HomeMy WebLinkAboutContractCAG -14 -004
CLAIMS ADMINISTRATION AGREEMENT
THIS AGREEMENT is made and entered into between EBERLE VIVIAN
INCORPORATED, with its principal place of business at 206 Railroad Ave, N.,
Kent, Washington, 98032 (hereinafter referred to as "EV "), and CITY OF RENTON,
with its principal place of business at 1055 South Grady Way, Renton, WA 98057
(hereinafter referred to as "the Client" or "Renton ").
WITNESSETH
WHEREAS, the Client maintains an insured plan to cover its Workers'
Compensation liabilities in the State of Washington; and EV has agreed to perform
certain services in connection therewith, as herein set forth:
NOW, THEREFORE, it is agreed as follows:
The term of this Agreement shall be for the period of one (1) year
commencing March 1, 2014 and ending February 28, 2015. Nonetheless, this
Agreement may be terminated by either party at any time by giving not less
than sixty (60) days written notice to the other party, and EV may terminate
this Agreement on shorter notice in the circumstances described in Sections
3(c) and 5(e). If no notice is given, this contract will be renewed for another
twelve (12) month period without further action by either party, upon the
same terms and conditions contained herein, and using the previous annual
(January to January) U.S. Department of Labor Consumer Price Index
percent change for the Seattle Metro area to increase the annual fee, plus an
increase of two percent of the current annual fee.
2. During the period of this Agreement, EV shall represent and act for the
Client in matters pertaining to the actual or potential liability of the Client
for claims based on injuries to the Client's employees which occur during the
term of this Agreement that are or should be, in the Client's judgment,
handled pursuant to the self - insured provisions of the Industrial Insurance
Act of the State of Washington (the "Act "). More specifically, EV shall:
a. Receive notice of and create files on each claim reported and
maintain these files for the Client.
b. Investigate all claims as required to determine their validity and
compensability.
c. Determine proper benefits due on compensable claims.
d. Make timely payment of benefits due, in accord with payment
procedures as established from funds provided by the Client. The
Client will be wholly responsible for providing such funds as may be
required for these payments.
e. Prepare documentation and defense of cases considered non -
compensable and assist legal counsel selected by the Client in
preparation of cases for hearing, appeals, and/or trial.
f. Maintain and provide the Client pertinent data on all claim payments
g. Provide monthly and/or quarterly computerized loss reports in a
tailored format, as mutually agreed at inception of the program,
showing descriptive data, details of each month's payments, total
payments, reserves and total experience for each claim.
h. Provide the Client's excess insurers such reports as they may
reasonably require within specific excess coverage reporting
requirement.
Provide information and assistance as may be reasonably required for
preparation and filing of all reports required by the Act and any other
applicable law in connection with the Client's approved self - insured
status.
j. File with the appropriate State of Washington administrative
agencies, including but not limited to the Department of Labor and
Industries, such information as is required by the Act and any other
applicable law with respect to each claim.
k. Provide loss control services, defined as loss control, consultations
and surveys as mutually agreed.
1. Perform all services to be rendered pursuant to this Agreement in full
compliance with the Act and all other applicable law.
m. EV RMIS (Risk Management Information System) will
electronically interface with the Centers for Medicare and Medicaid
Services (CMS) to capture and report data in the format prescribed
by the CMS Specifications.
n. EV RMIS will report directly to CMS on behalf of Client as an
Account Designee (reporting agent), as such term is defined in the
CMS User Guide published on March 16, 2009 ( "Account
Designee ").
o. If Client is the Responsible Reporting Entity ( "RRE ") as that term is
defined in MMSEA Section 111 as set forth in 42 U.S.C. 1395Y, EV
RMIS will assist client as follows:
i. EV RMIS will develop an electronic interface with CMS to
forward the information needed to meet Client's MMSEA
reporting obligations.
ii. As the custodian of the original claims information from
which the reports will be compiled, EV RMIS will be
authorized Account Designee for Client. As an Account
Designee, EV RMIS will prepare and submit test files to
CMS in accordance with the applicable regulations and the
requirements of the CMS Specifications.
iii. EV RMIS will prepare the CMS Medicare beneficiary
required data files and submit them to CMS or otherwise
forward them as required by applicable regulations instructed
by Client.
iv. EV RMIS will establish and implement proper safeguards
against unauthorized use and disclosure of the data exchanges
for the purposes of complying with MMSEA. Proper
safeguards shall include, but not be limited to, the adoption of
policies and procedures to ensure that the data obtained shall
be used solely in accordance with Section 1106 of the Social
Security Act [42 U.S.C. 1306], Section 1874(b) of the Social
Security Act [42 U.S.0 1395kk (b)], Section 1862(b) of the
Social Security Act [42 U.S.0 13958y(b), and the Privacy Act
of 1974, as amended [5 U.S.0 552a]. EV RMIS shall
establish appropriate administrative, technical, procedures
and physical safeguards to protect the confidentiality of the
data to prevent unauthorized access to the data provided by
CMS. Further EV RMIS agrees to grant an authorized
representative of the Center for Medicare and Medicaid
Services (CMS) and/or Client access to facilities where the
Client's Medicare data is stored or kept for the purpose of
inspecting security arrangements at a mutually agreeable date
and time. The purpose of any such inspection will be to
confirm that EV RMIS is in compliance with all applicable
security requirements. Access to the records matched to any
records created by the matching process shall be restricted to
authorized CMS, EV RMIS and Client employees, agents
and/or officials who require access to perform their official
duties in accordance with the uses of the information as
authorized under Section 111 of the MMSEA of 2007 and this
Addendum, Such Personnel shall be advised of (1) the
confidential nature of the information; (2) safeguards required
to protect the information; and (3) the administrative, civil
and criminal penalties for noncompliance contained in
applicable Federal laws.
p. EV RMIS will be responsible for payment of any and all fines
assessed to the Client in regards to compliance with the Medicare
beneficiary reporting requirements of Medicare, Medicaid and
SCHIP Extension Act of 2007 that relate to the negligent acts or
omissions of EV RMIS except to the extent that:
i. Such fines or penalties are the direct result of specific
direction given by Client and/or its agent or the negligent
actions or omissions of Client and /or its agent;
ft
ii. EV RMIS did not receive information from Client that is
essential to the performance of the duties set forth herein in a
timely manner so as to be able to comply with the terms of
this Addendum;
q. EV will perform all work, services, and meet obligations as described
in their signed Proposal presented to the Client on or about
November 1, 2013, which is attached and fully incorporated into this
Agreement by reference with this Agreement as Attachment "A ".
Except that in the event of any inconsistencies between EV's
Proposal and this Agreement, the Agreement shall prevail.
3. In consideration of the services to be performed by EV hereunder, the Client
shall pay to EV:
a. A service fee of $77,500.00 per year for all claims administration
service performed within the contract period. The service fee may be
paid either as a lump sum or in monthly installments of $6458.33, as
preferred by the Client, and subject to the annual adjustments.
b. Such additional fee as mutually agreed by the parties for any services
in addition to those described in Section 2 that are requested by the
Client.
Interest of 1.5% per month on invoices not paid within 30 days of
client's receipt thereof. In the event invoices are not paid within sixty
(60) days of client's receipt thereof, EV may terminate this
Agreement, at its option, after ten (10) days written notice to the
Client.
4. The Parties mutually agree that:
a. Client will indemnify, defend and hold harmless EV, its officers,
directors, employees, and agents, from all claims, losses, damages,
costs, liability or expenses, including attorneys' fees, caused by or
resulting from the negligence or willful misconduct of Client, its
officers, directors, employees, insureds, or agents, to the extent
permitted by law.
b. EV will indemnify, defend and hold harmless Client, its officers,
directors, employees, and agents, from all claims, losses, damages,
costs, liability or expenses, including attorney's fees caused by or
resulting solely from the negligence or willful misconduct of EV, its
directors, officers or agents, to the extent permitted by law, however
the parties agree that EV, its directors, officers, agents or employees,
will not be liable to Client or any third party for claims arising from
EV's performance under this Agreement in those cases where EV
acted at the request of or with the consent of Client.
c. Client agrees that it will not hold EV liable for, or reduce the
compensation of EV with respect to any failure of EV to deliver any
services resulting from any failure of cooperation on the part of
Client or the prior administrator, or from any files for takeover claims
which have not been properly maintained or are not delivered to EV
in good order.
d. This section of the Agreement shall survive the termination of the
Agreement.
5. The Client agrees:
a. To pay EV the fee provided for hereunder and any other fees agreed
to by the Client.
b. To pay all allocated loss expense, as hereinafter defined, in addition
to the fees to be paid to EV. Allocated loss expense is defined as
reasonable attorneys' fees, court and/or hearing costs, costs of
depositions, documents and exhibits, witness and expert fees,
medical and engineering appraisal, surveillance, independent
adjusting, photography and other incidental and special costs
incurred to evaluate compensability of claims..
