Workers' Compensation Self Insurance Third-Party Administration Addendum 1

REQUEST FOR PROPOSAL FOR

WORKERS’ COMPENSATION SELF-INSURANCE

THIRD-PARTY ADMINISTRATION

Bid Number: UA24-43

Issue Date: April 4, 2024

Close Date and Time: April 26, 2024 @ 11:00 AM

This Bid contains:

• Bid Requirements

• Bidding Forms

• Required Contract Terms

• Information to Bidders

• Local Business Preference

Notes:

• Bidder must quote firm or fixed prices for a period of 90 calendar days, unless otherwise noted in the specifications.

• The bid prices or agreed price will remain firm once a purchase order has been issued and delivered to the Bidder/Vendor.

• By submitting a bid for the City’s consideration, bidder acknowledges and agrees that the attached terms will be part of any contract with the City.

The City of Upper Arlington is currently soliciting proposals from qualified businesses to provide the City with workers’ compensation self-insurance third party administrative (TPA) services. TPAs responding to this proposal must be a recognized claims administrator of self-insured workers’ compensation programs, licensed to do such business in the State of Ohio. The Contractor will be responsible for all of the City’s workers’ compensation and administration needs, including for all of the City’s existing claims and any new claims that remain pending or open during the contract period.

The City of Upper Arlington is looking for a TPA partnership that will deliver objective and measurable results that will reduce the cost and duration of workers compensation claims, provide claim processing in a timely and professional manner, assist in returning injured employees back to work, and maintain strong communications with the injured worker and the City of Upper Arlington.

The contract(s) for services above is scheduled to begin on July 1, 2024. The City seeks to enter into a contract for three years, with an option by mutual agreement to renew for two additional one-year periods.

Background Information

The City of Upper Arlington is a municipality of approximately 36,600 residents located northwest of Columbus, Ohio. The City's self-insured workers’ compensation program covers approximately 242 full-time employees, including groups of employees represented by the following unions: Fraternal Order of Police (53), International Association of Fire Fighters (53) and the Teamsters Local' 284 (19), as well as 6 part-time and approximately 273 seasonal employees. Since 2011, the City has been a self-insured employer utilizing a TPA. Claim loss data is available upon request for informational purposes only. In the last 3-year period, March 1, 2021 to March 1, 2024, we had 32 new claims filed (those which had lost time or sought medical treatment). Not including non-expired claims, the City currently has 9 active claims. The City’s current consultant for self-insurance services is Sedgwick. The City remains committed to maintaining its self-insured status with the Ohio Bureau of Workers’ Compensation, unless it would become advantageous to do otherwise.

Scope of Services and Proposal Requirements

The Contractor will be responsible for acting as the City’s agent for an array of workers’ compensation and administrative needs in compliance with R.C. 4123, including but not limited to, claims reporting and management, account management, nurse case management, risk management information systems. Additional details, program requirements, and expectations of service are outlined below. Each proposer must address these program requirements in their proposal submission for the RFP to be considered. The selected TPA must be able to work within the time constraints and reporting requirements mandated by the City.

1. Executive Summary and Company Overview

Proposals should include concise, but complete information about your company, emphasizing your method and approach and why you believe your company to be uniquely qualified for this opportunity. The proposer should provide a brief overview of your company’s third-party administrator experience and qualifications while providing support to current municipality clients. The overview should include a brief description of your company, number of years in business providing TPA services, number of employees (full and part time), number of claim adjusters and claim support personnel, corporate headquarter location and location of the claim office that would be assigned to service the City of Upper Arlington. The overview should also address the following items:

• Customer Service Standards/Performance policies and results from recent surveys.

• Summary of your company’s best claim practices.

• Organizational chart for the service team that would be assigned to the City’s accounts, including relevant experience and expertise. The City requires that an account manager with experience with municipality claims be assigned to the City’s accounts.

• Any financial and/or ownership relationship with any other company that may pose a conflict of interest; and indicate whether any related person or business has been the subject of a Finding for Recovery under R.C. 9.24.

