend, if necessary or desired.
Our general criteria for referring cases for legal defense services include, but are not limited to when a deposition of the injured worker is warranted and/or when there are components of the claim that require legal review/analysis, i.e., personnel issues, other pending litigation, global - a real will it ie. settlement, etc. City approval will be obtained prior to any request for legal service and/or referral to the City's choice of attorney and we will adhere to all City protocols regarding litigation. We will also cooperate fully with all attorneys selected by the City including City attorneys, in-house attorneys, etc.
The City's choice of Defense Counsel will provide the City and us with an initial case analysis and plan of action within 10 workdays of the assignment. In addition, all preparation for trial will
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
involve the City so that all material evidence and possible witnesses are utilized in order to obtain the most favorable outcome for the City.
We will also maintain a litigation management budget for each litigated file and provide litigation status reports on a monthly basis for each litigated file, if necessary. Should an attorney near or exceed the previously stated/agreed-upon litigation budget, we will immediately review the claim and provide the City with an analysis as to the reason(s) and legitimacy for same; thereafter, we will recommend a plan of action, i.e., contact the attorney, obtain a new budget, etc. We also thoroughly review all attorney bills and confirm the services were performed prior to approving for payment.
All settlement proposals will be presented to the City in sufficient time to obtain authority, City Council authority (if applicable), etc. All settlement proposals will be in a format deemed acceptable to the City.
With regard to subrogation management, we actively pursue recovery in all subrogation claims.
We will identify and seek recovery from any individual, agency/entity (public or private), or State Fund that may be a party to a claim. Upon recognition of subrogation potential, we will place the at-fault party (parties) on notice that we will pursue maximum recovery reference all benefits and payments made on the claim file.
Whenever possible, in a civil action, we attempt to settle by means of a Third Party Compromise and Release. If this is not possible, we will make every effort to offset the Workers' Compensation expenses through a credit against the proceeds from the injured worker's civil action.
Subrogation claims will also be monitored to determine the need to file a Lien or a Complaint in Intervention (in a civil action) to preserve/protect the Statute of Limitations. If the injured worker brings an action against the party responsible for the injury, we will consult with the City reference the value of the subrogation claim and recommend a plan of action.
If necessary, upon City authorization, Subrogation Counsel may be assigned to file a Lien or a Complaint in Intervention. Upon assignment of the case, Subrogation Counsel will be required to provide a "not-to-exceed" estimate of fees. The fees will be authorized by the City prior to commencement of any work by Subrogation Counsel. Should Subrogation Counsel near the "not- to-exceed" fees, we will obtain continuing authority from the City prior to incurring additional costs and said authority will be clearly documented in our computer notepad The City will have real-time access to all claim information which includes all claims that may have subrogation potential. We will also provide a projection of the possibility of recovery and the probable recovery amount. Thereafter, we will provide subsequent statuses to the City and all interested parties.
With regard to medical care, our approach for maintaining the Utilization Review process is to adhere to: the Medical Treatment Utilization Schedule (MTUS)/the American College of Occupational and Environmental Medicine's (ACOEM) Guidelines, all applicable California Labor Codes, California Code of Regulations (CCRs), etc. reference Utilization Review in order to approve, modify, or deny Request for Authorization (RFA) treatment requests. Although all medical care information will be accessible to City-approved Staff, we are able to create protocols wherein we notify the City when medical care is denied or modified, etc.
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
Upon receipt of a Utilization Review Request for Authorization (RFA) that cannot be approved at the claims adjusting level, we will immediately forward (e-mail or place in the proper "workflow") the scanned request along with pertinent medical reports (scanned) to our Utilization Review department so that a decision is made within the strict mandatory timelines.
Utilization Review referrals are also made when a modification or denial of requested medical treatment/service (RFA) is necessary, a Peer Review is necessary, or when a non-examining medical opinion is needed. All of our Utilization Review actions, efforts, documents, etc. are noted and stored in our computer system for our City contacts) to review on a 24/7/365 basis.
Requests for medical treatment/service (RFA) that may be referred for Utilization Review include, but are not limited to requests for questionable medical treatment or services, overuse of medications or certain types of treatment such as chiropractic care, and treatment/service that appears to be medically inappropriate for the injured worker based on their medical history, and/or the claim file's accepted body parts) and/or diagnoses, etc.
We will manage all medical care by remaining in constant contact with all medical service providers including the City's choice of Nurse Case Managers (NCM), if any. We are also able to assist the City in developing, or recommending, a panel of preferred physicians for the initial and ongoing treatment of employee injuries/illnesses. We would also be able to assist by including medical specialists for treatment requiring long-term or specialty care, ancillary providers, etc.
It is important to note that preferred physicians and facilities will have experience in occupational medicine, historically and consistently produce successful treatment results with corresponding medical reports, and overall - each provider/facility will have a high level of experience in treating workplace injuries and have a respectable reputation within the medical community and Workers' Compensation industry.
In the event a claim warrants referral to a Nurse Case Manager (NCM) provider, we will contact the City for approval and to discuss the intent, scope and cost of the services needed. Cases that may benefit from NCM services include, but are not limited to catastrophic injuries or illnesses, complex surgeries or procedures, severe diagnoses, and problematic medical cases/claims. Claims that simply reach a certain lost time or "days opened" threshold, i.e., 30 days of lost time, or 120 days opened, etc., with no other factors present, are not appropriate cases for NCM services.
However, there are cases with unique circumstances that will warrant NCM services perhaps on day one of the claim; therefore, it is best to consider NCM services on a case-by-case basis.
NCM providers work in close collaboration with the injured workers physicians and all interested parties in order to return the injured worker to their usual and customary occupation, modified duties, a rehabilitation program, etc. They also assist claims staff in ensuring medical treatment and medical procedures lead to quantifiable results instead of unnecessary and/or excessive Daniel posite na.
medical treatment or procedures that have no possible value. NCM providers may also assist in ensuring that injured workers receive quality and appropriate care that is both cost-benefit sensitive and effective.
When a NCM provider is assigned to a claim, we will continue to evaluate the injured worker's physical capacity specific to their ability to return to work (modified/light duty - work restrictions; full duty - usual and customary occupation/U&C, etc.). We will work alongside the NCM provider
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
and treating physician(s) to ensure that the City's' injured workers receive all the benefits they are entitled to that is specific to the City's approach.
We will utilize whomever the City selects as their choice of NCM provider; and although we are able to recommend various NCM providers, the final selection rests with the City. It is also important to note that, as with all vendors, we do not receive and are not entitled to any commissions, fees or any other type of compensation from any vendor the City selects.
We will continuously review all open claims and provide a current plan of action towards closure in our computer notepad. As previously noted, our goal is to provide the injured worker with all the benefits they are entitled to that is specific to the City's approach. Therefore, all benefits are paid appropriately and timely, and all medical bills are reviewed for reductions per the Official Medical Fee Schedule (OMFS), Inpatient Hospital Fee Schedule (IFS), and Preferred Provider Organizations' (PPO) discounts, if applicable, as well as other network organization discounts, and/or negotiated rates, etc.
With regard to medical benefit payments, we will authorize payment of medical benefits as follows: prior to any payment, all bills will be reviewed for accuracy and appropriateness by claims adjusting staff. Medical bills submitted without supporting documentation will be objected to within 30 days of receipt and will not be reviewed for payment until such documentation is obtained, if applicable. Medical bills will be paid, objected to, or denied in accordance with State Statutes.
Medical-legal bills/costs will also be reviewed for appropriateness and necessity. Medical-legal bills/costs that do not qualify as valid medical-legal expenses will be objected to in a timely manner according to the Workers' Compensation Laws of California. As required by Senate Bill (SB) 899, payment of medical treatment regarding delayed (AOE/COE) claims will be processed through utilization review and bill review but will not exceed $10,000.
We are also mindful that an injured worker may hinder progression of their claims) due to nefarious or non-industrial reasons. If we anticipate or have knowledge that this is occurring or may occur, we will work closely with the City, and all parties involved, to ensure that the claim does not become stagnant. We will schedule conference calls and roundtable meetings with all parties involved which may include the claims adjuster, claims manager, our City contacts), the injured worker, physician, and if applicable, the defense attorney, so that there is constant action occurring on the claim file, not just "movement."
Once an injured worker's initial/final medical diagnosis is determined, we address all issues that may arise thereof, which include, but are not limited to: medical treatment/service requests, ergonomic studies, lost time benefits (Temporary Disability, Salary Continuation, Labor Code 4850, etc.), return to work/modified (light) duty, permanent disability (Permanent Disability Rating(s) Permanent Disability Benefits), rehabilitation (Vocational Rehabilitation/Supplemental Job Displacement Benefits (SJDB), and Americans with Disabilities Act (ADA) Interactive Meetings, etc. Also, when necessary and/or appropriate, we will obtain and utilize the City's "essential job functions" analysis and/or Job Description (Job Analysis).
We will assist with ensuring the City's injured employees, personnel, and other agencies address and/or provide rehabilitation, and/or reassignment of injured employees with physical or
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
performance limitations arising out of industrial injuries. This may include assisting with the Americans with Disabilities Act (ADA) Interactive Process.
Upon receipt of a medical report that requires a permanent disability rating, we will review and internally rate the report within 10 workdays of receipt. When necessary, we also request an informal/outside rating or board rating. We will also address any potential apportionment, credits, penalties, etc.
When required and/or necessary, Permanent disability (PD) advances are issued timely along with appropriate Division of Workers' Compensation (DWC) benefit notices no later than 14 calendar days of receipt of the qualifying report. Should the City/we object to the report's permanent disability findings, we will mail the appropriate objection notice reference the report/PD findings within 14 calendar days as required by State law. We will also re-review the reserves and set/re- set PD reserves accordingly, if necessary, at that time.
Once the above-noted final issues/matters are determined, we would be in a position to resolve and/or negotiate a settlement which will be based on all medical/legal and factual findings. Within 10 workdays of receiving all the necessary information, we will provide the City with our written settlement recommendation (Stipulations with Request for Award, Compromise and Release, etc.) prior to offering or agreeing to any settlement. Our settlement recommendation will include a brief history of the injury, the rating(s) of all pertinent medical reports, the amounts paid and reserved on the claim, the proposed settlement, the pros and cons of the proposed settlement which will include an estimate of future cost or consequences if the City were to reject the proposed settlement. We will also provide the City with any and all pertinent information that is available so that the most appropriate and cost-effective settlement may be agreed upon and offered.
Reference excess and excess reporting, applicable claim files wherein incurred reserves are nearing/at 50% of the City's self-insured retention (SIR) level (amount), or may have the potential to exceed the City's self-insured retention level, will be reported in accordance with the reporting criteria established by the City and the City's excess insurance carrier's policies within five workdays, or sooner if necessary, from the day on which it is known that any criteria is met.
When a claim nears/reaches one-half of the SIR, we are able to report to the client every 90 calendar days (on a quarterly basis) regarding the status of the claim. Our report will be on an approved form and will include a current status of the claim, our plan of action for the future handling of the claim, and the current paid-to-date and total incurred amounts listed by all payment categories.
Our process for reporting claims other than "at/near 50% incurred" to the City's excess insurance carrier (e.g., death, cerebral injury, one year of lost time, etc.) will be in accordance with the reporting criteria established by the City and the excess insurance carrier's policies. From the day on which the claim occurs/is made, or when it is known that any criteria is met, there will be no delay in reporting such claims to the excess insurance carrier.
The City will have real-time, online access to all excess correspondence prepared or received by our office. Requests for reimbursement will be made within 30 days of exceeding the SIR and every six months or sooner thereafter. The requests for reimbursement will be made on the form prescribed by the excess insurance carrier. Upon receipt of excess reimbursements, we will
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
immediately mail/provide the check to the City for deposit. Also, when applicable, we will send the City a closing report upon resolution of a claim involving excess insurance coverage.
In addition, reference qualifying settlements, we will effectively assist the City's choice of Medicare Set-Aside Allocation (MSA) service provider. We will also attend all WCAB/Rehab Hearings, Conferences, Proceedings, Trials, depositions, etc., as requested and at no additional cost. We will obtain City approval prior to settling any claim, lien, etc. as final settlement authority shall always rest with the City.
Furthermore, as the City's designated Reporting Agent (RA), we will provide reporting to CMS regarding Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA).
Initial and Subsequent Reporting includes initial and subsequent reporting as required by law, at no additional cost. At this time, we are the RA for 100% of our clients.
With regard to reducing/resolving "older" claims, we will review all claim files in their entirety to identify all pending items that may be prohibiting the file from moving forward/being closed.
After we review the "older" claims in detail, we will create a plan of action/strategy to resolve all outstanding issues that may be delaying the claim from moving towards disposition (settlement)/closure. Outstanding issues may include obtaining a current medical report, resolving liens, preparing a Stipulations with Request for Award, offering a C&R, etc. We will identify all areas that require attention to ensure "older" claims are resolved in a timely, professional, and cost- effective manner.
It is also important to note that our claims managers review all open claims on an ongoing basis as well as review/audit a minimum of 10% of each of their claims adjusters' caseloads on a continuous basis to ensure we are meeting and/or exceeding all standards. The purpose of our internal audits is to ensure proper claims handling procedures are being adhered to and that a current plan of action towards settlement and/or closure is documented in every open claim file.
All claim files will be available for review by City staff or by an auditor at any time.
We are also able to conduct quarterly claim file review meetings to discuss the overall case management of the claims, coordination of Workers' Compensation related activities, medical treatment, litigation, and any topics, issues, concerns, etc. related to the City's Workers' Compensation Program. These meetings may take place virtually, on-site at the City's location, our office, or however/wherever else the City prefers.
Also, at no additional charge, we will provide the City with any and all printed and electronic (with the ability to amend) Workers' Compensation Posters, Forms, Pamphlets, etc., as required by law.
With regard to assisting non-English speaking claimants, we are able to obtain multi-lingual speaking assistance from translating firms should a claimant prefer to verbally communicate with us in a language other than English.
Financial Management & Positive Pay Services
Per the RFP, the funding arrangement for issuing checks and vouchers (paper transactions), if any, on behalf of the City's Workers' Compensation Program is for the City to maintain a Trust Account (City owned trust account) from which all Workers' Compensation Benefits and Payments are to be paid. We will prepare and mail checks (our work product) directly to payees without delay. We
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
will sign checks with a facsimile signature. The City would continue to maintain an adequate balance in the Trust Account to meet all of its Workers' Compensation obligations without delay.
We will process payments/checks (our work product) for all approved expenses and statutory benefits by way of the City's (Workers' Compensation) Trust Account. We will adhere to all City financial management specifications and requirements. We will facilitate this task with a "transparent" approach in that we are able to provide daily, weekly, monthly, yearly, ad hoc, special, etc. reports to maintain the integrity of the Trust Account. We are also able to provide daily electronic check registers.
In addition to the above, we are able to administer Positive Pay Services alongside the City's choice of bank at no additional cost. Our Positive Pay Services provide protection against the potential of theft and fraudulent or tampered checks from being created, cashed, or deposited.
We are also able to provide the City with a daily report listing all transactions: checks, voided checks, vouchers (paper transactions), etc., that we issue on behalf of the City. Reports illustrating all bank transactions, such as check registers, can also be provided to the City on a daily, weekly, monthly, etc. basis. All Positive Pay Services that we provide directly to the City, including reports, are at no additional cost.
In summary, we are able to provide the City with live check, voided check, voucher (paper transaction), and positive pay, etc., information on a daily, weekly, monthly, etc. basis.
Loss Prevention Services - IDR & ADA
We are also able to assist the City with coordinating safety training and other loss prevention services with the assistance of organizations that specialize in many areas such as ergonomics ("ergonomic evaluations"), biomechanics and injury causation, environmental and industrial hygiene, and ADA compliance, etc. Our involvement will be at no cost and the services provided by the City's choice of service providers/outside vendors will always be at-cost as we will never add on any additional fees.
Also, considering that the great majority of our clients are cities with police and/or fire departments, we are very well versed regarding the presumptions for safety members, specifically police and/or fire, and their impact on CaPERS Retirement Benefits - Industrial Disability Retirement (IDR).
In addition, we are extremely knowledgeable and experienced with Workers' Compensation claims that involve the coordination of municipal claims administration, Labor Code 4850 Benefits, IDR/CaPERS, and Americans with Disabilities Act (ADA), etc. matters.
Client Training
The field of Workers' Compensation is constantly changing due to new information, case law, proposed changes, newly enacted Statutes and California Code of Regulations, etc. Constant change requires analysis and possible implementation of adjustments to our clients' Workers' Compensation Programs. Therefore, we are committed to continuously educating and providing training for our clients so that they are aware of the requirements that need to be met and the efforts that need to be made in order to ensure that they/we are in compliance with the Workers'
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
Compensation Laws of California and the Workers' Compensation industry's best practices and standards.
At no additional cost, we are able to provide the City with ongoing training, including all training materials/handouts, as well as conduct presentations and provide written communications to ensure that the Workers' Compensation procedures in place are proper and purposeful, and to ensure that all areas of the Workers' Compensation process are being adhered to.
Training involves providing information and guidance (review and discussion) regarding specific claims, general procedures, as well as positive and negative trends. The training subject matter will also include recent WCAB decisions, case law updates, and emerging trends in the Workers' Compensation industry. This type of training will also ensure the City's Workers' Compensation Program is administered in a professional and lawful manner.
We are also able to assist the City with coordinating safety training and other loss prevention services with the assistance of organizations that specialize in many areas such as ergonomics ("ergonomic evaluations"), biomechanics and injury causation, environmental and industrial hygiene, and ADA compliance, etc. Our involvement will be at no cost and the services provided by the City's choice of service providers/outside vendors will always be at-cost as we will never add on any additional fees.
In addition to the above, we are able to assist the City with staying current on the legal requirements and best practices of risk management in the Workers' Compensation arena by providing all pertinent information we receive from all channels throughout the Workers' Compensation industry, such as: the State of California, attorneys, conferences we attend, etc. We are also able to advise the City of industry meetings and conferences that would be beneficial to attend.
We are also able to keep the City updated on their Workers' Compensation financial trends by providing useful reports that may illustrate areas of the City's Workers' Compensation Program that deserve "kudos," or may require immediate attention and/or action.
At no additional cost, we are also able to provide assistance in developing policies and procedures relating to City's Workers' Compensation Program which will be created based on the information we gather through administering/handling and auditing the City's claims. We will also incorporate industry best practices and standards, as well as our internal standards, with the understanding that City Standards shall supersede ours.
Medical Provider Network (MPN) Services
We recommend the MedEx MPN to our clients. Per the RFP, the City currently utilizes MedEx.
Nevertheless, should the City decide to change MPNs, each of our clients has the option of utilizing their choice of Medical Provider Network (MPN). MPNs are to consist of medical experts, including specialists, who may be utilized to review and/or provide treatment. Should the City opt to utilize a MPN, same will be at-cost as we do not add on any additional fee, or receive any commission, or any other type of compensation from any MPN for the internal MPN Services we provide.
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
Pharmacy Card (Benefit) Network Services
We recommend MyMatrixx to our clients for Pharmacy Card (Benefit) Network Services in order to contain pharmacy costs. These services are at cost as we do not add on any additional fee, or receive any commission, or any other type of compensation from any service provider. However, should the City prefer a particular vendor regarding any Pharmacy Benefit Network Services, we will utilize whomever the City prefers. Should the City's choice of vendor charge a fee/cost, it will be at-cost as we do not add on any additional fee, or receive any commission, or any other type of compensation from any service provider.
Utilization Review Services
Since 2004, we have provided Utilization Review Services for our self-insured clients through our wholly owned subsidiary, MedReview, Inc. We do not provide Utilization Review Services for any Third Party Administrator (TPA) or entity other than our Workers' Compensation clients.
Each of our clients is able to customize their Utilization Review approach from the number of physical therapy sessions to prior authorizations, etc. We carefully tailor a customized Utilization Review approach for each of our clients based on their needs and requirements. Please refer to Attachment 1 for a list of our Workers' Compensation clients for which we provide Utilization Review Services.
Our Utilization Review Department is located in-house on AdminSure, Inc.'s premises, and is fully integrated with our claims adjusters and bill review personnel. The integration of these services has enabled our claims adjusters to promptly and accurately expedite the entire claims and utilization review process within the complex timeframes mandated by the Workers' Compensation system.
What distinguishes our utilization review approach from all others is our commitment to providing fair, timely, and professional services while achieving cost efficiencies. We are unique in that although we rely upon the Medical Treatment Utilization Schedule (MTUS)/American College of Occupational and Environmental Medicine's (ACOEM) Guidelines to determine utilization review decisions, we are mindful of the genuine injured worker in that we make great efforts to render appropriate decisions as quickly as possible as we are very aware that no one appreciates waiting to hear whether their requested medical treatment or service, etc. is approved.
Bill Review Services (Medical Billing Reviews)
Since 1998, we have provided Bill Review Services for our self-insured clients through our wholly owned subsidiary, MedReview, Inc. Please refer to Attachment 1 for a list of our Workers' Compensation clients for which we provide Bill Review Services. We do not provide Bill Review Services for any Third Party Administrator (TPA) or entity other than our Workers' Compensation clients.
Our Bill Review Department is located in-house on AdminSure, Inc.'s premises, and is fully integrated with our claims adjusters and utilization review personnel. The integration of these services results in a very prompt and interactive relationship between our claims adjusters and bill review personnel; thereby, ensuring only approved bills are reviewed and paid timely. This approach definitely distinguishes our organization from other bill review providers as we have
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
found that tightly integrating these services results in greater cost savings, timeliness, efficiency, and reliability; this is particularly important in view of the deadlines, penalties, and Electronic Data Interchange (EDI) requirements associated with these activities.
Our Bill Review Department's sole purpose is to obtain the greatest savings for our clients by comprehensively reviewing medical bills, reducing every medical bill per the Official Medical Fee Schedule (OMFS), Inpatient Hospital Fee Schedule (IHFS), and maximizing Preferred Provider Organizations (PPO) discounts, network organization discounts, and/or negotiated rates, etc. We provide an Explanation of Benefits (EOB) with every bill we review and complete. In addition, all EOBs are saved in our Risk Management Information System (RMIS) for review by the City, claims adjusters, etc.
We are truly committed to providing purposeful medical management services that ensure positive outcomes. We do not believe in over-promoting medical management services that exaggerate actual claim outcomes or overreach by suggesting self-serving, unrealistic savings through affiliated or outsourced service providers to our clients.
We prefer to focus on and provide prompt, assertive, and professional claims handling services along with applying reasonable Utilization Review and every Medical Management Service, Provider Network Savings, Preferred Provider Organization (PPO) Savings, and Fee Schedule (OMFS/IHFS) Savings, Negotiated Rates, etc. to the fullest extent allowed by law so that we may provide the City's injured workers with all the medical treatment and services they are medically and legally entitled to in the most timely and cost-effective and cost-sensitive manner.
Risk Management Information System (RMIS)
Our in-house Team of IS/IT Staff utilize and manage our Risk Management Information System (RMIS). Our RMIS system operates seamlessly in a "best practices" claims environment. Our RMIS is integrated with our Bill Review, Bill Payment, Check Processing (our work product), and Utilization Review, etc. systems.
Our RMIS is a 100% web-based claims administration system that can be accessed anywhere, at any time, through just a browser. At no additional cost, we will provide the City with read-only access to all claim files/data via a secure website. Read-only (includes report writing module) access to our RMIS will be at no additional cost for an unlimited number of City users. There are no restrictions to the read-only data. Should the City decide to have read-write access, the fee will be a pass-through fee as we would not add any cost/fee.
Our City contacts will have 24/7/365 internet-based access and services available at all times in order to manage, review, audit, etc., claim files and to retrieve information and create reports through our report writing module. Again, there are no fees associated with read-only access to our RMIS or when utilizing the report writing module. We will also provide system training for our City users (contacts) at no additional cost.
Our user-friendly RMIS provides very current, effective, and dependable technological capabilities that result in managing claims in a more informed and timely manner; thereby, providing our claims adjusting staff with more time to problem solve, administer claims, and settle/close claims.
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
Our system is a "one system" approach that encompasses all the functionality that is required/necessary to link/tie in the following Services: Claims Administration, Risk Management, Bill Review (Bill Payments), Utilization Review, Medical Management, Work Status Coordination, and Litigation Management, etc. This enables complete collaboration among all parties involved in the claims administration and risk management process.
Collaboration extends to online access to our claim notes, correspondence, diary, payment history, and much more. Everyone works on the same system, at the same time, sharing information in real time. The system empowers the City and us to make better, more informed decisions in a much shorter timeframe; thereby, ultimately lowering the costs associated with the City's Workers' Compensation Program.
Of the many capabilities our RMIS provides, one specific capability is producing ad hoc reports (specialized, custom, etc.). Our reports are useful from both a risk management and data management perspective and will be tailored to the City's specific needs. At no additional cost, we are able to provide hundreds of reports such as OSHA Forms (Logs/Summaries/Reports), and reports that illustrate pertinent claim information, loss history (paid losses), incurred costs, cost drivers and savings, as well as reports that track all information and payments made on each individual claim; claims losses showing severity, frequency and statistics in graph or other visual charts showing accident (injury) trends by type of injury, body part, days lost, etc.
Our computer system tracks all lost time scenarios within the "Work Status Tab" - please refer to Attachment 6 for a sample (screenshot). This "Tab" allows us to track all types of lost time benefits such as temporary modified duty and temporary partial disability such as: full time/full duty; full time/modified duty; part time/full duty; part time/modified duty; permanent modified duty; temporary total disability, etc.
In addition, our system tracks Labor Code 4850 benefits separately in that it applies the temporary disability rate as one transaction and the remaining balance as a Labor Code 4850 benefit transaction. This is especially important reference annual State reporting as the City's assessments are calculated based on the temporary disability rate amounts, not the entire Labor Code 4850 benefit amounts.
We are able to provide reports on a daily, weekly, monthly, quarterly, annual, etc. basis for and on behalf of the City, including those required by State and Federal law. Reports include a complete record of all financial transactions, including, but not limited to check registers that enumerate check issuance data, and/or voucher (paper transaction) data, whatever is appropriate for the City; as well as management summaries, claim listings and loss analyses (paid losses and incurred costs), etc. At no additional cost, we are able to provide the City with any/all requested reports/loss runs (loss run analysis, summary report, etc.) typically within five workdays, or sooner, of the request.
In summary, we will provide all requested/required monthly reports by no later than the 10th (usually within five workdays) day of the following month, or sooner. We will also provide read- only online access to our computer system (RMIS), which includes report writing capability, for an unlimited number of City users at no charge.
