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HomeMy WebLinkAboutExhibit - PSA - Third Party Claims Administration ServicesCity of Miami, Florida Contract No. RFP 605386 PROFESSIONAL SERVICES AGREEMENT Brand Bctr►ecn The CITY OF MIA:1II And USIS, INC. This Professional Services Agreement ("Agreement") is entered into this day of , 2017 ( "Effective Date") , by and between the City of Miami, a municipal corporation of the State of Florida, whose address is 444 S.W. 2nd Avenue, 10'h Floor, Miami, Florida 33130 ("City"), and, USIS, INC. a corporation, qualified to do business in the State of Florida whose principal address is 5728 Major Blvd., Suite 450, Orlando, FL 32819, hereinafter referred to as the ("Third Party Administrator"). RECITALS: WHEREAS, the City of Miami issued a Request for Proposals No. 605386 on, October 5, 2016, (the "RFP" attached hereto. incorporated hereby, and made a part of as Exhibit A) for the provision of Third Party Claims Administration Services ("Services" as more fully set forth in the scope of work "Scope" attached hereto as Exhibit 8) for the City's Risk Management Department and Third Party Administrator's proposal ('Proposal", attached hereto, incorporated hereby, and made part of hereof as Exhibit C), in response thereto, has been selected as the most responsive, responsible and qualified proposal for the provision of the Services; and WHEREAS, this Professional Services Agreement ("Agreement") was included in the RFP with a statement that it would require execution by the Successful Proposer selected as the Third Party Administrator; and, WHEREAS, the Evaluation/Selection Committee appointed by the City Manager determined that the Proposal submitted by the Third Party Administrator was responsive to the RFP requirements and recommended that the City Manager negotiate a contract with the Third Party Administrator; and WHEREAS, the City wishes to engage the Services of the Third Party Administrator, and the Third Party Administrator wishes to perform the Services for the City; and 1 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 WHEREAS, the City and the Third Party Administrator desire to enter into this Agreement under the terms and conditions set forth herein. NOW, THEREFORE, in consideration of the mutual covenants and promises herein contained, Third Party Administrator and the City agree as follows: TERMS: 1. RECITALS AND INCORPORATIONS; DEFINITIONS: A. The recitals are true and correct and are hereby incorporated into and made a part of this Agreement. The City's RFP is hereby incorporated into and made a part of this Agreement and attached hereto as Exhibit "A." The Services and Scope of Work are hereby incorporated into and made a part of this Agreement and attached as Exhibit "B." The Third Party Administrator's Response and Pricing Proposal dated, November 30, 2016, in response to RFP 605386, is hereby incorporated into and made a part of this Agreement as attached Exhibit "C." The Third Party Administrator's Insurance Certificate is hereby incorporated into and made a part of this Agreement as attached Exhibit "D." The order of precedence whenever there is conflicting or inconsistent language between documents is as follows in descending order of priority: (1) Professional Services Agreement ("PSA") (2) Addenda/Addendum to the RFP; (3) RFP; and (4) Third Party Administrator's Response and Price Proposal Schedule dated November 30, 2016, acknowledging scope of services and pricing component of services and, response to the Request for Proposals. 2. TERM: The Agreement shall become effective on the date on the first page of this Agreement, and shall be for an initial term of three (3) years. The City Manager shall have the option to administratively extend the Agreement as is needed in the opinion of the City Manager for a period of one hundred and twenty (120) days, and/or the option to renew the Agreement as provided in Section 3, or to terminate the Agreement for convenience, that is, for any or no cause, as provided in Section 16, City's Termination Rights. 2 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 3. OPTION TO RENEW: The City Manager shall have the option to renew for two (2) additional one (1) year periods, subject to availability and appropriation of funds. City Commission approval shall not be required for the above stated renewal terms. The total term of the Agreement inclusive of a!I renewals would be five (5) years. 4. SCOPE OF SERVICES: A. Third Party Administrator agrees to provide the Services as specifically described, and under the special terms and conditions set forth in Exhibits "A" and "B" hereto, which by this reference is incorporated into and made a part of this Agreement. B. Third Party Administrator represents and warrants to the City that: (i) it possesses all qualifications, licenses, certificates, degrees, authorizations, and expertise required for the performance of the Services under this Agreement, including but not limited to full qualification to do business in Florida; (ii) it is not delinquent in the payment of any sums due the City, including payment of permits, fees, occupational licenses, etc., nor in the performance of any obligations or payment of any monies to the City or presently in default of any contract it has with the City, or in presently in default of any contract with the State of Florida or any political subdivision of the State, or of any contract with a Public School Board or Special District of the State of Florida (collectively "Florida Public Agencies") nor has it been debarred or suspended under applicable laws and regulations by any of the foregoing Florida Public Agencies ; (iii) all personnel assigned to perform the Services are and shall be, at all times during the term hereof, fully qualified and trained to perform the tasks assigned to each; (iv) the Services will be performed in the manner described in Exhibit "A"; and (v) each person executing this Agreement on behalf of Third Party Administrator has been duly authorized to so execute the same and fully bind Third Party Administrator as a party to this Agreement. C. Third Party Administrator shall at all times provide fully qualified, competent and physically capable employees to perform the Services under this Agreement. Third Party Administrator shall possess and maintain any required licenses, permits, degrees, and certifications to perform the Services under this Agreement. City may require Third Party Administrator to remove any employee the City deems careless, incompetent, insubordinate, or otherwise objectionable and whose continued services under this Agreement is not in the best interest of the City. 3 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 5. COMPENSATION: A. The amount of compensation payable by the City to the Third Party Administrator shall be based on the rates quoted in Exhibit "C" hereto, which by this reference is incorporated into and made a part of this Agreement. The rates for the optional Plan Years 2020, and 2021, shall be negotiated. The Third Party Administrator shall advise the City of the recommended rates for each optional year one hundred twenty (120) days in advance of the City's open enrollment for the optional year, providing justification for any recommended rate increases above the previous year's rates. B. Payment shall be made in arrears based upon work performed to the satisfaction of the City within forty-five (45) days after receipt of Third Party Administrator's invoice for Services performed, which shall be accompanied by sufficient supporting documentation and contain sufficient detail, to allow a proper audit of expenditures, should the City require one to be performed. Invoices shall be sufficiently detailed so as to comply with the "Florida Prompt Payment Act," §218.70. - 218.79, Florida Statutes, and other applicable laws. No advance or future payments shall be made at any time. C. Third Party Administrator agrees and understands that (i) any and all y Subcontractors providing Services related to this Agreement shall be paid through Third Party Administrator and not paid directly by the City; and / or (ii) any and all liabilities regarding payment to or use of y Subcontractors for any of the Services related to this Agreement shall be borne solely by Third Party Administrator. D. Prices shall remain firm and fixed for the first two (2) years of the Contract. The City reserves the right to negotiate the rates for Year 3 of the initial contract, and for any renewal and/or extension periods. 