To make funds available to EV to be used by EV to pay claims that
the Client determines it should pay pursuant to the Act and allocated
loss expense.
d. To advise EV on a timely basis of all pertinent excess insurance
reporting requirements and/or reporting modifications for all annual
periods for which claim administration services are provided.
e. That this Agreement is entered into with the assumption that existing
Federal, State or other jurisdictional regulations will remain in effect
for the duration of this Agreement.
The Client agrees that should administrative or other costs of service
provided hereunder be substantially increased as a result of
modifications in existing law, enactment of new legislation, or
promulgation of new administrative guidelines, that the Client and
EV agree to attempt to negotiate an adjustment to the service fees to
equitably reflect the effect of such change.
If the parties cannot agree on a revised service fee, EV may terminate
this Agreement, at its option, after thirty (30) days written notice to
the Client.
6. The Parties acknowledge and agree that:
a. Any and all information emanating from either party's business in
any form, including compilations of otherwise public information, is
confidential and proprietary in nature. Each party will use its best
efforts during and after the termination of this Agreement to preclude
the duplication, use or disclosure of any such confidential and
proprietary information to any third party, unless such duplication or
disclosure is specifically authorized under this agreement or by the
party claiming ownership or otherwise required by law. In addition,
the parties agree that information provided by EV's RMIS or
otherwise in the context of this relationship shall be considered
confidential and proprietary and may constitute privileged and/or
attorney work product protected from discovery by law and/or rules
of court. Therefore, neither party will release any such information
unless:
i. Compelled by an order of a court of competent jurisdiction;
ii. Mandated by an insurance code, claim practices act, workers'
compensation law, or other applicable law or regulation to
provide information to the claimant or other person;
iii. Mandated by applicable court discovery rules in the opinion
of the claim professional responsible for the adjustment of the
claim or defense counsel, if any.
b. Any information sought to be produced will be prescreened by EV in
consultation with Client, provided such discovery requests comply
with applicable rules of court governing discovery litigation.
c. If there is an obligation to release part but not all of the information,
the part deemed not responsive will be withheld, but nothing in this
Agreement is intended to abrogate the duty of either party to comply
in good faith with such discovery requests.
d. Each party agrees that the information contained within EV's RMIS
must be treated in a confidential manner by all users who may gain
authorized access to the RMIS. In the event of a third party suit
alleging defamation, false light, or other invasion of privacy tort,
violation of civil rights, violation of federal or state medical privacy
statutes, or violation of fair employment practice laws, arising from
either party's use of EV's RMIS under this agreement, the liable party
agrees to indemnify and hold harmless the other party for all sums
due under the terms of a judgment or reasonable settlement,
including interest and attorneys' fees, upon a final judgment or
mutual agreement that one of the parties hereto is liable as charged in
such allegations.
e. EV shall hold the non - public personal information in strict
confidence and access it only for explicit business purpose of this
agreement. EV's Privacy and Confidentiality Policy, and as
applicable, all state and federal laws related to privacy, including, but
without limitation, Gramm- Leach - Bliley Act. Upon reasonable
request, Client may audit EV's compliance with EV's Privacy and
Confidential Policy as well as EV's compliance with state and federal
laws related to confidentiality of non - public personal information.
EV shall promptly notify Client in writing of any unauthorized use or
disclosure of non - public personal information. EV shall endeavor to
promptly notify Client of any unauthorized use or disclosure on non-
public personal information and it will take immediate steps to
remedy the situation and mitigate damage.
This section of the Agreement shall survive the termination of the
Agreement.
7. All claims and related files generated by EV as a result of its activity under
this Agreement shall remain at all times the property of the Client with the
exception of any supporting data required by EV to make such accountings
to the Client or excess insurers as are required in this Agreement.
EV will retain claim files for three (3) years following date of closure.
Thereafter, files may be returned, at the Client's direction and expense, to the
Client or forwarded to such location as may be designated for continued
storage. Upon EV's request, closed claim files will be returned for additional
administration as may be required.
In the event of termination or non - renewal of EV's services, EV will, at the
Client's request and expense, transfer all open and retained closed claim files
to the Client or its designee, as of the effective date of termination.
EV is retained by the Client only for the purposes and to the extent set forth
in this Agreement, and its relationship to the Client shall be that of an
independent contractor
9. The Client agrees that during the term of this Agreement and for a period of
one (1) year following its termination, it will not employ any person
employed by EV during the term of this Agreement without the prior written
consent of EV.
10. Any notice required or permitted to be given under this Agreement shall be
sufficient if given in writing and sent by registered or certified mail to the
Client or to EV at the addresses first set forth above or to any other address
of which written notice of change is given.
11. The waiver by EV or the Client of the breach of any provision of this
Agreement by the other party shall not operate or be construed as a waiver of
any subsequent breach by either party or prevent either party thereafter
enforcing any such provision.
12. This Agreement is for the term provided for in Section 1. Upon termination
of this Agreement, the Client shall have the option to:
a. Assume all open claims pending for the terminated or non - renewal
portion of the program as of the effective date of termination or non -
renewal, provided, however, that EV shall be entitled to receive its
full fee for all quarters beginning prior to the effective date of
termination or non - renewal; or
b. Upon agreement by both parties to a rate of compensation, require
EV to continue administration, to conclusion, of all open claims
associated with that portion of the program terminated or non -
renewed. Such rate of compensation shall thereafter be reviewed by
the parties on an annual basis and shall be the subject of mutual
agreement between the parties. Adequate funds shall continue to be
made available by the Client for the payment of claims and allocated
loss expense until all claims are liquidated.
c. In the event the Client requests EV to provide post - termination or
non - renewal claims administration, upon agreement by both parties
to a rate of compensation, the Client may continue to purchase
computer data services. Such rate of compensation shall thereafter
be reviewed by the parties on an annual basis and continued on -line
services shall be the subject of mutual written agreement between the
parties.
13. The obligation of EV to perform its duties hereunder is conditioned upon the
Client's cooperation with EV with respect to the activities of EV including,
but not limited to, responding to EV's requests for information promptly;
providing excess carrier reporting requirements; meeting with EV and/or
third parties, as may be needed; making decisions on matters which, in the
professional opinion of EV, should be made by the Client; the provision of
funds referred to in Section 5; and performance by the Client of all other
obligations of this Agreement.
14. This Agreement may not be assigned by either party without the prior
written consent of the other party, which consent will not be unreasonably
withheld.
15. Any unresolved dispute between the Client and EV that may arise from the
obligations of either party as set forth herein, will be resolved by arbitration
on the written request of either party. Such arbitration shall be binding upon
the Client and EV. The parties shall attempt in good faith to select a single
arbitrator within 15 days of the written request for arbitration. If they are
unable to select a single arbitrator within said period, then each party shall
select an arbitrator who will select a third. If the two arbitrators cannot agree
on a third within fifteen (15) days of the notice to the other party of the
selection of the first arbitrator, either party may file a petition in court to
request that selection be made by a judge of a court having competent
jurisdiction. Except as provided herein, the arbitration shall proceed pursuant
to RCW 7.04A. The laws of the State of Washington will apply. The
prevailing party in any such arbitration shall be entitled to an award by the
arbitrators of its reasonable attorneys' fees and costs associated with such
arbitration and in any subsequent court enforcement or appeal thereof.
16. This Agreement sets forth all of the terms, conditions, and agreements of the
parties relative to the subject matter hereof and supersedes any and all such
former agreements which are hereby declared terminated and of no further
force and effect upon the execution and delivery hereof. There are no terms,
conditions or agreements with respect thereto, except as herein provided and
no amendment or modification of this Agreement shall be effective unless
reduced to writing and executed by the parties. All terms, conditions, and
definitions as set forth in this Agreement will be interpreted under the laws
of the State of Washington.
17. Insurance.
a. EV shall secure and maintain the following insurance policies, and
shall not cancel or suspend the insurance policies identified below,
except after twenty (20) calendar day's prior written notice by
certified -mail to the City of Renton:
i. Commercial General Liability Insurance: Commercial general
liability insurance in the minimum amounts of $1,000,000 for
each occurrence /$2,000,000 aggregate throughout the
duration of this Agreement.
ii. Professional Liability Insurance: Professional liability
insurance, in the minimum amount of $1,000,000 for each
occurrence, shall also be secured for any professional services
being provided to Renton that are excluded in the commercial
general liability insurance.
iii. Workers' Compensation: Workers' compensation coverage, as
required by the Industrial Insurance laws of the State of
Washington.
iv. Fidelity Bond: A fidelity bond, or an alternative form of
coverage acceptable to Renton, in the minimum amount of
$1,000,000 covering all employees assigned to service
Renton's accounts.
b. Renton as an Additional Insured: It is agreed that on EV' S
commercial general liability policy, the City of Renton will be named
as an Additional - Insured on a primary and non - contributory basis.