Please refer to Attachment 6 for a summary of reports we are able to provide as well as sample claims reports (computer-generated reports)/analytics that illustrate our reporting capabilities
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
which include standard/regular monthly, quarterly, semi-annual, and annual computer loss runs, etc.
Data Conversion - Transition & Implementation Plan
Should we be selected, we will timely and accurately convert the City's claims data from its current Risk Management Information System (RMIS) to our RMIS. We expect that the data conversion will be completed within 30 workdays of receipt of the City's complete and final (exit) data. We have found that when a realistic data conversion plan is in place, transferring electronic claim files and data/documentation from one RMIS to another by a contract agreement start date is possible.
Please refer to Attachment 7 for our Transition and Implementation Plan (Data Conversion) that outlines the anticipated activities associated with the transition of claims and implementing all required services. Our proven approach ensures the least disruption during the transfer of electronic data, transfer of physical files (if any), and the service of required notices upon transition, etc.
It is important to note that we expect the City to have full access to all claim files we are assigned once we receive final (exit) data on July 1, 2024 (sample date) from the City's current RMIS provider so that we may finalize the entire data conversion. This is imperative in order to ensure all data is transferred correctly and to ensure claim files are coded as Indemnity, Future Medical, or Medical-Only, etc. and that each claim file is properly assigned to the appropriate claims adjuster for handling.
Data Integrity & Confidentiality - Disaster Recovery Plan We are a Certified Service Organization Controls (SOC) Organization with a Disaster Recovery Plan. This designation is meaningful as it signifies that we undergo yearly, in-depth examinations of our control objectives and control activities, which includes controls over information technology and related processes such as security, data integrity, and confidentiality measures.
This matters because you do not need to take our "word" for it - we are a proven, secure service provider.
Fees and Costs
Please refer to Attachment 5 for our Fee Proposal, thank you.
Ability of the Proposer to Perform
Our City of Vernon Team assigned to handle claims will be comprised of professional staff that includes our Workers' Compensation Claims Directors. Their broad role includes transitioning the City's claims to us, selecting (with prior City approval) and assigning all necessary best-fit Claims Adjusting Staff, and non-Claims Adjusting Staff, to perform each service required per the RFP.
Please refer to Attachment 8 for their resumes which detail their education, experience, years with our firm, etc.
It is important to note that our Workers' Compensation Claims Directors have successfully completed numerous Third Party Administrator (TPA) transitions; moreover, they have sufficient time and resources to devote to the City of Vernon's transition should we be selected. They will
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
also oversee the entire Project alongside the City's assigned Workers' Compensation Claims Manager to ensure we meet and exceed the City's needs and expectations.
As previously noted, our Workers' Compensation Claims Directors will - along with our City contacts) - assign the best-fit Workers' Compensation Claims Manager and Claims Team to the City's account as it is absolutely imperative to the success of the City's Self-Insured Workers' Compensation Program that the City's assigned Claims Adjusting Staff are compatible with our City contacts) and that our business relationship is based on mutual goals and shared philosophies.
It is important to reiterate that our Workers' Compensation Claims Directors and City's assigned Workers' Compensation Claims Manager will oversee the City's account to ensure the City of Vernon's Team administers and manages the services requested in the RFP in such a way that meets and exceeds the City's needs and expectations.
In addition, the City's assigned Workers' Compensation Claims Manager will have the authority to resolve client issues immediately including increasing staffing (should workloads increase over the life of the Agreement), or reassigning Staff to the City's satisfaction. If/when necessary, we will provide a qualified back-up claims adjuster in the event of any absence of the City's Claims Adjusting Staff. Should the City request/require a different approach, we will adhere accordingly.
It is also important to note that we have more than sufficient resources to provide the requested professional services in the timeframe required by looking to our 100+ Workers' Compensation Professional Staff to assist the assigned City of Vernon Workers' Compensation Team as follows:
• Staff - City of Vernon's Claims Team:
• Directors of Operations
• Workers' Compensation Claims Manager
• Workers' Compensation Claims Adjusters
• Workers' Compensation Claims Assistants
• Workers' Compensation Office Assistants
• Clerical Support Staff
• Utilization Review Staff
• Bill Review Staff
• Bill Pay Staff
• Check Processing Staff
• Information Systems/Technology (IS/IT) Support Staff
Our staffing backup plan when a City of Vernon team member is not available is achieved through our PTO (personal time off) "Buddy System." Each claims adjuster has a claims adjuster assigned to them to assist when they are on PTO and/or not available. This ensures all clients and injured workers receive the necessary attention and care at all times.
By appropriately staffing the City's account, the City's Claims Team will be able to consistently communicate with injured workers throughout the entire claims process. Our responsive, meaningful communication approach to claims handling results in good, injured worker relations and should result in claim cost reductions and claims settling/closing sooner.
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
Client References
As requested in the RFP, the following are three references similar in size and character to the City of Vernon:
• City of Huntington Park - Client since October 1, 2004 • City of South Gate - Client since July 1, 2005
• City of Lynwood - Client since March 1, 2004
Please refer to Attachment 1 for our Workers' Compensation Program Client List, thank you.
Affidavit of Non-Collusion
Please refer to Attachment 9 for our fully executed Affidavit of Non-Collusion.
Closing
Thank you for the opportunity to potentially partner with the City of Vernon. We believe we will best serve as the City's choice of service provider based on our:
• Entire proposal response
• Proposed cost for services
• Technical expertise
• Qualifications
• Years of specialized experience related to successfully administering complex claims in a considerate and consistent manner for Cities with Police Departments (safety members) - like the City of Vernon
We are confident we will provide the City of Vernon with the greatest overall cost-benefit advantages for its Self-Insured Workers' Compensation Program (Claims Administration Services, Utilization Review Services, and Bill Review Services). We sincerely hope we are extended the opportunity.
Should you have any questions or would like to further discuss our services, please contact me directly at 909.396.5814, or by way of e-mail at [email protected], as I am the contact person for this Request for Proposal (RFP) and am fully authorized to negotiate and contractually bind AdminSure Inc. Our proposal response shall remain valid for a period of not less than ninety (90) days from the date of submittal.
Thank you for your time and consideration.
Respectfully submitted,
seither dangas: Houd
Alithia Vargas-Flores, President
MBA, SIA, WCCP, WCCA
Admin Sure
Workers' Compensation Client List
The following is a list of our Workers' Compensation clients for which we provide various Services as follows: Claims Administration, Utilization Review, and Bill Review:
Alpine Fire Protection District
Antelope Valley Union High School District (AVUHSD)
Bonita-Sunnyside Fire Protection District
California Insurance Pool Authority (CIPA)
City of Adelanto
City of Anaheim
City of Arcadia
City of Baldwin Park
City of Barstow
City of Bell
City of Buena Park
City of Burbank
City of Canyon Lake
City of Carlsbad
City of Carson
City of Cathedral City
City of Coachella
City of Colton
City of Corona
City of Costa Mesa
City of Covina
City of Cypress
City of Desert Hot Springs
City of Downey
City of El Monte
City of El Segundo
City of Encinitas
City of Escondido
City of Fullerton
City of Garden Grove
City of Glendale
City of Glendora
City of Hawthorne
City of Hermosa Beach
City of Holtville
City of Hope National Medical Center
City of Huntington Park
City of Imperial Beach
City of Inglewood
City of Irvine
City of La Habra
City of Laguna Beach
City of Los Alamitos
City of Lynwood
City of Manhattan Beach
City of Montclair
City of Monterey Park
City of Moreno Valley
City of Murrieta
City of National City
City of Newport Beach
City of Norco
City of Oceanside
City of Ontario
City of Orange
City of Palm Springs
City of Placentia
City of Pomona
City of Rancho Mirage
City of Redlands
City of Redondo Beach
City of Rialto
City of San Bernardino
City of San Bernardino Water Department
City of San Clemente
City of San Fernando
City of San Jacinto
City of San Marcos
City of San Marino
City of Santa Ana
City of Santa Barbara
City of Santa Maria
City of South Gate
City of Tustin
City of Victorville
City of Vista
City of Westminster
City of Westmorland
City of Yorba Linda
Goodwill Industries of Southern California
Goodwill Retail Services
Hemet Unified School District (HUSD)
Independent Cities Risk Management Authority (ICRMA)
Kern County Hospital Authority
Lakeside Fire Protection District
Local Agency Workers' Compensation Excess (LAWCX)
Los Angeles Community College District (LACCD)
Los Angeles Department of Water and Power (LADWP)
Mariposa County
North County Fire Protection District
Out of the Shell, LLC
Palmdale School District
Pomona Valley Hospital Medical Center (PVHMC)
PRISM (Public Risk Innovation, Solutions, and Management) - Formerly:
California State Association of Counties - Excess Insurance Authority (CSAC- EIA) - Primary Workers' Compensation (PWC) Program
Public Entity Risk Management Authority (PERMA)
Rancho Santa Fe Fire Protection District
San Miguel Fire Protection District
South Coast Air Quality Management District (SCAQMD)
SunLine Transit Agency
Tarzana Treatment Centers
Taylor-Dunn Corporation
Trademark Construction Co., Inc. DBA J.M.W. Truss and Components Yum Yum Donut Shops, Inc. (Winchell's)
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WORKERS' COMPENSATION
CLAIMS ADMINISTRATION STANDARDS
(CALIFORNIA)
The following standards are intended to foster a professional, best practices approach to Workers' Compensation claims administration. Under no circumstances are they to be construed as having precedence over any new or existing statute, regulation or case law.
1. Caseload
An ideal caseload is 150-165 open indemnity claims, with each future medical claim (settled; no pending issues other than the payment of the approved Award, medical treatment, liens and excess) or medical-only claim being counted as one-half of an indemnity claim.
2. New Claim Set Up
Upon receipt of the Employer's Report of Occupational Injury or Illness (Form 5020), Workers' Compensation Claim Form (DWC 1), or Application for Adjudication of Claim, the claims administrator will create a claim file within two workdays.
In the event a DWC 1 Form is not received by the claims administrator within one to two workdays after receiving Form 5020, the claims administrator will contact the employer to ensure that a DWC 1 Form was provided to the injured worker within one workday of the employer's date of knowledge of the injury. If a DWC 1 Form was not provided, the claims administrator will immediately send a DWC 1 Form directly to the injured worker.
The claims administrator will immediately request Form 5020 from the employer when the Doctor's First Report of Occupational Injury or Illness (Form 5021) is received first.
All coding fields will be accurate and complete.
3. Compensability
The initial compensability determination (accept claim, deny claim, or delay acceptance pending the results of additional investigation or medical documentation) and the reasons for such a determination will be made and documented in the claims administrator's file notes no later than fourteen (14) calendar days of the filing of the claim with the employer.
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Upon knowledge of preexisting medical conditions which may be pertinent to a claim, medical records will be explored and obtained as necessary and/or approved by the employer.
When medical causation is unclear, a medical evaluation will be scheduled with a physician by way of a State Panel Qualified Medical Exam, Defense Qualified Medical Exam, or Agreed Medical Exam (AME). A cover letter, when appropriate, will be provided to the physician outlining the specific issues, concerns and questions.
All relevant medical reports, investigation reports, and information will be provided to the physician for review prior to the examination date.
Delayed claims will clearly document the reason for the delay, the information needed to determine compensability and the anticipated date of the final decision. If a claim was initially delayed pending a physician's report and/or other medical, legal, or investigation report, a decision will be made within five workdays from receipt of such reporting, or sooner, if any delay will result in a penalty situation.
For all denied claims, the claims administrator will document the factual, medical, and/or legal basis for the denial, in accordance with the Workers' Compensation Laws of California.
The claims administrator will notify the employer of all claims where a delay or denial is recommended. The claims administrator will also notify the employer before any questionable claim is accepted. Thereafter, a proper notice will be sent to the injured worker notifying him/her of the decision and their rights under the Workers' Compensation Laws of California.
In no case will a compensability decision be made more than ninety (90) days from the employer's date of knowledge of the injury and/or the employer's receipt of the Workers' Compensation Claim Form (DWC 1).
4. ISO ClaimSearch® and EDEX
The claims administrator will request a report from ISO ClaimSearch® and/or EDEX on all new indemnity claims. Thereafter, requests will be submitted if the possibility of other injuries is suspected, it appears permanent disability may be paid, or a claim file becomes litigated.
5. Three-Point Contact
a. Employers will be contacted within two workdays of receipt of a claim to discuss and verify compensability, disability, clarify issues, and request additional information, if necessary. Contact will be made sooner if any delay will result in a late payment, late notice, or any penalty situation.
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b. All injured workers will be contacted by telephone within two workdays of receipt of a claim. During this initial contact, injured workers will be provided with an explanation of their benefits and will be asked whether they have any questions or concerns regarding their claim.
Injured workers who have not returned to work will be contacted by telephone within two workdays of receipt of a lost time claim unless the injured worker is represented by an attorney. During this initial contact, injured workers will be provided with an explanation of their benefits and will be asked whether they have any questions or concerns regarding their claim.
Injured workers will continue to be contacted at least twice a month while they are disabled from working, unless they are represented by an attorney, or their claim has been finalized.
Treating physicians will be contacted within two workdays of notice or receipt of a lost time claim to verify the diagnosis, compensability, duration of disability, proposed treatment and other issues, as appropriate. Contact will be made sooner if any delay will result in a late payment, late notice or any penalty situation.
Thereafter, the claims administrator will maintain contact at least every thirty (30) days with the treating physician to monitor the disability status and the progress of medical treatment, facilitate an early return to work, and obtain medical reports.
6. Telephone and Written Communication
Telephone calls will be returned within one workday. If the designated claims administrator is not available within this time frame, another claims administrator will return the telephone call.
Written communications from the employer, defense counsel and injured workers requiring acknowledgment or action will be responded to within five workdays.
Written communications from all other parties will be responded to within thirty (30) days or sooner, if an immediate response is necessary or required. All incoming written communication will have the date of receipt clearly date stamped.
The claims administrator will respond to the employer's request for verbal status reports on claim files within twenty-four (24) to forty-eight (48) hours.
In lieu of written status reports, the employer will be provided with online computer access to claim status information.
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7. Investigation Management
With prior authorization from the employer, the claims administrator will immediately assign an investigator, as needed, when any identified issue arises that may impact the nature, extent, or scope of the employer's liability.
Referrals will be made within five workdays from the employer's approval and will include specific, written instructions regarding the scope of the investigation. The employer will be kept informed of the results of all investigations.
8. Fraudulent Claims
Any claim that is believed to be fraudulent will be referred to an investigator for additional investigation, and with the employer's prior approval, the claim will be referred to the appropriate law enforcement agency for further investigation.
9. Subrogation Management
Whenever practical, the claims administrator will aggressively pursue recovery in all subrogation claims. The claims administrator will attempt to maximize the recovery for benefits and payments made and assert credit against an injured worker's net recovery for future benefit payments.
Subrogation potential will be identified and appropriate steps will be taken to initiate an investigation within ten (10) workdays after information is available that subrogation may exist. In all cases where it appears a third party is responsible for the injury to the injured workers), and once the responsible party has been identified, the third party will be contacted within ten (10) workdays with notification of the employer's right to subrogation and the recovery of claim expenses.
The claim will be monitored to determine the need to file a complaint in order to preserve the statute of limitations. If the injured worker brings an action against the party responsible for the injury, the claims administrator will consult with the employer about the value of the subrogation claim and other considerations. Upon employer authorization, subrogation counsel will be assigned to file a Lien or a Complaint in Intervention in the action. The claims administrator will identify and seek recovery from a state fund, entity, or individual that may be a party to the claim.
The employer will be kept informed of the results of all subrogation efforts and findings.
Should an employer request that we not pursue subrogation efforts and/or the claims administrator recommends subrogation efforts not be made for whatever reasons, we shall document all discussions, decisions, etc. in our computer notepad.
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10. Litigation Management
When a defense attorney is not necessary, the claims administrator will work closely with the applicant's attorney towards disposition of the claim.
In the event the claims administrator and the employer determine a claim warrants referral to a workers' compensation defense attorney, the claim administrator will retain primary responsibility. Defense counsel will not be used to perform routine activities that are the responsibility of the claims administrator. Exceptions will be approved by the employer.
The claims administrator will communicate with the defense attorney to provide a complete overview of the claim. The claims administrator will also prepare a complete copy of the claim file for transmission to the defense attorney with a transmittal form or cover letter outlining the status of the case, results of investigations and discovery completed to date, primary issues, requested action and plan of action. Ongoing documentation will be sent to the defense attorney timely.
The claims administrator will carefully evaluate and monitor the defense attorney's aggressiveness in resolving claims, ability to identity issues, responsiveness, timeliness, and billing practices. The claims administrator will also provide the employer with advance notice of hearings and trials so they may attend, if necessary or desired.
11. Claim Reserves
Initial claim reserves will reflect the most probable value of the claim based on the information available at the time and the facts developed to date.
Initial claim reserves and subsequent reserve changes are reviewed and approved by a supervisor except under the following circumstance:
Claims administrators who possess the necessary Workers' Compensation experience and knowledge may have authority to establish initial reserves up to $75,000.00 and each subsequent reserve change up to $50,000.00.
As claim values increase and decrease, claim reserves will be reviewed on a regular basis and on each diary date, but not less than twice a year. The rationale for reserves will be documented in the file notes and the amounts allocated to each reserve category will be documented.
12. Claim Reconciliation
Claim files will be reconciled to ensure all medical, indemnity, vocational Claims Administration Standards Page 5 of 13
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rehabilitation, legal, and other expense payments are appropriate, were made to the correct individual/provider in the correct amount and were paid from the correct claim file. The physical file will be verified with the computer information.
All open claim files will be reconciled annually or when there is a change from one benefit to another. Proof of the reconciliation will be documented by way of a file note and a completed reserve worksheet, when applicable.
13. Payments
Prior to payment, all bills will be reviewed for accuracy and appropriateness.
All medical bills will be reviewed for reduction in accordance with the California Official Medical Fee Schedule (OMFS), InPatient Hospital Fee Schedule (IHFS), Preferred Provider Organization (PPO) discounts, and/or negotiated rates.
Medical bills submitted without supporting documentation will be objected to within thirty (30) days from receipt and will not be reviewed for payment until such documentation is obtained, if applicable. Medical bills will be paid, objected to, or denied no later than thirty (30) days from receipt and/or in accordance with state statutes.
Medical-legal costs will be reviewed for appropriateness and necessity. Bills that do not qualify as valid medical-legal expenses will be objected to on a timely basis according to the Workers' Compensation Laws of California.
As required by SB 899, payment of medical treatment regarding delayed AOE/COE claims will be processed through Utilization Review and Bill Review but will not exceed $10,000.00
Mileage reimbursement requests from injured workers will be processed and mailed to the injured worker within ten (10) workdays of receipt of the request. Advance travel expense payments will be mailed to the injured worker no later than seven days prior to the anticipated date of travel.
14. Diary
Indemnity claims that are not on a benefit payment schedule will be reviewed on diary every thirty (30) to sixty (60) days as activity warrants, or more frequently when needed, for resolution of any and all issues and closure.
Indemnity claims on a benefit payment schedule will be reviewed on diary every fourteen (14) days, or more frequently when needed, for resolution of any and all issues and closure.
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Medical-Only claims will be reviewed on diary every thirty (30) days for closure, or more frequently when needed. A medical-only claim will be converted to an indemnity claim when disability benefits are due, compensability becomes an issue, or litigation is initiated by either the injured worker or the employer.
Future-Medical claims will be reviewed on diary at least twice a year, or more frequently when needed, for the monitoring of future-medical care, Compromise and Release settlement and closure.
15. Indemnity Benefits
Accurate and timely indemnity benefit payments and notices will be computed, processed, and transmitted to injured workers as required by California Labor Codes, Statutes and Regulations.
Initial indemnity benefit payments and notices will be processed and mailed to the injured worker within fourteen (14) days of the first day of compensable disability.
All subsequent and final indemnity benefits payments and notices will be verified and issued in compliance with the Workers' Compensation Laws of California.
Late indemnity payments due directly to the injured worker will include a self- imposed 10% penalty in accordance with the Labor Code.
16. Penalties
Late payments of all undisputed bills, benefits, Awards, Commutations, or Compromise and Releases will include the appropriate self-imposed penalty in accordance with the Workers' Compensation Laws of California.
The employer will be advised of the assessment of any penalty for late payment, the reason, and the responsible party within ten (10) workdays of the assessment. In the event the claims administrator is the responsible party, the claims administrator will submit a reimbursement check to the employer within fifteen (15) workdays of the assessment.
17. Return to Work
The claims administrator will assist the employer in establishing a modified-work ight-duty) plan that is appropriate and accommodating for injured workers whil ley are recovering from their injury or illness and prior to their return to regula duties.
The claims administrator will immediately consult with the employer in those cases where the injury or illness residuals might involve permanent work restrictions and/or Claims Administration Standards Page 7 of 13
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retirement potential.
18. Medical Management
The claims administrator's Utilization Review process will monitor treatment recommendations and medical treatment to ensure it is appropriate, medically necessary, and consistent with the recommended standards set forth in the American College of Occupational and Environmental Medicine Occupational Medical Practice Guidelines (ACOEM).
For all conditions and injuries/illnesses not covered by the ACOEM Practice Guidelines, authorized treatment will be in accordance with other evidence-based medical treatment guidelines that are relevant to the request, generally recognized by the national medical community, and scientifically based.
The claims administrator will monitor the medical treatment to ensure it is related to the compensable injury or illness. The claims administrator will timely object to inappropriate medical reports.
When appropriate, the claims administrator will arrange a medical evaluation by way of a Labor Code Section §4050 Exam, State Panel Qualified Medical Exam, Defense Qualified Medical Exam, or Agreed Medical Exam (AME) to address the necessity and/or reasonableness of care for litigated and non-litigated injured workers and injured workers who have a valid predesignated physician. A cover letter, when appropriate, will be provided to the physician outlining the specific issues, concerns, and questions. All relevant medical reports, investigation reports, and information will be provided to the physician for review prior to the examination date.
If the employer has an approved Medical Provider Network (MPN) in place, all medical evaluations, determinations, and disputes shall be governed per California Labor Codes and Regulations, specifically Labor Code Sections §4616 through §4616.4, Regulations §9767.1 through §9767.14, and pertinent Workers' Compensation Laws of California.
In the event a claim warrants referral to an outside nurse case manager or any other outside medical management service, the employer will be contacted for prior approval and to discuss the intent and scope of services requested.
19. Resolution of Claims
The employer will be notified within ten (10) workdays after receipt of the treating physician's or other relevant physician's Maximum Medical Improvement (Permanent and Stationary) report.
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The claims administrator will determine the extent of permanent disability by completing a disability rating, arranging for an informal disability rating, or requesting a Summary Rating Determination (DEU Form 102) from the Disability Evaluation Unit. The claims administrator will also determine and take credit for legally permissible apportionment, if any.
The claims administrator will telephone the injured worker, if not represented by legal counsel, and mail a notice outlining permanent disability, future-medical care, and if applicable, provide a Qualified Medical Examination request form, within ten (10) workdays from receipt of a Maximum Medical Improvement (Permanent and Stationary) report. The purpose of the telephone call and notice is to explain the process and answer the injured worker's question(s). The claims administrator will take appropriate actions) to finalize the claim.
20. Rehabilitation Management
All notifications, determinations, and referrals regarding Vocational Rehabilitation Benefits or Supplemental Job Displacement Benefits, and Qualified Injured Worker or Non-Qualified Injured Worker status will be made timely in accordance with the Workers' Compensation Laws of California in place at the time of injury. The claims administrator will:
a. Notify the employer of the injured worker's permanent work restrictions so the employer may determine the availability of permanent modified or alternate work.
b. Notify the injured worker of their potential rehabilitation rights. c. With prior employer approval, assign an outside rehabilitation counselor or other service vendor when the need is identified for a formal job analysis, essential function job analysis, ergonomic evaluation, or a 90-Day QRR intervention.
d. Attempt to secure the prompt conclusion of vocational rehabilitation benefits, and settle rehabilitation where appropriate.
e. Monitor rehabilitation programs on an ongoing basis to verify appropriateness and progress.
f. Monitor and control rehabilitation benefits and costs through conclusion. In addition, the claims administrator will work with the employer to assist in the coordination of experts in complying with Americans with Disabilities Act (ADA) and AB 2222 interactive accommodation requirements.
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21. Approval of Settlements
The claims administrator and/or defense attorney, if applicable, will submit settlement requests to the employer for approval on all settlement requests. Settlement requests will be clear and concise and will consist of a verbal and/or written analysis of the claim/issue(s), and monetary recommendations. After supervisory approval, settlement requests will be presented to the employer in this manner so as to ensure receipt of a response in sufficient time to process the settlement.
If the settlement exceeds, or may have the potential to exceed, the employer's self- insured retention, the claims administrator will immediately submit a written analysis of the claim/issues(s) and contact the excess carrier by telephone to discuss the settlement and obtain approval.
Overpayments will be identified on all settlement requests and where appropriate, the claims administrator will pursue credit for the overpayment, if any.
22. Award Payments
Following receipt of the appropriate, fully executed documents), payments on undisputed Awards, Commutations, or Compromise and Releases will be issued within ten (10) workdays or sooner, if necessary to ensure payment within twenty (20) calendar days of the Workers' Compensation Appeals Board (WCAB) approval date, or if any delay will result in a late payment, late notice, or any penalty situation.
23. Excess Insurance
Claims that have the potential to exceed the employer's self-insured retention will be reported in accordance with the reporting criteria established by the employer's excess insurance carrier's policies.
Claims that meet the established reporting criteria will be reported to the excess carrier in accordance with the applicable policy but in no event will the claim be reported to the excess carrier more than thirty (30) days from the day on which it is known the criteria are met.
Excess reporting correspondence prepared by the claims administrator will be copied to the employer. Correspondence received by the claims administrator involving excess claims will be sent to the employer and responded to by the claims administrator within ten (10) workdays of receipt.
Requests for reimbursement on active claims will be made at least twice a year. For less active claims, reimbursement will be requested when reimbursement exceeds $2,500.00, but in no event less frequently than on an annual basis.
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24. File Documentation
Any significant development will be documented in the file notes. All file notes will have a "Plan of Action" that includes time frames for completing tasks or activities.
The progress of the "Plan of Action" will be documented as will the reasons for any delays or modifications to the "Plan of Action."
File documentation also includes all information that relates to the direction, value, and active claim strategy towards closure of the claim.
All files will be in chronological order with correspondence in the designated section.
All handwritten correspondence, if any, will be legible. All file notes, actions, or tasks completed on a claim will identify the date and the person(s) who completed it.