• Municipalities you currently support, including client’s name and contact person with telephone numbers and email addresses for which you currently provide workers’ compensation TPA services.

• Your company’s experience modification rate for the past 3 years.

• Whether you intend to subcontract any services to others and identify the proposed subcontractors including names, phone numbers and the qualifications of the subcontractor’s company.

• A sample of your claims intake script/form and/or description of your claim intake process.

• A proposed transition plan and implementation timetable.

• Confirmation that your company is a recognized claims administrator of self- insured WC programs licensed to do such business in Ohio; and

• Information on the circumstances and status of any disciplinary action taken or pending against your company during the last 3 years by any state or federal regulatory bodies or professional organizations.

2. Claims Administration Requirements and Expectations

The TPA must perform all services required to supervise and administer a self-insured workers’ compensation program for the City of Upper Arlington to ensure the City can meet its obligations under R.C. 4123 and as a self-insured employer, including, but not limited to, the following expectations of service:

• Timely process all claims, including but not limited to investigation, reserving and payment, filing reports, and negotiating and settling of claims for amount pre-approved by the City of Upper Arlington.

• Create and maintain a complete record of each claim; all claim records and claim files shall be the property of the City of Upper Arlington. TPA shall be responsible for providing claim data to the City of Upper Arlington upon request for data from the TPA’s administrative data system at the administrator’s expense.

• Provide a means to electronically view the progression of all claims, as well as access to any hard-copy, paper documents, or other claims file and related data maintained for the City of Upper Arlington.

• Maintain claims records in a means that complies with the BWC’s auditing requirements for self-insured employers, including the transfer of approximately 210 historical and unexpired claim files.

• Contact with City of Upper Arlington, claimant and medical provider within 24 hours of receipt of a claim for all other than medical only claims. For medical only claims, contact with City of Upper Arlington and medical provider within 24 hours of receipt of a claim.

• Response to any questions or inquiries by the City of Upper Arlington or claimants should be responded to within one business day.

• Provide a toll-free telephone number for the City of Upper Arlington and claimants.

• Upon knowledge of a catastrophic claim, such as a fatality, amputation, serious disfigurement, quadriplegic/paraplegic, serious burns, or brain injury, notification will be made immediately via telephone to the City of Upper Arlington.

• Initial investigation will be completed within 14 days from day of receipt of the claim and if needed, further investigation completed within 30 days or as soon as all the facts of the case can be reasonably gathered. An initial plan of action must be clearly documented in the claim file within 14 days from receipt of the claim and updated every 30-60 days.

• Initial estimate of reserves established within 14 days of receipt of claim. Adjusters must document the basis for each reserve calculation. Reserve increases of $5,000 or more on any one claim must be communicated and discussed with the City of Upper Arlington.

• Adjuster’s notes should include but not be limited to; comments regarding exposure, disposition plan for claim closure, financial transactions, supervisor’s notes, and any other relevant claim information.

• Provide prompt notification to the City of changes to a claim, including, but not limited to:

o Where the value of a claim increases by $10,000 or more; where the claim total exceeds a value of $50,000; or as demanded by the City.

o Prior to sending acceptance letters or denial of claims.

o When any previously closed claim is reopened and the rationale for reopening.

o When return to work letters are being sent to the claimant, anytime there are changes to the claimant’s work restrictions and at the time of any permanent work restrictions.

o Or as requested by the City.

• Claim reviews with the designated claims examiner must be held with the City on a quarterly basis, or upon request of the City. Meetings can be virtual or by phone.

• Receive pre-approval from the City on the following:

o The denial of compensability of any claim

o Appeals, including of District Hearing Officer orders

o The use of any outside case management services utilized, including but not limited to nurse case managers, vocational experts and investigative firms.

o Any legal actions must be approved through the City Attorney’s Office.

o The pursuit of any third-party action/subrogation claim.

o Requests for surveillance.

o Vocational rehabilitation services

o Nurse case management assignments.

o Other items as determined by the City.