Any coverage maintained by the City of Renton is solely for the
coverage and benefit of Renton, and its elected officials, officers,
agents, employees, representatives and volunteers.
c. Verification of Coverage: Subject to Renton's review and acceptance,
a certificate of insurance showing the proper endorsements, shall be
delivered to Renton before executing the work of this Agreement.
d. Review of Policy: Upon request, EV shall give Renton a full copy of
the insurance policy for its records and for the Renton City
Attorney's or Risk Manager's review. The policy limits may be
reviewed and the value reassessed annually.
Termination: Notwithstanding any other provision of this Agreement,
the failure of EV to comply with the above provisions of this section
shall subject this Agreement to immediate termination without notice
to any person in order to protect the public interest.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement in
duplicate counterparts as of this date written and the persons signing below warrant
that they have the authority to execute this Agreement.
N INCORPORATED
0
Date: a"�- % 1-3
I Y OF RE
4 N
By:
Title: Mayor
Date: 12130 1
Denis Law
Printed Name
A
ATTACHMENT A
SECTION II — SCOPE OF SERVICES
The selected TPA is expected to have an office and sufficient personnel assigned to the
city account, with access by telephone, fax, and e-mail. The city shall be informed
whenever assigned claims personnel are expected to be unavailable for periods longer
than 2 business days. The city must be notified with the name and contact information
for the alternate claims personnel who will handle business related to claims
processing, administration, questions, and issues.
Eberle Vivian's office is located at 206 Railroad Avenue North, Kent, Washington,
98032. We will assign an adjuster with extensive experience in handling public entities
to the City of Renton's account. This adjuster will be available by telephone, fax, e-mail
and with sufficient notice, in person as well.
Adjusters always advise all clients when they are to be away from their desk for one day
or more. In such an event, Eberle Vivian assigns back -up adjusters with equal
experience to cover any issues which may arise.
The contact information for the primary and also back -up adjuster will be provided to all
necessary City of Renton staff.
The selected TPA is expected to be available to meet on -site with City of Renton staff
for claims review meetings and /or discussions concerning specific difficult cases up to
four times per year.
Eberle Vivian's Kent office is located approximately twelve minutes from the City of
Renton's Risk Management office. We would be happy to meet with the City for claim
reviews four times per year or even more frequent as circumstances warrant.
The city reserves the right to select and approve legal representation necessary for the
administration of this program. The selected TPA may need to meet, as needed, with
the city's legal defense team, hired legal defense contractors, Risk Management
personnel and /or other designated employee(s) of the City for discussion and defense
planning of legal issues of selected claims.
Eberle Vivian agrees to work with the City's chosen defense counsel in any way
necessary. In addition, upon request, the City may avail itself of the vast network of
legal resources at Eberle Vivian's disposal.
TPA's scope of services shall include the following:
Claims Administration:
Examine all claims reported and determine if the claim is compensable under
state statutes and keep Risk Management and the injured employee advised of
the claim status.
Eberle Vivian will review all claims for compensability and make an appropriate,
timely determination. Both Risk Management and the worker will be advised of
the claim's status initially and at important intervals as the claim develops.
2. For the purpose of helping to determine claim compensability and for claims
administration, the TPA shall do the following:
- Establish contact with the designated Risk Management staff, and the injured
employee within twenty -four (24) hours of receipt of the reported claim,
Eberle Vivian protocols are to make such contact (to include the worker, the
employer, and the provider) within 24 hours of receipt of the claim, and to
document such contact in the claim notes.
- As determined or requested by Risk Management or as may be required by the
facts of the claim, the TPA will conduct interviews with the injured employee, co-
workers, witnesses or others who might have direct knowledge of the facts and
circumstances relating to the claim.
Eberle Vivian agrees to perform any such interviews as requested and as may
be necessary in order to determine the compensability of the claim.
• Conduct any other interviews or investigation deemed appropriate. All forms
used to gather information from the injured employee will be preapproved by
Risk Management.
2
Eberle Vivian agrees to conduct any such interviews and will seek approval
from the City for any forms used in the gathering of such information.
• Obtain approval from Risk Management prior to hiring claim specific case
managers or claims investigators.
Eberle Vivian agrees to this requirement.
- Process appeals approved by Risk Management in a timely manner and
communicate claim status.
Eberle Vivian agrees to process appeals as requested by the City and to
always keep the appropriate City personnel advised as to the updated claim
status.
- Keep all claim diaries and claim correspondence filing current and readily
accessible. Documented claim status updates on all open claims shall not
exceed 30 days.
Eberle Vivian adjusters are required to stay current on their diaries. Claims are
generally scheduled for review on a monthly basis but this review may be more
frequent depending on the circumstances of the claim.
The claim status, which will include the adjuster's plan of action, will be reflected
in the client - accessible claim notes via iComp.
• Provide a means to promptly correct filing and documentation errors.
Filing and documentation errors are extremely rare but when they do occur they
are promptly corrected.
3. Provide a medical cost containment program, to include:
• Fee schedule review
3
Eberle Vivian adjusts all medical bills in -house at no additional charge to the
client. All savings realized in the medical fee reductions are passed on to the
client, with no percentage of savings fees and no per -line fees. We have found
that this method of fee reduction generally results in a greater savings to the
client, and at no additional cost. Further, we do not need to wait for outside
vendors to review and return the bills, resulting in much faster turnaround times
Appropriate bills are generally paid within 20 days of receipt.
The Adjuster also carefully reviews bill data to verify that the treatment
corresponds with the injury and to ensure no unrelated conditions are treated
under the claim. Bills which require further clarification, or that are for a denied
condition, are immediately returned to the provider with an explanation for the
denial.
A sample savings report will be attached herewith.
• Hospital utilization review
Prior to admission to a hospital Eberle Vivian will have determined medical
necessity. Upon receipt of the bill and the medical reports from the inpatient stay
our claims mangers will review the reports for the services provided to match
them with billed items to ensure that the providers follow treatment guidelines
and acceptable practices. If we feel that they may fall outside of treatment
guidelines we will seek approval for review from a nurse case manager or an
independent company who performs utilization review. These requests will be
made on a case by case basis only.
• Hospital bill audit
Eberle Vivian audits all bills and services provided. After applying all costs
savings that we believe that we can obtain we then determine the possible value
of sending the bill out for independent review. If the savings that an independent
firm can save our client is more than the savings the Eberle Vivian can save plus
the cost of the bill audit, Eberle Vivian will seek approval for bill audit for that
individual bill. As this is rarely the case, we have found that this requesting
permission on a case by case basis is not burdensome to our clients and at the
same time has saved them thousands of bill audit dollars over the years.
4
Hospital /Physician discounts
At this time Eberle Vivian does not have any agreements with hospitals or
physicians for discounts. There have been numerous penalties issued for
payments made for these types of agreements and we have chosen to follow
the fee schedule rather than expose our clients to this liability.
4. Provide a quarterly medical cost containment report to the Risk Management
Department.
Eberle Vivian will provide such a report to the City's Risk Management
Department on a quarterly basis or as requested. In addition, Eberle Vivian
recommends quarterly stewardship meetings at which time we can discuss not
only cost savings, but also review other metrics such as the timeliness of claim
reporting and injury trends.
5. Compile and file, on behalf of the city, all notices, reports, and admissions
required by state and federal statutes relating to workers' compensation claims.
Eberle Vivian performs this service for all clients currently and will happily do so
for the City.
6. With the approval of Risk Management, arrange for independent medical
examinations, rehabilitation services and activity check -ups, when such
procedures may be constructive.
Eberle Vivian adjusters regularly employ these claim strategies in order to reduce
claim costs. Eberle Vivian will secure the approval of City Risk Management prior
to utilizing any of these strategies.
7. As requested by the city, cooperate and coordinate with the city's chosen legal
counsel in workers' compensation hearings and proceedings, including
stipulations.
Eberle Vivian agrees to this requirement.
8. Report claims to the city's excess insurer in accordance with policy requirements
and monitor all recoveries due. This shall include providing notice to excess
insurers of all claims or potential losses which may exceed the city's per
occurrence retention and, if requested, provide such insurers with necessary
information on the current status of those claims, including total aggregate loss
information for the respective policy year.
Eberle Vivian has an excellent working relationship with multiple excess carriers,
including but not limited to Midwest Employer's Casualty and Safety National.
Eberle Vivian regularly reports electronic claim data directly to these carriers
when requested by our clients.
Our interaction with the excess carriers also includes fulfilling specific reporting
requirements on individual claims and securing funds when the claims have
exceeded the retention level.
9. Develop a systematic approach to advise Risk Management concerning the need
for managed care, rehabilitation, and /or retraining of injured employees.
Eberle Vivian adjusters keep the client apprised of all important claim
developments. Any claim which may require managed care, vocational
rehabilitation, and /or retraining will immediately be brought to the attention
of designated City personnel, and prior to utilizing any of these claim
strategies, City approval will be secured.