6. OWNERSHIP OF DOCUMENTS: Third Party Administrator understands and agrees that any information, document, report or any other material whatsoever which is given by the City to Third Party Administrator, its employees, or any Subcontractor, or which is otherwise obtained or prepared by Third Party Administrator solely and exclusively for the City pursuant to or under the terms of this Agreement, is and shall at all times remain the property of the City. Third Party Administrator agrees not to use any such information, document, report or material for any other purpose whatsoever without the written consent of the City Manager, which may be withheld or conditioned by the City Manager in his/her sole discretion. Third Party Administrator is permitted to make and to maintain duplicate copies of the files, records, documents, etc. if Third Party Administrator determines 4 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 copies of such records are necessary subsequent to the termination of this Agreement; however, in no way shall the confidentiality as permitted by applicable laws be breached. The City shall maintain and retain ownership of any and all documents which result upon the completion of the work and Services under this Agreement as per the terms of this Section 5. 7. AUDIT AND INSPECTION RIGHTS AND RECORDS RETENTION: A. Third Party Administrator agrees to provide access to the City or to any of its duly authorized representatives, to any books, documents, papers, and records of Third Party Administrator which are directly pertinent to this Agreement, for the purpose of audit, examination, excerpts, and transcripts. The City may, at reasonable times, and for a period of up to three (3) years following the date of final payment by the City to Third Party Administrator under this Agreement, audit and inspect, or cause to be audited and inspected, those books, documents, papers, and records of Third Party Administrator which are related to Third Party Administrator's performance under this Agreement. Third Party Administrator agrees to maintain any and all such books, documents, papers, and records at its principal place of business for a period of three (3) years after final payment is made under this Agreement and all other pending matters are closed. Third Party Administrator's failure to adhere to, or refusal to comply with, this condition shall result in the immediate cancellation of this Agreement by the City. B. The City may, at reasonable times during the term hereof, inspect the Third Party Administrator's facilities and perform such tests, as the City deems reasonably necessary, to determine whether the goods or services required to be provided by Third Party Administrator under this Agreement conform to the terms hereof. Third Party Administrator shall make available to the City all reasonable facilities and assistance to facilitate the performance of tests or inspections by City representatives. All audits, tests and inspections shall be subject to, and made in accordance with, the provisions of Sections 18-100, 18-101, and 18-102 of the Code of the City of Miami, Florida, which apply to this Agreement, as same may be amended or supplemented, from time to time. The foregoing City Code Sections as well as the entirety of Chapter 18, "Finance", City of Miami Code, as amended and as applicable, is deemed as being incorporated by reference herein. 8. AWARD OF AGREEMENT: Third Party Administrator represents and warrants to the City that it has not employed or retained any person or company employed by the City to solicit or secure this Agreement and that it has not offered to pay, paid, or agreed to pay any person, any fee, commission, percentage, 5 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 brokerage fee, or gift of any kind contingent upon or in connection with, the award of this Agreement. 9. PUBLIC RECORDS: A. Third Party Administrator understands that the public shall have access, at all reasonable times, to all documents and information pertaining to City Agreements, subject to the provisions of Chapter 119, Florida Statutes, and agrees to allow access by the City and the public to all documents subject to disclosure under applicable laws. Third Party Administrator's failure or refusal to comply with the provisions of this section shall result in the immediate cancellation of this Agreement by the City. B. Third Party Administrator shall additionally comply with Section 119.0701, Florida Statutes, including without limitation: (1) keep and maintain public records that ordinarily and necessarily would be required by the City to perform this service; (2) provide the public with access to public records on the same terms and conditions as the City would at the cost provided by Chapter 119, Florida Statutes, or as otherwise provided by law; (3) ensure that public records that are exempt or confidential and exempt from disclosure are not disclosed except as authorized by law; (4) meet all requirements for retaining public records and transfer, at no cost, to the City all public records in its possession upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from disclosure requirements; and, (5) provide all electronically stored public records that must be provided to the City in a format compatible with the City's information technology systems. Notwithstanding the foregoing, Third Party Administrator shall be permitted to retain any public records that make up part of its work product solely as required for archival purposes, as required by law, or to evidence compliance with the terms of the Agreement. C. Should Third Party Administrator determine to dispute any public access provision required by Florida Statutes, then Third Party Administrator shall do so at its own expense and at no cost to the City. Third Party Administrator may maintain an exemption for such personal information such as Social Security Numbers of members or medical information exempted by general law. IF THE THIRD PARTY ADMINISTRATOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE THIRD PARTY ADMINISTRATOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT TIIE CUSTODIAN OF PUBLIC RECORDS AT (305) 416-1830, 6 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Via email at PublicRecords ii miamigov.com, or regular email at City of Miami Office of the City Attorney, 444 SW 2" Avenue, 9th FL, Miami, FL 33130. 