25. Supervisory Review
Supervisors do not have a caseload. Their primary role is to direct, monitor and review the work of claims administrators. All supervisory reviews will be documented in the file notes and labeled "Supervisory Review." All claims will be reviewed by a supervisor:
a. At file creation.
b. Before cases are delayed or denied.
c. Before referral to outside investigation, subrosa, medical case management or defense counsel.
d. When reserve increases, proposed settlements or payments exceed the claims administrator's limit of authority.
e. Before mandatory settlement conferences or trials.
In addition, supervisors will audit 10% of the claims administrator's caseload each month to evaluate the work product of the claims administrator, provide direction and review significant activities to ensure adherence to claims administration standards.
Finally, supervisors will review all incoming mail on a daily basis with an eye for anything that might portend a problem or require special attention.
26. Internal Auditing
In addition to supervisory audits, claim files are also randomly selected and reviewed by an internal auditor to further ensure compliance with performance standards outlined herein and to identify any areas of needed improvement in overall claims Claims Administration Standards Page 11 of 13
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handling and reserving.
27. Closure
Indemnity and medical-only claims will be reviewed for closure and closed within thirty (30) days from the date all issues, including those involving benefits, payments and notices, have been resolved.
Future-Medical claims will be reviewed for settlement not less than twice a year.
When future-medical benefits are the only remaining benefit due to the injured worker, and the claim is inactive for a period of two years, it will be closed no later than two years from the date of the last provision of Workers' Compensation benefits, flagged as "do not destroy" and placed in permanent storage.
28. Record Retention
The claims administrator will retain all claim files for five years after the closure date.
The claims administrator will retain all future-medical claim files for the entire life of the claim file.
Thereafter, the claims administrator will contact the employer to determine if the employer wishes to retain the claim file.
29. Personnel and Availability
Personnel who handle claim files will be well trained, appropriately certified and will receive continuing education and training.
The claims administrator, or a supervisor, will be available by telephone Monday through Friday, 8:00 a.m. to 4:30 p.m.
30. Client Services
The claims administrator will provide the employer with all necessary workers' compensation claim forms in an electronic format with printed forms available at cost.
The claims administrator will provide on-site training, attend on-site meetings, and complete file reviews for the employer on an as needed basis.
The claims administrator will participate in events pertaining to the employer's Workers' Compensation Program and will meet with injured workers to resolve issues that arise from claims on an as needed basis.
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The claims administrator will meet with the employer on an as needed basis to provide information, opinions and direction regarding proposed changes to the Workers' Compensation Laws of California and to meet with the employer's designated personnel to ensure they are effectively processing the employer's Workers' Compensation claims as required by law.
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MEDREVIEW
3380 Shelby Street
Ontario, California 91764
Phone (909) 978-2960 | Fax (909) 978-2970
Utilization Review Plan
Revised 6/12/23
Contents
Introduction 3
Medical Director and Personnel 3
Utilization Review Process 5
Receipt of Request for Authorization 5
Timeframes and Notification 6
Emergency Health Care Services and Concurrent Decisions to Deny 9 Timeframe Extension 10
Documentation 12
Utilization Review Decision-Making Process 12
IMR Appeals Process 13
Workers' Compensation Alternative Dispute Resolution Programs 14 Utilization Review Appeals Process 14
Confidentiality Policy 14
Confidentiality Policy (Physician Reviewers) 15
Definitions 15
Physician Review Services 15
Introduction
MedReview's utilization review process is pursuant to and in compliance with Labor Code Sections 4610, 4610.5, and title 8, California Code of Regulations (CCR), Sections 9792.6.1 through 9792.10.1.
MedReview's utilization review process is governed by written policies and procedures that ensure decisions are based on medical necessity to cure and relieve treatment recommendations by physicians. All decisions are consistent with the California Medical Treatment Utilization Schedule (MTUS), including the drug formulary, adopted pursuant to Labor Code Section 5307.27. MedReview updates and reviews the treatment guidelines per CCR Section 9792.25.1(a) MTUS Methodology for Evaluating Medical Evidence.
Pursuant to CCR 9792.6.1(v), "Reviewer" means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical issues involved in medical treatment services, where these services are within the scope of the reviewer's practice.
Pursuant to Labor Code Section 4610(g)(3)(B)(i), MedReview shall neither offer nor provide any financial incentive or consideration to a physician based on the number of modifications or denials made by the physician under this section.
A "utilization review decision" means a decision pursuant to Labor Code Section 4610 to approve, modify, or deny a treatment recommendation or recommendations by a physician prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code Sections 4600 or 5402(c).
This Utilization Review Plan is available to the public upon request. The claims administrator may charge reasonable copying and postage expenses related to disclosing the complete utilization review plan. Such charge shall not exceed $0.25 per page plus actual postage costs.
Medical Director and Personnel
MedReview's Medical Director is William Logan Tontz, Jr., M.D. Dr. Tontz is a practicing physician and surgeon who holds an unrestricted license to practice medicine in the State of California. Dr. Tontz's specialty is Orthopedic Surgery.
William Logan Tontz, Jr., M.D.
License Number A 69746
1300 Boca Ciega Isle Drive
St. Pete Beach, FL 33706
[email protected]
Telephone: (619) 770-0746
The Medical Director ensures that the process by which MedReview prospectively, retrospectively, or concurrently reviews and approves, modifies, or denies treatment recommendations by physicians complies with the requirements of Labor Code Section 4610.
Pursuant to CCR Section 9792.6.1(o), the Medical Director is a physician and surgeon licensed by the Medical Board of California or the Osteopathic Board of California who holds an unrestricted license to practice medicine in the State of California.
The Medical Director is responsible for all utilization review decisions. In addition to his duties as a reviewer, he is available to suggest courses of action to secure the medical information necessary to complete a review; available to provide additional resources of information to aid the non-physician reviewers with the primary review process; provides input and guidance to the other reviewers where appropriate; communicates with the requesting physicians when appropriate; reviews policies regarding the utilization review process; and provides educational information to the non-physician reviewers.
MedReview's Utilization Review is comprised of contracted physician reviewers licensed to practice in any state or the District of Columbia by their appropriate licensing boards, non- physician reviewers, consisting of licensed, certified, and trained health professionals, and assisting clerical personnel.
MedReview's physician reviewers are competent to evaluate the specific clinical issues involved in medical treatment services and, where these services are within the reviewer's scope of practice, may approve, modify, or deny requests for authorization of medical treatment for reasons of medical necessity to cure or relieve the effects of the industrial injury. Reviewers function as a secondary review when the non-physician reviewer is unable to approve medical treatment per appropriate guidelines.
MedReview's non-physician reviewers are comprised of individuals who possess an active, professional license or certification to practice as a health professional (Registered Nurse (RN), Certified Medical Assistant (MA) and Licensed Vocational Nurse (LVN)). MedReview's non- physician reviewers function as a primary reviewer applying specific criteria to requests for authorization for medical services. The non-physician reviewer may approve requests for authorization of medical services. The non-physician reviewer may discuss applicable criteria with the requesting physician, should the treatment for which authorization is sought appears to be inconsistent with the criteria. In such instances, the requesting physician may voluntarily withdraw a portion or all of the treatment in question and submit an amended request for treatment authorization. The non-physician reviewer may reasonably request appropriate additional information that is necessary to render a decision, but in no event, shall this exceed the time limitations per regulations. The non-physician reviewer shall not modify or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve or due to incomplete or insufficient information
MedReview's clerical personnel assist in the utilization review process by assigning received requests for authorization of medical treatment for initial review by a non-physician reviewer.
Additionally, the clerical personnel are available to answer telephone calls between the hours of 9:00 a.m. to 5:30 p.m., on business days, for healthcare providers to request authorization for medical services.
MedReview's transcription personnel proofreads and formats the reviewers' typed decisions and drafts MedReview letters.
Utilization Review Process
Receipt of Request for Authorization
MedReview personnel are available by telephone from 9:00 a.m. to 5:30 p.m., on business days, to receive treatment requests. A facsimile number is maintained for after-hours treatment requests. The utilization review process for responding to a treatment request begins when the request for authorization is first received by mail, facsimile, or electronic mail.
Pursuant to CCR Section 9792.9.1(c)(2)(A), upon receipt of a request for authorization as described in subdivision (c)(2)(B), or a DWC Form RFA that does not identify the employee or provider, does not identify a recommended treatment, is not accompanied by documentation substantiating the medical necessity for the requested treatment, or is not signed by the requesting physician, a non-physician reviewer, as allowed by Section 9792.7, or reviewer must either regard the request as a complete DWC Form REA and comply with the timeframes for decision set forth in this section or return it to the requesting physician marked "not complete," specifying the reasons for the return of the request no later than five (5) business days from receipt. The timeframe for a decision on a returned request for authorization shall begin anew upon receipt of a completed DWC Form RFA.
Utilization review of a medical treatment request may be deferred if the claims administrator disputes liability for either the occupational injury for which the treatment is recommended or the recommended treatment itself on grounds other than medical necessity.
Unless additional information is requested necessitating an extension, the utilization review process shall meet the required timeframes.
The first day in counting any timeframe requirement is the day after the receipt of the DWC Form RFA, except when the timeline is measured in hours. Whenever the timeframe requirement is stated in hours, the time for compliance is counted in hours from the time of receipt of the DWC Form RFA, pursuant to CCR Section 9792.9.1(c)(1).
Pursuant to Labor Code Section 4610(b)-(c), for all dates of injury occurring on or after January 1, 2018, any requests) for authorization received for emergency treatment services and medical treatment rendered, for a body part or condition that is accepted as compensable by the employer, within the 30 days following the initial date of injury shall be authorized without prospective utilization review, except as provided in subdivision (c).
Unless authorized by the employer or rendered as emergency medical treatment, the following medical treatment services, as defined in rules adopted by the administrative director, that are rendered through a member of the medical provider network or health care organization, a predesignated physician, an employer-selected physician, or an employer-selected facility, within the 30 days following the initial date of injury, shall be subject to prospective utilization review under this section:
~ Pharmaceuticals, to the extent they are neither expressly exempted from prospective review nor authorized by the drug formulary adopted pursuant to Section 5307.27. ~ Nonemergency inpatient and outpatient surgery, including all presurgical and postsurgical services.
~ Psychological treatment services.
~ Home health care services.
~ Imaging and radiology services, excluding X-rays.
~ All durable medical equipment, whose combined total value exceeds two hundred fifty dollars ($250), as determined by the official medical fee schedule. ~ Electrodiagnostic medicine, including, but not limited to, electromyography and nerve conduction studies.
~ Any other service designated and defined through rules adopted by the administrative director.
Timeframes and Notification
Prospective or concurrent utilization review decisions will not exceed five (5) business days from the date of receipt of the request for authorization. During the utilization review process, the reviewer or non-physician reviewer shall request information reasonably necessary to make a determination from the treating physician within five (5) business days from the date of receipt of the request for authorization.
Prospective decisions regarding requests for treatment covered by the MTUS Drug Formulary shall be made no more than five working days from the date of receipt of the medical treatment request.
Prospective or concurrent decisions related to an expedited review will not exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. A request
for expedited review must be supported by evidence establishing that the injured worker faces an imminent and serious threat to his or her health, or that the timeframe for utilization review would be detrimental to the injured worker's condition.
Retrospective decisions shall be made within 30 days of receipt of the request for authorization and medical information that is reasonably necessary to make a determination.
All decisions to approve a request for authorization shall specify the following:
~ The date the request for authorization was first received. ~ The medical treatment service requested.
~ The medical treatment service approved.
~ The date of the decision.
Prospective, concurrent, or expedited approvals shall be communicated to the requesting physician within 24 hours of the decision, initially by telephone, facsimile, or, if agreed to by the parties, secure email. Telephone communication of the decision shall be followed with a written notice to the requesting physician within 24 hours of the decision for concurrent review and within two (2) business days for prospective review. For retrospective approvals, the written decision shall be communicated to the requesting physician, the injured worker, and his or her attorney/designee, if applicable.
Pursuant to CCR Section 9792.6. 1(a), 'Authorization' means assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment to cure or relieve the effects of the industrial injury.
Payment, or partial payment, of a medical bill for services requested, within the 30-day timeframe, shall be deemed a retrospective approval.
Pursuant to CCR Section 9792.9.1(e)(1), the review and decision to deny or modify a request for medical treatment must be conducted by a reviewer, who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the individual's practice.
Prospective, concurrent, or expedited decisions to modify or deny shall be communicated to the requesting physician within 24 hours of the decision, initially by telephone, facsimile, or, if agreed to by the parties, secure email. Telephone communication of the decision shall be followed with a written notice to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney, within 24 hours of the decision for concurrent review and within two (2) business days for prospective review.
For retrospective decisions to deny part or all of the requested medical treatment, the written decision shall be communicated to the requesting physician, the injured worker, and his or her attorney/designee, if applicable, within 30 days of receipt of request for authorization and medical information that is reasonably necessary to make a determination.
Written decisions to modify or deny requests for authorization shall be provided to the requesting physician, the injured worker, the injured worker's representative, and if the injured worker is represented by counsel, the injured worker's attorney. The written decision shall be signed by either the claims administrator or the reviewer, and shall only contain the following information specific to the request, pursuant to CCR Section 9792.9.1(e)(5):
~ The date on which the request for authorization was first received. ~ The date on which the decision is made.
~ A description of the specific course of proposed medical treatment for which authorization was requested.
~ A list of all medical records reviewed.
~ A specific description of the medical treatment service approved, if any. ~ A clear, concise, and appropriate explanation of the reasons for the reviewing physician's decision, including the clinical reasons regarding medical necessity and a description of the relevant medical criteria or guidelines used to reach the decision pursuant to Section 9792.8. If a utilization review decision to modify or deny a medical service is due to incomplete or insufficient information, the decision shall specify the reason for the decision, the specific information that is needed, the date(s) and time(s) of attempts made to contact the physician to obtain the necessary information, and a description of the manner in which the request was communicated.
~ The Application for Independent Medical Review, DWC Form IMR, with all fields, except for the signature of the employee, to be completed by the claims administrator.
The application, set forth in Section 9792.10.2, and the written decision provided to the injured worker shall include an addressed envelope, which may be postage-paid for mailing to the Administrative Director or his or her designee. ~ A clear statement advising the injured employee that any dispute shall be resolved in accordance with the independent medical review provisions of Labor Code Section 4610.5 and 4610.6, and that an objection to the utilization review decision must be communicated by the injured worker, the injured worker's representative, or the injured worker's attorney on behalf of the injured worker on the enclosed Application for Independent Medical Review, DWC Form IMR, within 10 days after service of the utilization review decision(s) for formulary disputes and 30 days after service of the utilization review decision(s) for all other medical treatment disputes.
~ The following mandatory language:
~ "You have a right to disagree with decisions affecting your claim. If you have questions about the information in this notice, please call me (insert claims adjuster's name in parentheses) at (insert telephone number).
However, if you are represented by an attorney, please contact your attorney instead of me.
and
~ "For information about the workers' compensation claims process and your rights and obligations, go to www.dwc.ca.gov or contact an information and assistance (I&A) officer of the state Division of Workers' Compensation. For recorded information and a list of offices, call toll-free 1-800-736-7401."
~ Details about the claims administrator's internal utilization review appeals process for the requesting physician and a clear statement that the internal appeals process is a voluntary process that neither triggers nor bars use of the dispute resolution procedures of Labor Code Section 4610.5 and 4610.6, but may be pursued on an optional basis.
~ The written decision modifying or denying treatment authorization provided to the requesting physician containing the name and specialty of the reviewer or expert reviewer, and the telephone number in the United States of the reviewer or expert reviewer. The written decision discloses the hours of availability of either the reviewer, the expert reviewer, or the medical director for the treating physician to discuss the decision which is, at a minimum, four (4) hours per week during normal business hours, 9:00 a.m. to 5:30 p.m., Pacific Time, or an agreed upon scheduled time to discuss the decision with the requesting physician. In the event the reviewer is unavailable, the requesting physician may discuss the written decision with another reviewer who is competent to evaluate the specific clinical issues involved in the medical treatment services.
Emergency Health Care Services and Concurrent Decisions to Deny Pursuant to CCR Section 9792.6.1(i), "Emergency health care services" means health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy. Emergency health care services do not require prior authorization and may be subjected to retrospective review. Pursuant to CCR Section 9792.9.1 (e)(2), failure to obtain authorization prior to providing emergency health care services shall not be an acceptable basis for refusal to cover medical services provided to treat and stabilize an injured worker presenting for emergency health care services. Emergency health care services
may be subjected to retrospective review. Documentation for emergency health care services shall be made available to the claims administrator upon request.
A concurrent decision to deny authorization for medical treatment must meet the following requirements prior to discontinuation of medical care:
~ The requesting physician shall be notified of the decision. ~ A care plan has been agreed upon by the requesting physician that is appropriate for the medical needs of the employee.
~ Medical care provided during the review shall be treatment that is medically necessary to cure or relieve from the effects of the industrial injury.
Timeframe Extension
Except for treatment requests made pursuant to the MTUS Drug Formulary, when additional information reasonably necessary to make a determination is requested necessitating a timeframe extension, a reviewer or non-physician reviewer shall request the information from the treating physician within five (5) business days from the date of receipt of the request for authorization.
If the requested information is not received within fourteen (14) days from the receipt of the completed request for authorization for prospective or concurrent review, or within thirty (30) days of the request for retrospective review, the reviewer shall deny the request with the stated condition that the request will be reconsidered upon receipt of the information.
A reviewer may ask for the following:
~ An additional examination or test be performed upon the injured worker that is reasonable and consistent with professionally recognized standards of medical practice. ~ A specialized consultation and review of medical information by an expert reviewer.
When a reviewer asks for the above, the reviewer shall, within five (5) business days from the date of receipt of the request for authorization, notify the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney, in writing, that the reviewer cannot make a decision within the required timeframe. The written notification will include the anticipated date on which a decision will be rendered.
If the results of the additional examination or test are not received within thirty (30) days from the receipt of the completed request for authorization for prospective, concurrent, or retrospective review, the reviewer shall deny the request with the stated condition that the request will be reconsidered upon receipt of the information.
Upon receipt of the requested information:
~ For prospective and concurrent review:
• a non-physician reviewer shall make the decision to approve the request for authorization within five (5) business days of receipt of the information
• a reviewer shall make the decision to approve, modify, or deny the request for authorization within five (5) business days of receipt of the information.
The requesting physician shall be notified by telephone, facsimile, or, if agreed to by the parties, secure email within 24 hours of making the decision. The written decision shall include the date the information was received and the decision shall be communicated in the manner set out in Section 9792.9.1(d) or (e), whichever is applicable.
~ For prospective and concurrent decisions related to an expedited review:
• a non-physician reviewer shall make the decision to approve the request for authorization within 72 hours of receipt of the information Or
• a reviewer shall make the decision to approve, modify, or deny the request for authorization within 72 hours of receipt of the information.
The requesting physician shall be notified by telephone, facsimile, or, if agreed to by the parties, secure email within 24 hours of making the decision. The written decision shall include the date the information was received and the decision shall be communicated in the manner set out in Section 9792.9.1(d)(2) or (e)(3), whichever is applicable.
~ For retrospective review:
• a non-physician reviewer shall make the decision to approve the request for authorization within thirty (30) calendar days of receipt of the information
or
a reviewer shall make the decision to approve, modify, or deny the request for authorization within thirty (30) calendar days of receipt of the information.
The written decision to approve shall include the date it was made and shall be communicated to the requesting physician who provided the medical services and to the individual who received the medical services, and his or her attorney/designee, if applicable.
The written decision to deny part or all of the requested medical treatment shall include the date it was made and shall be communicated to the requesting physician who provided the medical services and to the individual who received thy setie ip i requend i at heritin ad medic i infrication tit is 30 reasonably necessary to make a determination.
Documentation
Pursuant to CCR Section 9792.9.1(g), whenever a reviewer issues a decision to deny a request for authorization based on the lack of medical information necessary to make a determination, the claims administrator's file must document the attempt by the claims administrator or reviewer to obtain the necessary medical information from the physician either by facsimile, mail, or e- mail.
Pursuant to Labor Code Section 4610(k), a utilization review decision to modify or deny a treatment recommendation shall remain effective for 12 months from the date of the decision without further action by the employer with regard to a further recommendation by the same physician, or another physician within the requesting physician's practice group, for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision.
Utilization Review Decision-Making Process
Pursuant to Labor Code Section 4610(h), the criteria or guidelines used in MedReview's utilization review process to determine whether to approve, modify, or deny medical treatment services are all of the following:
~ Developed with involvement from actively practicing physicians. ~ Consistent with the schedule for medical treatment utilization, including the drug formulary, adopted pursuant to Section 5307.27.
~ Evaluated at least annually and updated if necessary. ~ Disclosed to the physician and the employee, if used as the basis of a decision to modify or deny services in a specified case under review.
~ Available to the public upon request (no copying fees apply).
Non-physician reviewers and reviewers conduct the following medical evidence search sequence for the evaluation and treatment of injured workers:
~ Search the recommended guidelines set forth in the current MTUS to find a recommendation applicable to the injured worker's medical condition or injury. ~ In the limited situation where a medical condition or injury is not addressed by the MTUS or if the MTUS' presumption of correctness is being challenged, then:
• Search the most current version of ACOEM or ODG to find a recommendation applicable to the injured worker's medical condition or injury. Choose the recommendation that is supported with the best available evidence according to the MTUS Methodology for Evaluating Medical Evidence set forth in Section 9792.25.1.
~ If no applicable recommendation is found in ACOEM or ODG, or if the reviewing physician believes there is another recommendation supported by a higher quality and strength of evidence, then:
• Search the most current version of other evidence-based medical treatment guidelines that are recognized by the national medical community and are scientifically based to find a recommendation applicable to the injured worker's medical condition or injury. Medical treatment guidelines can be found in the National Guideline Clearinghouse. Choose the recommendation that is supported with the best available evidence according to the MTUS Methodology for Evaluating Medical Evidence set forth in Section 9792.25.1. ~ If no applicable recommendation is found in the National Guideline Clearinghouse, then:
• Search for current studies that are scientifically-based, peer-reviewed, and published in journals that are nationally recognized by the medical community to find a recommendation applicable to the injured worker's medical condition or injury. Choose the recommendation that is supported with the best available evidence according to the MTUS Methodology for Evaluating Medical Evidence set forth in Section 9792.25.1. A search for peer-reviewed published studies may be conducted by accessing the U.S. National Library of Medicine's database of biomedical citations and abstracts.
IMR Appeals Process
Any dispute shall be resolved in accordance with the independent medical review provisions of Labor Code Section 4610.5 and 4610.6. An objection to the utilization review decision(s) must be communicated by the injured worker, the injured worker's representative, or the injured worker's attorney on the injured worker's behalf on the Application for Independent Medical Review, DWC Form IMR, enclosed with the Utilization Review decision, within 10 days after service of the utilization review decisions) for formulary disputes and 30 days after service of the utilization review decision(s) for all other medical treatment disputes.
Pursuant to Labor Code section 4610.5(h)(1)(A)-(B), the employee may submit a request for independent medical review to the division. The request may be made electronically under rules adopted by the administrative director.
The request shall be made no later than as follows:
(A) For formulary disputes, 10 days after the service of the utilization review decision to the employee.
(B) For all other medical treatment disputes, 30 days after the service of the utilization review decision to the employee.
Workers' Compensation Alternative Dispute Resolution Programs Some clients have employees that belong to Police Officers' Associations and Fire Fighters' Associations. A portion of these associations have agreed upon Alternate Dispute Resolution (ADR) programs. These ADR processes replace the Independent Medical Review (IMR) procedures.
Utilization Review Appeals Process
The Internal Utilization Review Appeals Process (Appeal) is as follows:
It is a voluntary process that neither triggers nor bars use of the dispute resolution procedures of Labor Code Sections 4610.5 and 4610.6, but may be pursued on a voluntary basis. The injured worker or the treating physician must request an Appeal of the decision(s) within 10 days after receipt of the utilization review decision(s) by submitting additional information. The determination of the Appeal will be issued within 30 days of receipt of the Appeal. An Appeal shall be considered complete upon the issuance of a final Independent Medical Review (IMR) determination.
For information about the Workers' Compensation claims process and your rights and obligations, go to www.dwc.ca.gov or contact an information and assistance (I&A) officer of the state Division of Workers' Compensation. For recorded information and a list of offices, call toll free 1-800-736-7401.
Confidentiality Policy
Due to the nature of our work, it is imperative that employees maintain strict confidentiality when it comes to our clients' matters as well as our own policies and procedures. A breach of confidentiality will result in disciplinary action, including possible termination of employment.
Confidentiality Policy (Physician Reviewers)
Consultant agrees to maintain the confidentiality provisions of the materials reviewed and discussions conducted hereunder. Consultant understands and agrees that all information or data that Consultant receives from Administrator, or at the direction of Administrator, in connection with the process of providing services hereunder will be deemed confidential and may not be disclosed to anyone other than Administrator or its employees directly responsible for working with Consultant.
Definitions
Concurrent Review: Utilization review conducted during an inpatient stay. CCR Section 9792.6.1(c).
Expedited Review: Utilization review or independent medical review conducted when the injured worker's condition is such that the injured worker faces an imminent and serious threat to his or her health, including, but not limited to the potential loss of life, limb, or other major bodily functions, or the normal timeframe for the decision-making process would be detrimental to the injured worker's life or health or could jeopardize the injured worker's permanent ability to regain maximum function. CCR Section 9792.6.1().
Prospective Review: Any utilization review conducted, except for utilization review conducted during an inpatient stay, prior to the delivery of the requested medical services. CCR Section 9792.6.1(s).
Retrospective Review: Utilization review conducted after medical services have been provided and for which approval has not already been given. CCR Section 9792.6.1(u).
Physician Review Services
MedReview Inc. contracts with the following physicians/companies for Physician Review services:
Neil S. Ghodadra, M.D.
Orthopedic Surgery
License No. A 116163
Roman A. Shulze, D.O.
Family Practice and Occupational Medicine
License No. 8047
Aaron Emil McCoy, D.O.
Anesthesiology
License No. 15451
Scott McElmeel, M.D.
Anesthesiology
License No. C 153971
John V. Flores, PhD, MBBS, D.C.
Chiropractic and Sports Medicine
License No. 25215
William L. Tontz, M.D.
Orthopedic Surgery
License No. A 69746
Leslie R. Cadet, M.D.
Occupational Medicine
License No. A 164363
Advanced Medical Reviews, Inc.
Medical Director: Charles Totaro Carnel, M.D.
Medical Director Specialty: Physical Medicine & Rehabilitation Medical Director License No. MD.27631 (Alabama)
MedReview Inc. contracts with the following physicians/companies for Expert Review services:
Network Medical Review Co. Ltd.