While we believe monthly and /or quarterly claim reviews are helpful, these are by
no means the only time we update the client and request approval for these and
other strategies. We maintain regular contact via phone and email with our
clients in order to limit surprises, and ensure the claims move forward smoothly.
We believe client input is extremely important in all aspects of the claim.
Moreover, iComp, Eberle Vivian's client interface, allows clients to review
adjuster notes, diaries, and claim documents. iComp is just one more tool to help
us keep clients "in the loop" on important claim developments.
10. Provide systematic medical bill audits, subject to an agreed threshold bill amount.
All medical bills are reduced to Washington Fee Schedule.
11. Provide all data necessary to complete OSHANVISHA reports.
Eberle Vivian captures all data necessary for compliance with these reports.
12. Accommodate requests from the city for loss runs within 24 hours of request.
Eberle Vivian agrees to this request.
13. Ensure that data platforms and files are secure from cyber- attacks, including all
medical records and personally identifiable information.
Please see the attached description of Eberle Vivian's security protocols. We
have taken extensive measures to protect this valuable and private information.
Loss Control and Claims Reporting /RMIS Requirements
The selected TPA shall provide a fully integrated risk management information system.
In the areas of claim information, loss control information and general financial
information, the firm shall have the capability to provide the following:
Master loss run printouts by fiscal year (January 1 st through December 31 st) by
occupational classification. Each print run must be capable of selecting on the
basis of specified range parameters on any or all data fields and must be capable
of an ordered print.
Eberle Vivian agrees to provide such a loss run to the City.
Quarterly loss detail and summary reports. (Please provide samples.)
Eberle Vivian agrees to provide these reports. A sample of these reports can be
found attached herewith under the tab "Reports ". The "Loss Detail Report" is
omitted from the samples as it is an Excel report which is best shared
electronically. However, a sample Loss Detail Report can be shared via email
should the City wish to see one as part of the vetting process.
Quarterly accident analysis detailed reports. (Please provide samples.)
Eberle Vivian agrees to provide these reports. A sample can be found attached
herewith under the tab "Reports ".
Loss development factor /loss payout pattern listing.
Eberle Vivian agrees to provide this report.
Reserve adequacy analysis, including monthly and annual comparison of total
paid on claims closed during the period with the reserve for those claims effective
at an initial report, six months, twelve months, eighteen months, twenty -four
months and every twelve months thereafter until all claims in a given period are
closed. (Please provide samples.)
Eberle Vivian can and does provide highly customized reports for our clients to
meet their needs. These reports are developed with the client's input and
approval. While a sample of this report is not currently available, Eberle Vivian
agrees to develop such a report in corroboration with the client after contract
inception.
An excess carrier report by year.
Eberle Vivian agrees to provide this report.
Weekly and monthly check register detailing financial activity, including payments
issued, payee, amount of check, type of payment, claim number, date of injury
and claimant name. (Please provide report samples.)
0
Like most of our reports, check registers can be customized to meet with client
demands. A sample of some of our more standard check registers are attached
herewith. The data included can be modified to meet with City needs.
Capability for on -line access and ad hoc reports by Risk Management utilizing
historical loss information.
Eberle Vivian provides all customers with online access to claims information via
iComp. Through iComp, customers can view information on specific claims
including adjuster notes and claim documents. Clients can also run ad hoc
reports using iComp. Eberle Vivian would be happy to provide a demonstration of
iComp's capabilities to the City.
Customized loss reports are preferred.
Eberle Vivian will work with the City to develop customized loss reports.
SCHIP reporting on behalf of the city and as required by current regulations.
Eberle Vivian currently provides this service to all customers and will do so for
the City.
Provide for complete data migration for past and current claims into the TPA's
existing data base.
Eberle Vivian agrees to migrate all data for all past and current claims into our
claims system. There is no fee for this service.
Cooperate fully with the city and any authorized replacement TPA in the event
that contract agreement is non - renewed or is cancelled.
Eberle Vivian agrees to cooperate fully with the City and any replacement TPA in
such an event.
Submitted proposals should address ownership of data /loss files. It is the city's intent to
maintain ownership of all claim files. Please comment on special ownership of claim file
media.
All claim files are considered property of the client.
Financial and Accounting Services
Submitted proposals will require an explanation of the establishment of any fund that
may be required for payment of claims. Details should include, but not be limited to:
Any monthly requirements after initial establishment of the fund
The City would establish and maintain their own workers' compensation account
from which Eberle Vivian would write the benefit checks. With this arrangement,
the client may determine their own monthly requirement.
Procedures under which funds are to be transferred
This would be at the client's discretion.
Frequency of adjustment to determine accuracy of funding level
This would be at the client's discretion.
Reconciliation of check issuance
This would be at the client's discretion.
Maintain accurate and current claim payment records to prevent the issuance of
duplicate payments
10
Eberle Vivian's proprietary claims system, iComp, immediately record any
payment to vendors and workers in order to prevent any duplicate payments.
Please indicate basic funding arrangements available, i.e., daily replenishment
(budgeted basis or cleared bank basis), monthly replenishment, etc. Please indicate
anticipated amount of initial impress account.
As noted above, since this would be a client -owned and maintained account, these
matters would be at the client's discretion.
The selected TPA will need to maintain constant e-mail capability for communication
with the city's Risk Management Department, designated medical providers, and
attorneys. This may include making claims data available through secure website
access and encrypted e-mail.
All Eberle Vivian employees have email access and are expected to respond to emails
promptly. In addition to having unfettered access to their adjuster via phone and email,
City personnel will also be able to review claim status and claim documents online using
iComp, Eberle Vivian's secure client portal.
The selected TPA will assign specific personnel to handle all of the city's workers'
compensation claims. This claims team will deal with the city's Risk Management
Department or other designated employee(s) of the city on the day -to -day claims
functions.
Eberle Vivian will assign a primary adjuster, a backup adjuster, a clerical person, and a
supervisor to work directly with the City of Renton Risk Management Department. The
primary adjuster will be the main point of contact, however, should the primary adjuster
be away for any length of time, the City will have the contact information of the
adjuster's backup and also the supervisor.
The selected TPA is expected to return phone calls and /or respond to a -mails from
designated city staff and calls from injured city employees within one business day.
11
Eberle Vivian agrees to this requirement.
The selected TPA is expected to set an ultimate claim reserve for all lost time cases
within 30 days of the receipt of the claim. This reserve would be adjusted as needed to
always reflect the ultimate case reserve.
The Eberle Vivian adjuster will establish an ultimate claim reserve within 30 days of
receipt taking into account all known information about the claim. The adjuster will
complete a reserve worksheet which documents their reserve rationale, and which is
accessible to the client via iComp. Every 30 days thereafter, the adjuster will review
reserves for adequacy, ensuring the reserves always reflect the ultimate potential value
of the claim.
The selected TPA must have the ability to receive First Reports of Injury by facsimile or
email.
Eberle Vivian can receive new claims via fax at 253 - 854 -6404 or via email at
newclaim(),eberlevivian.com. Both the fax number and the email are checked multiple
times daily to ensure prompt entry of new claims.
The TPA shall maintain a separation of duties when it comes to check issuance,
including the ability to input payees, input checks, print checks, and /or mail checks. A
system for maintaining the security and access of check stock shall be established and
controlled whenever check stock is kept on the TPA's site or stored under the TPA's
direction.
Eberle Vivian agrees to maintain the above -noted separation of duties.
The TPA shall develop and maintain a workable disaster recovery planning program to
allow for continued operations with minimal interruptions.
Eberle Vivian's disaster recovery plan allows for the continuance of business operations
in the event of a disaster. Our disaster recovery plan is further outlined in answer to
question Y, under the Claims Administration Services Questionnaire.
12
SECTION III - PROPOSAL PREPARATION AND SUBMISSION REQUIREMENTS
A. Table of Contents to include clear identification of the material provided by
section and number.
A Table of Contents is included herewith.
B. A letter of transmittal indicating the respondent's interest in providing the service
and any other information that would assist the city in making a selection.
Provide a statement verifying that the submitted proposal is valid for 180 days
from date of receipt. This letter must be signed by a person legally authorized to
bind the firm to a contract.
Such a letter is herewith included. This proposal is valid for 180 days from the
date it is received.
C. A statement demonstrating understanding and your capability of providing the
services of each section of the Scope of Services.
Eberle Vivian has reviewed and responded to each individual section of the
Scope of Services above.
D. A written description of the respondent's qualifications and experience to provide
all services requested within this RFP.
Eberle Vivian has been providing claim services to self- insured employers since
July 1, 1986. We initially provided services to only a small handful of
organizations. But by providing excellent claims service and applying our intimate
understanding of Washington self- insurance in the overall community, Eberle
Vivian has grown to be the largest locally -owned TPA in Washington, and the
second largest overall. Eberle Vivian currently provides self- insurance claim
services to 18 public entities, including 4 cities, (the Cities of Bellevue, Kent,
Bellingham, and Tacoma).
