HomeMy WebLinkAboutContractAGREEMENT FOR CLAIMS AUDIT SERVICES
THIS AGREEMENT, dated for reference purposes only as June 9, 2021, is by and between the City
of Renton (the “City”), a Washington municipal corporation, and J. Graham, Inc., a foreign
(Tennessee) Corporation (“Consultant”). The City and the Consultant are referred to collectively
in this Agreement as the “Parties.” Once fully executed by the Parties, this Agreement is effective
as of the last date signed by both parties.
1. Scope of Work: Consultant agrees to provide claims audit services as specified in Exhibit
A, “City of Renton Claims Audit Proposal”, which is attached and incorporated herein and
may hereinafter be referred to as the “Work.”
2. Changes in Scope of Work: The City, without invalidating this Agreement, may order
changes to the Work consisting of additions, deletions or modif ications. Any such changes
to the Work shall be ordered by the City in writing and the Compensation shall be
equitably adjusted consistent with the rates set forth in Exhibit A or as otherwise
mutually agreed by the Parties.
3. Time of Performance: Consultant shall commence performance of the Agreement
pursuant to the schedule(s) set forth in Exhibit A. All Work shall be performed by no later
than December 31, 2021.
4. Compensation:
A. Amount. Total compensation to Consultant for Work provided pursuant to this
Agreement shall not exceed $12,500, plus any applicable state and local sales taxes.
Compensation shall be paid based upon Work actually performed according to the
rate(s) or amounts specified in Exhibit A. The Consultant agrees that any hourly or flat
rate charged by it for its Work shall remain locked at the negotiated rate(s) unless
otherwise agreed to in writing or provided in Exhibit A. Except as specifically provided
herein, the Consultant shall be solely responsible for payment of any taxes imposed
as a result of the performance and payment of this Agreement.
B. Method of Payment. The city will pay half the total fee or $6,250 upon signature of
this Service Agreement, and $6,250 upon release of the Final Claims Audit Report.
Payment shall be made by the City for Work performed within thirty (30) calendar
days after receipt and approval by the appropriate City representative of the voucher
or invoice. If the Consultant’s performance does not meet the requirements of this
CAG-21-164
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Agreement, the Consultant will correct or modify its performance to comply with the
Agreement. The City may withhold payment for work that does not meet the
requirements of this Agreement.
C. Effect of Payment. Payment for any part of the Work shall not constitute a waiver by
the City of any remedies it may have against the Consultant for failure of the
Consultant to perform the Work or for any breach of this Agreement by the
Consultant.
D. Non-Appropriation of Funds. If sufficient funds are not appropriated or allocated for
payment under this Agreement for any future fiscal period, the City shall not be
obligated to make payments for Work or amounts incurred after the end of the
current fiscal period, and this Agreement will terminate upon the completion of all
remaining Work for which funds are allocated. No penalty or expense shall accrue to
the City in the event this provision applies.
5. Termination:
A. The City reserves the right to terminate this Agreement at any time, with or without
cause by giving ten (10) calendar days’ notice to the Consultant in writing. In the event
of such termination or suspension, all finished or unfinished documents, data, studies,
worksheets, models and reports, or other material prepared by the Consultant
pursuant to this Agreement shall be submitted to the City, if any are required as part
of the Work.
B. In the event this Agreement is terminated by the City, the Consultant shall be entitled
to payment for all hours worked to the effective date of termination, less all payments
previously made. If the Agreement is terminated by the City after partial performance
of Work for which the agreed compensation is a fixed fee, the City shall pay the
Consultant an equitable share of the fixed fee. This provision shall not prevent the
City from seeking any legal remedies it may have for the violation or nonperformance
of any of the provisions of this Agreement and such charges due to the City shall be
deducted from the final payment due the Consultant. No payment shall be made by
the City for any expenses incurred or work done following the effective date of
termination unless authorized in advance in writing by the City.
