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HomeMy WebLinkAboutExhibit ACQASSE TSB Norkers Compensation Medical Only ndemnity nd-Tier II-Flonda, New York, Ohio and Texas City of Miami - 000757 2/15/2014 - 2/15/2015 EXHIBIT A PRICING OPTION: COST PLUS -LIFE OF PARTNERSHIP OPTION (Based on utilizing GBMCS) Life of Partnership Annual Cost Plus Estimated Year 3 41* @ASISE • ' All Fees included in salnes below All Fees included in salries below All Fees included in salves below All Fees included in seines below -lability 3eneral Bodily Injury All Fees included in seines below 3eneral Property Damage All Fees included in seines below Auto Bodily Injury All Fees included in salries below Auto Property Damage All Fees included in seines below Auto Physical Damage All Fees included in seines below professional Liability All Fees included in seines below Actual Salaries at Actual Salaries at Actual Salaries at Actual Salaries at Commencement of 1st Come nee ment of Conmenee ment of 3rd Cormtencernent of Actual Salaries at Year of City Option - 2nd Year of City Year of City Option - 4th Year of City Conmencement of 5th Total Salary Expense $682,515 Option - S641,114 $607,587 Option Year of City Option Total Estimated Service Fee (2.30 multiplier) S1,603,910 S1,474,562 $1, 397, 451 TBD TBD Annual Fee for Licensing of SysFacs (up to six users) S0 $17,500 517,500 TBD TBD Grand Total $1,603,910 $1,492,062 51,414,951 TBD TBD ' Quoted as Second Year of Fie Additional Year Long Options or the City of Miami to renew at their sole option. Total dollar ncrease from year to year not to exceed 4% over expiring year ' True Salanes to be Calculated al Beginning at Service Penod ' Client and GB to Agree on Staffing Pnor to Beginning or Semce Penod ' GB will perform normal salary administration pursuant to GB Procedures Quoted as third year of five additional year -long options for the City of Miami to renew at their sole option. Total dollar increase from year to year not to exceed 4% over expiring year. True Salaries to be Calculated at Beginning at Service Period Client and GB to Agree on Staffing Prior to Beginning of Serivce Period GB will perform normal salary administration pursuant to GB Procedures 14-00833-Exhibit A Budgeted Staff Cost & Terms (Revision date: 12/5/2013) Page 1 I 02 cQALssE�0. City of Miami - 000757 2/15/2014 - 2/15/2015 GR MANA(zFf CARP SFRVICFS 'gLLAGH� eAssE • SERVICES CHARGES Fee Schedule or UCR $8.50 per bill All Other Savings included: PPO Networks, Specialty Networks, Clinical Edits, Clinical Validation, Nurse Review, Out of Network (Provider & Rx), Physician Rx Dispensing. 25% of savings Enhanced Savings No Charge Electronic receipt of medical bills $2 additional per bill or 2 line header in all applicable states Telephonic Case Management $75 Medical Triage $290 per Indemnity claim (each 30 days) $130 per Medical Only claim (one time) Hospital Certification Program $120 per hospital certification Utilization Review Program $105 per review Physician Review/Peer Review $270 per review Task -Based Field Case Management • Task 1: One Visit Task • Task 2: Two Visit Task • Task 3: Labor Market Survey • Task 4: Vocational Assessment • Task 5: Home Visit $530 per assignment $705 per assignment $635 per assignment $590 per assignment $660 ($730 in CA) per assignment Medical Case Management and Vocational Rehabilitation - Hourly $92 per hour plus expenses $103 per hour — AK, CA, HI, NY Priority Care 365 $90 per call HCN Service Options Option#1 — unbundled rate: $17 per bill to include bill review & network access, $75 for triage Options #2 — bundled rate: $27 per bill to include bill review, network access & nurse triage Option #3 — percent of savings: 9.5% of total savings to include bill review, network access & nurse triage Medical Cost Projection (MCP) and Clinical Recommendations $125 per hour Dental Review Program Charged on a per review basis OSHA Reporting $4,500 per year (includes set-up, OSHA access & unlimited OSHA logs and summaries) Taxes All applicable taxes will be added to the service fees where required Client and GB agree as follows: If another preferred managed care vendor other than Gallagher Bassett Managed Care Services is utilized, an administrative fee may apply in exchange for bona fide administrative services. The administrative services may include, but not be limited to overhead costs for the oversight and management of Managed Care vendors which includes the development and oversight of quality standards, development and maintenance of EDI interfaces and reports, monitoring of Managed Care vendor performance, and ensuring proper mandatory state compliance and reporting. Budgeted Staff Cost & Terms (Revision date: 12/5/2013) Page 2 01110., --ABBE I City of Miami - 000757 2/15/2014 - 2/15/2015 