13
Eberle Vivian owns and maintains its own claims system, iComp. By owning and
maintaining their own claims program, Eberle Vivian can quickly respond to
changing laws and changing customer demands. In addition, when the State of
Washington has proposed changes to the state law, such as the recent Provider
Network, Eberle Vivian has had a programmer at the table with Labor and
Industries personnel in order to ensure the law is instituted in such a way that our
excellent service to our customers is not impacted. Although Eberle Vivian does
handle some out -of -state claims with iComp, this system was developed with
Washington customers in mind. Eberle Vivian adjusters also enjoy the ease and
flexibility provided by this system.
Eberle Vivian adjusters average 20 years of experience in handling Washington
self- insured claims. Along with this experience comes the understanding that
each client's culture is unique. We take the time to learn that culture and reflect
the client's wishes as closely as possible in our claims handling. Our goal is to
develop long -term partners. Our excellent client retention and tenure
demonstrates this level of commitment.
E. Completion of the Fee Proposal /Questionnaire.
A completed Fee Proposal / Questionnaire is herewith attached.
F. Evidence of the respondent's insurance as set forth:
Workers' Compensation — Statutory Limits, as required by the State of
Washington and /or the state where business is being conducted. 2. Commercial
General Liability with minimum limits of $1,000,000 per occurrence, $2,000,000
aggregate. Must include Employers Liability Stop Gap - WA coverage when
Washington workers' compensation coverage is required. 3. Professional
Liability. Minimum limits of $1,000,000, per occurrence. If the policy is on a
claims -made basis, the policy shall be continually renewed for two (2) years
beyond the date of contract expiration or cancellation. Professional Liability
coverage is for all professional services provided to the city that are not covered
by the TPA's Commercial General Liability insurance.
Eberle Vivian agrees to these requirements.
14
G. An appropriate Certificate of Insurance evidencing all required insurance
coverage is to be included at the point of contract award. If the contract for
proposed services is awarded, evidence of policy endorsements showing the city
as a non - contributing additional insured on the general liability coverage shall be
submitted prior to commencement of services under any such awarded contract.
Eberle Vivian agrees to this requirement.
H. The respondent, on award of the service contract, shall submit evidence of a
fidelity bond in the minimum amount of $1,000,000. Such bond shall provide for
the fidelity and faithful performance of all employees assigned to service the
account and for which accountability of city monies for claim payments is
established.
Eberle Vivian agrees to provide proof of such a bond at the time of contract
award.
Indemnification of City by Successful TPA
The successful TPA shall indemnify and hold the city harmless from any and all claims,
liabilities, losses and causes of action which may arise out of the negligent fulfillment of
the TPA's contractual obligations as outlined in this RFP. The TPA shall pay all claims
and losses of any nature whatever in connection therewith, and shall defend all suits in
the name of the city when applicable, and shall pay all costs and judgments, which may
issue thereon. The TPA will also be responsible for penalties assessed by the
Washington State L &I Department when the error is the result of the negligence of the
TPA.
Eberle Vivian will include with this RFP response a copy of our preferred terms and
conditions, including indemnification language. If Eberle Vivian is the successful TPA
under this RFP, we will seek to incorporate these preferred terms and conditions into the
agreement with the City. Eberle Vivian agrees that penalties resulting solely from our
negligent handling will be our responsibility.
Expected Time of Performance
15
The city would consider a multi -year agreement. Please provide your quote proposals
for one, two, and three years commencing March 1, 2014. Please also provide any
special conditions for contract renewals.
Eberle Vivian will provide pricing for one, two, and three years commencing March 1,
2014. There are no special conditions for contract renewals aside from those already
mentioned in our preferred terms and conditions.
SECTION IV - CLAIMS ADMINISTRATION SERVICES QUESTIONNAIRE
Claim Services Questionnaire
A. Name, address and phone number of firm.
Eberle Vivian Inc.
206 Railroad Ave N
Kent, WA 98032
253 - 854 -6323
B. Branch office(s), address(es), and phone, which would provide service under the
proposal.
We would provide service from our above -noted Kent office.
C. Are "toll free" numbers available? Indicate the proposed personnel (including
supervisory and management) who would be assigned to administer the city
program, provide details on job title, experience and education, public entity
experience, and length of time with firm.
Eberle Vivian's toll free number is (800) 927 -9448.
Kevin Kincade — Account Manager
Kevin Kincade has been in Washington workers' compensation for over twenty
years. He was hired at Johnston & Culberson, Inc. in 1992 as a Staff
Assistant and was promoted several times, eventually becoming a Supervisor in
16
1997. In 1999, he was hired by Gallagher Bassett to be their Seattle Branch
Manager. In 2004, Kevin was hired by Berkley Risk Administrators to be
the General Manager of their Seattle office. In January of 2013 Kevin
was hired by Eberle Vivian to be a Supervisor and an Account Manager. Kevin
has extensive experience in handling claims, overseeing proper
claims - handling of others, and working with the Department of Labor and
Industries to resolve audits of self- insured clients. Kevin currently supervises the
claim - handling for the Cities of Bellevue and Kent.
Geri Nelson — Account Executive
Geri Nelson has been in Washington workers' compensation since 1981 with the
exception of the three years she handled property claims at Cravens,
Dargan and Co. She was hired by GAB Business Services in 1981 initially as a
receptionist and transcriptionist, later being promoted to working on Metro
subrogation claims, workers' compensation Claim Assistant, then Medical -Only
Adjuster. She then worked at Cravens, Dargan and Co. handling property claims
from 1983 to 1986. From 1986 through 1992, Geri was a workers'
compensation Claims Manager for Willis, handling self- insured cities and
counties in Washington. Geri was hired in 1992 at Eberle Vivian as an Account
Executive and has been handling self- insured Washington claims that entire
time. Geri currently handles claims for Kitsap County and is very familiar with
the needs of public entities.
D. Submit verification that firm is a State - approved third party administrator for self -
insured workers' compensation programs.
Eberle Vivian is a State - approved third party administrator for self- insured
workers' compensation programs.
E. Please comment on your firm's professional staff qualifications and related
experience for personnel expected to be assigned to the city's account. What is
the caseload of open files that would be managed by the claim
examiner /adjusters assigned to the city? Break down into incoming claims,
outstanding claims, medical -only, and lost -time cases. What is the annual
turnover rate of adjusters? How is each adjuster's performance monitored? If
your firm is selected for an interview, you will be expected to bring the lead
17
adjuster expected to be assigned to the city's account. This adjuster should be an
active participant in the presentation.
In addition to the above -noted qualifications of the staff specifically assigned to
handle the City of Renton's claims, (see response to "C" above) Eberle Vivian staff
is intimately familiar with the needs of public entities and cities.
Having 18 current public entity clients, 4 of them cities, our experience with
Washington public entities is second to none.
Geri Nelson's current caseload is under 50 open claims which allows room for her
to absorb the City's open claims without interruption. Her caseload is lower than
normal due to the recent purchase of one of her clients by a national organization
who uses a national TPA. Normally, caseloads are maintained between 130 -150
open and active claims. The number of incoming claims my vary highly by client
and also their industry. However, this caseload differs from our competitors in that
our adjusters handle both MO claims and indemnity claims. Most of our
competitors will have separate lost -time adjusters and medical -only adjusters,
which means that not only is the adjuster's caseload full of more difficult and time -
consuming cases, but that the client is inconvenienced by having to work with two
separate adjusters.
For all practical purposes, our adjuster turnover rate is zero. In addition to
providing competitive pay and benefits to our adjusters, Eberle Vivian also creates
an excellent work atmosphere for all employees which fosters creativity and
togetherness.
Adjuster performance is monitored in a number of ways. Every Monday, all
supervisors receive a listing of each adjuster's pending diaries to ensure all claims
are reviewed in a timely manner. Supervisors are also assigned a secondary diary
on litigated claims, claims which exceed $50,000 in paid total, and any other claim
which may require additional attention at either the client's or Eberle Vivian's
discretion. Supervisors also attend most claim reviews to ensure that not only is
the adjuster providing excellent service, but to also help strategize with the client
on particularly difficult claims or scenarios. Lastly, we are in the process of
developing a file- review checklist for supervisors to use at the time of their claim
reviews.
Eberle Vivian agrees to bring Geri Nelson to the presentation should we be
selected for interview.
18
F. Would an Account Executive be assigned to the city as a primary contact on
items not directly related to specific claims?
Eberle Vivian empowers adjusters to also assist the client with other issues not
directly related to claims. Our experience with public entities allows us to provide
this additional service. However, a specific account manager, Kevin Kincade, will
be assigned as the claim supervisor and also to assist as the Account Manager /
Account Executive for such items.
G. Provide at least four (4) references. It is preferred that at least two would be
public agencies. Please give names, phone numbers and a brief description of
services provided. At least one (1) reference should be from a recently lost
client (not from merger or acquisition).