Medical Director: Robert C. Porter, M.D.
Medical Director Specialty: Occupational Medicine
Medical Director License No. 33237
Utilization Review - Claims Adjuster Authorization Criteria Claims adjusters may approve the following Request (s) for Authorization (RFAs). All RFAs outside of the authorization criteria listed below must be referred to and processed by Utilization Review. Please note: Only a Physician may modify or deny RFA(s).
Claim Adjusters should adhere to the MTUS Treatment Guidelines. These guidelines are located in L-Drive (UR Education for Claims > Guideline Folder).
Treatment Requests - first 30 days of injury or illness Treatment Request Claims Adjuster Authorization Criteria Per Labor Code 4610 (c) Unless authorized by the employer or rendered as emergency medical treatment, the following medical treatment services shall be subject to prospective utilization review:
First 30 days of injury or illness Pharmaceuticals that are non-exempt in the drug formulary • • Nonemergency inpatient and outpatient surgeries, including all pre-surgical and post-surgical services (Starts January I, 2018)
• Psychological treatment services
• Home health care services
• Imaging and radiology services excluding x-rays
• All DME that exceeds $250
• Electrodiagnostic testing
Treatment Requests - after 30 days of injury or illness Treatment Request Claims Adjuster Authorization Criteria Physical Methods: May have 24 visits for the life of the claim.
Occupational therapy
• Physical therapy Initial request - up to 4-6 visits.
• Chiropractic treatment Additional requests (sets of 4-6 visits) may be approved if provider documents functional improvement. • Acupuncture
Office Visits: May be approved by the claims adjuster.
• Initial evaluation
• Consultation Send the RFA to UR when questioning whether or not the consultation, second opinion, or transfer of care is medically • Second opinion necessary.
Transfer of care
• Office visits
Injections: Injections are recommended based on body part accepted and injury/illness. • Steroid
Initial steroid injections for diagnostic and pain management can be approved by claims adjuster. Additional requests shout epid eden on
Injections: jections are recommended based on body part and injury and must meet criteria oulined in the MUS Treatmen • EST Guidelines.
• Facet
• Hyaluronic
• PRP
• SI joint
Surgery All surgery requests must be processed by Utilization Review.
Pre-operative Testing/ Upon approval of surgery, claims adjuster may approve the following requests: CBC, CMP, PT/PTT, EKG and Chest X- Pre-operative Medical Ray.
Clearance
Radiology/Diagnostic: May be approved by the claims adjuster. • X-rays
• CT-scans See above for directions for the time period "first 30 days." • MRI
• EMG/NCV
Home Health Care The claims adjuster may approve home health care up to 7 days.
All requests for home health care greater than 7 days must be processed by Utilization Review.
Weight Loss/Gym Membership Weight loss and gym membership will be reviewed on a case-by-case basis to determine the necessity for utilization Transportation reclaims adjuster may approve transportation when appropriate.
Medication: Situation Yes UR
• Per MTUS Formulary Ongoing drugs Exempt Non-Exempt
• Adhere to MUS Off-label drugs Exempt Non-Exempt
treatment guidelines for Brand-name drugs Brand-name drugs injury/illness Physician-dispensed drugs First 7 days of injury, Exempt/Non-Exempt After first 7 days of injury, all FDA approved drugs, 4-day supply medications Exempt/Non-Exempt Generic drug Compound drugs Compound
Special fill drugs First 7 days of injury, Exempt/Non-Exempt, 4-day supply
Peri-operative fill drugs Exempt/Non-Exempt
4 days before/4 days after surgery
4-day supply
Health and safety post-exposure Responsibility of the employer to provide prophylaxis (PEP) urgent PEP after an exposure to bloodborne pathogens
Detox Programs All requests for detox programs will be processed by Utilization Review.
Psychiatric Requests for psychiatric/neuro-psych or counseling may be approved by the claims adjuster.
Cancer Treatment All specialized cancer treatment/therapy will require utilization review.
Durable Medical Equipment Claims adjuster may approve all DME purchases and/or rentals. See above for directions for the time period "first 30 days."
UTILIZATION REVIEW WORKFLOW
CLAIMS ADJUSTER REVIEW
• All Utilization Review is in accordance with CCR 9792.9.1, Utilization Review Standards - Timeframes, Procedures and Notice - On or After January 1, 2013
UR
• Receipt of Request for Authorization (RFA) (Received by Email, Facsimile or U.S. Mail - Electronically Assigned to Claim File) • Per Adjuster Authorization Criteria sheet, Intake confirms with Claims Adjuster to continue UR review Intake
• Per Adjuster Authorization Criteria sheet, Claims Adjuster confirms with Intake to continue UR review • Claims Adjuster faxes/mails approval determinations to the provider, injured worker and applicant attorney, when applicable Claims Adjuster
UTILIZATION REVIEW WORKFLOW
NON-PHYSICIAN REVIEW
• All Utilization Review is in accordance with CCR 9792.9.1, Utilization Review Standards - Timeframes, Procedures and Notice - On or After January 1, 2013
UR
• Receipt of Request for Authorization (RFA) (Received by Email, Facsimile or U.S. Mail - Electronically Assigned to Claim File) • Per Adjuster Authorization Criteria sheet, Intake confirms with Claims Adjuster to continue UR review Intake • RFA(s) are directly assigned to UR, when applicable • Per Adjuster Authorization Criteria sheet, Claims Adjuster confirms with Intake to continue UR review • Claims Adjuster submits RFA(s) to UR when the RFA does not meet guideline standards and/or Adjuster Authorization Criteria sheet Claims Adjuster
UR applies the MTUS, ACOEM and ODG guidelines to determine the medical necessity for the RFA UR faxes/mails request for information/approval determinations to the provider, injured worker and applicant attorney, when applicabl UR
• Receipt of response to request for information (Received by Email, Facsimile or U.S. Mail - Electronically Assigned to Claim File) • Intake notifies of response to request for information Intake
• UR faxes/mails approval determinations to the provider, injured worker and applicant attorney, when applicable • UR submits response to request for information to Physician Reviewer for UR determination (See MD Review Workflow) UR
UTILIZATION REVIEW WORKFLOW
PHYSICIAN REVIEW
• All Utilization Review is in accordance with CCR 9792.9.1, Utilization Review Standards - Timeframes, Procedures and Notice - On or After January 1, 2013
UR
• Receipt of Request for Authorization (RA) (Received by Email, Facsimile or U.S. Mail - Electronically Assigned to Claim File) • Per Adjuster Authorization Criteria sheet, Intake confirms with Claims Adjuster to continue UR review Intake • RFA(s) are directly assigned to UR, when applicable • Per Adjuster Authorization Criteria sheet, Claims Adjuster confirms with Intake to continue UR review Claims • Claims Adjuster submits RFA(s) to UR when the RFA does not meet guideline standards and/or Adjuster Authorization Criteria sheet Adjuster
• UR submits RFA(s) to a Physician Reviewer when the RFA does not meet guideline standards • The review and decision to deny or modify a REA must be conducted by a Physician Reviewer UR
• The Physician Reviewer makes the UR determination
Physician
Reviewer
• Transcription prepares all Physician Review dictations and drafts correspondence Tran-
scription
• UR proofreads all Physician Review determinations and prepares correspondence • UR faxes/mails approval determinations to the provider, injured worker and applicant attorney, when applicable UR • UR assigns a dairy to a claims assistant to create the IMR application and "How to Object" letter for all denial and modification determinations
UTILIZATION REVIEW WORKFLOW
EXPERT REVIEW
• All Utilization Review is in accordance with CCR 9792.9.1, Utilization Review Standards - Timeframes, Procedures and Notice - On or After UR January 1, 2013
• Receipt of Request for Authorization (RFA) (Received by Email, Facsimile or U.S. Mail - Electronically Assigned to Claim File) • Per Adjuster Authorization Criteria sheet, Intake confirms with Claims Adjuster to continue UR review Intake
• Per Adjuster Authorization Criteria sheet, Claims Adjuster confirms with Intake to continue UR review Claims • Claims Adjuster submits RFA(s) to UR when the RFA does not meet guideline standards and/or Adjuster Authorization Criteria sheet Adjuster
• UR submits RFA(s) to a Physician Reviewer when the RFA does not meet guideline standards UR • The review and decision to deny or modify a RFA must be conducted by a Physician Reviewer • The Physician Reviewer makes the determination to elevate to Expert Review Physician
Reviewer
Tran- • Transcription prepares all Physician Review dictations and drafts correspondence scription
• UR proofreads all Physician Review determinations and prepares correspondence UR • UR faxes determinations to the provider, injured worker and applicant attorney, when applicable • The Expert Reviewer reviews the RFA and makes UR determinations Expert
Reviewer
• Transcription prepares all Expert Review dictations and drafts correspondence Tran-
scription
• UR proofreads all Expert Review determinations and prepares correspondence • UR faxes/mails approval determinations to the provider, injured worker and applicant attorney, when applicable UR • UR assigns a dairy to a claims assistant to create the IMR application and "How to Object" letter for all denial and modification determinations Calendar Year: 2023
Utilization Review Performance Rating of Investigation of a Claims Administrator Investigation No: URA - S11-23 R1-5
Claims Administrator: AdminSure, Ine.
Location: Ontario
Utilization Review Management: MedReview
Number of Requests for Authorization: Decisions by Type:
Prospective 56 Approval 40
Concurrent 0 Modification 4
Retrospective Delay 0
Denial 13
I. FACTOR FOR UNTIMELY RESPONSE TO REQUEST
# late prospective responses divide by # of prospective requests 56 # late concurrent responses divide by # of concurrent requests 0 # late retrospective responses divide by # of retrospective requests 1 Totals 57
0.00000
2. FACTOR FOR FAULTY NOTICE CONTENT
# faulty prospective responses divide by # of prospective requests 56 # faulty concurrent responses divide by # of concurrent requests 0 # faulty retrospective responses divide by # of retrospective requests 1 Totals divide by Totals 57 =
0.00000
B. FACTOR FOR IMPROPER DISTRIBUTION OF NOTICE
prospective w/ improper distributio divide by # of prospective requests 56 concurrent w/ improper distributiu divide by # of concurrent requests # retrospective w/ improper distribution divide by # of retrospective requests 1 Totals 57
= 0.00000
UTILIZATION REVIEW PERFORMANCE RATING 100.0%
A Utilization Review Performance Rating of 0.85000 or greater is a passing score.
Calendar Year: 2023 Individual Exhibit 1A
Profile Audit Review Performance Rating of Randomly Selected Claims Audit No: LAO-11-23-R1-5
Subject: AdminSure, Inc.
Location: Ontario
L. FACTOR FOR FAILURE TO PAY ACCRUED AND UNDISPUTED INDEMNITY A. Frequency Rate
# claims with unpd indem divide by # claims with payable indem 59 0.08475 B. Average Amount of Unpaid Indemnity per Claim with Ubligation to Pay Indemnity Total unpd indem. = $ 4,767.71 divide by # of claims with obligation to pay indem. 59 Avg Unpd Ind = $ 80.81
C. Severity Rate
Avg Unpd Indem 80.81 divide by avg unpd indem 2019-2021 of $129.35 0.62473 D. Factor for Failure to pay Undisputed Accrued Indemnity Frequency rate 0.08475 Severity rate 0.62473 modifier of 2 = 0.10589
2. FACTOR FOR LATE FIRST PAYMENT OF TEMPORARY DISABILITY / VIOLATION FOR FIRST NOTICE OF SC # claims with late 1st TD divide by # with TD payments
# claims with first SC notice violations 20 divide by # with salary continuation 48 Totals 21 divide by Totals =
0.36207
3. FACTOR FOR LATE FIRST PAYMENT OF PERMANENT DISABILITY AND DEATH BENEFITS # claims with late first PD divide by # with first PD
# claims with late first DB divide by # with first DB paid Totals divide by Totals =
0.00000
4. FACTOR FOR LATE SUBSEQUENT INDEMNITY PAYMENTS
# claims with late subsequent payments divide by # with subsequent payments 13 =
0.00000
5. FACTOR FOR PROVISION OF AME/QME NOTICES
# claims with AME/QME notice violation 5 divide by # requiring notices 59
0.08475
PROFILE AUDIT REVIEW PERFORMANCE RATING - 2023 0.55270
Profile Audit Review Performance Rating of 1.76323 or greater is a failing score Form DWC-AU-860A (Rev 12/22)
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
Fee Proposal
Our proposed guaranteed Fee Proposal is made in good faith and demonstrates our ability to provide professional services for a competitive fee, as well as our commitment to creating and maintaining a long-term business relationship with the City of Vernon.
Our enclosed Fee Proposal is based on a straightforward fee structure that covers all Workers' Compensation Program Services; specifically, Claims Administration Services, Utilization Review Services, and Bill Review Services. Our Services are outlined within our entire proposal response which includes, but is not limited to, the following:
• 24/7/365 online access to our Risk Management Information System (RMIS) - includes report writing capabilities and an unlimited number of "read-only" City users at no additional cost • Financial Management/Manage the City's Workers' Compensation Trust Account (internal) • Manage Positive Pay Services (internal)
• City of Vernon's Workers' Compensation Team:
• Workers' Compensation Claims Supervisor/Manager
• Workers' Compensation Indemnity Claims Adjuster
• Workers' Compensation Medical-Only Claims Adjuster
Workers' Compensation Claims Assistant
• Workers' Compensation Office Assistant
• Support Staff:
• Directors of Operations
Workers' Compensation Claims Supervisors/Managers
• Workers' Compensation Claims Leads
Workers' Compensation Indemnity Claims Adjusters
Workers' Compensation Medical-Only Claims Adjusters
Workers' Compensation Claims Assistants
Workers' Compensation Office Assistants
• Clerical Support Staff
• Utilization Review Staff
• Bill Review Staff
• Bill Pay Staff
• Check Processing Staff (our work product)
• Information Systems/Technology (IS/IT) Support Staff
• Training- Claims Administration and Computer Software, Including Training Materials and Handouts (no additional cost)
• Meetings (includes meeting with ancillary service providers/vendors) • Presentations and Materials
• Quarterly File Reviews (any on-site location, virtual, and telephonic) with corresponding Claim Narratives/Management Reports
• Educational Seminars
• All Reports: Standard and Special/Ad Hoc//Customized Reports; State/Federal Reports (no additional cost; at-cost when data is not captured)
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
• Mandatory reporting to CMS regarding Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) - Initial and Subsequent Reporting will be at no additional cost
• As the City's choice of Bill Review Provider, we will complete the Workers' Compensation Information System (WCIS) Reporting at no additional cost, i.e., Medical Bill Review EDI (Electronic Data Interchange) Reporting and Services
• As the City's choice of Utilization Review Provider, we will provide and manage all Utilization Review Services
• Printed and Electronic (with the ability to amend) Workers' Compensation Posters, Forms, and Pamphlets
• Printed Checks - our work product (benefits and payments) • Stamped Envelopes for Mailing Workers' Compensation Checks and Correspondence (our work product)
• Index Claim Searches (ISO) at no additional cost
• Preparation of the Public Self-Insurer's Annual Report • OSHA Forms (logs/summaries/reports)
• Preparation and Issuance of Federal Form 1099 Notices • Storage for Closed Claim Files — At no cost, we will provide storage for all claim files closed within the last five years/fiscal years and all closed Future Medical files regardless of the date of closure
In addition, we will accomplish the work and satisfy the City's service objectives as described in the Request for Proposal (KFP) by performing the following Claims Administration Services, Utilization Review Services, and Bill Review Services, which includes, but is not limited to:
• AOE/COE Determination
• Investigation, Sub-Rosa (Surveillance), and Fraud Management • Consultation Services
• Litigation Management
• Subrogation Management
• Benefit Administration (Indemnity, Medical, etc.), Management and Execution • Utilization Review Management and Services
• Bill Review Management and Services
• If applicable, Medical Provider Network (MPN) - we shall not add on any additional fee/cost to the City's choice of MPN's Service Provider's fee/cost, if any • Medical Management
• Return-to-Work (RTW) Program and Permanent Modified Duty Program Management • Industrial Disability Retirement Management (IDR/CalPERS) • ADA Interactive Process Meetings (compliance)
• Supplemental Job Displacement Benefits (SJDB)/Vocational Rehabilitation Management • Settlement Management
• Medicare Set-Aside Allocation (MSA) Assistance
• Excess Reporting and Management
• Cost Containment/Loss Control Management
• ADR adherence, if any, and Assist with Incentive Programs, if any
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
It is important to reiterate that we do not provide Utilization Review Services or Bill Review Services for any Third Party Administrator (TPA) or entity other than our Workers' Compensation Clients as we are committed to dedicating our time and efforts to only our Clients.
Regarding Bill Review Services, should we not be selected to provide Bill Review Services for the claims we administer/handle, there will be a $8 per-bill fee for our partial bill review services/our direct costs; specifically, for the obtaining/receiving of electronic files from the City's choice of Bill Review provider (their work product), and for the processing/handling (our Staff's efforts/time) of same, as well as the printing (our paper/toner) and mailing (our envelope/stamp) of each check/EOB (Explanation of Benefits document - their work product) on behalf of the City's choice of Bill Review provider.
As previously noted, nearly 100% of our clients utilize us for Bill Review Services. We believe this is so for the following very important reasons:
• Cost Efficiencies
• Transparency
• Control
• Accountability
• Trust
We are truly committed to providing purposeful medical management services that ensure positive outcomes. We do not believe in over-promoting medical management services that exaggerate actual claim outcomes or overreach by suggesting self-serving, unrealistic savings through affiliated and/or outsourced service providers to our clients.
We prefer to focus on and provide prompt, assertive, and professional claims handling services along with applying reasonable Utilization Review and every Medical Management Service, Provider Network Savings, Preferred Provider Organization (PPO) Savings, and Fee Schedule (OMFS/IHFS) Savings, Negotiated Rates, etc. to the fullest extent allowed by law so that we may provide the City's injured workers with all the medical treatment and services they are medically and legally entitled to in the most timely and cost-effective and cost-sensitive manner.
We believe this proven approach will produce meaningful results, real savings, and will truly strengthen the City's position in maintaining a professional and well-managed Workers' Compensation Program.
In closing, based on our:
• Qualifications
• Technical Expertise
• Proposal Response
• Fee Proposal
• Years of specialized experience related to successfully administering complex claims in a considerate and consistent manner for Cities with Police Departments (safety members) - like the City of Vernon
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response — City of Vernon May 14, 2024
We truly believe we are the best suited Third Party Administrator (TPA) to administer the City of Vernon's Self-Insured Workers' Compensation Program (Claims Administration Services, Utilization Review Services, and Bill Review Services).
It is important to note that the cost of administering the City's Workers' Compensation Program and the handling of the City's existing open files is included in our proposed Workers' Compensation Claims Administration fee. In addition, we considered the City's caseload volume and the economic challenges the public sector continues to experience when quoting our proposed fee. Therefore, our proposed guaranteed fee is guaranteed throughout the term of the Contract Agreement.
We believe these good faith gestures demonstrate our ability to provide professional services for a competitive fee as well as our commitment to creating and maintaining a long-term business relationship with the City of Vernon.
Should you have any questions or would like to further discuss our services, please contact me directly at (909) 396-5814, or by way of e-mail at [email protected] as I am fully authorized to bind our proposal, execute a Contract Agreement, and act on behalf of AdminSure Inc. Our proposal response shall remain valid for a period of not less than ninety (90) days from the date of submittal.
Thank you for your time and consideration.
Respectfully submitted,
slither Jrgas: Hore
Alithia Vargas-Flores, President
MBA, SIA, WCCP, WCCA
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
Fee Proposal
Claims Administration Services • Year 1: $6,940 per month. (Includes Internal Support Staff) • 3% annual increase.
Flat Fee
Bill Review Services • $10 per bill for all Official Medical Fee Schedule (OMFS), In- Patient Hospital Fee Schedule (IFS) and Out-Patient, etc., Flat Fee reviews; and when applicable, plus .75 cents for State of California required E-Bill/OCR Services; or $8 per bill for 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 • Physician (includes Peer and Expert)/Non-Physician Review & Decision: $300 per hour billed in 10-minute increments/ Flat Fee approximately 4% of total charges; $85 adjuster/$125 utilization review.
• 3% annual 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 any "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
Workers' Compensation Third Party Claims Administration Services Request for Proposal Response - City of Vernon
Admin Sure May 14, 2024
Summary
Workers' Compensation Program Reports
The following list of reports illustrates a sample of our reporting capabilities which includes daily, weekly, monthly, quarterly, semi-annual, and annual reports and loss runs:
Sample Standard Reports:
• Work Status Tab (Screen Shot)
• Active Claims Listed by Allocation
• Reserve Report
• Claims Voucher (Paper Transaction)/Check Register
• Claims Detail Summary
• Claims by Nature of Injury
• Claims by Claim Cause
• Claims by Body Part
• Claims Closed this Month
• Claims Closed by Month
• Claims Opened this Month
• Claims Opened by Month
• Claim Lag Time
• Litigated Claims by Claimant Type
• Work Status
• Claims Settled Last Month
• Claims Summary by Year
• Claims Transaction Report
• Balance Sheet Report
• Check Reconciliation Report
• OSHA's Form 300 Report
• OSHA's Form 300A Report
• OSHA's Form 301 Report
• Comparison Report
• Frequency and Severity by Nature of Injury
• Claims Handling Analysis
• Claim Ratios
• Average Claim Costs/Data Analysis-Metrics
• Cost of All Claims
• Batch Pay Sample Check
• Batch Pay Sample Report
Sample Detailed/Analytical Reports:
• Five-Year New Claims Opened
• Five-Year New Claims Opened and Claims Closed
• Percentage of New Claims Opened - Indemnity
Workers' Compensation Third Party Claims Administration Services Request for Proposal Response - City of Vernon
Admin Sure May 14, 2024
• Average Cost Per New Claim Added by Department
• Police, Five-Year New Claims Opened by Claim Type
• Fire, Five-Year Claims Opened by Claim Type
• All Other Departments, Five-Year Claims Opened by Claim Type • Police, Total Incurred = Paid & Reserved
• Fire, Total Incurred = Paid & Reserved
• All Other Departments, Total Incurred = Paid & Reserved • Citywide, Total Incurred = Paid & Reserved
• Police, Stratification Loss
• Fire, Stratification Loss
• All Other Departments, Stratification Loss
• All Departments, Litigated Claims
• Safety (Police & Fire) Litigated Claims
• Non-Safety Litigated Claims
• All Departments, Litigated Expenses vs. Total Paid
• Five-Year Top 10 New Claim Distribution by Department (Bar) • Five-Year Top 10 New Claim Distribution by Department (Pie) • Five-Year Claim Distribution by Top 10 Cause of Loss (Bar) • Five-Year Claim Distribution by Top 10 Cause of Loss (Pie) • Claim Distribution by Cause of Loss Reference
• Five-Year Claim Distribution by Top 10 Nature of Injury (Bar) • Five-Year Claim Distribution by Top 10 Nature of Injury (Pie) • Claim Distribution by Nature of Injury Reference
• Five-Year Claim Distribution by Top 10 Body Part (Bar) • Five-Year Claim Distribution by Top 10 Body Part (Pie) • Claim Distribution by Body Part Reference
• Modified Duty Days - All Departments
• Modified Duty Days - Safety (Police & Fire)
• Modified Duty Days - None-Safety
• Metrics
• *Comparisons - Percentage of New Claims Added
• *Comparisons - Closing Ratio
• *Comparisons - Frequency Rate (Per 100 Employees)
• *Comparisons - Percentage of Annual Medical Only Claims • *Comparisons - Percentage Litigated for New Claims Added • *Comparisons - Percentage of Total Paid (All Claims)
We have also included snapshots of our Dashboard which is currently being updated. It is important to reiterate that there are literally hundreds of reports we are able to create for the City of Vernon at no additional cost. Thank you for your time and consideration.