6. Warranties And Right To Use Work Product: Consultant represents and warrants that
Consultant will perform all Work identified in this Agreement in a professional and
workmanlike manner and in accordance with all reasonable and professional standards
and laws. Compliance with professional standards includes, as applicable, performing the
Work in compliance with applicable City standards or guidelines (e.g. design criteria and
Standard Plans for Road, Bridge and Municipal Construction). Professional engineers shall
certify engineering plans, specifications, plats, and reports, as applicable, pursuant to
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RCW 18.43.070. Consultant further represents and warrants that all final work product
created for and delivered to the City pursuant to this Agreement shall be the original work
of the Consultant and free from any intellectual property encumbrance which would
restrict the City from using the work product. Consultant grants to the City a non-
exclusive, perpetual right and license to use, reproduce, distribute, adapt, modify, and
display all final work product produced pursuant to this Agreement. The City’s or other’s
adaptation, modification or use of the final work products other than for the purposes of
this Agreement shall be without liability to the Consultant. The provisions of this section
shall survive the expiration or termination of this Agreement.
7. Record Maintenance: The Consultant shall maintain accounts and records, which
properly reflect all direct and indirect costs expended and Work provided in the
performance of this Agreement and retain such records for as long as may be required by
applicable Washington State records retention laws, but in any event no less than six
years after the termination of this Agreement. The Consultant agrees to provide access
to and copies of any records related to this Agreement as required by the City to audit
expenditures and charges and/or to comply with the Washington State Public Records Act
(Chapter 42.56 RCW). The provisions of this section shall survive the expiration or
termination of this Agreement.
8. Public Records Compliance: To the full extent the City determines necessary to comply
with the Washington State Public Records Act, Consultant shall make a due diligent search
of all records in its possession or control relating to this Agreement and the Work,
including, but not limited to, e-mail, correspondence, notes, saved telephone messages,
recordings, photos, or drawings and provide them to the City for production. In the event
Consultant believes said records need to be protected from disclosure, it may, at
Consultant’s own expense, seek judicial protection. Consultant shall indemnify, defend,
and hold harmless the City for all costs, including attorneys’ fees, attendant to any claim
or litigation related to a Public Records Act request for which Consultant has responsive
records and for which Consultant has withheld records or information contained therein,
or not provided them to the City in a timely manner. Consultant shall produce for
distribution any and all records responsive to the Public Records Act request in a timely
manner, unless those records are protected by court order. The provisions of this section
shall survive the expiration or termination of this Agreement.
9. Independent Contractor Relationship:
A. The Consultant is retained by the City only for the purposes and to the extent set forth
in this Agreement. The nature of the relationship between the Consultant and the City
during the period of the Work shall be that of an independent contractor, not
employee. The Consultant, not the City, shall have the power to control and direct the
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details, manner or means of Work. Specifically, but not by means of limitation, the
Consultant shall have no obligation to work any particular hours or particular
schedule, unless otherwise indicated in the Scope of Work or where scheduling of
attendance or performance is mutually arranged due to the nature of the Work.
Consultant shall retain the right to designate the means of performing the Work
covered by this agreement, and the Consultant shall be entitled to employ other
workers at such compensation and such other conditions as it may deem proper,
provided, however, that any contract so made by the Consultant is to be paid by it
alone, and that employing such workers, it is acting individually and not as an agent
for the City.
B. The City shall not be responsible for withholding or otherwise deducting federal
income tax or Social Security or contributing to the State Industrial Insurance
Program, or otherwise assuming the duties of an employer with respect to Consultant
or any employee of the Consultant.
C. If the Consultant is a sole proprietorship or if this Agreement is with an individual, the
Consultant agrees to notify the City and complete any required form if the Consultant
retired under a State of Washington retirement system and agrees to indemnify any
losses the City may sustain through the Consultant’s failure to do so.
10. Hold Harmless: The Consultant agrees to release, indemnify, defend, and hold harmless
the City, elected officials, employees, officers, representatives, and volunteers from any
and all claims, demands, actions, suits, causes of action, arbitrations, mediations,
proceedings, judgments, awards, injuries, damages, liabilities, taxes, losses, fines, fees,
penalties, expenses, attorney’s or attorneys’ fees, costs, and/or litigation expenses to or
by any and all persons or entities, arising from, resulting from, or related to the negligent
acts, errors or omissions of the Consultant in its performance of this Agreement or a
breach of this Agreement by Consultant, except for that portion of the claims caused by
the City’s sole negligence.