10. PRIVACY AND CONFIDENTIALITY Third Party Administrator agrees to develop, adopt, and implement standards to safeguard the privacy and confidentiality of all personal information about eligible employees and members of the Program. For example, Third Party Administrator shall ensure that Third Party Administrator does not have completed forms containing personal information sitting in public view, left in unsecured boxes or files, or left unattended in any off -site location. Third Party Administrator's procedures shall include but not limited to safeguarding the identity of members as members of the Program and preventing unauthorized disclosure of personal information. Third Party Administrator agrees to report any unauthorized use or disclosure of the members' personal information to the City, within twenty-four (24) hours of any incident of which it becomes aware. Third Party Administrator agrees to comply with all federal and state laws concerning the privacy and confidentiality of members' information, and agrees to implement any regulations when they become effective. In the absence of exigent circumstances, Third Party Administrator shall not disclose any member's personal information to another business associate for pecuniary gain unless the City specifically prior authorizes such disclosure in writing. Third Party Administrator agrees to mitigate, to the extent practicable, any harmful effect that is known to the Third Party Administrator of a use or disclosure of members' information by the Third Party Administrator in violation of the requirements of this Agreement or federal or state laws, Third Party Administrator agrees to (i) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic personal information of members that Third Party Administrator creates, receives, maintains, or transmits; (ii) report to the City any security incident of which the Third Party Administrator becomes aware, and (iii) ensure that any agent of the Third Party Administrator, including any Subcontractor or sub consultant, agrees to the same restrictions and conditions that apply to the Third Party Administrator with respect to such information. Third Party Administrator agrees not to sell member information. Third Party Administrator shall not use member information unless it is aggregated blinded data, which is not identifiable on a member basis. Third Party Administrator shall not use member identified or non -aggregated information for advertising, marketing, promotion or any activity intended to influence sales or market share of any product or service. 7 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Third Party Administrator shall have full financial responsibility for any penalties, fines, or other payments imposed or required as a result of Third Party Administrator's non-compliance with, or violation of, federal or state requirements, and the Third Party Administrator shall indemnify the City with respect to any such penalties, fines, or payments. Third Party Administrator shall assure that all Third Party Administrator's staff, including Subcontractor or sub consultant, is trained in all privacy requirements, as applicable. At the request of the City, Third Party Administrator shall offer credit protection for those times in which a member's personal information is accidentally or inappropriately disclosed. This Section is not to be construed to conflict with the provisions of Chapter 119, Florida Statutes nor any exemptions from this Statute. 11. INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION AND/OR PROTECTED HEALTH INFORMATION. Any person or entity that performs or assists the City with a function or activity involving the use or disclosure of"Individually Identifiable Health Information (IIHI)" andlor Protected Health Information (PHI) shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA mandates the privacy, security, and electronic transfer standards, include but are not limited to: 1. Use of information for performing services required by the Contract or as required law; 2. Use of appropriate safeguards to prevent non -permitted disclosures; 3. Reporting to the City of any non -permitted use or disclosures; 4. Assurances that any agents and Subcontractor agree to the same restrictions and conditions that apply to the Third Party Administrator and reasonable assurances that IIHIIPHI will be held confidential; 5. Making PHI available to the customer; 6. Making PHI available to the customer for review and amendment; incorporation of any amendments requested by the customer; 7. Making PHI available to the City for an accounting of disclosures; and 8. Making internal practices, books, and records related to PHI available to the City for compliance audits. PHI shall maintain its protected status regardless of the form and method of transmission paper records, and/or electronic transfer of data). The Third Party Administrator must give its customers written notice of its privacy information practices including specifically 8 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 a description of the types of uses and disclosures that would be made with protected health information. 12. COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS: Third Party Administrator understands that agreements with local governments are subject to certain laws and regulations, including laws pertaining to public records, conflict of interest, record keeping, etc. City and Third Party Administrator agree to comply with and observe all such applicable federal, state and local laws, rules, regulations, codes and ordinances, as they may be amended from time to time. Third Party Administrator further agrees to include in all of Third Party Administrator's agreements with Subcontractor for any Services related to this Agreement this provision requiring Subcontractors to comply with and observe all applicable federal, state, and local laws rules, regulations, codes and ordinances, as they may be amended from time to time. 13. INDEMNIFICATION: Third Party Administrator shall indemnify, defend (at its own cost and expense) and hold harmless the City and its officials, employees and agents for claims (collectively referred to as "lndemnitees") and each of them from and against all Toss, costs, penalties, fines, damages, claims, expenses (including attorney's fees) or liabilities (collectively referred to as "Liabilities") by reason of any injury to or death of any person or damage to or destruction or loss of any property arising out of, resulting from, or in connection with (i) the negligent performance or non- performance of the Services contemplated by this Agreement (whether active or passive) of Third Party Administrator or its employees, agents or Subcontractor (collectively referred to as "Third Party Administrator") which is directly caused, in whole or in part, by any act, omission, default or negligence (whether active or passive or in strict liability) of the lndemnitees, or any of them, or (ii) the failure of the Third Party Administrator to comply materially with any of the requirements herein, or the failure of the Third Party Administrator to conform to statutes, ordinances, or other regulations or requirements of any governmental authority, local, federal or state, including without limitation, a claim for infringement of an intellectual property right, copyright, patent or trademark used by the Third Party Administrator, in connection with the performance of this Agreement even if it is alleged that the City, its officials, agents, and/or employees were negligent. Third Party Administrator expressly agrees to indemnify, defend and hold harmless the lndemnitees, or any of them, from and against all liabilities which may be asserted by an employee or former employee of Third Party Administrator, or any of its Subcontractors, as provided above, 9 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 for which the Third Party Administrator's liability to such employee or former employee would otherwise be limited to payments under state Workers' Compensation or similar laws. Third Party Administrator further agrees to indemnify, defend and hold harmless the Indemnitees from and against (i) any and all Liabilities imposed on account of the violation of any law, ordinance, order, rule, regulation, condition, or requirement, related directly to Third Party Administrator's negligent performance under this Agreement, compliance with which is left by this Agreement to Third Party Administrator, and (ii) any and all claims, and/or suits for labor and materials furnished by Third Party Administrator or utilized in the performance of this Agreement or otherwise. Third Party Administrator's obligations to indemnify, defend and hold harmless the Indemnitees shall survive the termination and/or expiration of this Agreement. The Third Party Administrator acknowledges that the granting of this Agreement is sufficient and independent consideration for the giving of this Indemnity. Third Party Administrator understands and agrees that any and all liabilities regarding the use of any Subcontractors for Services related to this Agreement shall be borne solely by Third Party Administrator throughout the duration of this Agreement and that this provision shall survive the termination or expiration of this Agreement, as applicable. 