OTHER SERVICES SERVICES CHARGES risxfacs.com - Additional Users $1,000 per user GB International Claims Services Varies by Country (pricing provided upon request) Consultative Services Loss Control Consulting Services $140 per hour Appraisal Services TBD MountainView ClaimZone RMIS Module TBD Fraud Prevention — Gallagher Bassett Investigative Services (GBIS) Special Fraud Investigations - SIU $85 per hour plus expenses Surveillance Investigations $70 per hour plus expenses Targeted Field Investigations $80 per hour plus expenses Targeted Database Investigations Rate per report Medlnsights MSA/MSP Compliance Services (This pricing is for Medlnsights services only. If another vendor is selected, then other pricing applies) Social Security Verification (Entitlement Determination) $175.00 per verification Medicare Lien Evaluation Conditional Payment Search $250 per search Manual Medicare Eligibility Inquiry (Rush Request) $35 Conditional Payment Lien Negotiations $150 per hour Medical Cost Projection $125 per hour MSA Resolution Unit Service $450 Fee Pharmaceutical Drug Review $450 per review (If PDR doesn't prove to reduce lifetime costs by $5,000 the fee reduced to $35) Medicare Set -Asides Workers Compensation Medicare Set -Aside Allocation (WCMSA) $2,300 per allocation Rush Fees (MSA com.leted within 7 days) $450 per case Revisions: $150 per hour (One free revision within six months of submission) Liability Medicare Set -Aside Allocation (LMSA) $1,535 Fee MSA Submission to CMS $850 Fee Taxes All applicable taxes will be added to the service fees where required Budgeted Staff Cost & Terms (Revision date: 12/5/2013) Page 3 City of Miami - 000757 2/15/2014 - 2/15/2015 PROGRAM SPECIFIC TERMS AND CONDITIONS Giq ALLAGv, QASSE' 1. Billing and Payment Terms: Fees will be billed Monthly during the calendar year. Fees are payable within 30 days upon receipt of the invoice. Gallagher Bassett reserves the right to charge 1 % per month, or the maximum legal rate, on balances unpaid after 30 days. 2. Budgeted Staffing Claim Pricing Terms: Claims will be handled for the life of the partnership with no additional per claim fees. If you should decide to non -renew or stop using GB in a specific state, the existing open files can be handled in one of three ways. O. Gallagher Bassett would continue to handle the open files at our prevailing rates fee per year per open file. ► Gallagher Bassett would continue to handle the open files on a Time and Expense basis. ► Gallagher Bassett would return the files to the client (contingent upon Carrier approval) at the client's expense. *Please see Claim Charges outlined in footnote 7 under Program Specific Terms and Conditions. Note: There will be additional charges for ongoing Data Management (RISX-FACS®), risxfacs.com users, Administration, Banking fees and monthly reports for as long as GB handles claims. 3. Account Administration includes the following: a. Designated Account Manager b. Detailed Status Reports @ $50,000 c. Settlement Authority @ $10,000 (WC), $3,000 (Liability) d. Banking Administration (SIMMS) e. Two Claim Reviews a Year or One Audit f. Acknowledgement Letter to claimant 4. Data Management includes the following: New Claim Setup Historical Claims • Monthly Report by Email or the Website • Carrier Report Package by Email or Website 5. Pricing is based on using GB Managed Care (GBMCS) for Bill Review, PPO, utilization review, Budgeted Staff Cost & Terms (Revision date: 12/5/2013) Page 4 -m" _. CALLAGNE� BASSETS Enter Client's Full Legal Name Start Date - End Date 1-.51,AALLAeGSSE 6. Claim Charges: The Claim charge is applicable per claim per line of coverage. Example: A client employee during working hours is involved in an automobile accident with another vehicle with two occupants. Both occupants were injured, both cars were damaged and our client employee was injured. The claims handling charges (example only) will be: Claimant #1 - Auto Liability Bodily Injury $0 Claimant #2 - Auto Liability Bodily Injury $0 Claimant Owner - Auto Liability Property Damage $0 Client — Workers' Compensation $0 Client — Auto Physical Damage $0 $0 All charges are included within Cost Plus Staffing model. 7. Gallagher Bassett Services, Inc. will not pay a fee, commission, or rebate to any party for the privilege of presenting our proposal or in order to secure the awarding of any program to Gallagher Bassett Services. 