Attached herewith is a complete list of all Eberle Vivian clients. Eighteen of the
clients are public entities and four of them are cities. Eberle Vivian has not
recently lost any clients that weren't due to a merger or acquisition.
H. Provide a brief description of your firm's claim handling philosophy.
Eberle Vivian is a service- oriented company. Service to us means total
commitment to serving the needs of your entire organization. We make it our
business to know your operations, your key people, your operational
philosophy, and your overall culture. We then work to develop and implement a
self- insurance program that is uniquely yours. We reject the notion that one
size fits all. The only way to truly serve our clients is by learning everything
we can about them.
Our well- trained Adjusters are empowered to work closely with the client and
arrive at common -sense approaches to claims. We understand that each claim
is different. We understand that the majority of workers who have been injured
need someone to listen to them and take the time to explain the process. We
also understand that some claims may require a more aggressive stance in order
to keep the claim from spiraling out of control. In each case, we treat
the worker with respect. We find that this overall approach keeps workers'
compensation costs low and worker and client satisfaction high, and results in far
less costly claim litigation.
19
Our outstanding reputation in the field of claims handling has been achieved only
through a continual intense effort to maintain and improve our high standards.
Although we work with your dollars and your people, we look upon them as if
they are our own.
Describe your investigative and reporting procedures. What criteria will be used
to determine the extent of an investigation?
Eberle Vivian may use a number of investigative techniques. The method and
also the extent of the investigation will be driven by client request, adjuster input,
and by examining the cost / benefit ratio.
Recorded Statements — A recorded statement from the worker and /or witnesses
may be taken to confirm the facts behind an accident. Recorded statements are
saved in a "wav" file and maintained in the electronic claim file.
Accident -Scene Investigation — An Eberle Vivian adjuster may visit the
accident -scene with the worker when possible to more accurately verify the facts
behind the injury. Photos will be maintained as part of the claim file when
necessary.
Medical History / Medical Records — Eberle Vivian adjusters will secure a
treatment history from the worker and secure any medical records for prior
treatment when applicable. Such an investigation may determine that the injury
occurred away from the job, or, may help to mitigate costs under the claim if it is
allowed.
Independent Medical Evaluation (IME) — An IME may be used to determine if
an injury or occupational disease is related, on a more probable than not basis,
to the claimed incident or exposure. Eberle Vivian ensures only quality, reputable
doctors for such exams, and we regularly collaborate with our extensive network
of legal consultants to ensure that only quality doctors are used for such exams.
Sub Rosa — Eberle Vivian will, with client approval, assign private investigators
to determine if the worker's reported disability corresponds with their activities
when they are unaware of such observation.
As noted above, the extent of any investigation can vary greatly but will heavily
depend on client input as well as the cost / benefit ratio.
J. What will be the frequency of status reports on any claim involving temporary
total disability and /or permanent total disability?
20
The frequency of status reports is driven by the needs of the client and also by
the nature of the claims. Eberle Vivian is happy to meet with the client to discuss
claims at any frequency. We also provide clients with online access which allows
them to check claim status, review adjuster notes, review payments, and view
claim documents at any time of their choosing.
K. Describe your procedures for making initial and follow -up contact with injured
employees, supervisors, and the Risk Management Department. Will you be able
to perform this within 24 hours of receiving the claim? What criteria will be used
to determine on -site versus telephone investigations? Terms of required field
investigations are to be contained within the service agreement.
Eberle Vivian adjusters complete an initial contact form for each new claim
received. This form requires that the adjuster call the employer, the employee,
and the provider, and can be completed within 24 hours of our receipt of the
claim. If voice -to -voice contact is not established, follow -up attempts will be made
periodically until contact is successfully achieved.
At the time each claim is received, Eberle Vivian adjusters will determine, with
input from the client, whether or not on -site investigation is necessary. Should an
on -site investigation be necessary, it will be promptly scheduled. Eberle Vivian's
main office in Kent is only a few minutes away from Renton, which allows us to
serve the City particularly well in this regard.
L. Describe your approach to claims adjusting and management, including but not
limited to: scheduling independent medical evaluations; arranging rehabilitation
services; securing medically- approved employment; activity checks, and legal
assistance.
Independent Medical Evaluations (IME) — We may schedule an IME in order to
secure a second opinion on a non - emergent surgical procedure, for a second
opinion on causation, for a closing /rating evaluation, or for a multitude of other
reasons when there is a medical question on a claim.
When possible, Eberle Vivian only uses physicians who are still actively
practicing in their field of specialty and who are board certified. Further, we
21
periodically discuss independent doctors with legal counsel to determine which
physicians are more respected at the Board of Industrial Insurance Appeals.
Lastly, we understand that an IME can be disrupting and stressful for the worker.
With that in mind we will accommodate their schedule as much as possible and
ensure that the IME doesn't cause any unneeded inconvenience.
Rehabilitation Services — Eberle Vivian will choose a vocational counselor,
(VRC) who is familiar with the City and their requirements. We will choose a
vendor who has extensive experience in working with both self- insured employers
and with municipalities. Eberle Vivian will only assign a VRC with the City's
approval.
Medically- Approved Employment — We believe that early return -to -work is a key
element to any successful workers' compensation program. Early return -to- work
can cut costs and keep worker satisfaction high. Moreover, workers feel more
connected to the workplace when the can contribute in a meaningful way following
an injury. Eberle Vivian agrees to help in whatever way needed in order to
facilitate early return -to -work. This includes securing completed job analyses,
calling the physician to request activity prescription forms, (APFs) and, when
needed, assigning a VRC to assist with early return -to -work.
Activity Checks — In the event that a worker's subjective complaints seem to
outweigh the objective findings, or if we receive a tip that a worker may be more
active than they claim to their doctor, Eberle Vivian adjusters will, with client
approval, assign an investigator to perform an activity check to verify facts about
the worker. Should it appear that the worker may be more active than they claim,
we may order sub -rosa with client approval.
Legal Assistance — Eberle Vivian works with the worker and client towards
litigation avoidance whenever possible. We believe that finding win -win situations
between the worker and their employer helps avoid costly legal fees. We do this by
treating the worker with respect at all times.
Our attempts at litigation avoidance notwithstanding, Eberle Vivian has developed
an extensive network of attorneys who are extremely knowledgeable in the area of
Washington workers' compensation. If and when a claim does need legal review or
representation, Eberle Vivian will assign an attorney who meets with the City's
approval.
22
Overall Approach — Our overall approach to claims - handling can best be
described with one word — Service. We never forget that we represent our clients
and that everything we do reflects on them. With that in mind, we treat workers,
providers, vendors, and all other parties with utmost respect at all times. We find
that this approach results in win -win situations and helps avoid costly litigation.
M. The city is interested in having the ability to maintain a PPO network that
provides a broad geographical spread and has a sufficient specialty mix (i.e.,
orthopedics, physical therapists) and sufficient access to other providers (i.e.,
radiology, surgical centers, emergency care facilities). Utilizing such a network
must be compliant with all state regulations. Describe what your firm has done or
is doing to establish a preferred provider network. Please explain how you would
propose the city utilize a PPO network on workers' compensation claims.
Eberle Vivian has participated in PPO networks in the past and has found that
these national networks cannot keep their networks current enough to allow for
proper bill payment within the Washington workers' compensation system. Usage
of PPO networks has resulted in the largest amount of penalties issued to self -
insured employers with regard to bill payment. Proper bill payment has now
become the top priority of the Self- Insurance Ombudsman as well as recent
legislation. Since we have a very aggressive administrative fee schedule, if
properly applied, we have opted out of using a PPO network until such a time
that we can assure our clients that usage of such will not result in frustration for
their injured employees, to the providers attending to their medical needs, or in
penalties to their programs form inaccurate information provided by the PPO
network about their participants.
N. What type of discounts can the city expect from the firm's choice of PPO? Please
provide a sample of a PPO report.
We are not participating in any PPO networks at this time.
O. Please describe procedures used to assure adherence to State - approved
medical fee schedules.
23
While most of our competitors contract out bill review, we help you control your
costs with an integrated in -house medical bill review module. Using the state fee
schedule, our claims management system reprices medical bills based on
standard CPT codes. In addition, our system monitors duplicate billings and new
for 2013 will be a module to manage, pay and monitor the requirements of the
new L & I Provider Network.
Fee transparency is very important to us and our clients. For that reason, we do
not charge any additional fees for this service. We will not charge a percentage
of savings, per bill, or per line fee. We feel that all savings captured by our
bill review process should be realized by the client.
P. Describe your mechanism for early warning on short-term cases that are
potentially long -term ones?
Eberle Vivian will assign all claims to the same adjuster. We have found that this
approach helps to maintain continuity of claim - handling for all employees. In
addition, our clients appreciate knowing that there is one person to call for all
claims.