14. DEFAULT: If Third Party Administrator fails to comply with any term or condition of this Agreement, or fails to perform in any material way any of its responsibilities or obligations hereunder, and fails to cure such failure after reasonable notice from the City, which period to cure shall be complied with when stated in the written notice form the City, then Third Party Administrator shall be in default. Upon the occurrence of a default, hereunder the City, in addition to all remedies available to it by law, may immediately, upon written notice to the Third Party Administrator, terminate this Agreement whereupon all payments, advances, or other compensation paid by the City to Third Party Administrator while Third Party Administrator was in default shall be immediately returned to the City. Third Party Administrator understands and agrees that termination of this Agreement under this section shall not release Third Party Administrator from any obligation accruing prior to the effective date of termination. Should Third Party Administrator be unable or unwilling to commence to perform the Services within the time provided or contemplated herein, then, in addition to the foregoing, Third Party Administrator shall be liable to the City for all expenses incurred by the City in preparation and negotiation of this Agreement, as well as all costs and expenses incurred by the City in the re -procurement of the Services, including consequential and incidental damages. 10 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 15. RESOLUTION OF AGREEMENT DISPUTES: Third Party Administrator understands and agrees that all disputes between Third Party Administrator and the City based upon an alleged violation of the terms of this Agreement by the City shall be submitted to the City Manager for his/her resolution, prior to Third Party Administrator being entitled to seek judicial relief in connection therewith. In the event that the amount of compensation hereunder exceeds Twenty -Five Thousand Dollars and No/Cents ($25,000), the City Manager's decision shall be approved or disapproved by the City Commission. Third Party Administrator shall not be entitled to seek judicial relief unless: (i) it has first received City Manager's written decision, approved by the City Commission if the amount of compensation hereunder exceeds Twenty -Five Thousand Dollars and No/Cents ($25,000), or (ii) a period of sixty (60) days has expired, after submitting to the City Manager a detailed statement of the dispute, accompanied by all supporting documentation one hundred twenty (120) days if City Manager's decision is subject to City Commission approval; or (iii) City has expressly waived compliance with the procedure set forth in this section by written instruments, signed by the City Manager. In no event may the amount of compensation under this Section exceed the total compensation set forth in Section 5 (A) of this Agreement. 16. CITY'S TERMINATION RIGHTS; OBLIGATIONS UPON TERMINATION: A. The City, acting by and through its City Manager, shall have the right to terminate this Agreement, in its sole discretion, and without penalty, at any time, by giving written notice to Third Party Administrator at least thirty (30) calendar days prior to the effective date of such termination. In such event, the City shall pay to Third Party Administrator compensation for Services rendered and approved expenses incurred prior to the effective date of termination. In no event shall the City be liable to Third Party Administrator for any additional compensation and expenses incurred, other than that provided herein, and in no event shall the City be liable for any consequential or incidental damages. The Third Party Administrator shall have no recourse or remedy against the City for a termination under this subsection except for payment of fees due prior to the effective date of termination. B. The City, by and acting through its City Manager, shall have the right to terminate this Agreement, in its sole discretion, and without penalty, upon the occurrence of an event of an event of default hereunder, and failure to cure the same within thirty (30) days after written notice of default. In such event, the City shall not be obligated to pay any amounts to Third Party Administrator for Services rendered by Third Party Administrator after the date of termination, but 11 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 the parties shall remain responsible for any payments that have become due and owing as of the effective date of termination. In no event shall the City be liable to Third Party Administrator for any additional compensation and expenses Incurred, other than that provided herein, and in no event shall the City be liable for any direct, indirect, consequential or incidental damages. 17. INSURANCE: A. Third Party Administrator shall, at all times during the term hereof, maintain such insurance coverage(s) as may be required by the City. The insurance coverage(s) required as of the Effective Date of this Agreement are attached hereto as Exhibit "D" and incorporated herein by this reference. The City RFP number and title of the RFP must appear on each certificate of insurance. The Third Party Administrator shall add the City of Miami as an additional insured to its commercial general liability, and auto liability policies, and as a named certificate holder on all policies. Third Party Administrator shall correct any insurance certificates as requested by the City's Risk Management Administrator, All such insurance, including renewals, shall be subject to the approval of the City for adequacy of protection and evidence of such coverage(s) and shall be furnished to the City Risk Management Director on Certificates of Insurance indicating such insurance to be in force and effect and any cancelled or non -renewed policy will be replaced with no coverage gap and a current Certificate of Insurance will be provided. Completed Certificates of Insurance shall be filed with the City Risk Management Director prior to the performance of Services hereunder, provided, however, that Third Party Administrator shall at any time upon request file duplicate copies of the Certificate of Insurance with the City. B. Third Party Administrator understands and agrees that any and all liabilities regarding the use of any of Third Party Administrator's employees or any of Third Party Administrator's Subcontractors for Services related to this Agreement shall be borne solely by Third Party Administrator throughout the term of this Agreement and that this provision shall survive the termination of this Agreement. Third Party Administrator further understands and agrees that insurance for each employee of Third Party Administrator and each Subcontractors providing Services related to this Agreement shall be maintained in good standing and approved by the City Risk Management Administrator throughout the duration of this Agreement. C. Third Party Administrator shall be responsible for assuring that the insurance certificates required under this Agreement remain in full force and effect for the duration of this Agreement, including any extensions hereof. If insurance certificates are scheduled to expire during the term of this Agreement and any extension hereof, Third Party Administrator shall be responsible for submitting new or renewed insurance certificates to the City's Risk Management 12 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Director as soon as coverages are bound with the insurers. In the event that expired certificates are not replaced, with new or renewed certificates which cover the term of this Agreement and any extension thereof: (i) the City shall suspend this Agreement until such time as the new or renewed certificate(s) are received in acceptable form by the City's Risk Management Director; or (ii) the City may, at its sole discretion, terminate the Agreement for cause and seek re -procurement damages from Third Party Administrator in conjunction with the violation of the terms and conditions of this Agreement. D. Compliance with the foregoing requirements shall not relieve Third Party Administrator of its liabilities and obligations under this Agreement. 