Alithia Vargas-flores
Alithia Vargas-Flores, President
MBA, SIA, WCCP, WCCA
Workers' Compensation Third Party Claims Administration Services Admin Sure Request for Proposal Response - City of Vernon May 14, 2024
WORK STATUS TAB
SCREEN SHOT
otepad Claim Insured Alocation Post Injury Benefit Data Correspondence Attachment Scheduled Payment Assel To Vehicle Contacts Ulization Review Work Status Compensation Payment History
Work Status Overview
Exam Date Modified Release Date Modified Through Date
Next Appointment Date: Release to Begin Days: Days:
*Work Status Type: Hours:
Full Time / Full Duty
Full Time / Modified Duty
Claims Assistant Full Time / Modified Duty - Not Accomm - Lost Time Part Time / Full Duty
Other Information Part Time / Full Duty - Not Accomm - Lost Time Part Time / Modified Duty
Assigned by Physician: Part Time / Modified Duty - Not Accomm - Lost Time Permanent Modified Duty
Work Status/Restrictions Temporary Total Disability
End Date Days Release To Begin Days Work Statu Next Appointment Date Hours Amount [Location supe Fir Pho Job Description Assigned Comment
Workers' Compensation Active Claims Listed by Allocation Employee's Name Case No. laim Tyr Injury Date Paid
Cause of Injury Status epartmer Days Lost this Period Paid Outstanding Incurred Recovery Description of Injury Closing Date
Org1 Desc: Administrative Services
14-120112 Future Med-Lim 04/30/2014 Medical 0.00 2,339.88 2,160.12 4,500.00 0.00 Developed discomfort in the Open ADMSRV 0.00 TD 0.00 0.00 0.00 0.00 0.00 base of her left 160 PD 0.00 0.00 0.00 0.00 0.00
Left hand/fingers and Right Rehab 0.00 0.00 0.00 0.00 0.00 hand Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expense 0.00 0.00 0.00 0.00 0.00
Other Expense 0.00 195.78 389.22 585.00 0.00
Total 0.00 2,535.66 2,549.34 5,085.00 0.00
Org1 Desc 1 Medical 0.00 2,339.88 2,160.12 4,500.00 0.00 TD 0.00 0.00 0.00 0.00 0.00
PD 0.00 0.00 0.00 0.00 0.00
Rehab 0.00 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expense 0.00 0.00 0.00 0.00 0.00
Other Expense 0.00 195.78 389.22 585.00 0.00
Org1 Desc 0.00 2,535.66 2,549.34 5,085.00 0.00
Prepared by AdminSure Page 1 of 54
Workers' Compensation Active Claims Listed by Allocation Employee's Name Case No. Claim Type Injury Date Paid
Cause of Injury Status Department Days Lost this Period Paid Outstanding Incurred Recovery Description of Injury Closing Date
13-115343 Future Medical 02/10/2013 Medical 0.00 1,438.01 11,892.10 13,330.11 0.00 Developed severe pain in Open PUBSAF 3.00 TD 0.00 905.31 0.00 905.31 0.00 his right foot when walking 471 PD 0.00 1,381.85 0.00 1,381.85 0.00 Right Foot Pain Rehab 0.00 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00
Legal Expense 0.00 0.00 0.00
Other Expense 0.00 414.63 1299210 1,514.63
Total 0.00 4,139.80 17,131.90
2008001048 Future Medical 09/25/2006 Medical 0.00 45,273.61 35,051.76 80,325.37 0.00 CONTINOUS TRAUMA TO Open PUBSAF 117.00 TD 0.00 32,336.97 0.00 32,336.97 0.00 NECK 471 PD 0.00 21,342.62 0.00 21,342.62 0.00
STRAIN DISC NECK Rehab 0.00 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expense 0.00 0.00 0.00 0.00 0.00
Other Expense 0.00 121.59 7,128.41 7,250.00 0.00
Total 0.00 99,074.79 42,180.17 141,254.96 0.00
Org1 Desc 196 Medical 54,662.69 5,355,484.38 6,028,742.58 11,384,226.96 -12,500.00 TD 52,037.44 3,817,187.62 358,027.23 4,175,214.85 -12,500.00 PD 6,289.54 2,559,240.47 1,508,352.59 4,067,593.06 0.00 Rehab 0.00 144,601.00 61,752.20 206,353.20 0.00
Other Indemnity 10,351.21 436.632.69 499,336.95 935,969.64 -1.024.875.44 Legal Expense 2,039.10 435,963.74 48,775.32 484,739.06 0.00 Other Expense 7,411.88 292,394.04 798,209.34 1,090,603.38 -15,000.00 Org1 Desc 132,791.86 13,041,503.94 9,303, 196.21 22,344,700.15 -1,064,875.44 Grand Total: 244 Medical 66,469.92 6,510,797.23 7,656,584.54 14,167,381.77 -20,000.00 TD 74,718,64 4,381,846.79 535,402.19 4,917,248.98 -12,500.00 PD 935.86 3,008,507.24 1,847,677.43 4,856,184.67 0.00
Rehab 0.00 172,745.31 81,752.20 254,497.51 0.00
Other Indemnity 10,351.21 485,862.51 518,936.20 1,004,798.71 -1,137,644.57 Legal Expense 2,811.15 679,960.35 119,307.77 799,268.12 0.00 Other Expense 16,199.60 498,626.92 1,024, 196.14 1,522,823.06 -15,000.00 Grand Total: 171,486.38 15,738,346.35 11,783,856.47 27,522,202.82 -1,185,144.57 Prepared by AdminSure Page 54 of 54
Reserve Total
Processed Claim Number Claimant Incident Transaction Type Reason Examiner Amount Claim Number: 02IRV00684
03/17/2015 02IRV00684 02/09/2002 Other Expense Barrile, Ronece 5,767.88 03/25/2015 02IRV00684 02/09/2002 Permanent Disability Barrile, Ronece 9,749.00 03/25/2015 02IRV00684 02/09/2002 Permanent Disability Barrile, Ronece -9,749.01 Claim Number Total 3 5,767.87
Claim Number: 04IRV00895
03/09/2015 04IRV00895 04/03/2004 Other Indemnity Barrile, Ronece 750.00 Claim Number Total 1 750.00
Claim Number: 05IRV01027
03/26/2015 05IRV01027 03/01/2005 Medical Auto Cuevas, Diana -58,000.00 03/26/2015 05IRVO1027 03/01/2005 Other Expense Auto Cuevas, Diana -5,959.29 03/26/2015 05IRV01027 03/01/2005 Rehab Auto Cuevas, Diana -1,000.00 Claim Number Total 3 -64,959.29
Claim Number: 06IRV01238
03/12/2015 06IRV01238 11/16/2006 Medical Auto Barrile, Ronece -6,163.68 03/12/2015 06IRV01238 11/16/2006 Other Expense Auto Barrile, Ronece -1,246.40 Claim Number Total 2 -7,410.08
Claim Number: 11-110195
03/11/2015 11-110195 01/19/2011 Other Expense Barrile, Ronece -7,057.80 03/11/2015 11-110195 01/19/2011 Permanent Disability Barrile, Ronece -27,100.97 03/11/2015 11-110195 01/19/2011 Permanent Disability Barrile, Ronece 457.17 03/11/2015 11-110195 01/19/2011 Barrile, Ronece -4,000.00 03/11/2015 11-110195 01/19/2011 Temporary Disability Barrile, Ronece -457.17 Claim Number Total 5 -38,158.77
Claim Number: 11-110691
03/30/2015 11-110691 03/25/2011 Medical Auto Cuevas, Diana -9,304.84 03/30/2015 11-110691 03/25/2011 Other Expense Auto Cuevas, Diana -1,860.00 Claim Number Total 2 -11,164.84
Processed Claim Number Claimant Incident Transaction Type Reason Examiner Amount Claim Number: 9603140027
03/31/2015 9603140027 10/24/1995 Medical Barrile, Ronece -104,417.36 03/31/2015 9603140027 10/24/1995 Other Expense Barrile, Ronece -11,996.15 03/31/2015 9603140027 10/24/1995 Other Indemnity Barrile, Ronece -129.94 03/31/2015 9603140027 10/24/1995 Permanent Disability Barrile, Ronece -88,550.00 Claim Number Total 4 -205,093.45
Grand Total 142 -60,285.97
Workers' Compensation Claims Voucher/Check Register
For Month Ending
Number Date Amount Payee Description Claimant Code Claim Number Payment Method Desc: Check
74814 03/04/2015 330.08 Higuera, Ron J. D.C., M.S. Chiropractic Treatment PUBSAF 11-112189 74815 03/04/2015 168.00 Team Makena, LLC Medical Appliance PUBSAF 13-117025 74816 03/04/2015 119.12 National Ambulatory Hernia Ins Medical Treatment PUBSAF 14-121165 74817 03/04/2015 102.08 Ortho Med Group & ARC Physical Therapy PUBWRK 15-121376 74818 03/04/2015 102.08 Ortho Med Group & ARC Physical Therapy PUBWRK 15-121376 03/04/2015 102.08 Ortho Med Group & ARC Physical Therapy PUBWRK 15-121376 03/04/2015 81.97 Nicholas E Rose M.D Medical Treatment PUBSAF 14-117523 03/04/2015 92.05 National Ambulatory Hernia Ins Medical Treatment PUBSAF 13-117103 74822 03/04/2015 123.37 Pacific Cardiovascular Association Medical Treatment PUBSAF 06IRV01207 74823 03/04/2015 751.98 Stone River Pharmacy Solutions ** Medical Prescription PUBSAF 9503140060 74824 03/04/2015 104.21 California Rehabilitation & Sports Physical Therapy COMDEV 15-121330 74825 03/04/2015 163.31 Michael P. Weinstein M.D. Medical Treatment PUBSAF 06IRV01178 74826 03/04/2015 49.98 Sand Canyon Medical Group Medical Treatment PUBSAF 13-117422 74827 03/04/2015 73.91 Sand Canyon Urgent Care Medical Treatment COMSRV 15-121612 74828 03/04/2015 82.36 Sand Canyon Urgent Care Medical Treatment COMSRV 15-121557 74828 03/04/2015 283.67 Cindy I Chen Md Apc Medical Treatment PUBSAF 07IRVO1299 74830 03/04/2015 93.77 California Rehabilitation & Sports Physical Therapy PUBSAF 14-120290 74831 03/04/2015 105.69 Align Networks, Inc. Physical Therapy PUBSAF 12-114633 74832 03/04/2015 125.26 Elite Orthopedics Medical Treatment PUBWRK 9303140078 74833 03/04/2015 8,642.87 Saddleback Memorial Medical Center * Medical Treatment PUBSAF 14-120344 74834 03/04/2015 90.12 ProCare Work Injury Center Irvine Medical Treatment PUBSAF 12-113561 74835 03/04/2015 69.02 Sand Canyon Medical Group Medical Treatment PUBSAF 14-120750 74836 03/04/2015 881.90 Newport Harbor Anesthesia Cons Medical Treatment PUBSAF 8403140001 Prepared by AdminSure Page 1 of 33
Workers' Compensation Claims Voucher/Check Register
For Month Ending
Number Date Amount Payee Description Claimant Code Claim Number Payment 36 -30,135.11
Payment Method Desc: Void
75033 03/18/2015 -42.04 Stone River Pharmacy Solutions ** Medical Prescription PUBSAF 13-116114 Payment 1 -42.04
Grand Total: 766 60,599.94
Prepared by AdminSure Page 33 of 33
Claimant Name 12-114974
Status: Open Type: Indemnity
Incident Date: 12/03/2012 Closed Date: Opened Date: 12/28/2012 Denied Date: Insured Reported Date: 12/21/2012 Deductible: 0.00 Insured:
Public Safety
Claimant: SSN: XXX-XX-7262
Claimant Address Sex: Female
Rancho Santa Margarita, CA 92688
Birth Date: 02/07/1978 Examiner:
Hire Date: 12/30/2002 Weekly Wage: 1,658.00
Incident: During a simulation training, a tourniquet was applied to the left arm Type:
Cause: Miscellaneous Strain
Body Part: Multiple Body Parts
Nature of Injury: Multi Physical Injuries
Total Incurred Payments Outstanding Recovery
Medical 81,095.47 20,915.15 60,180.32 0.00
TD 90,784.14 90,784.14 0.00 0.00
PD 42,000.00 11,922.29 30,077.71 0.00
Rehab 8,000.00 0.00 8,000.00 0.00
Other Indemnity 2,156.25 656.25 1,500.00 0.00
Legal 15,000.00 10,339.45 4,660.55 0.00
Other Expense 35,225.33 26,599.33 8,626.00 0.00
Total: 274,261.19 161,216.61 113,044.58 0.00
Claims by Nature of Injury
Nature of Injury Frequency % Total Incurred % Average/Claim % Total Paid % All Other Cumulative Trauma 1 1 12,763 2 12,763 156 337 100 Cancer 2 2 28,285 4 14,142 173 0
Contusion 3,110 622 8 1,375 80
Dermatitis 1 1 145 0 145 2 145 8
Foreign Body 2 2 1,317 658 8 281 13
Fracture 2 19,000 3 9,500 116 12,878 86
Hearing Loss (Cumulative) 1 1 9,550 1 9,550 117 0
Hernia 3 4 71,900 11 23,967 293 9,854 40
Inflammation 1 1 174 174 2 174 1
Laceration 5 6 2,017 403 5 2,017 7
Miscellaneous 5 6 1,032 206 1,032 4
Multi Physical Injuries 1 1 4,200 1 4,200 51 311 1
Puncture 4 5 858 0 215 3 858 3
Respiratory Disorders 1 1 12,735 2 12,735 156 0
Sprain 8 10 89,889 14 11,236 137 8,609 23
Strain 38 48 397,836 61 10,469 128 120,550 76
Grand Total: 80 654,811 8,185 158,420
Claims By Nature Of Injury
All Other Cumulative Trauma = 1 • Cancer= 2 • Contusion = 5 • Dermatitis = 1 • Foreign Body = 2 • Fracture = 2
Hearing Loss (Cumulative) = 1 • Hernia = 3 • Inflammation = 1 • Laceration = 5 Miscellaneous = 5 © Multi Physical Injuries = 1 • Puncture = 4 • Respiratory Disorders = 1 • Sprain = 8 Strain = 38
Claims by Claim Cause
Claim Cause Frequency % Total Incurred Average/Claim %
Cut/Scraped by Broken Glass 1 37,469 3 37,469 198
Cut/Scraped by Other Object 1 143 143 1
Fall on Same Level 1 16,750 16,750 89
Fall on Stairs 2 3 1,959 979 5
Foreign Matter/Object in Eye 1 377 377 2
Hit by Falling/Flying Object 1 1 0
Hit/Injured by Animal/Insect 4 23,606 2 7,869 42
Holding or Carrying 1 9,000 1 9,000 48
Lifting 1 57,063 5 57,063 302
Miscellaneous Cause 28 42 848,061 67 30,288 160
Miscellaneous Exposure/Contact 1 1 430 0 430 2
Miscellaneous Fall or Slip 4 54,542 4 18,181 96
Miscellaneous Strain 6 9 61,517 5 10,253 54
Miscellaneous Vehicle Accident 1 1 2,944 0 2,944 16
Other Cumulative Trauma 10 110,382 9 15,769 83
Pushing or Pulling 1 1 1,772 1,772 9
Reaching 2 3 14,950 7,475 40
Repetitive Motion 5 7 15,286 1 3,057 16
Vehicle Upset 1 1 9,859 1 9,859 52
Grand Total: 67 1,266,110 18,897
Claims By Claim Cause
Cut/Scraped by Broken Glass = 1 • Cut/Scraped by Other Object = 1 • Fall on Same Level = 1 © Fall on Stairs = 2
Foreign Matter/Object in Eye = 1 • Hit by Falling/Flying Object = 1 Hit/Injured by Animal/Insect = e Holding or Carrying = 1 • Lifting = 1 • Miscellaneous Cause = 28
Miscellaneous Exposure/Contact = 1
Miscellaneous Fall or Slip = 3 • Miscellaneous Strain = 6 Miscellaneous Vehicle Accident = 1 • Other Cumulative Trauma = 7 Pushing or Pulling = 1 • Reaching = 2 © Repetitive Motion = 5 › Vehicle Upset = 1
Claims by Body Part
Body Part Frequency % Total Incurred % Average/Claim %
Abdomen/Groin 4 5 72,427 11 18,107 221
Ankle 1 1 0 11
Buttock(s) 1 1 2
Chest (Ribs/Sternum/Other) 1 3
Ear(s) 1 1 1 117
Elbow 4 5 1 22
Eye(s) 2 2 8
Facial Soft Tissue 6 6 102
Fingers) 3 4 0 4
Foot 6 8 3 45
Hand 3 4 2
Head Injury 2 2 8
Knee 8 10 150
Lower Arm 2 2 1 27
Lower Leg 1 1 2
Lumbar/Sacral Vertebrae 9 30 344
Lung(s) 1 1 2 156
Miscellaneous 2 2 5
Mouth 1 1 0
Multiple Body Parts 6 8 8 109
Multiple Trunk 1 1 2 137
Neck 2 2 16
Shoulder(s) 9 4 49
Thoracic and Lumbar 2 2 0 7
Thumb 1 1 95 0 95 1
Upper Arm/Clavicle/Scapula 1 1 12 995
Upper Leg 2 2 3
Wrist 3 4 1 17
Grand Total: 80 654,811 8,185
Claims By Body Part
Abdomen/Groin = 4 • Ankle = 1 • Buttock(s) = 1
© Chest (Ribs/Sternum/Other) = 1 • Ear(s) = 1 @ Elbow = 4 Eye(s) = 2 • Facial Soft Tissue = 5 • Fingers) = 3 • Foot = 6 Hand = 3 @ Head Injury = 2 • Knee = 8 • Lower Arm = 2
• Lower Leg = 1 • Lumbar/Sacral Vertebrae = 7 • Lung(s) = 1 Miscellaneous = 2 © Mouth = 1 @ Multiple Body Parts = 6 Multiple Trunk = 1 • Neck= 2 • Shoulder(s) = 7
• Thoracic and Lumbar = 2 • Thumb = 1
Upper Arm/Clavicle/Scapula = 1 • Upper Leg = 2 • Wrist = 3 Workers' Compensation Claims Closed this Month
For Month Ending
Employee's Name Case No. Department Injury Date Paid
Cause of Injury Status Closing Date this Period Paid Outstanding Incurred Recovery Description of Injury Claim Type Days Lost
14-119454 PUBSAF 05/25/2014 Medical 0.00 2,307.97 0.00 2,307.97 0.00 He rolled his ankle on uneven Closed 411 03/23/2015 TD 0.00 9,023.68 0.00 9,023.68 0.00 ground when jumping over a Indemnity 44.00 PD 0.00 0.00 0.00 0.00 0.00 fence Rehab 0.00 0.00 0.00 0.00 0.00
Right ankle fracture Other Indemnity 0.00 0.00 0.00 0.00 0.00 Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 0.00 158.97 0.00 158.97 0.00
Total 0.00 11,490.62 0.00 11,490.62 0.00
14-120530 PUBSAF 06/09/2014 Medical 0.00 1,619.67 0.00 1,619.67 0.00 Stepped on curb and right Closed 471 03/12/2015 TD 0.00 0.00 0.00 0.00 0.00 ankle rolled off curb while Medical Only 0.00 PD 0.00 0.00 0.00 0.00 0.00 walking back to police Rehab 0.00 0.00 0.00 0.00 0.00
Right ankle / Right foot strain Other Indemnity 0.00 0.00 0.00 Legal Expenses 0.00 3311 0.00 3311 0.00
Other Expenses 0.00 .OC
Total 0.00 0.00
06IRV01238 PUBSAF 11/16/2006 Medical 0.00 452.59 0.00 0.00 Continuous trauma; routine Closed 03/12/2015 TD 0.00 U.I .00 police duties contact with Future Medical 0.00 PD 0.00 0. .00 numerous people on course of Rehab 0.00 0. .00
TB Exposure Other Indemnity 0.00 0. .00 0.00
Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 0.00 9.00 0.00 9.00 0.00
Total 0.00 461.59 0.00 461.59 0.00
11-110691 PUBSAF 03/25/2011 Medical 0.00 0.00 0.00
Exposure to sun when Closed 481 03/30/2015 TD 0.00 0.00 0.00 responding to outdoor calls for Future Medical 4.00 PD 0.00 0.00 0.00 service. Rehab 0.00 0.00 0.00 0.00
Skin Cancer Other Indemnity 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00
Other Expenses 0.00 344.65 0.00 0.00
Total 0.00 1,603.65 0.00 0.00
2009105552 PUBSAF 06/05/2009 Medical 0.00 18,524.09 0.00 0.00 (CONTINUOUS TRAUMA) Closed 420 03/12/2015 TD 0.00 10,022.42 0.00 0.00 Routine police duties, i.e., Future Medical 42.00 PD 1,380.00 0.00 0.00 getting in and out of patrol car, Rehab 0.00 0.00 0.00
Bilateral Shoulder Strain/ Other Indemnity 0.00 0.00 0.00 0.00 0.00 Right Knee Strain Legal Expenses 0.00 0.00 0.00 0.00
Other Expenses 0.00 195.54 0.00 0.00
Total 0.00 30,122.05 0.00 30,122.05 0.00
Prepared by AdminSure Page 1 of 4
Workers' Compensation Claims Closed this Month
For Month Ending
Employee's Name Case No. Department Injury Date Paid
Cause of Injury Status Closing Date this Period Paid Outstanding Incurred Recovery Description of Injury Claim Type Days Lost
05IRV01027 PUBSAF 03/01/2005 Medical 0.00 54,248.25 0.00 54,248.25 0.00 Strained low back, CT. Closed 03/26/2015 TD 0.00 39,137.42 0.00 39,137.42 0.00 wearing gunbelt, sitting in car, Future Medical 0.00 PD 0.00 19,806.29 0.00 19,806.29 0.00 twisting in car to use Rehab 0.00 420.00 0.00 420.00 0.00 Lower Back Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 0.00 36.00 0.00 36.00 0.00
Total 0.00 113,647.96 0.00 113,647.96 0.00
14-121095 PUBSAF 10/07/2014 Medical 0.00 952.51 0.00 952.51 0.00 Developed pain in his right foot Closed 471 03/18/2015 TD 0.00 0.00 0.00 0.00 0.00 after participating in block Indemnity 0.00 PD 0.00 0.00 0.00 0.00 0.00 training / baton use Rehab 0.00 0.00 0.00 0.00 0.00
Right foot pain/plantar fascitis Other Indemnity 0.00 0.00 0.00 0.00 0.00 Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 0.00 191.47 0.00 191.47 0.00
Total 0.00 1,143.98 0.00 1,143.98 0.00
14-121165 PUBSAF 11/20/2014 Medical 119.12 491.16 0.00 491.16 0.00 Strained his lower abdominal Closed 411 03/18/2015 TD 0.00 0.00 0.00 0.00 0.00 he clang the prices Medical Only 0.00 PD 0.00 0.00 0.00 0.00 0.00 Rehab 0.00 0.00 0.00 0.00 0.00
Lower abdomen / groin strain Other Indemnity 0.00 0.00 0.00 0.00 0.00 Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 10.25 36.08 0.00 36.08 0.00
Total 129.37 527.24 0.00 527.24 0.00
Grand Total: 18 Medical 1,552.81 89,732.90 0.00 89,732.90 0.00 TD 0.00 66,841.79 0.00 66,841.79 0.00
PD 0.00 21,186.29 0.00 21,186.29 0.00
Rehab 0.00 420.00 0.00 420.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 148.09 3,404.18 0.00 3,404.18 0.00
Grand Total: 1,700.90 181,585.16 0.00 181,585.16 0.00
Prepared by AdminSure Page 4 of 4
Claims Closed by Month
Number of Claims Closed → FY XX
IFYXX
+-FY XX
1 August October November December January February March Nat June September
Measures the total number of claims that are closed in a month period. Ideally, we want to close more claims than are opened in a month. Closing the claims is an important factor in mitigating the overall cost of claims. The higher the number, the better.
Prepared by AdminSure
CLAIMS CLOSED BY Claims Closed YTD
MONTH DecEMBER 20Xx Comparison
• FY XX • FY XX • FY XX 20
19 18
7 16
14 12
10 8
6 4
4 2
0 DECEMBER FY 20XX FY 20XX FY 20XX
Measures the total number of claims that are closed in a month period. Ideally, we want to close more claims than are opened in a month.
Closing the claims is an important factor in mitigating the overall cost of claims. The higher the number the better.
Workers' Compensation Claims Opened this Month
Employee's Name Case No. Claim Type Injury Date Paid
Cause of Injury Status Department Days Lost this Period Paid Outstanding Incurred Recovery Description of Injury
15-122031 Indemnity 03/12/2015 Medical 0.00 0.00 10,000.00 10,000.00 0.00 Developed a hernia after his Open PUBSAF 0.00 TD 0.00 0.00 11,006.40 11,006.40 0.00 motorcycle struck a curb and 471 PD 0.00 0.00 0.00 0.00 0.00 Left Abdominal hernia Rehab 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 0.00 0.00 1,150.0 1,150.00 0.00
Total 0.00 0.00 2,156.4 2,156.40 0.00
15-122032 Medical Only 03/19/2015 Medical 0.00 0.00 2,100.00 2,100.00 0.00 While struggling with a Open PUBSAF 0.00 TD 0.00 0.00 0.00 0.00 0.00 combative mental health 411 PD 0.00 0.00 0.00 0.00 0.00 Left shoulder strain Rehab 0.00 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00
Other Expenses 0.00 00 190. 0. .00
Total 0.00 0.00 2,290 2,290.00 0. .00
15-122008 Medical Only 03/20/2015 Medical 0.00 0.00 2,500 2,500 .00 0.00 Sustained injury to his right Open PUBWRK 0.00 TD 0.00 0. 0.00 wrist while digging post holes 551 PD 0.00 000 88888 0.00 Right wrist sprain Rehab 0.00 .00
Other Indemnity 0. 00 .00
Legal Expenses 0.00 0.00 0.00 0.00
Other Expenses 0.00 225.00 225.00 0.00
Total 0.00 2,725.00 2,725.00 0.00
15-121893 Indemnity 03/09/2015 Medical 0.00 0.00 10,000.00 10,000.00 0.00 Exposure to sun during the Open PUBSAF 0.00 TD 0.00 0.00 9,500.00 9,500.00 0.00 ourse of work caused her to 411 PD 0.00 0.00 0.00
Left ear skin cancer Rehab 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00
Other Expenses 0.00 0.00 1,350.00 1,350.00 0.00
0.00 0.00 20,850.00 20,850.00 0.00
15-121829 Medical Only 02/15/2015 Medical 83.26 83.26 0.00 83.26 0.00 EE was reaching for keys Closed PUBSAF 0.00 TD 0.00 0.00 0.00 0.00 when his left thumb hit a 411 PD 0.00 0.00 0.00 0.00
Left Thumb Puncture Wound Rehab 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00
11.90 Other Expenses 11.94 0.00 11.94 0.00
Total 95.20 95.20 0.00 95.20 0.00
Prepared by AdminSure Page 1 of 2
Workers' Compensation Claims Opened this Month
Employee's Name Case No. Claim Type Injury Date Paid
Cause of Injury Status Department Days Lost this Period Paid Outstanding Incurred Recovery Description of Injury
15-121948 Medical Only 03/12/2015 Medical 0.00 0.00 950.00 950.00 0.00 While cleaning the range area Open PUBSAF 0.00 TD 0.00 0.00 0.00 0.00 0.00 / walking in the parking lot on a 411 PD 0.00 0.00 0.00 0.00 0.00 Left eye irritation Rehab 0.00 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00 0.00
Other Expenses 0.00 0.00 86.00 86.00 0.00
Total 0.00 0.00 1,036.00 1,036.00 0.00
15-121993 Indemnity 12/12/2014 Medical 0.00 1,500.00 1,500.00 0.00 EE injured her left knee while Open PUBSAF 0.00 TD 0.00 0.00 0.00 0.00 walking and then colliding with 423 PD 0.00 0.00 0.00 0.00 Left knee contusion Rehab 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00
Other Expenses 0.00 235.00 235.00 0.00
Total 0.00 1,735.00 1,735.00 0.00
Grand Total: 7 Medical 83.26 83.26 27,050.00 27,133.26 0.00 TD 0.00 0.00 20,506.40 20,506.40 0.00
PD 0.00 0.00 0.00 0.00 0.00
Rehab 0.00 0.00 0.00 0.00 0.00
Other Indemnity 0.00 0.00 0.00 0.00 0.00
Legal Expenses 0.00 0.00 0.00 0.00
Other Expenses 11.94 1.90 3,236.00 3,247.94
Grand Total: 95.20 95.20 50,792.40 50,887.60 0.00
Prepared by AdminSure Page 2 of 2
Claims Opened by Month
mber of Claims Opened
→ FY XX
-FY XX
→ FY XX
August September October November December January February March Measures the total number of new claims filed in a month. This number includes claims that have been or may be denied. This number may reflect unsafe work practices or morale problems.
Typically the cost associated with these claims become most prevalent two years later. The lower the number the better.
Prepared by AdminSure
CLAIMS OPENED BY Claims Opened YTD
MONTH DecEMBER 20xx Comparison
• FY XX • FY XX • FY XX
22 4
20 3 15
15 14
2 10
5 DECEMBER FY 20XX FY 20XX FY 20XX
Measures the total number of new claims filed in a month. This number includes claims that have been or may be denied. This number may reflect unsafe work practices or morale problems. Typically the cost associated with these claims become most prevalent two years later.