8. Client and GB agree as follows: As part of our comprehensive claims service delivery model, Gallagher Bassett (GB) partners with selected best -in -class third party providers. These services are generally purchased on a wholesale or negotiated basis with GB delivering additional value-added customizations that may include scanning, electronic bill processing, maintenance and operation of EDI interfaces, vendor management, quality assurance, mandatory state compliance and provision of savings and outcome reports. Within these arrangements, GB may receive revenue commensurate with our work product to integrate and manage these relationships and services. As a company policy, we do not disclose the terms of these contracts and arrangements. We are, however, confident that when compared to other providers in the industry, our end -pricing as outlined in the Cost and Terms document is competitive in the marketplace and provides excellent value to our clients. Budgeted Staff Cost & Terms (Revision date: 12/5/2013) Page 5 Enter Client's Full Legal Name Start Date - End Date GENERAL CONTRACT TERMS AND CONDITIONS eRSSEI-C 1. Independent Adjuster for Catastrophes - If applicable, any significant Property loss as a result of a single event (i.e. hurricane, tornado, flood, earthquake, etc.), GB reserves the right to retain outside resources (adjusters) when appropriate and those fees will be paid as an Allocated Expense off the file. 2. Material Change - GB reserves the right to modify its fees upon sixty (60) days prior notice to CLIENT if: a. It is determined that the historical data upon which GB's fees and service charges developed were based upon erroneous, obsolete or insufficient information, or that a change in CLIENT's business will materially change the nature and/or volume of its business or claims as contemplated at the inception of the Agreement b. During the term of the Agreement, legislative and/or regulatory requirements materially impact or change the scope of GB's services or responsibilities 3. Taxes - All applicable taxes will be added to the service fees where required 4. Allocated Expenses: Shall be your responsibility and shall include, but not be limited to: Legal Fees Medical Examinations > Professional Photographs > Travel made at client's request Costs for witness statements s Court reports s Medical records > Accident reconstruction • Experts' rehabilitation costs Chemist Fees for service of process Collection cost payable to third parties on > Architects, contractors Engineer • Any other similar cost, fee or expense reasonably chargeable to the investigation, negotiation, settlement or defense of a claim or loss which must have the explicit prior approval of the client Police, fire, coroner, weather, or other such reports Property damage appraisals, SIU, surveillance and sub rosa investigation Official documents and transcripts Pre- and post -judgment interest paid Outside Investigation Index Bureau Reporting Second Injury Fund Recovery Data Intelligence Self -Service Reports Managed Care - Managed Care services may include, but are not limited to: i. Preferred provider organization networks ii. Utilization review services iii. Automated state fee scheduling iv. Light duty/return-to-work programs v. Medical case management and Vocational rehabilitation network vi. Prospective injury management services vii. Hospital bill audit services V V V V V V V V V V Budgeted Staff Cost & Terms (Revision date: 12/5/2013) Page 6 Ott - JP. eA38EW Enter Client's Full Legal Name Start Date - End Date DEFINITIONS Workers Compensation - Medical Only Claims A medical only claim is a work -related Claim that meets the following criteria: (i) payments for either indemnity or vocational rehabilitation were not required, (ii) the Claim has not become contested or in suit, (iii) investigation to determine compensability or subrogation requirements was not required, (iv) no loss notices, captioned reports, client meetings (other than routine meetings where the claim is listed and noted) or settlement authority approvals were required, and (v) payments on the Claim have not exceeded $2,500. Workers Compensation - Indemnity Claims An indemnity claim is a Workers Compensation claim that is not a Medical Only Claim. Incident - Electronic and Manual An Incident is a loss reported electronically through ClaimLine and/or the Web, or set up manually at the branch. GB will review the Incident and make a courtesy call [if necessary] to determine if it is a claim or Incident. GB will have full discretion in the determination and handling of these Incidents and/or their conversion into claim status. Liability Claims Investigate, evaluate and adjudicate ail third -party claims for which you may be legally obligated. Third - party claims will be managed and administered in accordance with our product guidelines. Auto Physical Damage (APD)/Property Claims Investigate, evaluate and adjudicate all first -party claims which you report involving damage or loss of real or personal property. First -party claims will be managed and administered in accordance with our product guidelines. Budgeted Staff Cost & Terms (Revision date: 12/5/2013) Page 7