18. NONDISCRIMINATION: Third Party Administrator represents to the City that Third Party Administrator does not and will not engage in discriminatory practices and that there shall be no discrimination in connection with Third Party Administrator's performance under this Agreement on account of race, color, sex, religion, age, handicap, marital status or national origin. Third Party Administrator further covenants that no otherwise qualified individual shall, solely by reason of his/her race, color, sex, religion, age, handicap, marital status or national origin, be excluded from participation in, be denied services, or be subject to discrimination under any provision of this Agreement. 19. ASSIGNMENT: The Third Party Administrator's services are considered unique in nature and highly specialized. This Agreement shall not be assigned, sold, transferred, pledged, encumbered, hypothecated, or otherwise conveyed by Third Party Administrator, in whole or in part, and Third Party Administrator shall not assign any part of its operations, without the prior written consent of the City Manager, which may be withheld, denied, or conditioned, in the City's sole discretion through the City Manager. 20. SUBCONTRACTUAL RELATIONS A. If the Third Party Administrator will cause any part of this Agreement to be performed by a Subcontractor, the provisions of this Agreement will apply to such Subcontractor and its officers, agents and employees in all respects as if it and they were employees of the Third Party Administrator; and the Third Party Administrator will not be in any manner thereby discharged from its obligations and liabilities hereunder, but will be liable hereunder for all acts 13 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 and negligence of the Subcontractor, its officers, agents, and employees, as if they were employees of the Third Party Administrator. The services performed by the Subcontractor will be subject to the provisions hereof as if performed directly by the Third Party Administrator. B. The Third Party Administrator, before making any subcontract for any portion of the services, will state in writing to the City the name of the proposed Subcontractor the portion of the Services which the Subcontractor is to do, the place of business of such Subcontractor, and such other information as the City may require. The City will have the right to require the Third Party Administrator not to award any subcontract to a person, firm or corporation disapproved by the City. C. Before entering into any subcontract hereunder, the Third Party Administrator will inform the Subcontractor fully and completely of all provisions and requirements of this Agreement relating either directly or indirectly to the Services to be performed. Such Services performed by such Subcontractor will strictly comply with the requirements of this Contract. D. In order to qualify as a Subcontractor satisfactory to the City, in addition to the other requirements herein provided, the Subcontractor must be prepared to prove to the satisfaction of the City that it has the necessary facilities, skill and experience, and ample financial resources to perform the Services in a satisfactory manner. To be considered skilled and experienced, the Subcontractor must show to the satisfaction of the City that it has satisfactorily performed services of the same general type which is required to be performed under this Agreement. E. The City shall have the right to withdraw its consent to a subcontract if it appears to the City that the Subcontractor will delay, prevent, or otherwise impair the performance of the Third Party Administrator's obligations under this Agreement. All Subcontractors are required to protect the confidentiality of the City's and City's proprietary and confidential information. Third Party Administrator shall furnish to the City copies of all subcontracts between Third Party Administrator and Subcontractor and suppliers hereunder. Within each such subcontract, there shall be a clause for the benefit of the City in the event the City finds the Third Party Administrator in breach of this Contract, permitting the City to request completion by the Subcontractor of its performance obligations under the subcontract. The clause shall include an option for the City to pay the Subcontractor directly for the performance by such Subcontractor. Notwithstanding, the foregoing shall neither convey nor imply any obligation or liability on the part of the City to any Subcontractor hereunder as more fully described herein. 14 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 20. NOTICES: All notices or other communications required under this Agreement shall be in writing and shall be given by hand-deiivery or by registered or certified U.S. Mail, return receipt requested, addressed to the other party at the address indicated herein or to such other address as a party may designate by notice given as herein provided. Notice shall be deemed given on the day on which personally delivered; or, if by mail, on the fifth day after being posted or the date of actual receipt, whichever is earlier. TO THIRD PARTY ADMINISTRATOR: Ron Warble Executive Vice President 5728 Major Blvd., Suite 450 Orlando, FL 32819 Phone: 407-949-3150 Email Address: ron.warble(c�usis-tpa.com TO THE CITY: Daniel J. Alfonso City Manager 444 SW 2nd Avenue, 10th Floor Miami, FL 33130-1910 Annie Perez, CPPO Procurement Director 444 SW 211d Avenue, 6`h Floor Miami, FL 33130-1910 Victoria Mendez City Attorney City of Miami 444 SW 2nd Avenue, 9th Floor Miami, Florida 33130 Ann -Marie Sharpe Risk Management Director City of Miami 444 SW 2nd Avenue, 9th Floor Miami, Florida 33130 21. MISCELLANEOUS PROVISIONS: A. This Agreement shall be construed and enforced according to the laws of the State of Florida. Venue in any proceedings between the parties shall be in Miami -Dade County, Florida. Each party shall bear its own attorney's fees. Each party waives any defense, whether asserted by motion or pleading, that the aforementioned courts are an improper or inconvenient venue. Moreover, the parties consent to the personal jurisdiction of the aforementioned courts and 15 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 irrevocably waive any objections to said jurisdiction. The parties irrevocably, voluntarily and knowingly waive any rights to a jury trial. B. No waiver or breach of any provision of this Agreement shall constitute a waiver of any subsequent breach of the same or any other provision hereof, and no waiver shall be effective unless made in writing. C. Should any provision, paragraph, sentence, word or phrase contained in this Agreement be determined by a court of competent jurisdiction to be invalid, illegal or otherwise unenforceable under the laws of the State of Florida or the City of Miami, such provision, paragraph, sentence, word or phrase shall be deemed modified to the extent necessary in order to conform with such laws, or if not modifiable, then the same shall be deemed severable, and in either event, the remaining terms and provisions of this Agreement shall remain unmodified and in full force and effect or limitation of its use. D. Third Party Administrator shall comply with all applicable laws, rules and regulations in the performance of this Agreement, including but not limited to licensure, and certifications required by law for professional service Third Party Administrators. E. This Agreement constitutes the sole and entire agreement between the parties hereto. No modification or amendment hereto shall be valid unless in writing and executed by properly authorized representatives of the parties hereto. Except as otherwise set forth in Section 2 above, the City Manager shall have the sole authority to extend, amend, or modify this Agreement on behalf of the City. 22. SUCCESSORS AND ASSIGNS: This Agreement shall be binding upon the parties hereto, their heirs, executors, legal representatives, successors, or assigns. 