Should a court of competent jurisdiction determine that this ag reement is subject to RCW
4.24.115, (Validity of agreement to indemnify against liability for negligence relative to
construction, alteration, improvement, etc., of structure or improvement attached to real
estate…) then, in the event of liability for damages arising out of bodily injury to persons
or damages to property caused by or resulting from the concurrent negligence of the
Consultant and the City, its officers, officials, employees and volunteers, Consultant’s
liability shall be only to the extent of Consultant’s negligence.
It is further specifically and expressly understood that the indemnification provided in
this Agreement constitute Consultant’s waiver of immunity under the Industrial
Insurance Act, RCW Title 51, solely for the purposes of this indemnification. The Parties
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have mutually negotiated and agreed to this waiver. The provisions of this section shall
survive the expiration or termination of this Agreement.
11. Gifts and Conflicts: The City’s Code of Ethics and Washington State law prohibit City
employees from soliciting, accepting, or receiving any gift, gratuity or favor from any
person, firm or corporation involved in a contract or transaction. To ensure compliance
with the City’s Code of Ethics and state law, the Consultant sh all not give a gift of any kind
to City employees or officials. Consultant also confirms that Consultant does not have a
business interest or a close family relationship with any City officer or employee who was,
is, or will be involved in selecting the Consultant, negotiating or administering this
Agreement, or evaluating the Consultant’s performance of the Work.
12. City of Renton Business License: Unless exempted by the Renton Municipal Code,
Consultant shall obtain a City of Renton Business License prior to performing any Work
and maintain the business license in good standing throughout the term of this
agreement with the City.
Information regarding acquiring a city business license can be found at:
http://www.rentonwa.gov/cms/One.aspx?portalId=7922741&pageId=9824882
Information regarding State business licensing requirements can be found at:
http://dor.wa.gov/doing-business/register-my-business
13. Insurance: Consultant shall secure and maintain:
A. Commercial general liability insurance in the minimum amounts of $1,000,000 for
each occurrence/$2,000,000 aggregate for the Term of this Agreement.
B. In the event that Work delivered pursuant to this Agreement either directly or
indirectly involve or require Professional Services, Professional Liability, Errors and
Omissions coverage shall be provided with minimum limits of $1,000,000 per
occurrence. "Professional Services", for the purpose of this section, shall mean any
Work provided by a licensed professional or Work that requires a professional
standard of care.
C. Workers’ compensation coverage, as required by the Industrial Insurance laws of the
State of Washington, shall also be secured.
D. Commercial Automobile Liability for owned, leased, hired or non-owned, leased, hired
or non-owned, with minimum limits of $1,000,000 per occurrence combined single
limit, if there will be any use of Consultant’s vehicles on the City’s Premises by or on
behalf of the City, beyond normal commutes.
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E. Consultant shall name the City as an Additional Insured on its commercial general
liability policy on a non-contributory primary basis. The City’s insurance policies shall
not be a source for payment of any Consultant liability, nor shall the maintenance of
any insurance required by this Agreement be construed to limit the liability of
Consultant to the coverage provided by such insurance or otherwise limit the City’s
recourse to any remedy available at law or in equity.
F. Subject to the City’s review and acceptance, a certificate of insurance showing the
proper endorsements, shall be delivered to the City before performing the Work.
G. Consultant shall provide the City with written notice of any policy cancellation, within
two (2) business days of their receipt of such notice.
14. Delays: Consultant is not responsible for delays caused by factors beyond the
Consultant’s reasonable control. When such delays beyond the Consultant’s reasonable
control occur, the City agrees the Consultant is not responsibl e for damages, nor shall the
Consultant be deemed to be in default of the Agreement.
15. Successors and Assigns: Neither the City nor the Consultant shall assign, transfer or
encumber any rights, duties or interests accruing from this Agreement without the
written consent of the other.