The lower the number the better.
Claim Lag Time
Days between Days between Days between
Claim Number Claimant Incident Date Insured Reported Incident/Reported Adjusting Loc. Received Reported/Received Incident/Received 15-121829 02/15/2015 02/20/2015 5 03/03/2015 11 16
15-121893 03/09/2015 03/09/2015 03/09/2015
15-121948 03/12/2015 03/12/2015 03/16/2015 4 4
15-121993 12/12/2014 03/19/2015 97 03/23/2015 4 101
15-122008 03/20/2015 03/20/2015 03/24/2015 4 4
15-122031 03/12/2015 03/27/2015 15 03/27/2015 0 15
15-122032 03/19/2015 03/26/2015 03/27/2015 1 8
Grand Total: 7 Median Lag Time: 5.00 4.00 8.00
Average Lag Time: 17.71 3.43 21.14
Litigated Claims by Claimant Type
Claimant Type Open Count Closed Count Frequency % Total Incurred % Average/Claim % Future Medical 32 32 46 5,585,257 34 174,539 74
Indemnity 26 26 37 5,117,056 31 196,810 83
Indemnity/Future Medical 12 17 5,883,500 35 490,292 207 Grand Total: 70 16,585,813 236,940
Claims By Claimant Type
Future Medical = 32 @ Indemnity = 26
Indemnity/Future Medical = 12
Work Status
Accepted
Claim Number Claimant Injury Date Exam Date Next Appointment Date Work Status Delayed Work Status/Restrictions Denied
11-110678 03/12/2011 12/29/2014 03/22/2015 Temporary Total Disability Y TTD N
N
14-119529 06/03/2014 01/27/2015 03/10/2015 Full Time / Modified Duty N No squatting/kneeling; No climbing ladders greater than 6 feet N
N
14-119538 03/31/2014 01/19/2015 03/12/2015 Part Time / Modified Duty N continue working 4 hours per day N
N
14-120344 08/07/2014 03/03/2015 03/31/2015 Full Time / Modified Duty Y 40 hours per week; limited pushing, pulling reaching and overhead N
N
14-120784 10/15/2014 02/13/2015 03/09/2015 Full Time / Modified Duty N No heavy lifting greater than 25 Ibs.; No repetitive lifting greater than N 15 Ibs.
N
14-120940 10/30/2014 01/22/2015 03/19/2015 Full Time / Modified Duty N No repetitive reaching, pushing, and pulling. Restricted to desk-type N work and/or detective-type work; she should not be out in the fiel interacting with suspects where she may have to do takedowns, etc N
14-121112 11/30/2014 01/05/2015 03/04/2015 Full Time / Modified Duty Y NO FORCEFUL OR REP PUSH/PULLING WITH RIGHT HAND; NO N LIFTING/PULLING/PUSHING OVER 10 LBS
N
15-121893 03/09/2015 03/10/2015 03/23/2015 Full Time / Modified Duty N N
N
15-121993 12/12/2014 02/27/2015 03/27/2015 Full Time / Modified Duty N Limited kneeling N
15-122008 03/20/2015 03/20/2015 03/27/2015 Part Time / Modified Duty Y Must use splint or brace, no use of right hand.
N
N
Grand Total: 11
Claims Settled Last Month
Claimant Claim Number Injury - Date Claim Type Litigated Examiner Settle - Date Settlement Type Settlement Amount 12-113827 06/28/2012 Future Medical N RBARRILE 03/06/2015 Stipulated Award 0.00
Workers' Compensation Claims Summary by Year
For Month Ending
Policy Period Paid Incurred
by Date of Injury Open Total Claims Days Lost This Period This Period Paid Outstanding Incurred Recovery Net Incurred 1965-1966 0.00 0.00 0.00 0.00 0.00 0.00 0.00
1975-1976 0.00 0.00 2,090.75 2,090.75 0.00 2,090.75
1976-1977 0.00 0.00 14,876.35 14,876.35 0.00 14,876.35
1977-1978 4 0.00 0.00 38,799.00 38,799.00 0.00 38,799.00 1978-1979 11 0.00 0.00 76,978.34 76,978.34 0.00 76,978.34 1979-1980 71 0.00 0.00 49,930.23 49,930.23 0.00 49,930.23 1980-1981 83 0.00 0.00 0.00
1981-1982 86 0.00 0.00 129,444.76
1982-1983 85 0.00 0.00 54,895.72
1983-1984 1 76 0.00 0.00 0.00
1984-1985 81 0.00 0.00 85,430.78 0.00 85,430.78
1985-1986 99 0.00 0.00 316,736.66 0.00 316,736.66
1986-1987 117 0.00 0.00 479,259.74 0.00 479,259.74
1987-1988 90 0.00 0.00 274,088.14 0.00 274,088.14
1988-1989 135 0.00 0.00 394,446.77 0.00 394,446.77
1989-1990 1 115 102.01 0.00 698,313.80 103,577.75 210.00 801,681.55 1990-1991 2 120 0.00 0.00 1,298,327.03 123,252.72 0.00 1,421,579.75 1991-1992 1 108 230.82 0.00 740,442.90 12,122.18 752,565.08 0.00 752,565.08 1992-1993 2 159 378.54 0.00 1,010,352.31 98,804.44 1,109,156.75 0.00 1,109,156.75 1993-1994 1 141 0.00 0.00 1,082,444.32 91,424.43 1,173,868.75 37,132.79 1,136,735.96 1994-1995 3 124 2,074.48 0.00 1,073,590.83 170,078.06 1,243,668.89 97,654.52 1,146,014.37 1995-1996 3 105 2,462.06 -205,093.45 1,846,429.19 182,414.93 2,028,844.12 170,769.13 1,858,074.99 1996-1997 118 0.00 0.00 0.00 582,548.68 0.00 582,548.68 14,370.10 568,178.58 1997-1998 4 112 0.00 18.00 0.00 1,053,564.84 289,142.08 1,342,706.92 3,000.00 1,339,706.92 Prepared by AdminSure Page 1 of 2
Workers' Compensation Claims Summary by Year
For Month Ending
Policy Period Paid Incurred
by Date of Injury Open Total Claims Days Lost This Period This Period Paid Outstanding Incurred Recovery Net Incurred 1998-1999 2 123 0.00 0.00 0.00 1,182,484.06 72,249.67 1,254,733.73 16,500.00 1,238,233.73 1999-2000 3 106 0.00 0.00 0.00 1,943,619.07 75,846.55 2,019,465.62 84,632.72 1,934,832.90 2000-2001 8 110 419.00 2,216.45 0.00 2,540,887.38 821,560.28 3,362,447.66 195,693.10 3,166,754.56 2001-2002 9 121 10.00 1,930.14 5,767.87 2,270,590.18 666,566.48 2,937,156.66 15,000.00 2,922,156.66 2002-2003 117 2882.00 848.01 0.00 1,537,003.04 557,801.03 2,094,804.07 23,643.00 2,071,161.07 2003-2004 5 132 412.00 3,975.29 750.00 1,323,512.19 244,294.66 1,567,806.85 18,146.75 1,549,660.10 2004-2005 7 128 620.00 4,039.84 -64,959.29 2,602,584.01 1,254,260.33 3,856,844.34 584,164.00 3,272,680.34 2005-2006 11 130 1093.00 3,015.26 0.00 1,902,690.49 641,943.25 2,544,633.74 39,545.22 2,505,088.52 2006-2007 8 121 2009.00 1,210.54 -7,410.08 1,260,739.15 238,993.83 1,499,732.98 6,716.04 1,493,016.94 2007-2008 5 118 1867.00 34.25 -100.00 877,640.41 143,009.65 1,020,650.06 1,194.34 1,019,455.72 2008-2009 10 135 4125.00 5,519.15 -18,387.14 2,390,267.05 1,188,804.22 3,579,071.27 187,328.09 3,391,743.18 2009-2010 14 108 2558.00 5,320.26 0.00 1,505,808.30 789,623.48 2,295,431.78 1,844.10 2,293,587.68 2010/2011 17 113 3190.00 17,747.45 49,323.61 1,446,772.17 573,167.48 2,019,939.65 50,717.86 1,969,221.79 2011/2012 22 115 1866.00 23,030.56 6,000.13 1,249,010.86 1,019,303.82 2,268,314.68 1,858.23 2,266,456.45 2012/2013 26 111 2455.00 13,295.06 5,174.53 1,030,373.67 1,043,377.25 2,073,750.92 2,190.65 2,071,560.27 2013/2014 35 142 2153.00 37,601.33 15,198,37 987,335.96 860,877.02 1,848,212.98 0.00 1,848,212.98 2014/2015 35 80 248.00 49,237.36 252,096.70 158,420.27 496,390.80 654,811.07 0.00 654,811.07 Grand Total: 244 4053 174,286.86 -60,285.97 38,532,845.83 11,783,619.71 50,316,465.54 1,736,651.12 48,579,814.42 Prepared by AdminSure Page 2 of 2
Workers' Compensation Claims Transaction Report
For Month Ending
Number Date Amount Payee From Thru Claimant Code Claim Number Payment Transaction Desc: Chiropractic Treatment
74840 03/04/2015 165.66 Ideal Chiropractic 01/29/2015 02/12/2015 PUBSAF 03IRV00765 74814 03/04/2015 330.08 Higuera, Ron J. D.C., M.S. 01/28/2015 02/06/2015 PUBSAF 11-112189 74866 03/11/2015 172.30 Higuera, Ron J. D.C., M.S. 02/11/2015 02/11/2015 PUBSAF 11-112189 75020 03/18/2015 150.80 Higuera, Ron J. D.C., M.S. 02/18/2015 02/20/2015 PUBSAF 11-112189 75073 03/25/2015 138.63 Higuera, Ron J. D.C., M.S. 02/20/2015 02/25/2015 PUBSAF 11-112189 Payment 5 957.47
Payment Transaction Desc: Court Reporter Expense
75132 03/25/2015 508.90 Peranich Reporting 11/21/2014 11/21/2014 COMSRV 01IRV00531 75130 03/25/2015 958.75 BARRETT REPORTING INC 02/13/2015 02/13/2015 PUBSAF 04IRV00895 Payment 2 1,467.65
Payment Transaction Desc: Medical Appliance
74815 03/04/2015 168.00 Team Makena, LLC 01/09/2015 01/09/2015 PUBSAF 13-117025 74978 03/18/2015 83.95 Recovery Medical Services, LLC 02/20/2015 02/20/2015 PUBSAF 14-117491 75086 03/25/2015 131.16 Team Makena, LLC 02/23/2015 02/23/2015 PUBWRK 14-119045 75084 03/25/2015 145.86 South Coast Medical 02/27/2015 02/27/2015 COMSRV 9303140150 75087 03/25/2015 150.00 At Medical Supplies 02/23/2015 02/23/2015 PUBSAF 14-117468 75062 03/25/2015 400.00 Advanced Hearing Services 03/10/2015 03/10/2015 PUBSAF 9603140097 Payment 1,078.97
Payment Transaction Desc: Medical Case Management
74852 03/04/2015 1,881.00 Comp Nurse Solutions 01/12/2015 02/20/2015 PUBSAF 14-119538 75047 03/18/2015 671.00 CNS LLC 02/07/2015 03/04/2015 PUBWRK 13-116144 75138 03/25/2015 836.00 CNS LLC 01/10/2015 03/13/2015 PUBWRK 14-119045 Payment 3 3,388.00
Prepared by AdminSure Page 1 of 12
Workers' Compensation Claims Transaction Report
For Month Ending
Number Date Amount Payee From Thru Claimant Code Claim Number 75121 03/25/2015 104.21 Prosport Physical Therapy RSM 02/27/2015 02/27/2015 PUBSAF 2009105542 75114 03/25/2015 107.25 The Kinetic Chain Physical Therapy 02/24/2015 02/24/2015 PUBSAF 75112 03/25/2015 184.20 Gateway Rehab and Wellness 02/25/2015 02/27/2015 PUBSAF 75113 03/25/2015 219.27 The Kinetic Chain Physical Therapy 02/26/2015 03/03/2015 75115 03/25/2015 303.68 Gateway Rehab and Wellness 02/13/2015 02/19/2015 75116 03/25/2015 624.83 ACIC Physical Therapy 01/07/2015 01/29/2015 75068 03/25/2015 104.21 Prosport Physical Therapy RSM 02/20/2015 02/20/2015 75069 03/25/2015 104.21 Prosport Physical Therapy RSM 02/18/2015 02/18/2015 75070 03/25/2015 104.21 Prosport Physical Therapy RSM 02/11/2015 02/11/2015 75071 03/25/2015 104.21 Prosport Physical Therapy RSM 02/26/2015 02/26/2015 75072 03/25/2015 105.69 Fairbanks Power Physical Therapy 02/23/2015 02/23/2015 75067 03/25/2015 110.29 California Rehabilitation & Sports 03/02/2015 03/02/2015 75083 03/25/2015 242.68 MSC Group, Inc 01/05/2015 01/05/2015 PUBSAF 2009105542 Payment 60 8,219.82
Grand Total: 257 68,369.03
Prepared by AdminSure Page 12 of 12
Client Name
Bank Name
Bank Statement Balance: $180,273.84
Less: Outstanding Checks: ($21,373.82)
Reconciled Bank Balance: $158,900.02
Less: Bank Adjustments & Errors $0.00
Adjusted Checkbook Balance: $158,900.02
Difference $0.00
Bank Adjustment & Error Detail: $0.00
Minimum Trust Amount: $0.00
Reconciled Bank Balance: $0.00
Funding Amount Needed: $0.00
Prior Month Funds Request Balance: $0.00
Disbursements Made This Period: $0.00
Less: Voids $0.00
Less: Interest Paid $0.00
Less: Credits Received This Period: $0.00
Funding Amount Due: $0.00
Prepared by AdminSure
CHECK RECONCILIATION REPORT
Check Cleared Outstanding
Check Date Check Number Payee Amount Amount Check Amount 12/19/14 19497 Hooman Rastegar, M.D. $146.91 $0.00 $146.91 01/05/15 19585 Peranich Reporting $620.50 $0.00 $620.50 02/10/15 19807 MedReview Inc. $41.02 $41.02 $0.00
02/11/15 19813 MedReview Inc. $1,020.16 $1,020.16 $0.00 02/11/15 19814 MedReview Inc. $146.34 $146.34 $0.00
02/12/15 19826 MedReview Inc. $187.25 $187.25 $0.00
02/12/15 19827 MedReview Inc. $60.00 $60.00 $0.00
02/12/15 19828 MedReview Inc. $1,466.65 $1,466.65 $0.00 02/13/15 19838 Apex Healthcare Medical Center, Inc. $219.59 $219.59 $0.00 02/13/15 19840 MedReview Inc. $1,231.34 $1,231.34 $0.00 02/13/15 19841 MedReview Inc. $69.06 $69.06 $0.00
02/13/15 19845 New Age Translations, Inc. $177.00 $177.00 $0.00 02/17/15 19851 MedReview Inc. $88.09 $88.09 $0.00
02/18/15 19869 Apex Healthcare Medical Center, Inc. $162.44 $162.44 $0.00 02/18/15 19870 Apex Healthcare Medical Center, Inc. $211.05 $211.05 $0.00 02/18/15 19871 Apex Healthcare Medical Center, Inc. $116.49 $116.49 $0.00 02/18/15 19875 B. Richard Burke DPM * $141.91 $141.91 $0.00 02/18/15 19877 MedReview Inc. $2,745.34 $2,745.34 $0.00 02/18/15 19878 MedReview Inc. $29.59 $29.59 $0.00
02/19/15 19885 Foundation Medical Group, Inc $130.19 $130.19 $0.00 02/19/15 19886 Alliance Urgent Care $72.24 $72.24 $0.00 02/19/15 19896 MedReview Inc. $215.85 $215.85 $0.00
02/19/15 19897 MedReview Inc. $110.81 $110.81 $0.00
02/19/15 19898 MedReview Inc. $11.30 $11.30 $0.00
02/20/15 19901 University Spine and Orthopedics $178.66 $178.66 $0.00 02/20/15 19903 San Bernardino Medical Orthopedic Group $235.22 $235.22 $0.00 02/20/15 19904 MedReview Inc. $636.44 $636.44 $0.00
02/23/15 19907 San Bernardino Medical Orthopedic Group $211.42 $211.42 $0.00 02/23/15 19908 SOUTH COAST DME $182.51 $182.51 $0.00
02/23/15 19909 Mh Express Pharmacy $119.34 $119.34 $0.00 02/23/15 19911 MedReview Inc. $288.62 $288.62 $0.00
02/23/15 19913 ISYS $384.00 $384.00 $0.00
02/24/15 19914 EA Integrated Health Services $96.90 $96.90 $0.00 02/24/15 19915 San Bernardino Medical Orthopedic Group $11.91 $11.91 $0.00 02/24/15 19916 MedReview Inc. $9.69 $9.69 $0.00
02/25/15 19917 John G. Ellis, M.D. Inc. $162.44 $162.44 $0.00 PREPARED BY ADMINSURE CHECKS CLEARED as of PAGE 1 OF 9
CHECK RECONCILIATION REPORT
Check Cleared Outstanding
Check Date Check Number Payee Amount Amount Check Amount 03/26/15 20169 Walgreens $16.57 $0.00 $16.57
03/26/15 20170 University Spine and Orthopedics $546.88 $546.88 $0.00 03/26/15 20171 Physical Medicine Institute $2,250.00 $0.00 $2,250.00 03/26/15 20172 Walgreens $13.63 $0.00 $13.63
03/26/15 20173 MedReview Inc. $1,031.55 $0.00 $1,031.55 03/26/15 20174 MedReview Inc. $86.47 $0.00 $86.47
03/27/15 20177 Arrowhead Evaluation Services, Inc. $5,000.00 $0.00 $5,000.00 03/27/15 20178 CompToday $9.14 $0.00 $9.14
03/27/15 20179 CompToday $8.74 $8.74
03/27/15 20180 CompToday $28.38 $28.38
03/27/15 20181 Healthpointe Med Grp dba SCOSMC $15.21 $15.21 03/27/15 20182 Southern Calif Permanente Med Grp** $144.94 $144.94 03/27/15 20183 CA Emerg Phys Med Grp $202.50 ..... $202.50 03/27/15 20184 Align Networks, Inc. $129.41 $129.41
03/27/15 20185 Align Networks, Inc. $76.30 $76.30
03/27/15 20186 Align Networks, Inc. $674.20 $674.20
03/27/15 20187 Fairbanks Power Physical Therapy $112.11 $112.11 03/27/15 20188 Fairbanks Power Physical Therapy $112.11 $112.11 03/27/15 20189 Align Networks, Inc. $56.41 $0.00 $56.41 03/27/15 20190 Align Networks, Inc. $399.25 $0.00 $399.25 03/27/15 20191 outhland Spine & Rehab Med Ct $39.18 $0.00 $39.18 03/27/15 20192 airbanks Power Physical Therap $296.67 $0.00 $296.67 03/27/15 20193 Align Networks, Inc. $98.02 $0.00 $98.02 03/27/15 20194 MedReview Inc. $755.88 $0.00 $755.88
03/27/15 20195 MedReview Inc. $2,408.26 $0.00 $2,408.26 03/30/15 20196 CompToday $19.70 $0.00 $19.70
03/30/15 20197 MedReview Inc. $129.48 $0.00 $129.48
03/31/15 20199 Economy Transport LLC $648.00 $0.00 $648.00 03/31/15 20200 KAISER FOUNDATION HOSPITAL $487.53 $0.00 $487.53 03/31/15 20201 Southland Spine & Rehab Med Ctr $152.13 $0.00 $152.13 03/31/15 20202 Healthpointe Med Grp dba SCOSMC $1,898.43 $0.00 $1,898.43 03/31/15 20203 MedReview Inc. $329.34 $0.00 $329.34
03/31/15 20204 MedReview Inc. $998.44 $0.00 $998.44
GRAND TOTALS: $127,757.43 $87,875.21 $39,882.22
PREPARED BY ADMINSURE CHECKS CLEARED as of PAGE 9 OF 9
Attention: This form contains information relating to
OSHA's Form 300 Year
Log of Work-Related Injuries and Illnesses U.S. Department of Labor occupational safety and health purposes. Occupational Safety and Health Administration ou must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfe For approved OMB no. 1218-0176 ays away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed healt care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to Establishment name use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this City State
form. If you're not sure whether a case is recordable, call your local OSHA office for help.
Identify the person Describe the case Classify the case CHECK ONLY ONE box for each case Enter the number of
(A) (B) (C) (D) (E) (F)
Case Where the event occurred pated on the most serious outcome for days the injured or heck the "Injury" column Employee's name Job title Date of injury Describe injury or illness, parts of body affected, ill worker was: noose one type of illnes (e.g. Welder) (e.g. Loading dock north end) and object/substance that directly injured of illness or made person ill (eg. Second degree burns on Remained at Work (M) Away Onjob
right forearm from acetylene torch) Days away Other record- from transfer or See The Legend Below Sorestato cases
Death from work work restriction
(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)
XXXXX| xXXXX Police Department 03/12/2015 Other/unknown Hemia Abdomen/Groin 0.00 days 0.00 days XXXXX XXXXX Police Department 03/19/2015 Other/unknown Strain Shoulder(s) 0.00 days 0.00 days XXXXX XXXXX Public Works 03/20/2015 Other/unknown Sprain Wrist 0.00 days 11.00 days XXXXX XXXXX Police Department 03/09/2015 Other/unknown Cancer Facial Soft Tissue 0.00 days 13.00 days XXXXX XXXXX Police Department 02/15/2015 Other/unknown Puncture Thumb 0.00 days 0.00 days XXXXX XXXXX Police Department 03/12/2015 FBI Range Foreign Body Eye(s) 0.00 days 0.00 days XXXXX xxxxx Police Department 12/12/2014 Office Contusion Knee 0.00 days 28.00 days Grand Total 0 3 4 0.00 52.00 6 1 0
(1) (2) (3) (4) (5) (6)
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review Be sure to transfer these totals to the Summary page (Form 300A) before you post it. the instructions, search and gather the data needed, complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office Legend: 1- injury 2- Skin disorder 3- Respiratory condition 4 Poisoning 5- Hearing loss 6- All other illness
OSHA's Form 300A
Year
Summary of Work-Related Injuries and Illnesses U.S. Department of Labor Occupational Safety and Health Administration
From approved OMB no. 1218-0176
All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log to very matie emes are compete ana accurate perore complete is summary.
Establishment information
Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from every page of the Log. If you had no cases, write "0". Your establishment name
Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or Street its equivalent. See 29 CFR Part 1094.35, in OSHA's recordkeeping rule, for further details on the access provisions for these forms City State CA _ZIP
Number of Cases Industry description (eg. Manufacture of motor truck trailers) Total number of Total number of Total number of Total number of deaths cases with days cases with job other recordable Standard Industrial Classification (SIC), if known (eg.3715) away from work transfer or restriction cases 9229SC
3 4 OR
(G) (H) (1) (0)
North American Industrial Classification (NAICS), if known (e.g.336212) Number of Days
Employment information (if'you don't have these figures, see the Total number of days away Total number of days of job
Worksheet on the back of this page to estimate.)
from work transfer or restriction
Annuall average number of employees
0.00 52.00
(K) (L) Total hours worked by all employees last year
Injury and Illness Types Sign here
Total number of ... Knowingly falsifying this document may result in a fine. (M)
(1) Injuries (4) Poisonings
(5) Hearing loss
(2) Skin disorders (6) All other illnesses
(3) Respiratory conditions
Company executive Title
Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
Phone Date
Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instructions, scarch and gather the data needed, and complete and review the collection of information. Persons are required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW.
Washington, DC 20210. Do not send the completed forms to this office.
Attention: This form contains information relating to
OSHA's Form 301 employee health and must be used in a manner that protects the confidentiality of employees to the exten
bossible while the information is being used fo U.S. Department of Labor Injury and Illnesses Incident Report occupational safety and health purposes Occupational Safety and Health Administration
For approved OMB no. 1218-0176
Information about the employee Information about the case This Injury and illness Incident Report is one of the xxxxX xXXXX (Transfer she case number from the Log after you record the case.) 1) Full name 10) Case number from the Log
first forms you must fill out when a recordable work- xXXXX 02/15/2015 2) Street 11) Date of injury or illness
related injury or illness has occurred. Together with 6:00 AM XXXXX CA ZIP 92860 12) Time employee began work
the Log of Work-Related Injuries and Illnesses and the State check if time cannot be determined 13) Time of event 6:00 PM
accompanying Summary, these forms help the 3) Date of birth 06/21/1960 employer and OSHA develop a picture of the extent 02/22/1996 4) Date nired
and severity of work-related incidents.
Within 7 calendar days after you receive 5) X Male
information that a recordable work-related injury or •Female illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation,
insurance, or other reports may be acceptable Information about the physician or other health care substitutes. To be considered an equivalent form, professional eveloped soreness in wrist over time. any substitute must contain all the information
asked for on this form. 6) Name of Physicans or other health care professional E was reaching for keys when his left thumb hit a wooden storage box located in his patr ar and he received puncture wound from a splint
According to Public Law 91-596 and 29 CFR Sand Canyon Urgent Care 1904, OSHA's recordkeeping rule, you must keep 7) If treatment was given away from the worksite, where was it given? What was the nur ries ate part of te ady the hasted and or a dece o this form on file for 5 years following the year to
which it pertains. Facility tunnel syndrome."
If you need additional copies of this form, you Street Left Thumb Puncture Wound may photocopy and use as many as you need. City . State ZIP 17) What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; 8) Was employee treated in an emergeney room? "radial arm saw." If this question does not apply to the incident, leave it blank. • Yes N/A
M No
Completed by
9) Was employee hospitalized overnight as an in-patient? Title • Yes 18) If the employee died, when did death occur? Date of death Phone ( Date _'_'-
blic reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to t lection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution A venue, N Washington, DC 20210. Do not send the completed forms to this office.
Attention: This form contains information relating to
OSHA's Form 301 employee health and must be used in a manner that protects the confidentiality of employees to the exten
bossible while the information is being used fo U.S. Department of Labor Injury and Illnesses Incident Report occupational safety and health purposes Occupational Safety and Health Administration
For approved OMB no. 1218-0176
Information about the employee Information about the case This Injury and illness Incident Report is one of the xXXXX xxxxX (Transfer she case number from the Log after you record the case.) 1) Full name 10) Case number from the Log
first forms you must fill out when a recordable work- xXXXX 03/19/2015 2) Street 11) Date of injury or illness
related injury or illness has occurred. Together with 6:00 AM XXXXX CA ZIP 92705 12) Time employee began work
the Log of Work-Related Injuries and Illnesses and the State check if time cannot be determined 13) Time of event 1:13 PM
accompanying Summary, these forms help the 3) Date of birth 04/27/1979 employer and OSHA develop a picture of the extent 12127/1999 4) Date nired
and severity of work-related incidents.