23. INDEPENDENT THIRD PARTY ADMINISTRATORS: Third Party Administrator has been procured and is being engaged to provide Services to the City as an independent Third Party Administrator, and not as an agent or employee of the City. Accordingly, neither Third Party Administrator, nor its employees, nor any Subcontractor hired by Third Party Administrator to provide any Services under this Agreement shall attain, nor be entitled to, any rights or benefits under the Civil Service or Pension Ordinances of the City, nor any rights generally afforded classified or unclassified employees. Third Party Administrator further understands that Florida Workers' Compensation benefits available to employees of the City are not available to Third Party Administrator, its employees, or any Subcontractor hired by 16 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Third Party Administrator to provide any Services hereunder, and Third Party Administrator agrees to provide or to require Subcontractor (s) to provide, as applicable, workers' compensation insurance for any employee or agent of Third Party Administrator rendering Services to the City under this Agreement. Third Party Administrator further understands and agrees that Third Party Administrator's or Subcontractor's use or entry upon City properties shall not in any way change its or their status as an independent Third Party Administrator. 24. CONTINGENCY CLAUSE: Funding for this Agreement is contingent on the availability of funds and continued authorization for program activities and the Agreement is subject to amendment or termination due to lack of funds, reduction of funds, failure to allocate or appropriate funds, and/or change in applicable laws or regulations, upon thirty (30) days written notice from the City Manager. 25. FORCE MAJEURE: A `Force Majeure Event" shall mean an act of God, act of governmental body or military authority, fire, explosion, power failure, flood, storm, hurricane, sink hole, other natural disasters, epidemic, riot or civil disturbance, war or terrorism, sabotage, insurrection, blockade, or embargo. In the event that either party is delayed in the performance of any act or obligation pursuant to or required by the Agreement by reason of a Force Majeure Event, the time for required completion of such act or obligation shall be extended by the number of days equal to the total number of days, if any, that such party is actually delayed by such Force Majeure Event. The party seeking delay in performance shall give notice to the other party specifying the anticipated duration of the delay, and if such delay shall extend beyond the duration specified in such notice, additional notice shall be repeated no less than monthly so long as such delay due to a Force Majeure Event continues. Any party seeking delay in performance due to a Force Majeure Event shall use its best efforts to rectify any condition causing such delay and shall cooperate with the other party to overcome any delay that has resulted. 26. CITY NOT LIABLE FOR DELAYS: Third Party Administrator hereby understands and agrees that in no event shall the City be liable for, or responsible to Third Party Administrator or any Subcontractor, or to any other person, firm, or entity for or on account of, any stoppages or delay(s) in work herein provided for, or any damages whatsoever related thereto, because of any injunction or other legal or equitable proceedings or on account of any delay(s) for any cause over which the City has no 17 Third Party Claims Administration Services City of Miami, Florida control. Contract No. RFP 605386 27. USE OF NAME: Third Party Administrator understands and agrees that the City is not engaged in research for advertising, sales promotion, or other publicity purposes. Third Party Administrator is allowed, within the limited scope of normal and customary marketing and promotion of its work, to use the general results of this project and the name of the City. The Third Party Administrator agrees to protect any confidential information provided by the City and will not release information of a specific nature without prior written consent of the City Manager or the City Commission. 28. NO CONFLICT OF INTEREST: Pursuant to City of Miami Code Section 2-611, as amended ("City Code"), regarding conflicts of interest, Third Party Administrator hereby certifies to the City that no individual member of Third Party Administrator, no employee, and no Subcontractor under this Agreement nor any immediate family member of any of the same is also a member of any board, commission, or agency of the City. Third Party Administrator hereby represents and warrants to the City that throughout the term of this Agreement, Third Party Administrator, its employees, and its Subcontractor shall abide by this prohibition of the City Code. 29. NO THIRD -PARTY BENEFICIARY: No persons other than the Third Party Administrator and the City (and their successors and assigns) shall have any rights whatsoever under this Agreement. There are no express or implied beneficiaries to this Agreement. 30. SURVIVAL: All obligations (including but not limited to indemnity and obligations to defend and hold harmless) and rights of any party arising during or attributable to the period prior to expiration or earlier termination of this Agreement shall survive such expiration or earlier termination. 31. TRUTH -IN -NEGOTIATION CERTIFICATION, REPRESENTATION AND WARRANTY: Third Party Administrator hereby certifies, represents and warrants to the City that on the date of Third Party Administrator's execution of this Agreement, and so long as this Agreement shall remain in full force and effect, the wage rates and other factual unit costs supporting the compensation to Third Party Administrator under this Agreement are and will continue to be 18 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 accurate, complete, and current. Third Party Administrator understands, agrees and acknowledges that the City shall adjust the amount of the compensation and any additions thereto to exclude any significant sums by which the City determines the contract price of compensation hereunder was increased due to inaccurate, incomplete, or non -current wage rates and other factual unit costs. All such contract adjustments shall be made within one (1) year of the end of this Agreement, whether naturally expiring or earlier terminated pursuant to the provisions hereof. 32. COUNTERPARTS: This Agreement may be executed in three or more counterparts, each of which shall constitute an original, but all of which, when taken together, shall constitute one and the same agreement. 33. ENTIRE AGREEMENT: This instrument and its attachments constitute the sole and only agreement of the parties relating to the subject matter hereof and correctly set forth the rights, duties, and obligations of each to the other as of its date. Any prior agreements, promises, negotiations, or representations not expressly set forth in this Agreement are of no force or effect. 