• Nurse case manager’s action plans and notes will be documented in the claim file, and as appropriate NCM’s will participate in claim reviews or when consultation with the NCM is requested by the City of Upper Arlington.

• TPA must provide copies of all correspondence or make available electronically to the City whatever is sent to employees on the same day the original is sent to the employee. Making this correspondence available to the City in an online portal would satisfy this same day requirement, if timely uploaded.

• Transitional/modified duty must be documented in the claim file and should include the medical diagnosis, work restrictions and estimated duration of disability.

• Documented follow-up to the treating physician(s) is required no later than every 30 days prior to MMI status. Ongoing disability will be documented though ongoing medical reports.

• Schedule and administer independent medical exams (IMEs) and file reviews as necessary. The City reserves the right as to who will be examined. Provide a detailed monthly report of all scheduled IMEs and their results.

• Notify the City of Upper Arlington of any legal or administrative actions that affect their claims including, but not limited to, appeals and Industrial Commission hearings. Prior to all IC hearings, including DHO and SHO hearings, provide a summary of the issues to be heard.

• The City Attorney’s Office contracts with outside counsel for representation at workers’ compensation hearings; however, the City reserves the right to determine whether the TPA will attend and/or represent it at hearings. The expense must be included in your rates.

• Notify the excess carrier of potential claims as provided by the carrier’s Service agreement terms.

• Review medical provider bills for appropriateness of fees charged utilizing the Ohio Official Medical Fee Schedule.

• Provide all printed workers’ compensation documents which the City of Upper Arlington may require, i.e. Workers’ Compensation I.D. Cards, Employers First Report of Injury, medical authorization form, benefit letters, delay/denial letters, etc.

• Process and mail annual 1099s.

3. Litigation management

Any legal action must be approved by the City Attorney’s Office or its outside counsel for workers’ compensation. Any determination to refer a case or claim to defense counsel must be discussed and approved by the City Attorney’s Office.

4. Claim Staffing and Handling Expectations

A dedicated claims team must be provided, including a claims account manager. The claims account manager is expected to have responsibility to ensure:

• Administration of the City’s contract

• Trouble shooting and providing effective solutions to resolve issues or problems with the service agreement and/or services.

• Identify key outcome-based measurements that are tracked and deliver program improvements and cost reduction results.

• Monitor claim trends and audit claim handling procedures to ensure a high level of customer service and best in class claim service deliverables.

• Host (quarterly) telephonic or in-person claim reviews for the City of Upper Arlington, with participation of the claim adjuster(s) and as needed; defense attorneys and nurse case managers.

• Coordination of an annual stewardship meeting to present service performance metrics, benchmarking and claim trending/loss analysis reports.

Dedicated adjusters assigned to the City’s claims must have at least 5 years of technical claim adjusting experience within Ohio. The proposal must identify proposed staff members who would be assigned to the City’s claims and provide resumes or statements detailing their qualifications and experience with municipalities. The proposal should provide a sample adjuster’s claim status report, and describe the following items:

• Caseloads of your adjusters and how your company adjusts to meet increased staffing needs

• Turnover ratio among management and adjusters over the past 3 years

• Staffing plan when the assigned team member(s) are unavailable

• Adjuster’s bi-lingual capabilities

• How adjusters cooperate with other benefit plans to avoid duplication of benefits.

• How your company ensures that claim adjusters, support personnel and management team are trained and knowledgeable of legislative changes and current industry trends.

• Whether your company employs board certified physicians or vocational rehabilitation specialists. If so, how do they support the claim adjusters

• What percentage of claims (separated by medical only and indemnity) do your adjusters close within one year, 2 years and beyond 2 years?

• How often do your adjusters maintain contact with the claimants throughout the duration of the claim? What is your adjuster’s standard method of communication to clients and claimants?

• How your adjusters identify and manage fraudulent claims.

• How your company determines initial and subsequent reserves, as well as supervisory review and approval process.

• How your adjusters pursue early return to work and assist with the provisions of reasonable accommodations with the treating physician, claimant and the City of Upper Arlington.