Within 7 calendar days after you receive 5) X Male
information that a recordable work-related injury or •Female illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation,
insurance, or other reports may be acceptable Information about the physician or other health care * What repo reta a de are ceral me retraced on at her, marke substitutes. To be considered an equivalent form, professional leveloped soreness in wrist over time." any substitute must contain all the information
6) Name of Physicans or other health care professional While struggling with a combative mental health patient, he injured his left shoulder asked for on this form.
According to Public Law 91-596 and 29 CFR Sand Canyon Urgent Care 1904, OSHA's recordkeeping rule, you must keep 7) If treatment was given away from the worksite, where was it given? What was the nur ries ate part of te ady the hasted and or a dece o this form on file for 5 years following the year to
Facility tunnel syndrome."
which it pertains.
If you need additional copies of this form, you Street Left shoulder strain may photocopy and use as many as you need. City . State ZIP 17) What object or substance directly harmed the employee? Examples: "conerete floor"; "chlorine"; 8) Was employee treated in an emergeney room? "radial arm saw." If this question does not apply to the incident, leave it blank. • Yes N/A
M No
Completed by
9) Was employee hospitalized overnight as an in-patient? Title • Yes 18) If the employee died, when did death occur? Date of death Phone ( Date _'_'-
ablic reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, scarching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to 1l lection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, N' Washington, DC 20210. Do not send the completed forms to this office.
WORKERS' COMPENSATION CLAIMS
CLIENT COMPARISON REPORT AS
OF
#of Total Paid Outstanding Outstanding Reserves Total Incurred in Q1 2015 #of # of Open Client Employees This Quarter Reserves Per Total # of Employees Total Pd Q1 + Outstanding Open Claims Litigated Claims Client X 2,986 $920,366.80 $10,026,752.09 $3,357.92 $10,947,118.89 191 59 Client Y 4,623 $988,715.96 $13,758,746.45 $2,976.15 $14,747,462.41 231 80 AVERAGES 3,805 $954,541.38 $11,892,749.27 $3,167.04 $12,847,290.65 211 70 Prepared by AdminSure Page 1 of 1
WORKERS' COMPENSATION CLAIMS
FREQUENCY & SEVERITY BY NATURE OF INJURY
TOP TEN LISTED BY FREQUENCY
as of
Client X Client Y
#of Total Average Per #of Total Average Per
Nature of Injury Claims Incurred Claim Nature of Injury Claims Incurred Claim Strain 88 $9,244, 148.00 $114,620.00 Strain 94 $14,197,761.00 $151,040.00 Miscellaneous 24 $731,037.00 $30,460.00 Miscellaneous 36 $1,902,197.00 $52,839.00 Sprain 20 $2,079,150.00 $103,957.00 All Other Cumulative Trauma 25 $4,789,022.00 $191,561.00 All Other Cumulative Trauma $1,464,653.00 $112,666.00 Sprain 20 $1,504,961.00 $75,248.00 Contusion 12 $3,023,302.00 $251,942.00 Contusion 19 $2,104,025.00 $110,738.00 Fracture 8 $531,734.00 $66,467.00 Carpal Tunnel Syndrome 10 $571,972.00 $57,197.00 Multi Physical Injuries 6 $481,307.00 $80,218.00 Fracture $597,706.00 $85,387.00 Mental Stress 6 $123,189.00 $20,531.00 Multi Physical/Mental injuries 5 $470,084.00 $94,017.00 All Other Specific Injury 4 $62,769.00 $15,692.00 Mental Stress 4 $1,171,495.00 $292,874.00 Puncture 2 $200,934.00 $100,467.00 Contagious Disease 3 $264,424.00 $88,141.00 TOTAL 183 $17,942,223.00 $897,020.00 TOTAL 223 $27,573,647.00 $1,199,042.00
CLAIMS HANDLING ANALYSIS
# OF CLAIMS REPORTED PER YEAR
2010 2011 2012 2013 2014 2015
Future Medical 13 15 13 9 1
Indemnity 49 59 45 60 65 9
Medical Only 66 60 15
TOTAL 132 140 118 129 126 24
#OF LITIGATED CLAIMS
2010 2011 2012 2013 2014 2015
TOTAL 2 20 8 18 7
DAYS FROM EMPLOYEE'S INJURY TO DATE EMPLOYER NOTIFIED
2010 2011 2012 2013 2014 2015
Average Lag Time 9.38 94.23 18.77 23.39 58.61 12.17
DAYS FROM EMPLOYERS DATE OF KNOWLEDGE TO DATE REPORTED TO TPA 2010 2011 2012 2013 2014 2015
Average Lag Time 6.75 58.82 15.98 8.14 11.18 9.67
AVERAGE DAYS OPEN PER CLAM
2010 2011 2012 2013 2014 2015
Future Medical 1279 1203 967 614 434 37
Indemnity 432 460 481 338 205 39
Medical Only 78 97 54 71 78 38
Litigated 1663 1012 1064 619 351
AVERAGE # OF DAYS LOST PER CLAM
2010 2011 2012 2013 2014 2015
Future Medical 99 274 65 15
Indemnity 67 49 74 55 33 9
Medical Only
Litigated 122 299 304 136 43
Data Valued as of
Prepared by AdminSure Page 1 of 1
CLAIM RATIOS
RATIO OF MEDICAL ONLY CLAIMS TO INDEMNITY CLAIMS
2010 2011 | 2012 % 2013 % 2014 % _ 2015 %
Medical Only 70 66 -6% 60 -9% 60 0% 60 0% 15 -75%
Indemnity 49 59 20% 45 -24% 60 33% 65 8% 9 -86%
TOTAL 119 125 105 120 125 24
RATIO OF LITIGATED TO NON-LITIGATED CLAIMS
2010 2011 2012 % 2013 % 2014 % 2015 %
Litigated 2 20 900% 8 -60% 18 125% -61% - 100%
Non-Litigated 130 120 -8% 110 -8% 111 1% 119 7% 24 -80% TOTAL 132 140 118 129 126
RATIO OF FUTURE MEDICAL TO NON-FUTURE MEDICAL CLAIMS
2010 2011 % | 2012 % 2013 % 2014 % 2015 %
Future Medical 13 15 15% 13 -13% 9 -31% 1 -89% - 100%
Non-Future Medical 119 125 5% 105 -16% 120 14% 125 4% 24 -81% TOTAL 132 140 118 129 126
RATIO OF OPEN TO CLOSED CLAIMS
2010 2011 % | 2012 % 2013 % 2014 % 2015 %
OPEN 7 13 86% 27 108% 30 11% 39 30% 18 -54%
CLOSED 125 127 2% 91 -28% 99 9% 87 -12% 6 -93%
TOTAL 132 140 118 129 126 24
Prepared by AdminSure Data Valued as of Page 1 of 1
CLIENT X
AVERAGE CLAIM COSTS
AVERAGE COST PER CLAIM PER YEAR - MEDICAL ONLY
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $820.75 $834.81 2% $662.51 $924.85 40% $1,154.63 25% | $1,266.40 10% Temporary Disability $0.00 $0.00 0% $0.00 $0.00 0% $0.00 0% $17.15 Permanent Disability $0.00 $0.00 0% $0.00 $0.00 0% $23.00 0% $0.00 Voc Rehab $0.00 $0.00 0% $0.00 $0.00 0% $0.00 0% $0.00 0% Other Indem $0.00 $0.00 0% $0.00 $0.00 0% $0.00 0% $0.00 0% Legal $0.00 $0.00 0% $0.00 0% $0.00 0% $0.00 0% $0.00 0% Other $10.39 $23.01 0% $2.43 0% $48.84 1910% $317.21 0% $134.58 -58% TOTAL $831.14 $857.82 3% $664.94 -22% $973.69 46% | $1,494.84 54% |$1,418.13| -5%
AVERAGE COST PER CLAIM PER YEAR - INDEMNITY
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $6,030.82 $14,747.98 145%| $24,543.37 66% $17,994.69 -27% $13,153.71 -27% $4,988.17 -62% Temporary Disability $3,668.03 $4,638.96 26% $6,747.29 45% $8,063.74 20% $4,622.25 43% $1,187.92 -74% Permanent Disability $2,450.32 $2,932.67 20% $4,926.23 68% $5,437.97 10% $2,272.97 -58% $0.00 - 100% Voc Rehab $275.76 $376.84 37% $761.14 102% $532.08 -30% $223.08 -58% $0.00 -100% Other Indem $372.41 $561.43 51% $265.00 -53% $1,014.48 283% $384.82 -62% $0.00 -100% Legal $608.21 $2.569.56 322% $2,378.80 -7% $3,271.26 38% $1,380.52 -58% $0.00 -100% Other $1,473.05 $2.344.97 59% $3,314.84 41% $4,270.26 29% $2,747.17 -36% $900.85 -67% TOTAL $14,878.60|$28,172.41 89% $42,936.67 52% $40,584.48 -5% | $24,784.52| -39% | $7,076.94 -71%
AVERAGE COST PER CLAIM PER YEAR - FUTURE MEDICAL
2010 2011 % 2012 % 2013 % 2014 %
Medical $31,927.33 $20,616.91 -35% $29,596.32 44% $21,682.14 -27% $18,000.00 -17% Temporary Disability $10,049.74 $3,707.97 63% $6,302.72 70% $1,091.19 -83% $0.00 Permanent Disability $10,934.61 $6,480.68 41% $5,824.81 -10% $542.35 -91% $0.00 Voc Rehab $810.35 $0.00 - 100% $1,017.63 -5% $0.00 0% $0.00 Other Indem $514.27 $975.30 90% $964.14 - 1% $0.00 0% $0.00 Legal $1,884.64 $3,922.62 108% $2,562.18 -35% $0.00 0% $0.00 Other $4,113.53 $4,077.15 -1% $4,552.03 12% $2,719.67 -40% $3,600.00 TOTAL $60,234.47 $39,780.63 -34% $50,819.83 28% $26,035.35-49% $21,600.00-17% -100% Prepared by AdminSure Data Valued as of Page 1 of 2
AVERAGE CLAIM COSTS
AVERAGE COST PER CLAIM PER YEAR - LITIGATED
2010 2011 % 2012 % 2013 % 2014 % 2015
Medical $50,634.41|$42,421.63-16% $101,044.34 138% | $39,654.15 -61% $25,818.39 -35% $0.00 LL-100% Temporary Disability $12,725.85 $10,973.56-14% $28,670.94 161% $20,160.95 -30% $7,953.51 -61% $0.00 L-100% Permanent Disability $11.962.68 $11,558.06 -3% $23,627.14 104% $15,303.58 -35% $10,416.74 -32% $0.00 1-100% Voc Rehab $2.279.05 $1,105.63 -51% $5,828.87 427% $1,713.85 -71% $1,714.29 0% $0.00 -100% Other Indem $3,157.66 $2,332.68 -26% $2,567.22 10% $3,338.43 30% $1,744.57 48% $0.00 - 100% Legal $14,750.14 $9,402.56 -36% $14,620.26 55% $10,618.56 -27% $9,247.69 -13% $0.00 -100% Other $12,074.76 $6,794.71 44% $12,836.64 89% $10,919.29 -15% $8,583.62 -21% $0.00 L-100% TOTAL $107,584.55| $84,588.83-21% -21%$189,195.41 124% $101,708.81 -46% $65,478.81 -36% $0.00 1-100%
AVERAGE COST PER CLAIM PER YEAR - CLOSED
2010 2011 % 2012 % 2013 % 2014 % 2015 %
Medical $2,272.59 $2,100.43 -8% $1,130.23 -46% $1,740.15 54% $872.71 -50% $548.25 -37% Temporary Disability $1,428.07 $567.07 -60% $336.43 -41% $743.19 121% $487.90 -34% $4.91 -99% Permanent Disability $728.58 $341.90 -53% $130.17 -62% $62.72 -52% $205.71 228% $0.00 -100% Voc Rehab $50.09 $0.95 0% $0.00 -100% $10.87 #DIV/O! $0.00 0% $0.00 0% Other Indem $92.50 $53.92 42% $0.00 -100% $27.39 #DIV/O! $34.48 0% $0.00 0% Legal $170.42 $493.32 189% $99.82 -80% $151.48 52% $94.13 0% $0.00 0% Other $397.99 $377.22 -5% $177.06 -53% $411.23 132% $400.00 -3% $116.70 -71% TOTAL $5,140.24 $3,934.81 -23% $1,873.71 -52% $3,147.03 68% $2,094.93 -33% $669.86 -68% Prepared by AdminSure Data Valued as of Page 2 of 2
Cost of All Claims
$900,000
$844,949
$800,000 $764,843
$700,000
$600,000
$500,000
$414,200
$400,000
$300,000
$200,000
$100,000
$0
• FY XX • FY XX • FY XX
Measures the total liability of claims. This number indicates how well Client is at controlling costs through reduced claims, return to work, and claim closure. This number will directly correlate to increases in annual deposits that must be paid. The lower the number the better.
Prepared by AdminSure Valued as of
COST OF ALL CLAIMS YTD Comparison
DECEMBER 20XX $72,000
• FY XXXX • FY XXXX • FY XXXX
$60,738 $63,735 $70,000
$68,000
$48,932
$66,000
$64,000
$62,000
$60,000
$10,013
$7,045
$2,507 $2,471 $58,000
$1,748 $725 $346 $941
FUTURE MEDICAL INDEMNITY INDEMNITY/FUTURE MEDICAL ONLY $56,000
MEDICAL FY XXXX FY XXXX FY XXXX
1470 South Valley Vista Drive, Suite 230
Diamond Bar, California 91765
Admin Sure Telephone (909) 861-0816
Fax (909) 860-3995
BATCH PAY SAMPLE CHECK
Employer Client Name Payee Name MedReview Inc.
Check Number 81468 Payee Address Post Office Box 5108
Check Date 04/09/20XX Diamond Bar CA 91765
Claimant Name Incident Date Claim Number From Through Description Document # Amount xXXXX 03/25/2015 15-122054 03/25/2015 03/25/2015 Medical Review 413197P 3.90 XXXXX 03/25/2015 15-122054 03/25/2015 03/25/2015 Medical Review 4131970 21.67 XXXXX 12/05/2014 14-121177 03/16/2015 03/16/2015 Medical Review 413198F 4.33 XXXXX 12/05/2014 14-121177 03/16/2015 03/16/2015 Medical Review 413198P 0.95 XXXXX 12/05/2014 14-121177 03/16/2015 03/16/2015 Medical Review 4131980 6.50 Number of Claims: 2 Check Total: 5 37.35
CLIENT NAME BANK OF AMERICA CHECK
16-66 81468
22 North Catalina Avenu 1220
Workers' Compensation Redondo Beach, CA 9027 NUMBER
Administered by AdminSure (909) 861-0816 DATE AMOUNT
**********37.35
PAY Thirty Seven Dollars And 35/100
TO MedReview Inc.
THE Post Office Box 5108
ORDER
OF Diamond Bar, CA 91765
THIS CHECK EXPIRES AND IS VOID
90 DAYS FROM CHECK DATE
BATCH PAY SAMPLE REPORT
Workers' Compensation Claims Check Register
For Month Ending XXXXXX
Number Date Amount Payee Description Claimant Code Claim Number 81468 04/09/2015 0.95 MedReview Inc. Medical Review Services XXXXX L0054 xXXXX 81468 04/09/2015 3.90 MedReview Inc. Medical Review Services XXXXX L0060 XXXXX 81468 04/09/2015 4.33 MedReview Inc. Medical Review Services XXXXX L0054 XXXXX 81468 04/09/2015 6.50 MedReview Inc. Medical Review Services XXXXX L0054 XXXXX 81468 04/09/2015 21.67 MedReview Inc. Medical Review Services XXXXX L0060 XXXXX Grand Total: 5 37.35
Prepared by AdminSure Page 1 of 1
City of X
Workers' Compensation Analytics
Admin Sure
TABLE OF CONTENTS
Page Page
2 - Five-Year New Claims Opened 25 - Five-Year Claim Distribution by Top 10 Nature of Injury (Bar) 3 - Five-Year New Claims Opened and Claims Closed 26 - Five-Year Claim Distribution by Top 10 Nature of Injury (Pie) 4 - Percentage of New Claims Opened - Indemnity 27 - Claim Distribution by Nature of Injury Reference 5 - Average Cost Per New Claim Added by Department 28 - Five-Year Claim Distribution by Top 10 Body Part (Bar) 6 - Police, Five-Year New Claims Opened by Claim Type 29 - Five-Year Claim Distribution by Top 10 Body Part (Pie) 7 - Fire, Five -Year Claims Opened by Claim Type 30 - Claim Distribution by Body Part Reference 8 - All Other Departments, Five-Year Claims Opened by Claim Type 31 - Modified Duty Days - All Departments 9 - Police, Total Incurred = Paid & Reserved 32 - Modified Duty Days - Safety (Police & Fire) 10 - Fire, Total Incurred = Paid & Reserved 33 - Modified Duty Days - None-Safety 11 - All Other Departments, Total Incurred = Paid & Reserved 34 - Metrics 12 - Citywide, Total Incurred = Paid & Reserved 35 - *Comparisons - Percentage of New Claims Added 13 - Police, Stratification Loss 36 - *Comparisons - Closing Ratio 14 - Fire, Stratification Loss 37 - *Comparisons - Frequency Rate (Per 100 Employees) 15 - All Other Departments, Stratification Loss 38 - *Comparisons - Percentage of Annual Medical Only Claims 16 - All Departments, Litigated Claims 39 - *Comparisons - Percentage Litigated for New Claims Added 17 - Safety (Police & Fire) Litigated Claims 40 - *Comparisons - Percentage of Total Paid (All Claims) 18 - Non-Safety Litigated Claims
19 - All Departments, Litigated Expenses vs. Total Paid 20 - Five-Year Top 10 New Claim Distribution by Department (Bar) 21 - Five-Year Top 10 New Claim Distribution by Department (Pie) 22 - Five-Year Claim Distribution by Top 10 Cause of Loss (Bar) 23 - Five-Year Claim Distribution by Top 10 Cause of Loss (Pie) 24 - Claim Distribution by Cause of Loss Reference
2 CITY OF *Sample*
5YR NEW CLAIMS OPENED
FISCAL YEARS 2014/2015 THROUGH 2018/2019
300 300
5yr Average
280 265.0 280
260 260
240 240
220 220
200 200
180 165 180 ur
160 144
CLAIMS 140
125 122
115
120
100 92
77 84 80 82
80 80
60 60 51 60
45 43, 40
40 45 42 44 144 40
20 23 20
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
Police 77 84 80 92 82
Fire 45 60 51 43 40
All Other 144 165 115 125 122
Total Claims 266 309 246 260 244
- - 5yr Average 270.3 270.3 270.3 270.3 265.0
- Litigated 45 42 44 44 23
3 CITY OF *Sample*
5YR NEW CLAIMS OPENED AND CLAIMS CLOSED
FISCAL YEARS 2014/2015 THROUGH 2018/2019
850
800
750
700
650
600
550
500
450
400
350
300
250
200
150
100
50 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
• Claims Opened 266 309 246 260 244
• Claims Closed 303 327 255 238 260
• Open Claim Inventory 698 680 708 765 780
4 CITY OF *Sample*
PERCENTAGE OF NEW CLAIMS OPENED - INDEMNITY
VALUATION DATE 6-30-2019
250
225
200
175
150 50%
125 52% 42% 41%
43%
100
75 23% 22%
18% 25% 22%
50 25 30% 27% 34% 38% 35%
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
Total Claims
172 202 154 153 143
Indemnity
• All Other 90 101 64 62 61
• Fire 31 46 38 33 32
• Police 51 55 52 58 50
5 CITY OF *Sample*
AVERAGE COST PER NEW CLAIM ADDED BY DEPARTMENT
VALUATION DATE 6-30-2019
$150,000
$140,000
$130,000
$120,000
$110,000
$100,000
$90,000
$80,000
AVERAGE COST PER CLAIM
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$-
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
• Police Average $122,394 $92,672 $65,493 $52,866 $26,282 • Fire Average $80,905 $56,425 $39,036 $61,357 $27,054
•All Other Average $50,450 $37,853 $25,453 $36,093 $17,908 6 CITY OF *Sample* - POLICE DEPARTMENT
5YR NEW CLAIMS OPENED BY CLAIM TYPE
FY 2014/2015 THROUGH 2018/2019
100
90 8%
80 1%
25% 18%
70 37%
30% 39%
60 50 35%
35%
40 34%
30 55% 60%
20 48%
40%
36%
10 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
• Police - FM, Indem / FM, FM-Lim 23 21 14 7 1
• Police - Medical Only 26 29 28 34 32
• Police - Indemnity 28 34 38 51 49
Total New Claims Reported (Police) 77 84 80 92 82
Total New Reportable Claims (Citywide) 266 309 246 260 244 Police to Citywide Ratio 29% 27% 33% 35% 34%
7 CITY OF *Sample* - FIRE DEPARTMENT
5YR NEW CLAIMS OPENED BY CLAIM TYPE
FY 2014/2015 THROUGH 2018/2019
100
90 80
70 60
25%
50 25%
40 7%
29% 23%
23% 20%
30 25%
31%
20 52% 70% 80%
49%
10 40%
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
1 Fire - FM, Indem / FM, FM-Lim 13 15 13
• Fire - Medical Only 14 14 13 10 8
• Fire - Indemnity 18 31 25 30 32
Total New Claims Reported (Fire) 45 60 43
Total New Reportable Claims (Citywide) 266 309 246 260 244 Fire to Citywide Ratio 17% 19% 21% 17% 16%
8 CITY OF *Sample* - ALL OTHER DEPARTMENTS
5YR NEW CLAIMS OPENED BY CLAIM TYPE
FY 2014/2015 THROUGH 2018/2019
200
190
180
170
160
10%
150
140
13%
130
120 6%
39% 4%
110
100 38%
90 50%
44% 50%
80 70
60 50
40 52%
49%
30 51% 44% 50%
20 10
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
•All Others - FM, Indem / FM, FM-Lim 19 16 5
• All Others - Medical Only 54 64 51 63 61
• All Others - Indemnity 71 85 59 55 61
Total New Claims Reported (All Others) 144 165 115 125 122 Total New Reportable Claims (Citywide) 266 309 246 260 244 All Others to Citywide Ratio 54% 53% 47% 48% 50%
CITY OF *Sample* - POLICE DEPARTMENT
TOTAL INCURRED = PAID & RESERVED
VALUATION DATE 6-30-2019
$6,500,000
$6,000,000
$5,500,000
$5,000,000
$4,500,000
$4,000,000
$3,500,000
TOTAL INCURRED
$3,000,000
$2,500,000
$2,000,000
$1,500,000
$1,000,000
$500,000
$0
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
Police Total Incurred $6,265,133 $5,121,084 $3,428,430 $3,112,014 $1,373,290 • Police Total Reserved $2,458,743 $1,642,353 $1,085,825 $1,109,358 $883,466 • Police Total Paid $3,806,390 $3,478,731 $2,342,605 $2,002,657 $489,824 10 CITY OF *Sample* - FIRE DEPARTMENT
TOTAL INCURRED = PAID & RESERVED
VALUATION DATE 6-30-2019
$3,000,000
$2,750,000
$2,500,000
$2,250,000
$2,000,000
$1,750,000
TOTAL INCURRED $1,500,000
$1,250,000
$1,000,000
$750,000
$500,000
$250,000
$0 2014/2015
2015/2016 2016/2017 2017/2018 2018/2019
Fire Total Incurred $2,512,519 $2,610,898 $1,490,837 $2,029,266 $883,872 • Fire Total Reserved $368,209 $1,200,115 $582,820 $693,276 $597,587 • Fire Total Paid $2,144,310 $1,410,783 $908,016 $1,335,990 $286,285 11 CITY OF *Sample* - ALL OTHER DEPARTMENTS
TOTAL INCURRED = PAID & RESERVED
VALUATION DATE 6-30-2019
$5,000,000
$4,500,000
$4,000,000
$3,500,000
$3,000,000
TOTAL INCURRED $2,500,000
$2,000,000
$1,500,000
$1,000,000
$500,000
$0
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
All Other Total Incurred $4,602,051 $3,892,601 $1,665,576 $2,302,951 $1,180,543 • All Other Total Reserved $1,430,092 $1,136,674 $753,107 $1,010,315 $896,314 • All Other Total Paid $3,171,959 $2,755,927 $912,469 $1,292,636 $284,230 12 CITY OF *Sample* - CITYWIDE
TOTAL INCURRED = PAID & RESERVED
VALUATION DATE 6-30-2019
$15,000,000
$14,000,000
$13,000,000
$12,000,000
$11,000,000
$10,000,000
$9,000,000
$8,000,000
TOTAL INCURRED
$7,000,000
$6,000,000
$5,000,000
$4,000,000
$3,000,000
$2,000,000
$1,000,000
$0
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
Citywide Total Incurred $13,379,703 $11,624,582 $6,584,844 $7,444,231 $3,437,705 • Citywide Total Reserved $4,257,044 $3,979,141 $2,421,753 $2,812,948 $2,377,367 • Citywide Total Paid $9,122,659 $7,645,440 $4,163,090 $4,631,283 $1,060,338 13 CITY OF *Sample*
STRATIFICATION LOSS - POLICE DEPARTMENT
VALUATION DATE 06-30-2019
$20,000,000 415
$19,299,951
$18,000,000
$16,000,000
$14,000,000
$12,000,000
$10,000,000
53 28 16
$8,000,000 $4,722,834 $5,697,398
$5,219,889
77 $6,000,000 84 317
$2,216,971 1
$4,000,000 80 92 $1,442,860