19 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed by their respective officials thereunto duly authorized, this the day and year above written. ATTEST: Todd B. Hannon, City Clerk ATTEST: Print Name: Title: (Corporate Seal) APPROVED AS TO LEGAL FORM AND CORRECTNESS: Victoria Mendez City Attorney 20 Third Party Claims Administration Services "City" CITY OF MIAMI, a municipal corporation By: Daniel J. Alfonso, City Manager "Third Party Administrator" USIS, INC., a Corporation Title: Executive Vice President (Authorized Corporate Officer) State of Florida County of Seminole On 3292017. before me. Ron Warble Petsonaiy appeared Ron Warble LX, j Personally known to me OR LI Proved to me on the basis of sabslootory evidence to be the person(Sk whale names) Bare subscribed to the withal instrument and has hereby acknowledged to me that he/she hey have executed the saute m hisiherafieir authorized capactty(ies). and that by heulterAbeir al natures) on the instrument the persons) or the entity upon behalf of which the person(s) acted executed the mstrumertt Wetness my hand and official seal iki(11411.11iltbnAng Notary Signature Leslie Whittemore APPROVED AS TO INSURANCE REQUIREMENTS: Ann -Marie Sharpe Risk Management Director City of Miami, Florida Contract No. RFP 605386 CORPORATE RESOLUTION (This Resolution needs to authorize the signatory to sign) WHEREAS, USIS, INC., a Florida corporation, desires to enter into an agreement with the City of Miami for the purpose of performing the work described in the contract to which this resolution is attached; and WHEREAS, the Board of Directors at a duly held corporate meeting has considered the matter in accordance with the bylaws of the corporation; NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF DIRECTORS that this corporation is authorized to enter into the Agreement with the City, and the President and the Secretary are hereby authorized and directed to execute the Agreement in the name of this Corporation and to execute any other document and perform any acts in connection therewith as may be required to accomplish its purpose. IN WITNESS WHEREOF, this 29th day of March , 2017. USIS. INC. ("Third Party Administrator") An Florida (State) Corporation By: r (sign) Print Name: Ron Warble TITLE: Executive Vice President (sign) Print Name: State of Fkonda County of Seminole On 3129,2017. before me. Ron Warble Personally appeared. Ron Warble LXJ Personally known to me OR [J Proved to me on Ow bans of satisfactory evidence 10 be the person(s) whose name(s) &are subscribed to the within rnsUumCnt and has hereby acknowledged to me that hershehey have executed the same in hrs+her:ilrerr authorized capacrty(res) and that by hrdheri1herr signature(s) an the instrument the person(s) or the entity upon behalf of which the person(s) acted. executed the instrument Witness my hand and official seal Notary Signature Leslie Whdtemore 21 Third Party Claims Administration Services LESUE A. WHITTEMORE Notary Public, State of Ronda My Comm. Expires June 14, 2018 Commission No. FF 108261 City of Miami, Florida Contract No. RFP 605386 EXHIBIT A RFP NO. 605386 22 Third Party Claims Administration Services ANNIE PEREZ, CPPO Procurement Director it! ADDENDUM \O. 1 DATE: October 13, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. A. Attached is a copy of the Pre -Proposal Conference attendance sheet. DANIELJ. ALFONSO City Manager B. Section 3.3. Part 1, Workers' Compensation and Liability Claims Administration, Sub Section 3.3.1, A., titled Hearings Conferences/Trials, Rom 4, Page 45, is hereby deleted in its entirety and replaced with the following due to a scrivener's error. 4. Any recommendations made by the SGcessfui Proposer Office of the City Attorney pertaining to the file should be carried out or referred to Office of theme-ity--Attorney Successful Proposer. C. The following are the inquiries as received and the corresponding responses: Ql. Is this RFP for all Liability Claims or only BI and large loss? Al. All liability claims. Q2. Please provide the number of open liability claims to be transferred to the new Third Party Administrator (TPA), broken out by type of claim. A2. Table of open liability claims to be transferred to the new TPA: Open Claim Count Auto Liability - Bodily Injury 22 Auto Liability - Property Damage 1 Employee Benefit Liability 6 Employment Practices Liability 2 Errors & Omissions 12 General Liability Bodily Injury 207 General Liability Property Damage 4 Police Professional Liability 86 Q3. Please provide the number of open Workers' Compensation claims, broken out by Indemnity, and Medical Only. A3. See table below: WC — Indemnity WC— Medical Open Claim Count 667 39 Q4, Please provide the number of new claims for each of the past three (3) years, broken out by type of claim. A4. See table below. Please note that the claims count includes report/incident only claims. Claim Count 2013 2014 2015 2016 Auto Liability - Bodily Injury Auto Liability - Property Damage Employee Benefit Liability Employment Practices Liability Errors & Omissions 3 0 1 0 0 1 0 2 2 4 0 0 0 0 0 0 1 2 3 1 General Liability Bodily Injury 52 General Liability Property Damage 2 53 106 2 163 5 Police Professional Liability 22 24 18 5 Workers' Compensation 794 652 828 631 Totals for 2013-2016 875 739 957 808 Q5. Please provide a breakdown of the current TPA's staffing levels for the services to be provided: a) Workers' Compensation (WC) Supervisors; b) WC Indemnity Adjusters; c) WC Medical Only Adjusters; d) Liability adjusters; and e) Telephonic Nurse Case Managers. A5, a) 1; b)4; c) 1;d)2; ande)0 Q6. Please provide the number of medical bills for each of the past three (3) years. A6. Following are the number of medical bills by year: 2013: 14.552 2014: 13,648 2015: 15,022 2016 YTD: 12,170 Q7. Please provide a Medical Bill Savings Report for each of the past three (3) years. A7. Following is the Medical Savings Report by year: 2013: $11,291,126.39 2014: $10,516,730.55 2015: $11,203,698.45 2016 YTD: $11,658,641.71 Q8. Please provide the name of the current PPO network provider. AS. Gallagher Bassett Managed Care Services Q9. Does the City currently have all Workers' Compensation claims medically triaged by Telephonic Nurse Case Managers? If not, how many claims were medically triaged for each of the past three (3) years? A9. No. Q10. How many claims on average are assigned to Telephonic Nurse Case Management? Al 0. Twenty-seven (27) claims are assigned an average per year. Q11. How many claims on average are assigned to Field Nurse Case Management? Al 1. Sixty-seven (67) claims, on average, are assigned per year All other information remains the same. APPROVED: L.A ' A " aA�i 1�it/ Arj ie Perez, CPPO, Director o' Procurement AP:Io c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadlissa Calderon, CPPB, Senior Procurement Manager, Procurement. ATTENDANCE SHEET RFP/RFQ NUMBER: RFP 605386 - Third Party Claims Administration and Managed Care Services LOCATION: (nth FL Large Conference Room PURPOSE: Pre Proposal Conference BATE: Wednesday, October 12, 2016 at 2:00 PM Completing this attendance sheet is optional. NAME COMPANY ADDRESS.r PHONE E-MAIL 'fed c-(A'a 5ti r t re. Lr.l\ `i 1\ S u »C z lap r-o rim Colnrn-R.rze etv-dl ,ter �. ,6a,(classa..r' `:-CA (,�4v)-✓t -FC— 4 -7 (Jr6*i) t i 1 22-2 `goc iCF'c n , rnee, Q ( ) Rev. 10/18/99 ) Page of ANNIE PEREZ, CPPO Procurement Director Tilt! of t x t ADDENDUM NO. 2 DATE: October 17, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. DANIEL!. ALFONSO City Manager A. Attachment B, Price Proposal Schedule has been deleted in its entirety and replace with two separate Price Proposal Schedules. to accommodate Part 1, Claims Administration, and Part II, Managed Care. See attached: a. Attachment B1: Claims Administration Price Proposal Schedule; and b. Attachment B2: Managed Care Price Proposal Schedule. Updated forms have also been attached to the Header Section of this solicitation, AU references in the Solicitation to Attachment B, Price Proposal Schedule will now be referred to as Attachment B1: Claims Administration Price Proposal Schedule, or B2, Managed Care Price Proposal Schedule, whichever is applicable. B. The following are the inquiries as received and the corresponding responses: Q1. Is this RFP for all Liability Claims or only BI and large loss? Al . All liability claims. Q2. Can a firm submit a combined proposal? A2. No. Proposers may submit a Proposal for either Part 1: Workers' Compensation Claims and Liability Claims Administration, and/or Part 11 - Managed Care/Medical Bill Review. Proposers must clearly indicate for which Part(s) Proposer is submitting its Proposal for, and must provide all of the information and documentation, in