This approach also helps us to identify, early on, those claims that may appear to
be straightforward at first but can later become complex. An inexperienced
"medical- only" examiner may not be trained to recognize certain red - flags,
and use the wrong claim - handling techniques. By using experienced adjusters
for all claims, Eberle Vivian avoids the pitfall of mishandling certain claims early
in the process.
Despite using experienced adjusters for all claims, Eberle Vivian will still assign a
supervisor on any medical -only claim open longer than 180 days. The supervisor
will establish a secondary diary and will continue to review the claim periodically,
with annotated input, until claim closure. This helps to ensure a second
set of eyes is reviewing the claims to ensure proper claim - handling at all times.
Q Identify any outside firms currently under contract with your firm for
investigations, rehabilitation, independent medical exams, and reporting that
would likely be used to help administer city claims.
Eberle Vivian does not directly contract with any firms for such services. Instead,
we work with the employer to find a vendor who meets their requirements. If and
24
when the employer needs help in choosing an appropriate vendor, Eberle Vivian
has excellent connections in the industry, and can make recommendations for
such services.
R. Describe criteria used for providing systematic medical /hospital bill audits.
Eberle Vivian audits all bills and services provided. After applying all costs
savings that we believe that we can obtain we then evaluate the value of sending
the bill out for independent review. If the savings that an independent firm can
save our client is more than the savings that Eberle Vivian can save plus the cost
of the bill audit, Eberle Vivian will seek approval for bill audit for that individual
bill. As this is rarely the case, we have found that this requesting permission on a
case by case basis is not burdensome to our clients and at the same time has
saved them thousands of bill audit dollars over the years.
S. Please describe procedures and frequency for reviewing the adequacy of claim
reserves.
Eberle Vivian understands the importance of accurate reserving on a claim. We
understand that our client's assigned account is impacted by our reserves.
Moreover, we realize that our clients need to know at any given time their
outstanding financial exposure.
Adjusters establish a reserve on the claim file at the time of their initial review.
This initial reserve and all future changes must be accompanied by a reserve
worksheet which can, upon request, be shared with the client for review and
approval. The adjuster takes into account all known information about the claim
in order to determine the client's financial exposure.
Reserves are then reviewed at each diary for adequacy. If necessary, an
adjustment will be made at the time of the review, however, stair - stepping of
reserves is strongly discouraged. Adjusters are trained to ensure that the
reserve accurately reflects the client's financial exposure at all times.
Reserve changes in excess of $50,000 require supervisor review and
approval. However, the client is kept apprised of reserve changes at their own
pre- determined threshold.
T. Are the employer's liability claims to be handled under your proposal?
25
We are not proposing to handle the City's liability claims.
U. Explain your capabilities in adhering to the RMIS requirements as outlined under
the Scope of Services.
Eberle Vivian is capable of delivering the City's RMIS requirements. We hope we
have adequately addressed each of these needs by responding individually to
each of the loss control and claims reporting /RMIS requirements listed earlier in
this RFP. However, we welcome the opportunity to further demonstrate our
abilities should this be requested as part of the vetting process.
Eberle Vivian believes in working smarter and harder. Our claims management
system, iComp, has been designed for and by the claims adjusters and
administrators. It is a unique tool, in that it has been created specifically to
handle the complexities of managing claims in Washington State. No other
software integrates so completely with the reporting requirements of the State.
Our programmers have worked closely with various State committees as they
have established reporting requirements for both SIEDRS and the new L & I
Provider Network. This focus gives our staff the ability to quickly and accurately
manage and administer claims.
iComp's unique disability history record supports Cockle, calculates time loss
rates, LEP worksheets and PPD schedules automatically for you. It also
handles COLA and SBI Reimbursements. It has built in support for State
Forms including the various SIF5 forms, APF, EC Closure, MO Closure, Denial of
Claim, Quarterly and Annual reports. In addition to Washington State's unique
requirements, our technology also manages reporting for Section 111 and
generates 1099's for the IRS.
We also provide our clients with the ability to access their claims information
online through our suite of services. Access is provided as view -only and clients
can run standard reports. In addition, customized reports and exports can
be automated by our staff.
V. Explain any aspect of the Scope of Services that your firm cannot perform.
Eberle Vivian has reviewed and individually responded to each aspect of the
Scope of Services, and there is no aspect of the Scope of Services that we
cannot perform.
W. It is the desire of the city to retain the right to periodically conduct file audits.
Please acknowledge permission to conduct audits of claim files, either by city
staff or other duly authorized representatives. Please submit a copy of your firm's
established Audit Protocol and your internal standards for file management.
Additionally, please verify /acknowledge the city's right to review any /all third party
auditor's reports and /or management letters as they may pertain to city claim
files.
Eberle Vivian will grant the City and their authorized representatives unlimited
access to the claims for the purposes of conducting audits.
Eberle Vivian curtails its internal file management standards to meet with each
client's demands. Such a document will be created with City input and approval.
X. All claim files are to remain property of the city. Please state your
acknowledgment as to ownership of files.
Eberle Vivian agrees that the City of Renton maintains ownership of the claim
files.
Y. Explain your disaster recovery planning as it relates to data protection and office
operations.
Eberle Vivian is committed to providing timely service to our clients. We
recognize the importance of preparing for various disaster scenarios that could
hamper our ability to provide service. Eberle Vivian has taken aggressive steps
to provide for business contingency and continuity planning under a variety of
potential scenarios. We continue to evaluate our continuity plans and take the
necessary action to ensure the proper resources are available to provide for the
recovery and timely resumption of critical business operations to our staff, and
clients.
27
Eberle Vivian has its headquarters and principle operations staff in Kent, WA. In
addition, we maintain two remote offices for data processing (Spokane, WA and
Portland, OR) and all of our claims administration staff are able to remotely
process claims. We also maintain a remote backup facility in Stanwood, WA. In
the event of a disaster that would make the Kent office unserviceable, the
Stanwood location would bring remote services online and would act as the data
processing center.
The Kent, Spokane, and Portland offices serve as primary locations for our
mission - critical departments, including: Operations, Claims Administration, and
Client Reporting. Each office serves as a backup to the others and claims
administration staff are able to process claims remotely.
Eberle Vivian's production data center is located in the Kent location. The
alternate data center is located in the Stanwood location. The physical location of
the backup site and reliance on alternate networking and power sources mitigate
potential threats of business disruption to this remote site.
If Eberle Vivian loses the ability to perform business at it's primary site (Kent,
WA), recovery staff associated with mission - critical functions will begin
processing at our alternate processing site (Stanwood, WA). Staff associated
with non - mission critical functions will be relocated to alternative sites (ie. hotel,
home) in an unaffected area. We have plans in place for this relocation and they
are tested periodically. Recovery time objectives vary based on the criticality of
the function that is disrupted.
Z. Provide a sample of the annual OSHA reporting forms to be provided to the city.
Attached herewith is a sample OSHA extract. The data necessary to complete
the OSHA logs will be provided in a format similar to the attached example.
SECTION V - MEDICAL CASE MANAGEMENT QUESTIONNAIRE
A. Please describe your medical case management program with details on who
provides the service, components of the service, criteria used in selecting cases,
and coordination with employees, employers, medical providers and the city.
Please provide a description of the professional experience /qualifications on
medical case management personnel who would be assigned to work with the
city.
28
We may assign a Nurse Case Manager based on the needs of the needs of the
claim or upon client request. Since the assignment of a Nurse Case
Manager is an additional allocated claim cost, we choose carefully which files
need such an assignment. When possible, adjusters work directly with the
doctors and /or their assistants to resolve medical questions. This arrangement
avoids unnecessary and costly referrals to a Nurse Case Manager.
Since Eberle Vivian uses outside Nurse Case Managers, this allows us the
flexibility to select one who works best with the City. Eberle Vivian will be happy
to either work with the City's chosen Nurse Case Manager after contract
inception, or, we will be happy to help the City select an outside Nurse Case
Manager who meets their qualifications.
B. How often are reports on managed care cases submitted? Please provide a copy
of a "typical" medical case management report. Will the managed care personnel
be willing to play an active role in our critical claims management process? If so,
In what capacity would they see their role in this process?
The Nurse Case Managers assigned to our cases will update us via phone,
email, or fax as often as is needed. Formal reporting is done monthly but since
updates are immediate, the reports generally are a summary of action taken.
Since Eberle Vivian uses a number of different Nurse Case Managers, a typical
report is not available. We would work with the City's chosen Nurse Case
Manager to develop a case management reporting format that suits the City's
needs.
The Nurse Case Manager would play a critical role including meeting the worker,
meeting the doctor, and attending regular claim reviews if requested. When
needed, the Nurse Case Manager will help to direct care to an appropriate
provider and assist with scheduling the appointment.
SECTION VI - RMIS QUESTIONNAIRE
A. Please provide an explanation of the RMIS capabilities of your firm.
Eberle Vivian's proprietary claims system, iComp, was developed internally
specifically for handling Washington self- insured workers' compensation claims.