16. Notices: Any notice required under this Agreement will be in writing, addressed to the
appropriate party at the address which appears below (as modified in writing from time
to time by such party), and given personally, by registered or certified mail, return receipt
requested, by facsimile or by nat ionally recognized overnight courier service. Time period
for notices shall be deemed to have commenced upon the date of receipt, EXCEPT
facsimile delivery will be deemed to have commenced on the first business day following
transmission. Email and telephone may be used for purposes of administering the
Agreement, but should not be used to give any formal notice required by the Agreement.
CITY OF RENTON
Wendy Rittereiser, HR Benefits Manager
1055 South Grady Way
Renton, WA 98057
Phone: (425) 430-7657
ebradley-mak@rentonwa.gov
Fax: (425) 430-7665
CONSULTANT
John Graham
8011 Brooks Chapel Road #4035
Brentwood, TN 37027
Phone: (615) 924-4663
john@jgrahaminc.com
Fax: (615) 581-1299
17. Discrimination Prohibited: Except to the extent permitted by a bona fide occupational
qualification, the Consultant agrees as follows:
PAGE 7 OF 10
A. Consultant, and Consultant’s agents, employees, representatives, and volunteers
with regard to the Work performed or to be performed under this Agreement, shall
not discriminate on the basis of race, color, sex, religion, nationality, creed, marital
status, sexual orientation or preference, age (except minimum age and retirement
provisions), honorably discharged veteran or military status, or the presence of any
sensory, mental or physical handicap, unless based upon a bona fide occupational
qualification in relationship to hiring and employment, in employment or application
for employment, the administration of the delivery of Work or any other benefits
under this Agreement, or procurement of materials or supplies.
B. The Consultant will take affirmative action to ensure that applicants are employed
and that employees are treated during employment without regard to their race,
creed, color, national origin, sex, age, sexual orientation, physical, sensory or mental
handicaps, or marital status. Such action shall include, but not be limited to the
following employment, upgrading, demotion or transfer, recruitment or recruitment
advertising, layoff or termination, rates of pay or other forms of compensation and
selection for training.
C. If the Consultant fails to comply with any of this Agreement’s non-discrimination
provisions, the City shall have the right, at its option, to cancel the Agreement in
whole or in part.
D. The Consultant is responsible to be aware of and in compliance with all federal, state
and local laws and regulations that may affect the satisfactory completion of the
project, which includes but is not limited to fair labor laws, worker's compensation,
and Title VI of the Federal Civil Rights Act of 1964, and will comply with City of Renton
Council Resolution Number 4085.
18. Miscellaneous: The parties hereby acknowledge:
A. The City is not responsible to train or provide training for Consultant.
B. Consultant will not be reimbursed for job related expenses except to the extent
specifically agreed within the attached exhibits.
C. Consultant shall furnish all tools and/or materials necessary to perform the Work
except to the extent specifically agreed within the attached exhibits.
D. In the event special training, licensing, or certification is required for Consultant to
provide Work he/she will acquire or maintain such at his/her own expense and, if
Consultant employs, sub-contracts, or otherwise assigns the responsibility to perform
the Work, said employee/sub-contractor/assignee will acquire and or maintain such
training, licensing, or certification.
PAGE 8 OF 10
E. This is a non-exclusive agreement and Consultant is free to provide his/her Work to
other entities, so long as there is no interruption or interference with the provision of
Work called for in this Agreement.
F. Consultant is responsible for his/her own insurance, including, but not limited to
health insurance.
G. Consultant is responsible for his/her own Worker’s Compensation coverage as well as
that for any persons employed by the Consultant.
19. Other Provisions:
A. Approval Authority. Each individual executing this Agreement on behalf of the City
and Consultant represents and warrants that such individuals are duly authorized to
execute and deliver this Agreement on behalf of the City or Consultant.
B. General Administration and Management. The City’s project manager is Wendy
Rittereiser, HR Benefits Manager. In providing Work, Consultant shall coordinate with
the City’s contract manager or his/her designee.
C. Amendment and Modification. This Agreement may be amended only by an
instrument in writing, duly executed by both Parties.