• The process and timing of involvement with a medical case manager and physician.

• Your experience with claims management for public entities, including entities with sworn police officers and/or firefighter personnel.

• Your process for detecting duplicate medical bills and ensuring that bills are timely paid.

• Reconciliation procedure for medical payments, including payments in error and overpayments

A proposal that requires City Staff to call into a call center or be unable to reach someone to discuss our claims is unacceptable to the City and will be considered unresponsive.

5. Performance Guarantee

Indicate your willingness to agree to a performance guarantee, subject to mutual agreement between your company and the City of Upper Arlington. Include your suggestions regarding the performance areas to be measured, how they would be measured and at what intervals. Include a sample of your standard performance guarantee.

6. Risk Management Information System (RMIS)

The TPA’s Risk Management Information System (RMIS) must have the following abilities:

• Internet based claim system with access 24 hours a day, 7 days a week to view claim adjuster and supervisor notes, generate loss runs or other pre-scheduled or adhoc loss management/claim reports.

• Export claim data into various Microsoft products, i.e. word, excel, power point.

• Provide RMIS technical support for questions, problems or development of customized reporting.

• Preferably claim data is real time, or uploaded every 24 hours.

• Provide a list of data elements you capture and indicate which data elements are available in reportable form.

• Import all prior loss data dated before July 1, 2024 into a single database. Any proposed timeline for conversion must allow the City to meet our ongoing statutory and self-insured employer duties.

• Provide scheduled loss reports to be sent electronically to the City of Upper Arlington each month, each quarter and upon request. These reports will include, but not limited to:

o Detailed listing of open claims & closed claims.

o Summaries of all open and closed claims.

o Listing of incident-only claims.

o Claims cost detail.

o Claims by department.

o Claim trending.

o Financial reconciliation ledger.

• Customized reports that may include, but not be limited to; job titles, injury types, loss causation, lost workdays, modified work days, use of MPN or other medical clinics, and managed care reports that track cost containment activities and fees charged for these activities (i.e. bill review, utilization review, etc.).

• Quality control program to ensure data integrity and claimant confidentiality. Any RMIS problems will be resolved within 24 hours or less.

• Image system to scan all documents received pertaining to the claim.

• Fully compliant with MMSEA Section 111 reporting requirements. Disclose any fees associated with this service, including the names of any 3rd party TPA used for this reporting.

• System must be secured as noted in the required contract terms, including but not limited to, security audits, intrusion-prevention and intrusion-detection systems, encrypted email, disaster-recovery plan, protection of claimant’s personal information or personal health information is protected, and other appropriate methods to protect confidential City data. The City must be promptly notified of any data breaches, hacking, or other intrusions.

• Describe your process for data transmittal at the end of service agreement period, including the format for data provided to the City and conversion assistance with converting to a new TPA.

• The City requires 2 users to have access to RMIS.

7. Quality Management Program

Describe your claim audit program including areas that are audited, frequency of the audit, and corrective action on areas in need of improvement. Also provide details on your customer satisfaction program and how concerns are addressed and resolved.

8. Pricing

Proposals should include a summary of all fees, including account and claim set up fees, and any fees for additional services that may be charged to an individual claim. Please include pricing for both life of claim and life of service agreement. Pricing must include the maximum costs for service for July 1, 2024, to June 30, 2025, and expected maximum costs for the three-year contract period. Any additional increases at the time of a contract extension must be agreed in writing and are not automatic. Provide detailed cost breakdown for the following:

• Any costs associated with this access or any fees charged related to storage, copying or transferring any data to the City of Upper Arlington.

• Costs of your services for network access and any other charges related to the provision of provider networks.

• Any charges related to MMSEA reporting and requirements.

• Any pricing changes over the course of the service agreement and if you offer any flat rate guarantee.

• Any costs for data transmittal to the City at the end of the service agreement period, including any fees for conversion assistance to convert data to a new TPA.

• Any costs related to customized reports from your RMIS system

• Any charges for RMIS upgrades

• Any other additional anticipated costs.