No other TPA has a system solely developed for this purpose. Where our
competitors must rely on technology services from out -of -state specialists who
are unaware of Washington's unique demands, Eberle Vivian has an internal
team devoted to the development of reports and enhancements.
Eberle Vivian works proactively with the Department of Labor and Industries
whenever changes in the law may require system enhancements. For instance,
29
when the new provider network was implemented on January 1, 2013, Eberle
Vivian had already met with Department professionals on multiple occasions to
ensure we were ready for the changes. This allowed for a smooth transition for
our clients and their workers.
Reports can and will be customized to meet individual client needs. We don't
believe the client should ever simply "make do" with what they are given as far as
data. We firmly believe you should have exactly what you need, and we make
sure you get it. While every company will say this, Eberle Vivian is the only
company with professionals in Washington devoted solely to that purpose.
B. Please provide samples of all loss reports (summary and detail) that would be
under a service agreement.
Attached herewith under the section entitled "Reports" you will find such
samples.
C. With what frequency will reports be provided?
Reports are provided to clients at any frequency they desire. The most common
requests are either monthly or quarterly.
D. What other management reports will be routinely provided as a part of the
administrative services?
Eberle Vivian looks forward to working with the City to develop customized
management reports which allow the Risk Management department to focus on
the areas which need the most attention. Such reports can also assist
management when reporting to other City personnel. As noted, these reports can
and will be developed after inception and with City input.
30
E. Describe what on -line capabilities are available to the city.
By accessing iComp online, our customers can view our daily claim
management activities. iComp allows the viewer to see adjuster diary dates,
claim notes, payment activity, reserves, and claim documents, such as Activity
Prescription Forms. iComp activity is real -time, so our clients essentially have a
window into our claim - handling.
iComp also allows the user to run certain reports on their own. Eberle Vivian will
be happy to perform a demonstration of iComp as a part of the vetting process.
F. Upon termination of any service agreement, will the city continue to receive
periodic loss reports on open and closed claims? If so, what will be the costs for
such reports? Will online access to claim information be available after
agreement termination? If so, what will be the charge?
Eberle Vivian will ensure that all data, including historical data, will be transferred
to the new TPA in order that the new TPA would be able to provide the City with
such reports. There is no charge for transferring data to the new TPA. Online
access to claim information would cease at the time of contract termination
unless separate arrangements were made for a pre- determined cutoff date.
G. Explain your ability to provide SCHIP reporting, as may be necessary.
Eberle Vivian currently provides this service to all current clients, and would be
happy to do so for the City as well with no additional charge.
H. Explain your expected data migration plan from the previous TPA's database to
yours.
Eberle Vivian will secure a sample of claim data and record layouts from the
previous TPA roughly 60 days prior to contract inception. Eberle Vivian will then
review and build the conversion program.
At the time of contract inception, Eberle Vivian will verify all claim counts and
financial information provided by the previous TPA. We will then migrate the
previous TPA claim data into iComp within days of contract inception, usually
31
over a weekend. Eberle Vivian adjusters will then have access to all historical
and current claim data. Such claim data will also be readily available in the
client's online access portal.
SECTION VII — FEE PROPOSAL QUESTIONNAIRE
Claims Administration / Adjusting
A. Please indicate your proposed fees for administration / adjustment of workers'
compensation claims. Explain basis of fee structure (i.e., composite rate, cost per
lost time / medical only, etc.)
Eberle Vivian proposes one of the following agreements, at the choice of the
City:
1 -year - $77,500 per year
2 -year - $81,000 per year
3 -year - $83,500 per year
Should the City wish to renew any agreement above, the fee increase after the
renewal would be the Seattle /Metro CPI plus 2 %.
The fee agreement is easy to explain and understand. Our fees include
everything necessary for the administration of the City's workers' compensation
program, including the Scope of Services of this RFP.
a �
Z �
We do not impose any additional fees for bill review, data transfer, takeover of
run -in claims, online access, or regular and customized reports. Put simply, there
are no hidden fees anywhere in our agreement.
Any allocated fees which may be billed to the claim file are listed below in
response to question H.
B. Will the claims service fee for a work - associated injury follow to the final
settlement of the claim regardless of time involved? If not, explain. Please
provide a quote on a "life of the claim" basis.
32
Eberle Vivian's fee proposal contemplates everything necessary to see the claim
to conclusion, regardless of the amount of time involved. Allocated fees may be
billed to the claim file but only with client permission and as listed below, in
response to question H.
Eberle Vivian's agreement is for the life of the contract. Should you wish to have
Eberle Vivian continue to administer claims which remain open after the
expiration of the contract and any renewal periods, the cost would be a fixed fee
agreed upon at that time, reflecting the estimated hours of service needed per
quarter at $150 per hour.
C. Please note if the above quoted fee is based on a minimum volume level. If so,
show fee at different volume levels.
Our fee contemplates the most recent full claim year, where the City had 119
claims. We will be happy to annually review claim volumes and provide different
fee structures should the claim volume vary significantly from 119 per year. Any
request for fee change would need to be within 60 days of the contract's annual
renewal.
D. In the event of termination of the contract by either party, describe how the runoff
of claims will be handled. What are the per claim runoff charges? Is there a
service time limit associated with the charges?
Should you wish to have Eberle Vivian continue to administer claims which
remain open after the expiration of the contract and any renewal periods, the
cost would be a fixed fee agreed upon at that time, reflecting the estimated
hours of service needed per quarter at $150 per hour.
E. Please provide a sample contract.
A sample contract is attached herewith.
F. Are occupational disease claims included in the service fee? If not, describe.
Yes, our fee contemplates the handling of occupational disease claims.
33
G. This item was left blank in the original RFR
H. Define "claim" or "claimant" as it applies to your fee structure. Define "allocated"
expense as it applies to your fee structure.
A claim would be each SIF2 completed by a worker and forwarded to us for
handling.
Allocated expenses will be charged against the file upon which they are incurred.
Allocated expenses include:
• Court, trial, formal hearings and defense costs, including fees for attorney.
• Expenses and fees of experts.
• Cost of photocopies of records from public authorities, medical facilities and state
agencies.
• Professional photocopy charges.
• Activity investigations.
• Arbitration filing fees.
• Medical or consultant witness fees.
• Any assessment, taxes, filing fees, cost of surety bonds, etc., as required by
state regulatory authorities.
Is there a dollar maximum for a medical -only claim above which the claim is
classified as an indemnity for fee purposes? If so, what is that dollar amount?
Since Eberle Vivian assigns each claim, regardless of complexity, to an
experienced adjuster, we have no different fee level for medical -only claims. This
arrangement is beneficial to the client in a number of ways. First, it allows the
34
client to only call one person for claims questions, rather than have to determine
who is handling the claim. More importantly the client can rest easy knowing that
someone experienced will be looking at every single claim. This experienced
adjuster will know how to identify red flags and will be able to apply appropriate
handling to all claims from the beginning.
J. Under the city's Return to Work /Alternative Duty program, we require assertive
claims administration and case medical management since this program has
shown significant improvement in claim severity. We have many cases, which are
A
r
medical -only which would be indemnity claims if it weren't for our Return to
Work/ Alternative Duty program. This often creates a "hybrid" claim; one that
incurs medical costs only, but requires administration and management much like
a list time indemnity case. How would your firm price such "hybrid" claims?
As noted earlier, our fee structure contemplates all claims of all complexities.
Eberle Vivian's claims philosophy, it would seem, is in that manner similar to the
City's, since we assign an experienced adjuster to all claims. We would welcome
this arrangement since we already apply this additional level of handling to all
claims.
K. If there are costs / charges for RMIS that are not included in the fee
proposed /quoted for claims adjusting and administration, please state what
charges will apply.
Our fees already contemplate our RMIS services.
Note: Please be sure to comment on any additional or recurring fees that may be
charged for services requested that may be outside your "basic" services. If there
are to be additional charges for your firm's participation in this requested service,
be sure to show those charges separate from all other "basic" services. If no
separate charges are denoted, the city will assume all requested services are
included in base fee quoted.
As noted earlier, Eberle Vivian's fee structure is easy to understand and easy to
explain. There are simply no hidden fees anywhere.
35
r
Medical Case Management
A. Please provide fees for the various case management services.
Eberle Vivian has no additional fee for case management, however, Nurse Case
Manager fees may be charged to the file as an allocated fee. We only assign Nurse
Case Mangers with client approval. We only assign Nurse Case Managers when
absolutely necessary, recognizing the additional claim cost.
B. How and at what frequency are these costs charged?
Nurse Case Manager fees are generally billed by our vendors on a monthly basis.
RMIS Fees
A.
fee.
We have no additional fee for periodic computer loss runs.
B. Provide fee proposal for on -line access, if any, such as set up charge, monthly
maintenance, special reports, etc.
Eberle Vivian does not charge an additional fee for online access, set up, monthly
maintenance, or special reports.
36