D. Conflicts. In the event of any inconsistencies between Consultant proposals and this
Agreement, the terms of this Agreement shall prevail. Any exhibits/attachments to
this Agreement are incorporated by reference only to the extent of the purpose for
which they are referenced within this Agreement. To the extent a Consultant
prepared exhibit conflicts with the terms in the body of this Agreement or contains
terms that are extraneous to the purpose for which it is referenced, the terms in the
body of this Agreement shall prevail and the extraneous terms shall not be
incorporated herein.
E. Governing Law. This Agreement shall be made in and shall be governed by and
interpreted in accordance with the laws of the State of Washington and the City of
Renton. Consultant and all of the Consultant’s employees shall perform the Work in
accordance with all applicable federal, state, county and city laws, codes and
ordinances.
F. Joint Drafting Effort. This Agreement shall be considered for all purposes as prepared
by the joint efforts of the Parties and shall not be construed against one party or the
other as a result of the preparation, substitution, submission or other event of
negotiation, drafting or execution.
PAGE 9 OF 10
G. Jurisdiction and Venue. Any lawsuit or legal action brought by any party to enforce or
interpret this Agreement or any of its terms or covenants shall be brought in the King
County Superior Court for the State of Washington at the Maleng Regional Justice
Center in Kent, King County, Washington, or its replacement or successor. Consultant
hereby expressly consents to the personal and exclusive jurisdiction and venue of
such court even if Consultant is a foreign corporation not registered with the State of
Washington.
H. Severability. A court of competent jurisdiction’s determination that any provision or
part of this Agreement is illegal or unenforceable shall not cancel or invalidate the
remainder of this Agreement, which shall remain in full force and effect.
I. Sole and Entire Agreement. This Agreement contains the entire agreement of the
Parties and any representations or understandings, whether oral or written, not
incorporated are excluded.
J. Time is of the Essence. Time is of the essence of this Agreement and each and all of
its provisions in which performance is a factor. Adherence to completion dates set
forth in the description of the Work is essential to the Consultant’s performance of
this Agreement.
K. Third-Party Beneficiaries. Nothing in this Agreement is intended to, nor shall be
construed to give any rights or benefits in the Agreement to anyone other than the
Parties, and all duties and responsibilities undertaken pursuant to this Agreement will
be for the sole and exclusive benefit of the Parties and no one else.
L. Binding Effect. The Parties each bind themselves, their partners, successors, assigns,
and legal representatives to the other party to this Agreement, and to the partners,
successors, assigns, and legal representatives of such other party with respect to all
covenants of the Agreement.
M. Waivers. All waivers shall be in writing and signed by the waiving party. Either party’s
failure to enforce any provision of this Agreement shall not be a waiver and shall not
prevent either the City or Consultant from enforcing that provision or any other
provision of this Agreement in the future. Waiver of breach of any provision of this
Agreement shall not be deemed to be a waiver of any prior or subsequent breach
unless it is expressly waived in writing.
N.Counterparts. The Parties may execute this Agreement in any number of
counterparts, each of which shall constitute an original, and all of which will together
constitute this one Agreement.
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IN WITNESS WHEREOF, the Parties have voluntarily entered into this Agreement as of the date
last signed by the Parties below.
CITY OF RENTON
By:_____________________________
CONSULTANT
By:____________________________
Ellen Bradley-Mak
Administrator
John Graham
President
_____________________________
Date
_____________________________
Date
Approved as to Legal Form
By: __________________________
Shane Moloney
City Attorney
Contract Template Updated 9/9/2020
_____________________________________________________________
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6/21/2021ϲͬϮϮͬϮϬϭϮ
(approved via email from Alex Tuttle)
CityofRenton
ClaimsAuditProposal
May28,2021
8011BrooksChapelRoad#4035|Brentwood,TN37027
(615)924Ͳ4663|www.jgrahaminc.com
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CityofRenton
May28,2021Page|i
Table of Contents
Overview ......................................................................................................................... 1
Our Background and Purpose ........................................................................................ 2
Audit Scope .................................................................................................................... 3
Timeline .......................................................................................................................... 4
Employer Information Request ....................................................................................... 5
Pricing ............................................................................................................................. 6
Project Team Descriptions .............................................................................................. 7
CityofRenton
May28,2021Page|1
OVERVI EW
Thank you for the opportunity to present our claims audit services to City of Renton.