Proposals should also describe and demonstrate the capabilities and cost savings comparative of your managed care/medical cost containment program including, but not limited to; case management services, utilization review and bill reviews. Indicate which services are owned by your company and which services you use subcontractors. If services are subcontracted out, disclose any commissions and/or any other type of compensation you receive from the subcontractors.

Proposal should address any unbundling ancillary services. If applicable, please describe the services and fees charged in the areas of allocated claim expenses, such as bill review, utilization review, prescription drug programs, managed care/preferred provider or other provider networks.

9. Funding Workers’ Compensation claims

Confirm your ability to adhere to the City of Upper Arlington’s self-insurance workers’ compensation internal service fund and process, as described below:

The City of Upper Arlington has a self-insurance workers’ compensation internal service fund checking account to cover payments and reimbursements applicable to the self-insured workers’ compensation program. The self-insurance workers’ compensation internal service fund checking account shall be established in the name of the TPA as agent of the City of Upper Arlington. Deposits shall be made to the account as required to ensure that funds are available for payment of claims for settlement and allocated loss expenses upon presentation of check or warrant. The TPA shall provide the bank checks stock. Checks shall be protected with state-of-the-art security features. TPA shall not draw on the trust fund checking account for any purpose other than adjustment of claims and payment of allocated loss expenses. Once a week, TPA shall submit a pre-pay register to the City of Upper Arlington for verifying and releasing payment. Once each month, TPA shall provide the City of Upper Arlington with a detailed accounting of all workers’ compensation benefits and allocated loss expenses paid from the fund. The detailed accounting shall include the date and check number of all benefit and allocated loss payments and shall also include appropriate supporting documentation for allocated loss expense payments. A monthly check register summary shall be provided. TPA is responsible for erroneous payments made from the account by their error. The amount of any such erroneous payments made from the account shall be deducted from administrative fee payments. TPA shall develop, implement and maintain security procedures to ensure safeguard of funds in the account and the bank checks. Such procedures shall be approved by the City of Upper Arlington.

Provide a sample monthly reconciliation report.

10. State Tail Fund Claims Administration

The City became self-insured in 2011. With respect to State Fund Tail Claims Administration, the TPA shall provide all case management/administrative services required for the remaining term of the claim, including but not limited to, reviewing BWC claim files as necessary for activity, reviewing claims for lump sum settlement, and reviewing the accuracy of assessments charged back to the City. The City of Upper Arlington has 2 open and/or non-expired State Fund Claim(s).

11. Confidentiality and Protection of Health information

Proposals must indicate how your company will ensure the confidentiality of City claim data, including employee Social Security numbers and personal health information, and protect against the unauthorized release or disclosure, except as permitted under the contract or required by law.

To the extent applicable, proposals must warrant that their software and systems used for storing claim data comply with the Health Insurance Portability and Accountability Act (HIPAA); including that your company shall:

a) Not use or disclose protected health information other than as permitted or required by the agreement or as required by law;

b) Use appropriate safeguards, and comply with Subpart C of 45 CFR Part 1764 with respect to electronic protected health information, to prevent use or disclosure of protected health information other than as provided for by the agreement;

c) Timely report to coveted entity any use or disclosure of protected health information not provided for by the agreement of which it becomes aware, including breaches of unsecured protected health information as required at 45 CFR 164.410, and any security incident of which it becomes aware;

d) In accordance with 45 CFR 164.502€(1)(ii) and 164.308(b)(2), if applicable, insure that any subcontractors that create, receive, maintain, or transmit protected health information on behalf of the business associate agree, in writing, to the same restrictions, conditions, and requirements that apply to the business associate with respect to such information;

e) Make available protected health information in a designated record set to the Covered Entity, as necessary to satisfy covered entity’s obligations under 45 CFR 164.524;

f) Make any amendments(s) to protected health information in a designated record set as directed or agreed by the Covered Entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy covered entity’s obligations under 45 CFR 164.526;

g) Maintain and make available the information required to provide an accounting of disclosures to the Covered Entity as necessary to satisfy covered entity’s obligations under 45 CFR 164.258;

h) To the extent the business associate is to carry out one or more of covered entity’s obligation(s) under SubpartE of 45 CFR part 164, comply with the requirements of Subpart E that apply to the Covered Entity in the performance of such obligation(s); and

i) Make its internal practices, books and records available to the Secretary and to the Covered Entity for purposes of determining compliance with the HIPAA Rules.