$2,000,000 82 > 8 6
7574 14 11 11 10
50 59 59 1 21
$0
Police Total Incurred Sum of 0-50K Sum of 50-150K Sum of 150-250K Sum of 250-500K Sum of > 500K GRAND TOTALS $19,299,951 $2,216,971 $4,722,834 $5,219,889 $5,697,398 $1,442,860 • 2014/2015 $6,265,133 $120,940 $1,090,293 $1,217,900 $2,393,140 $1,442,860 • 2015/2016 $5,121,084 $328,383 $1,081,632 $1,297,701 $2,413,368 $0 • 2016/2017 $3,428,430 $339,159 $961,869 $1,507,471 $619,932 $0 • 2017/2018 $3,112,014 $779,357 $1,031,376 $1,030,323 $270,958 $0 2018/2019 $1,373,290 $649,132 $557,664 $166,494 $0 $0
14 CITY OF *Sample*
STRATIFICATION LOSS - FIRE DEPARTMENT
VALUATION DATE 06-30-2019
$10,000,000
239
$9,000,000 $9,527,391
$8,000,000
$7,000,000
$6,000,000
46 $4,394,740
INCURRED $5,000,000
$4,000,000 15
$2,757,908
176
$3,000,000 45 60 $1,582,058
43 $2,000,000 1
51 12 1
6 5 $271,554
40 10 10 $521,131
$1,000,000 8 3
30 43 40 29 34 1
1 / 1
$0 Sum of 0-50k
Fire Total Incurred Sum of 50-150K Sum of 150-250K Sum of 250-500K Sum of > 500K GRAND TOTALS $9,527,391 $1,582,058 $4,394,740 $2,757,908 $271,554 $521,131 • 2014/2015 $2,512,519 $185,431 $754,216 $1,051,740 $0 $521,131 • 2015/2016 $2,610,898 $331,227 $1,309,234 $970,436 $0
• 2016/2017 $1,490,837 $425,667 $913,252 $151,918 $0 $0 • 2017/2018 $2,029,266 $237,860 $936,039 $583,813 $271,554 $0 • 2018/2019 $883,872 $401,873 $481,999 $0 $0 $0
15 CITY OF *Sample*
STRATIFICATION LOSS - ALL OTHER DEPARTMENTS
VALUATION DATE 06-30-2019
$15,000,000
671
$14,000,000 / $13,643,723
$13,000,000
$12,000,000
$11,000,000
$10,000,000
$9,000,000
$8,000,000 61
IRRED $7,000,000 $5,710,306
$6,000,000 593
INCU $3,778,375
$5,000,000 144
• 165 11
$4,000,000 52002,174
$2,153,867
$3,000,000 125
115 18 21
$2,000,000 122 139 111 12 4
118 107 118 4 2
$1,000,000 6 4 3 2 2
$0
All Other Total Sum of 50-150K
Sum of 0-50K Sum of 150-250K Sum of 250-500K Sum of > 500K Incurred
I GRAND TOTALS $13,643,723 $3,778,375 $5,710,306 $2,153,867 $2,001,174 $0 • 2014/2015 $4,602,051 $729,530 $1,834,676 $780,249 $1,257,595 • 2015/2016 $3,892,601 $675,297 $1,903,776 $569,949 $743,579 $0 • 2016/2017 $1,665,576 $739,899 $488,012 $437,665 $0
• 2017/2018 $2,302,951 $789,486 $1,147,462 $366,004
2018/2019 $1,180,543 $844,163 $336,380 $0 $0 $0
16 CITY OF *Sample* - ALL DEPARTMENTS
LITIGATED CLAIMS
FISCAL YEARS 2014/2015 TO 2018/2019
500
450
400
350
300
250
200
150
100
16.92% 13.59% 17.89% 16.92% 9.43%
50 - Litigated • Litigated • Litigated - Litigated - Litigated 45 42 44 44 23
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
• Total Number of Claims 266 309 246 260 244
• Litigated 45 42 44 44 23
% Litigated 16.92% 13.59% 17.89% 16.92% 9.43%
17 CITY OF *Sample* - SAFETY (POLICE & FIRE)
LITIGATED CLAIMS
FISCAL YEARS 2014/2015 TO 2018/2019
500
450
400
350
300
250
200
150
100
22.13% 19.85% 20.00% 8.20%
50 18.75%
- Litigated - Litigated - Litigated - Litigated
- Litigated
27 26 27 10
27 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
• Total Number of Claims 122 144 131 135 122
• Litigated 27 27 26 27 10
% Litigated 22.13% 18.75% 19.85% 20.00% 8.20%
18 CITY OF *Sample* - NON-SAFETY
LITIGATED CLAIMS
FISCAL YEARS 2014/2015 TO 2018/2019
500
450
400
350
300
250
200
150
100
12.50% 9.09% 13.60% 10.66%
15.65%
50 - Litigated Litigated - Litigated
• Litigated - Litigated
18 15 18 17 13
2014/2015 2015/2016 2016/2017 2017/2018 2018/2019
• Total Number of Claims 144 165 115 125 122
• Litigated 18 15 18 17 13
% Litigated 12.50% 9.09% 15.65% 13.60% 10.66%
19 CITY OF *Sample* - ALL DEPARTMENTS
LITIGATED EXPENSES vs TOTAL PAID
CLAIMS OPENED FY 14/15 TO 18/19 - VALUED AS OF 6-30-2019 12%
10%
8%
% LEGAL EXPENSE vs TOTAL PAID 6%
4%
2%
0%
2014/2015 Total 2015/2016 Total 2016/2017 Total 2017/2018 Total 2018/2019 Total • % Legal 4.48% 6.45% 10.15% 5.62% 5.26%
LEGAL $408,473.06 $493,458.30 $422,366.58 $260,051.44 $55,786.04 TOTAL PAID $9,122,658.72 $7,645,440.48 $4,163,090.41 $4,631,283.30 $1,060,338.49 20 CITY OF *Sample* WORKERS' COMPENSATION
5YR TOP 10 NEW CLAIM DISTRIBUTION BY DEPARTMENT
FY 2014/2015 THROUGH 2018/2019
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Human
Planning Information Health Water & Water & Water &
Services & Public Works Fire Police
Department Services Department Recreation Power - Admin Power - Water Power - Power •% Claims 1.74% 1.81% 3.32% 3.77% 3.85% 5.74% 7.40% 16.23% 18.04% 31.32% •% Incurred 2.35% 0.88% 2.38% 0.67% 2.11% 2.43% 7.26% 10.39% 22.43% 45.44% 21 CITY OF *Sample* WORKERS' COMPENSATION
5YR TOP 10 NEW CLAIM DISTRIBUTION BY DEPARTMENT
FY 2014/2015 THROUGH 2018/2019
Water & Power - Power; 7%
Water & Power - Water
76 Public Works
Water & Power - Admin 215
All Other 51
Departments
7% Human Services & Recreation
Health Department
44 Top 10 Departments
Information Services
93%
24 Fire
239
Planning Department_
23 Police
415
22 CITY OF *Sample* WORKERS' COMPENSATION
5YR CLAIM DISTRIBUTION BY TOP 10 CAUSE OF LOSS
FY 2014/2015 THROUGH 2018/2019
30.00%
28.00%
26.00%
24.00%
22.00%
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Fall from Robbery / Other than
Exposure / Fall on Pushing or Repetitive Cumulative
Different Twisting Assault / Physical Lifting Motion
Contact Same Level Pulling Trauma
Level Other Crime Cause
•% Claims 2.26% 3.17% 3.32% 3.77% 4.23% 4.60% 6.49% 7.32% 12.83% 13.36% •% Incurred 3.18% 1.10% 4.45% 3.97% 5.77% 3.76% 4.55% 9.74% 14.65% 26.15% 23 CITY OF *Sample* WORKERS' COMPENSATION
5YR CLAIM DISTRIBUTION BY TOP 10 CAUSE OF LOSS
FY 2014/2015 THROUGH 2018/2019
Other than Physical Cause
7% Lifting
97 Robbery / Assault / Other Crime
61 Pushing or Pulling
56 etitive Motion
All Other Claim Causes Top 10 Cause of Loss 170
39% 61% Fall on Same Level
50 Twisting
44 Exposure / Contact
42 Cumulative Trauma
Fall from Different Level 177
30 24
CLAIM DISTRIBUTION BY CAUSE OF LOSS REFERENCE
VALUATION DATE 6-30-2019
Cause Description Claims Total Incurred Avg/Claim Cause Description Claims Total Incurred Avg/Claim Abnormal Air Pressure Exposure 1 $69,410 $69,410 Reaching 12 $242,973 $20,248 Fire / Flame Contact 1 $2,335 $2,335 Hit by Falling / Flying Object 13 $111,663 $8,589 Hit by Explosion / Flareback 1 $966 $966 , Abrasive Repetitive Motion 14 $403,732 $28,838 Hot Object / Substance Contact 1 $800 $800 Absorbed / Ingested / Inhaled 14 $121,166 $8,655 Caught in Machine 2 $979 $489 Caught in Handled Object 14 $67,445 $4,817 Cut / Scraped by Hand Tool $236 $118 Climbing 14 $540,191 $38,585 2 $3,950 $1,975 Hit by Miscellaneous Object 14 $371,716 $26,551 Fall from Ladder / Scaffolding
Multi-Vehicle Accident 14 $1,677,423 $119,816
Hit by Moving Parts / Machine $35,944 $17,972
Struck Stationary Object 14 $58,093 $4,150
Hit by Object Handled by Other 2 $80,438 $40,219
Hot Fluid / Steam Contact $1,266 Bending / Stooping 15 $266,115 $17,741 2 $633
Dust / Gas / Fume / Vapor Exposure 15 $24,739 $1,649
Vehicle hit Fixed Object 2 $392,043 $196,022
Foreign Matter / Object in Eye 16 $32,771 $2,048
Continual Noise 3 $26,517 $8,839
Trip did not fall 16 $261,332 $16,333
Fall into Opening 3 $14,176 $4,725
Holding or Carrying 18 $902,784 $50,155
Struck / Stepped on Sharp Object 3 $3,378 $1,126
Running 19 $191,671 $10,088
Struck Moving Parts of Machine 4 $33,363 $8,341
Slip did not fall 19 $519,832 $27,360
Cut / Scraped by Broken Glass 5 $5,353 $1,071
Using Tool or Machine 22 $705,798 $32,082
Cut / Scraped by Powered Tool 5 $3,386 $677
Hit / Injured by Animal / Insect 23 $19,542 $850
Extreme Temperature Exposure 5 $11,771 $2,354
Cut / Scraped by Other Object 27 $60,026 $2,223
Struck Miscellaneous Object 5 $149,831 $29,966
Hit by Handled Object 27 $249,053 $9,224
Fall on Slippery Substance 6 $192,439 $32,073
Miscellaneous Fall or Slip 29 $362,002 $12,483
Struck Handled / Lifted Object 6 $8,049 $1,342
Fall from Different Level 30 $1,352,057 $45,069
Vehicle Accident 6 $321,209 $53,535 Exposure / Contact 42 $466,592 $11,109
Caught by Miscellaneous Object 7 $103,619 $14,803 44 $1,889,636 Twisting $42,946
Strain 7 $41,450 $5,921 Fall on Same Level 50 $1,684,917 $33,698 Hit by Hand Tool / Machine 8 $5,937 $742 Pushing or Pulling 56 $2,448,577 $43,725 Hit by Co-Worker / Patient $159,203 $17,689 Robbery / Assault / Other Crime 61 $1,595,643 $26,158 Hit by Motor Vehicle 10 $210,335 $21,033 Other than Physical Cause 86 $1,930,650 $22,449 Jumping 10 $444,269 $44,427 Lifting 97 $4,136,148 $42,641 Fall on Stairs 11 $29,582 $2,689 Repetitive Motion 170 $6,221,434 $36,597 Cut / Scraped by Handled Object 12 $98,729 $8,227 Cumulative Trauma 177 $11,104,381 $62,737 GRAND TOTALS Claims: 1325 Incurred: $42,471,065 Average: $32,053.63 25 CITY OF *Sample* WORKERS' COMPENSATION
5YR CLAIM DISTRIBUTION BY TOP 10 NATURE OF INJURY
FY 2014/2015 THROUGH 2018/2019
60.00%
55.00%
50.00%
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
All Other
Mental No Physical Nature of
Foreign Body Puncture Inflammation Unknown Laceration Contusion Sprain Strain Stress Injury Injuries
•% Claims 1.58% 1.96% 2.04% 2.26% 3.40% 5.13% 5.36% 8.15% 15.85% 39.09% 15.17% •% Incurred 1.51% 0.24% 0.29% 1.09% 0.32% 2.84% 0.54% 3.25% 16.08% 56.76% 0.00% 26 CITY OF *Sample* WORKERS' COMPENSATION
5YR CLAIM DISTRIBUTION BY TOP 10 NATURE OF INJURY
FY 2014/2015 THROUGH 2018/2019
Contusion, 108
Laceration, 71
Sprain, 210
No Physical Injury, 68
Unknown, 45
All Other Nature of
Injuries Top 10 Nature of Injuries
Inflammation, 30
85%
15%
Puncture, 27
Foreign Body, 26
Mental Stress, 21
Strain, 518
27 CLAIM DISTRIBUTION BY NATURE OF INJURY REFERENCE
VALUATION DATE 6-30-2019
Nature of Injury Claims Total Incurred Avg/Claim Nature of Injury Claims Total Incurred Avg/Claim Cardiovascular Disease 1 $36,820 $36,820 Dizziness 8 $18,009 $2,251 Concussion 1 $222 $222 Heart Trouble 8 $385,561 $48,195 Pneumonia 1 $42,160 $42,160 Hypertension 8 $257,074 $32,134 Poisoning - General 1 $864 $864 Dermatitis 10 $111,090 $11,109 Tinnitus Cumulative 1 $83,448 $83,448 Abrasion 11 $95,676 $8,698 Tinnitus Specific 1 $704 $704 Asbestosis 12 $193,348 $16,112 Vision Loss 1 $1,546 $1,546 Cancer 12 $999,048 $83,254
Amputation 2 $57,516 $28,758 Fracture 13 $2,707,139 $208,241 Electric Shock 2 $774 $387 Infection 15 $40,532 $2,702
Elevated Heart Rate 2 $27,471 $13,735 Carpal Tunnel Syndrome 16 $635,787 $39,737 Myocardial Infarction 2 $327,231 $163,616 Hernia 16 $483,179 $30,199 Syncope 2 $3,241 $1,620 Mental Stress 21 $640,260 $30,489 Hearing Loss (Cumulative) 3 $95,530 $31,843 Foreign Body 26 $103,976 $3,999 Hearing Loss (Specific Trauma) 3 $101,660 $33,887 Puncture 27 $123,567 $4,577 Contagious Disease $4,671 $1,168 Inflammation 30 $461,111 $15,370 Dislocation 4 $73,075 $18,269 Unknown 45 $134,521 $2,989 Exposure Bloodborne Pathogen 4 $1,813 $453 No Physical Injury 68 $1,205,505 $17,728 Smoke Inhalation 4 $15,610 $3,903 Laceration 71 $227,683 $3,207 Rupture 5 $241,193 $48,239 Contusion 108 $1,379,646 $12,775 Respiratory Disorders 6 $142,387 $23,731 Sprain 210 $6,828,444 $32,516 Crushing 7 $36,204 $5,172 Strain 518 $24,105,724 $46,536 Heat Prostration 7 $28,706 $4,101
Burn 8 $11,338 $1,417
GRAND TOTALS Claims: 1325 Incurred: $42,471,065 Average: $32,053.63 28 CITY OF *Sample* WORKERS' COMPENSATION
5YR CLAIM DISTRIBUTION BY TOP 10 BODY PART
FY 2014/2015 THROUGH 2018/2019
40.00%
38.00%
36.00%
34.00%
32.00%
30.00%
28.00%
26.00%
24.00%
22.00%
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00% 1LHl
0.00%
Lower Back
Body No Physical Multiple All Other
Eye(s) Hand Finger(s) Ankle Shoulders) (Lumbar / Knee
Systems Injury Body Parts Body Parts
Sacral)
• % Claims 3.32% 3.40% 3.62% 3.85% 4.15% 4.23% 7.25% 8.45% 10.34% 13.43% 37.96% •% Incurred 0.24% 1.85% 1.83% 2.65% 0.73% 3.21% 14.07% 10.96% 11.51% 22.24% 0.00% 29 CITY OF *Sample* WORKERS' COMPENSATION
5YR CLAIM DISTRIBUTION BY TOP 10 BODY PART
FY 2014/2015 THROUGH 2018/2019
Shoulder(s), 96
Lower Back (Lumbar / Sacral),
Ankle, 56 112
Fingers), 55
All Other Body Parts Top 10 Body Parts No Physical Injury, 51 38% 62% Knee, 137
Hand, 48
Body Systems, 45
Eye(s), 44
Multiple Body Parts, 178
30 CLAIM DISTRIBUTION BY BODY PART REFERENCE
VALUATION DATE 6-30-2019
Body Part Claims Total Incurred Avg/Claim Body Part Claims Total Incurred Avg/Claim Buttock(s) 1 $1,538 $1,538 Head Injury 16 $65,852 $4,116 Miscellaneous 1 $1,498 $1,498 Facial Soft Tissue 17 $134,165 $7,892 Pelvis 1 $3,800 $3,800 Upper Arm / Clavicle / Scapula 18 $519,321 $28,851 Cervical and Thoracic 2 $4,965 $2,482 Thumb 20 $186,901 $9,345 Great Toe 2 $1,322 $661 Internal Organs 21 $551,201 $26,248 Unknown 3 $17,095 $5,698 Upper Extremity(s) 21 $567,255 $27,012 Neck Soft Tissue 3 $982 $327 Elbow 24 $611,642 $25,485
Facial Bones 4 $5,700 $1,425 Lumbar / Sacral Vertebrae 24 $954,209 $39,759 Mouth $23,895 $5,974 Abdomen / Groin 27 $579,422 $21,460 Cervical and Lumbar 7 $263,477 $37,640 Lower Arm 30 $87,661 $2,922 Lower Extremity(s) 7 $810,804 $115,829 Lower Leg 35 $704,027 $20,115 Nose 7 $216,413 $30,916 Foot 38 $713,907 $18,787
Skull 7 $5,522 $789 Wrist 40 $828,052 $20,701
Toe(s) 7 $14,409 $2,058 Eye(s) 44 $100,964 $2,295
Wrists) and Hand(s) 7 $131,559 $18,794 Body Systems 45 $783,701 $17,416 Thoracic and Lumbar 8 $842,103 $105,263 Hand 48 $775,311 $16,152 Upper Leg 9 $158,331 $17,592 No Physical Injury 51 $1,126,438 $22,087 Hip 11 $1,031,185 $93,744 Fingers) 55 $310,320 $5,642
Upper Back (Thoracic) 11 $420,751 $38,250 Ankle 56 $1,363,822 $24,354 Lung(s) 12 $187,327 $15,611 Shoulder(s) 96 $5,975,342 $62,243 Heart 13 $738,090 $56,776 Lower Back (Lumbar / Sacral) 112 $4,653,406 $41,548 Chest (Ribs / Sternum / Other) 15 $698,113 $46,541 Knee 137 $4,889,507 $35,690 Ear(s) 15 $282,727 $18,848 Multiple Body Parts 178 $9,447,509 $53,076 Neck 15 $679,525 $45,302
GRAND TOTALS Claims: 1325 Incurred: $42,471,065 Average: $32,053.63 31 CITY OF *Sample*
MODIFIED DUTY DAYS - ALL DEPARTMENTS
ACROSS ALL CLAIMS WITH MOD. DAYS > 0 AT FY END - REGARDLESS OF DOI/OPEN DATE 10000 1000
9000 900
8000 800
7000 700
6000 600
5000 500
4000 400
3000 300
2000 200
1000 100
2015/2016 2016/2017 2017/2018 2018/2019
• Total Number of Modified Days 922 5885 8661 8505
- Total Number of Claims 43 112 150 129
32 CITY OF *Sample*
MODIFIED DUTY DAYS - SAFETY (POLICE & FIRE)
ACROSS ALL CLAIMS WITH MOD. DAYS > 0 AT FY END - REGARDLESS OF DOI/OPEN DATE 10000 1000
9000 900
8000 800
7000 700
6000 600
# MODIFIED DAYS
5000 500
4000 400
3000 300
2000 200
1000 100
2015/2016 2016/2017 2017/2018 2018/2019
Total Number of Modified Days 493 1883 3079 3715
• Total Number of Claims 15 39 53 53
33 CITY OF *Sample*
MODIFIED DUTY DAYS - NON-SAFETY
ACROSS ALL CLAIMS WITH MOD. DAYS > 0 AT FY END - REGARDLESS OF DOI/OPEN DATE 10000 1000
9000 900
8000 800
7000 700
6000 600
# MODIFIED DAYS # CLAIMS
5000 500
4000 400
3000 300
2000 200
1000 100
-
0 2015/2016 2016/2017 2017/2018 2018/2019
Total Number of Modified Days 429 3972 5582 4790
- Total Number of Claims 28 73 97 76
34 CITY OF *Sample*
METRICS
2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019
1. Average Cost Per Claim $6,593 $5,679 $6,160 $7,812 $6,561 $4,346 Total Claim Costs (Total Paid) @ End of Fiscal Year $1,753,750 $1,754,658 $1,515,292 $2,031,136 $1,060,338 Total # of Reported Claims 266 309 246 260 244
2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019 $34,296 $24,743 $16,923 $17,813 $23,443 $4,346
Total Claim Costs as of 6/30/2019 $9,122,659 $7,645,440 $4,163,090 $4,631,283 $1,060,338 Total # of Reported Claims 266 309 246 260 244
2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019
2. Annual Cost Per FTE $930 $918 $793 $1,092 $933 $496
Total Claim Costs (Total Paid) @End of Fiscal Year $1,753,750 $1,754,658 $1,515,292 $2,031,136 $1,060,338 Total # of FTE's Covered Under WC 1886 1912 1912 1860 2138 2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019 $4,837 $3,999 $2,177 $2,490 $3,376 $496
Total Claim Costs as of 6/30/2019 $9,122,659 $7,645,440 $4,163,090 $4,631,283 $1,060,338 Total # of FTE's Covered Under WC 1886 1912 1912 1860 2138 2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019
3. Frequency Rate (per 100 employees) 14.10% 16.16% 12.87% 13.98% 14.28% 11.41% Total # of Reported Claims 266 309 246 260 244
Total # of FTE's Covered Under WC 1886 1912 1912 1860 2138 2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019
4. Percentage of Annual Indemnity Claims 58.65% 62.46% 59.76% 53.85% 58.68% 58.20% #of New Indemnity Claims 156 193 147 140 142
Total # of Reported WC Claims 266 309 246 260 244
2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019
5. WC Costs as Percentage of Payroll 1.05% 1.02% 0.85% 1.12% 1.01% 0.56% Total Claim Costs (Total Paid) @ End of Fiscal Year $1,753,750 $1,754,658 $1,515,292 $2,031,136 $1,060,338 Total Payroll $167,628,100 $171,675,261 $178,726,586 $181,973,165 $190,299,253 2014/2015 2015/2016 2016/2017 2017/2018 4yr. Avg. 2018/2019
5.44% 4.45% 2.33% 2.55% 3.69% 0.56%
Total Claim Costs as of 6/30/2019 $9,122,659 $7,645,440 $4,163,090 $4,631,283 $1,060,338 Total Payroll $167,628,100 $171,675,261 $178,726,586 $181,973,165 $190,299,253 35 CITY COMPARISON
PERCENTAGE OF NEW CLAIMS ADDED
FISCAL YEAR 2018/2019
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
*Sample* Orange County 1 Orange County 2 Los Angeles County 1 •% Police 33.61% 71.82% 39.84% 55.94%
• % Fire 16.39% 0.55% 34.38% 43.36%
• % All Other 50.00% 27.62% 25.78% 0.70%
36 CITY COMPARISON
CLOSING RATIO
FISCAL YEAR 2018/2019
150%
140%
130%
120%
110%
100%
90%
80%
% CLAIMS CLOSED
70%
60%
50%
40%
30%
20%
10%
0%
*Sample* Orange County 1 Orange County 2 Los Angeles County 1 • Closing Ratio 107% 118% 120% 103%
37 CITY COMPARISON
FREQUENCY RATE (PER 100 EMPLOYEES)
FISCAL YEAR 2018/2019
20.00%
18.00%
16.00%
14.00%
12.00%
RATE PER 100 EMPLOYEES
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
*Sample* Orange County 1 Orange County 2 Los Angeles County 1 • FREQUENCY RATE (PER 100 EMPLOYEES) 11.41% 12.11% 13.11% 7.63% 38 CITY COMPARISON
PERCENTAGE OF ANNUAL MEDICAL ONLY CLAIMS
FISCAL YEAR 2018/2019
100.00%
90.00%
80.00%
70.00%
60.00%
% MO CLAIMS 50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
*Sample* Orange County 1 Orange County 2 Los Angeles County 1 • Percentage of Annual Medical Only Claims 41.39% 46.96% 49.22% 37.06% 39 CITY COMPARISON
PERCENTAGE LITIGATED FOR NEW CLAIMS ADDED
FISCAL YEAR 2018/2019
10.00%
9.00%
8.00%
7.00%
6.00%
% LITIGATED 5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
*Sample* Orange County 1 Orange County 2 Los Angeles County 1 •% Litigated 9.43% 6.08% 1.56% 7.69%
40 CITY COMPARISON
PERCENTAGE OF TOTAL PAID (ALL CLAIMS)
FISCAL YEAR 2018/2019
50.00%
45.00%
40.00%
35.00%
30.00%
% PAID 25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
*Sample* Orange County 1 Orange County 2 Los Angeles County 1 • MEDICAL 41.08% 36.13% 45.02% 33.47%
• TD 15.04% 9.15% 18.79% 22.00%
• PD 18.60% 30.10% 11.06% 23.22%
• VOC REHAB 0.44% 0.12% 0.01% 0.06%
• OTHER INDEM 1.18% 1.10% 2.07% -2.83%
• LEGAL 8.35% 5.53% 5.35% 4.00%
• OTHER 6.68% 12.10% 7.61% 4.88%
• LC 4850 8.63% 5.79% 10.09% 15.21%
MEDREVIEW
P.O. Box 3730 Ontario, CA 91761
Test Savings and Fee Summary
Client: Total:Total
Metric Amount Percentage
Bill Count 1,073
Work Units
Additional Charge $0.00
Total Charges $1,967,720.48
Dup Red $487,414.40
BR Reg Red $1,068,235.51
PPO Red $26,635.81
OSR Red $275.35
All Other Red $296.92
Total Red $1,582,857.99 80.44%
Red Less Dups $1,095,443.59 74.00%
OCR Fee $502.20
eBill Fee $141.60
BR Fee $9,279.00
IPFS Fee $0.00
UR Advisor Fee $0.00
Nurse Fee $0.00
Neg Fee $0.00
AP Fee $0.00
PPO Fee $4,610.75
OSR Fee $49.56
SR Fee $0.00
All Other Fee $0.00
Total Fee $14,583.11
Net Savings $1,080,860.48 73.02%
ROI 109:1