The claims audit will be a repeat project as JGI conducted the same comprehensive
claims audit for this plan on audits of HMA in 2015 and 2018. Our team’s background
with the City of Renton as well as our experience across dozens of employer groups,
industries, public sector groups, audit scopes and third-party administrators ensures
that we are exceptionally well positioned to address your unique needs on this project.
We again recommend our comprehensive audit scope for this project which includes
data mining of all paid claims for the plan covering a wide variety of potential errors.
The sample for the claims audit is selected from the results of this data mining process,
so claims are reviewed based on their potential as errors as opposed to a random
selection. This detailed focus on exceptions and errors allows for identification of plan
improvement opportunities, clarification on plan interpretation and root causes that
can be corrected for future cost savings. We are able to modify the scope of the audit
to meet objectives that come to light during the initial planning phases of the project,
including any targeted areas of concern for your plan. Combining quality improvement
available through an exceptional claims audit approach with direct recoveries from
overpayment correction will offer City of Renton an outstanding return on investment.
JGI is ready to begin the project immediately. Our proposed pricing of $12,500
includes all out-of-pocket costs, and there are no additional charges for audit
remediation or follow-up. This proposal contains descriptions of our approach and
scope for the project, and we are happy to schedule time to answer any additional
questions at your discretion.
CityofRenton
May28,2021Page|2
OUR B ACKGRO UN D A ND PURPOSE
J. Graham Inc. was founded by experienced claims audit personnel with an exceptional
track record of producing results for some of the largest employers in the country. Our
firm is built by professionals with experience auditing data sets as large as $5 billion
using various audit approaches including random sample, targeted and recovery-
focused projects. Our team has audited claims for hundreds of self-insured employers
and at every major national carrier with ASO business including Aetna, Anthem, Cigna,
Humana, Meritain, UMR, Optima, UnitedHealthcare and practically every BCBS plan in
the country.
Error rates in healthcare range from 1% to 3% not including fraud, and our goal with
every audit is to recover some of these lost expenses for our client. With recovery of
overpayments paying for most or all of the total costs of the audit and root cause
corrections generating future cost savings, our claims audits produce a tremendous
return-on-investment for our clients.
Our company was founded to address the following core purposes:
Accessibility of Audit Services – We seek to ensure that all self-insured employers have
access to exceptional audit services no matter their size or unique benefit management
arrangements. J. Graham Inc. prices our services competitively, offers multiple audit
approaches and uses creative structuring of engagements to meet the needs of
employer groups that vary significantly in size, industry and goals.
Corporate Responsibility – Our company keeps top of mind awareness on sustainable
business practices including Reduce, Reuse and Recycle efforts; energy efficient and
green cleaning office space; policies that reduce travel and encourage meeting and
work in teams by virtual presence when possible and infrastructure to allow for paper-
free audit trails, proposals and reports. Employee initiatives for social responsibility
are supported and encouraged. We donate 2% of total revenue to local charitable
causes that are selected by our employees annually.
Life Balance – Work makes up a significant portion of our daily lives, but J. Graham Inc.
encourages its employees to ensure that they maintain adequate focus on priorities in
all aspects of life. We value results over process – our employees are judged by what
they produce for our clients and how they work within our team foremost. All of our
staff enjoy the flexibility to cover life responsibilities freely as needed, are provided
time to work from home rather than the office and are expected to utilize time off
regularly. We have no formal vacation limits as we expect each employee to responsibly
determine the time off that they need at various times and phases of their lives, and
we work with each other collaboratively to cover projects accordingly.