SUBMISSION REQUIREMENTS

A. Proposal Format

The Proposal must be submitted on the UAOH eBid system accessed through the City’s website, https://upperarlingtonoh.gov/finance-department/bids-purchasing/ . Registration and Inquiries must also be done on that site.

Please note that all submissions, inquiries regarding the RFP, and other items provided to the City may be subject to release under R.C. 149.43.  To the extent Proposers maintain that portions of their submission must be withheld as a confidential trade secret or other statutory exemption to release, Proposer’s must clearly identify those limited portions of their proposal. Responses purporting to render all or significant portions of the proposal “Confidential” “Trade Secret” or “Proprietary” shall be regarded as non-responsive. The City shall have no duty to defend the rights of the Proposer or its agents or affiliates in any records requested to be disclosed. Please be advised that once awarded, proposals become “public record” and are available to all for inspection and copying, upon request.

B. The bidder must respond to this RFP by submitting all data required herein in order for this proposal to be evaluated and considered for award. Failure to submit such data shall be deemed sufficient cause for disqualification of a proposal from further consideration for award.

C. Proposals must be valid for ninety (90) days following the proposal receipt date. The bidder shall not withdraw their proposal until after that time.

D. Inquiries

All inquiries regarding this RFP must be submitted no later than 8:00 a.m. on April 17, 2024. The City reserves the right to determine whether any questions should be answered. Responses will made available on the City’s UAOH eBid system. No other means of communication, whether oral or written, shall be construed as a formal or official response or statement. The City is not responsible for the validity of any information received outside of the Inquiry Process through IonWave.

If this RFP requires amendment, it is the responsibility of the Proposer to check the City’s website for verification of any issued addenda. Bidders are strongly encouraged to read the terms and conditions carefully prior to the submission of a proposal. The bidder must comply with all requirements stated.

PROPOSAL EVALUATION

A. Evaluation Process

After determining that a proposal satisfied the requirements stated in the RFP, a comparative assessment of the relative benefits and deficiencies of the proposal in relationship to the published evaluation criteria shall be made by using subjective judgment. The award of a contract resulting from this RFP shall be based on the lowest and best proposal received in accordance with the evaluation criteria of cost, experience, expertise, and reliability, proposed method of performance, completeness of proposal, references, and quality of operation. The City of Upper Arlington reserves the right to maintain a contract relationship with its current consultant if it is in the best interest of the City.

After an initial screening process, a technical question and answer conference or interview may be conducted, if deemed necessary, to clarify or verify the bidder's proposal and to develop a comprehensive assessment of the proposal. Additionally, the City may make on-site visits of proposed vendors.

The City of Upper Arlington reserves the right to consider historic information and fact, whether gained from the bidder's proposal, question and answer conferences, references, or any other source, in the evaluation process.

The bidder is cautioned that the City of Upper Arlington is under no obligation to solicit such information if it is not included with the bidder's proposal. Failure of the bidder to submit such information may cause an adverse impact on the evaluation of the bidder's proposal.

B. Evaluation Criteria

Proposals will be evaluated based on the bidder's distinctive plan for meeting the needs of the City of Upper Arlington and on proposal cost. In addition, if applicable, any projected and potential cost savings and other outcomes of performance will be evaluated. Therefore, the bidder is advised to respond in detail to all requests for such information contained in the Scope of Work.

Proposals will be evaluated for completeness and responsiveness to all criteria. The criteria that will be used to evaluate proposals may include, but are not limited to, responsiveness, experience, capability to meet City’s requirements, and cost.

Listed references may be contacted and their responses evaluated.