CityofRenton
May28,2021Page|3
A UDIT S CO PE
J. Graham Inc. will request a complete claims, eligibility and banking file from HMA
covering the audit period (most likely January 2020 to June 2021). We will query the
data for a wide variety of potential errors, including but not limited to:
x Duplicate claims
x Eligibility confirmation
x Coordination of Benefits and other Third Party Liability
x Pricing of claims to network discounts, UCR or other out-of-network limits
x Modifier discounts such as multiple procedures, assistant surgeons
x Medical edits such as unbundling of codes
x Patient portions – deductible, copayments, coinsurance
x Plan benefit limits and covered services
x Timely filing
x Turnaround time
x Authorizations
x Accurate data entry including member, provider, payee (tested on site only)
Audit staff will review the output of these detailed queries and determine how best to
construct the claim sample to maximize recoveries, resolve any high-dollar potential
errors and address all systemic concerns. We will request a sample size of 300 claims
with HMA, though the audit can be accomplished with fewer site visit claims if required.
J. Graham Inc. will identify the maximum number of contract review selections to
ensure that we test pricing and contractual terms on the highest paid facilities.
The project includes a one-week site visit with HMA which we would expect to be
handled remotely given the current environment. JGI has completed many remote
audits this past year with no negative impact on the process. We would expect the
majority if not all of the answers to these write-ups during the site visit week. Within
two weeks of answers to write-ups, we will provide the Draft Audit Report and out-of-
sample claims to both HMA and City of Renton. We will incorporate the formal
response from HMA into a Final Audit Report. The last stage of the audit process
includes a meeting(s) between City of Renton, HMA and J. Graham Inc. to plan
resolution of all findings including recovery and root cause correction where
appropriate.
CityofRenton
May28,2021Page|4
TI M ELINE
J. Graham Inc. is prepared to begin the project immediately. Below is an outline of key
project steps and general timing of each.
Phase One: Con tr acts and Data Gathering
Contract and BAA with City of Renton Week 1
Audit Scope to HMA Week 1
Client Information Request Week 1-2
Audit Agreement or NDA with HMA Week 2
Data due from HMA Week 4
Eligibility, Claims, Banking, Account Structure
Phase Two: Data Mining and Sample Selectio n
Load and scrub data Week 5
Map benefits from plan documents Week 5
Run standard and custom algorithms Week 6
Review output and select samples Week 6-8
Sample due to HMA Week 8
Four week wait time imposed by HMA Week 9-12
Phase T hree: Site Visit and Report
Remote site visit with HMA Week 13
Responses to all write-ups due Week 14
Draft Audit Report Week 16
Response from HMA due Week 18
Final Audit Report Week 19
Phase Four: Remed i ation
Conference call with City of Renton and HMA Week 20
HMA correction of root cause issues Week 22
Recovery of overpayments at client discretion Ongoing
CityofRenton
May28,2021Page|5
EMPL O Y ER IN FORMATION REQUEST
Very little time and effort is required from the client in our turnkey claims audit solution,
but below is a brief description of the information we require in order to proceed with
the project.
x Copies of plan documents for all benefit plan years included in the audit scope
x Copy of the ASO agreement for all plan years included
x Information on reinsurance policies in force over the time period including
reimbursements received if available
x Summary of amounts funded to the claim account for the audit time period for
comparison to the data set extracted from HMA
x Electronic eligibility file if available showing all members who had eligibility
during the audit time period
CityofRenton
May28,2021Page|6
PRI CING
In recognition of the City of Renton as a repeat client and the unique pricing
arrangement that was utilized for the City in the past, we have priced this project
aggressively at a total fixed fee of $12,500 for the medical claims audit. Prices quoted
include all services and expenses related to the claims audit including audit
remediation. When comparing our price to other quotes received, pay particular
attention to those that list expenses as an add-on to the fee quotes and those that
break out audit remediation into a separate or undefined pricing. J. Graham Inc.
believes claims audits are best quoted as a turnkey solution since most employer
groups do not have the healthcare claims expertise to navigate these important final
steps of the project without assistance. We price our services to include all necessary
phases so the client sees the exact cost for the entire project.
CityofRenton
May28,2021Page|7
PRO JE CT TE A M DE SCRI P TIONS
J. Graham Inc. performs all claims audit functions directly with no use of independent
contractors on any phase of engagements. We believe this approach to staffing
provides the most effective training, quality assurance and project management
available. Proposed project team members for this engagement include:
John Graham, Client Manager
John will handle overall quality assurance review on these projects and will present all
findings through the closing phases. John has performed and managed claims audits
for self-insured employers for twenty years and has personally led the recovery of
millions of dollars for clients in this time period. John has contributed to the
development of the industry by significantly increasing acceptance of comprehensive
claims audits over his career and developing unique arrangements for clients including
negotiating more aggressive audit rights, enhanced provider contract audits and higher
frequency of claims audits. John’s broad healthcare consulting experience also includes
financial modeling for healthcare providers and payers, contract management system
development and implementation, fee schedule analysis and strategic planning. He has
served as an expert for multiple litigation support projects focused on claims accuracy
and testing. John graduated from Duke University with a Bachelor of Arts degree in
Economics and earned the Group Benefits Associate designation through IFEBP.
Tom McFarling, Lead Auditor
As the Lead Auditor on this project, Tom will document all plan benefits, ensure peer
review for output of our claims algorithms, lead sample selections and participate in
the site visit. Tom has over twenty years of healthcare experience including
programming and application support, with the majority dedicated to auditing medical,
dental and pharmacy claims for self-funded employers. He has also supported the
information technology structure of auditing firms and designed and validated related
security policies and protocols.Tom has been instrumental in auditing over 250 million
claims in his career by utilizing high level programming and data analysis skills while
applying extensive and detailed knowledge of the claims adjudication process.Such
experience includes management of claims and eligibility datasets, query development,
detailed analysis of results, creation of site visit sample and out-of-sample reports,
customized benefits analysis from employer plan documents, third-party administrator
site visits, provider contract analysis, collections tracking and audit report
development. Tom is also a HITRUST Certified CSF Practitioner (CCSFP) which is
utilized on HIPAA Privacy and Security issues for JGI. Tom graduated from the
University of Tennessee, Knoxville with a Bachelor of Science in Mathematics.
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Susan Theroff, Healthcare Benefits Analyst
Susan will document plan benefits for this project and will be the primary researcher
for any new queries required for these plans or refinements to current logic necessary
to address unique plan design. Susan has over fourteen years of experience in group
benefits administration and management. She has worked on both the brokerage and
employer side of healthcare benefits for companies ranging in size from 10 to 10,000
employees. Susan’s background includes extensive experience in data analysis,
auditing, reporting and compliance. She is detail oriented and strives to provide
thorough and accurate work on every client project. Susan graduated Summa Cum
Laude from Vincennes University with an Associate of Applied Science in Business
Management. She also holds a Bachelor of Science degree in Theatre from the
University of Southern Indiana.
Guy Brooks, Claims Data Specialist
Guy plays a lead role in data functions at J. Graham Inc. including setting our company
standards for data scrubbing and data integrity, reviewing standard query output,
developing custom queries and designing data flow functions to support efficient and
maximized production output. Guy has over twenty years of experience in healthcare
with focus in data processing, product development, business intelligence and quality
improvement. He has worked in claims auditing over the last six years with direct
experience serving multiple employer groups including Fortune 500 companies,
municipalities, multi-employer groups and union plans across various administrators
and claims platforms. Guy graduated from Western Kentucky University with a Bachelor
of Science degree in Computer Information Systems.
Crystal Kelly, Client Coordinator
Crystal serves as a primary contact with clients in her role at J. Graham Inc., focusing
on resource gathering for projects, client and internal team communication, document
production and audit remediation tracking. She will be the initial point of contact for
any issues or questions that arise during the course of the project and will ensure that
appropriate audit staff are available and responsive. Crystal is committed to ensuring
that our clients’ needs are accommodated throughout each claims audit project. She
has worked within this team for six years serving a lead role in administration, and her
familiarity with overall project management in our team and individual skill sets is critical
to maintaining this commitment. Crystal also handles coordination of proposals and
RFP responses, accounts receivable functions and administrative infrastructure at our
company. Crystal graduated from the University of Tennessee, Knoxville with a
Bachelor of Science in Exercise Science and has past work experience in the pharmacy
industry.