addition to the Supplemental Proposer Questionnaire (Attachment A), which is attached in the Header Section of this Solicitation. Q3. Should all questions be answered for both Par 1 and Part 11? A3, Yes, All relevant questions must be responded to. if a question is not relevant to the category (Part 1 or II) Proposer is responding to, the Proposer should respond with "WA". Proposers must also include the Supplemental Proposer Questionnaire for both category. Q4. Should pricing be submitted on separate forms? A4. Refer to item A above. Q5. Will the City consider an extension if requested? A5 All inquiries and questions are considered. Q6. When does the City anticipate taking the recommendation to City Commission? A6. It is anticipated that the agenda item for award recommendation will be presented to City Commission in January/February 2017. Q7. When does the City expect for the implementation of the project to commence? A7. It is anticipated that the agenda item for award recommendation will be presented to City Commission in January/February 2017. The notice to proceed with the project will be issued shortly after that. Q8. Does local preference apply to this solicitation? A8, Local preference does not apply to this solicitation. Q9. Will the City require a dedicated or designated Liability Supervisor? A9. The City requires a Liability Supervisor who will be assigned to the contract. Q10. Does the City have an established caseload requirements? A10. No. The Proposer shall indicate it its proposal their established caseload All other information rer/nai s the same. APPROVED: V;--�<t,ue /0// An ie Perez, PRO, Director yProcurement Date/ AP:lo c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement City of Miami, Florda RFP No.605386 ATTACHMENT 81 CLAIMS ADMINISTRATION PRICE PROPOSAL SCHEDULE INSTRUCTIONS: The Proposer's price shall be submitted on this form -Price Proposal Schedule", and in the manner stated herein. Proposer is requested to fill in the applicable blanks on this form and to make no other marks. If proposing more than one category of services (Part I or Part II) Proposer must complete one separate Price Proposal Schedule for each category of service. This Price Proposal Schedule is for Part 1 Services Only: Workers' Compensation Claims and Liability Claims Administration. 1. INITIAL TERM (Years 1 through 3) A. Proposed Total Fees and Costs for Initial Term (Years 1 through 3): The proposed total fees and costs shall include all fees, including one-time and recurring, and value added options, for Part I Services only. r (Total fees and costs should be the aggregate price for the initial three years) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The Proposer shall break down its price for providing the Claims Administration Services as specified in Section 3, Specifications/Scope of Work. The proposed fees shall be based on: a) the three year initial term Agreement; b) approximately 695 new indemnity claims per year; c) approximately 144 new medical only claims per year; d) a flat fee broken down on an annual basis for the initial three (3) year term; e) the cost for anticipated staffing levels, based on the Proposer's proposal; and f) the implementation costs. 1. T I IJIJI.JaUU ULQI11119, , Positions FTE Annual Salary Total Costs 1 Supervisor $ $ 2 $ $ 3 5 $ 4 $ $ 5 $ $ 6 S $ 7 S $ 8 ,$ 1 5 9 $ $ 10 S $ 11 S $ 12 $ $ Proposed Total Fees and Costs $ Third Party Claims Adminis:r;?.tion Rcv. )2') 16 City of Miami. Florida 2. Proposed Annual Costs (inclusive of staffing costs) RFP No.605386 Base Cost ($) Projected Increase (%) Total Costs Year 1 Year 2 Year 3 $ $ Proposed Grand Total (Years 1-3) $ 3. Proposed One -Time Implementation Costs Item Description Total Costs 1 S 2 S 3 S $ 5 $ Proposed Total Fees and Costs $ Notes. 1) The City reserves the right to correct and re -calculate any errors found in Proposer's calculation. 2) Total Fees and Costs from Tables 1, 2, and 3 in Section 1 B above, should equal the aggregate costs in Section 1 A above. 2. OPTION TO RENEW YEARS (Two. One -Year Periods - Years 4 and 5) The Proposer shall state its price below for the cost during the optional renewal years. This Price Proposal Schedule is for Part 1 Services only: Workers' Compensation Claims and Liability Claims Administration. A. Proposed Total Fees and Costs for Option to Renew Years (Years 4 and 5): The proposed total fees and costs shall include all fees, and value added options, for Part l Services only. (Total fees and costs should be the aggregate price for the two renewal years) B. Breakdown of Total Fees and Costs for Option to Renew Years (Years 4 and 5) The Proposer shall break down its price for providing the Claims Administration Services as specified in Section 3; Specifications/Scope of Work, during the option to renew years. The proposed fees shall he based on: a) the two (2) additional years of the Agreement; b) approximately 695 new indemnity claims per year; c) approximately 144 new medical only claims per year; d) e flat fee broken down on an annual basis for the two (2) additional years; e) the cost for anticipated staffing levels. City of Miami, Florida RFP No.605386 4. Proposed Staffing Positions i FTE Annual Salary Total Costs 1 Supervisor S $ 2 $ $ 3 $ $ 4 1 $ $ 5 S $ 1 6 $ $ '7 1 $ y$ 8 $ $ $ Proposed Total Fees and Costs *Use additional paper if required 5. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (%) Total Costs Year 1 5 Year 2 $ Proposed Grand Total (Years 4 and 5) Notes: 1) The City reserves the right to correct and re -calculate any errors found in Proposer's carciction. 2) Total Fees and Costs from Tables 4 and 5 in Section 2B above, should equal the aggregate costs in Section 2A above. 3. Additional Services The Scope of Work outlined herein identifies the work that the selected Proposer shall perform under the Agreement. To address future City requests for any additional services; modifications, or changes outside of the scope of work, please provide not -to -exceed hourly rates for personnel who will be assigned to his contract. 6. Additional Services Proposed Hourly Rates Personnel 1 Not -To -Exceed Hourly Rates $ $ S $ S *Use additional paper if required 3 City of Miami. Florida RFP No 605386 Notes: 1. The proposed prices above in Sections 1A, shall be fixed and firm for the initial term of the Agreement. The proposed prices for the option to renew years, in Sections 2A, may be negotiated prior to the renewal of the contract for each option to renew period, at the sole discretion of the City. Any extensions to the Agreement beyond the five year period, will be at the then current rates. 2. AU out-of-pocket expenses, including employee travel, per diem and miscellaneous costs and fees, should be included in the Proposer's proposed price, as they will not be reimbursed separately by the City. Refer to CH.112.061 of the Florida Statutes regarding adherence to travel expenses. 3. Sections 1 and 2 will be used to determine the price points for the price criteria as indicated in Section 5.1, Evaluation Criteria of this Solicitation, 4. Notwithstanding the proposed hourly rates in Sections 3, Additional Services, above, the City reserves the right to negotiate the not -to -exceed pricing on a year by year basis, at the City's sole discretion. 5. The positions identified in the table above shall be the same as the key positions identified in the Proposer's proposal. The City expects that the personnel in those positions will be performing the services. 4 City of Miami, Florida RFP No.605386 ATTACHMENT B2 MANAGED CARE PRICE PROPOSAL SCHEDULE INSTRUCTIONS: The Proposer's price shall be submitted on this form "Price Proposal Schedule", and in the manner stated herein. Proposer is requested to fill in the applicable blanks on this form and to make no other marks. If proposing more than one category of services (Part I or Part II) Proposer must complete one Price Proposal Schedule for each category of service. This Price Schedule is for Part II Services only: Managed Care/Medical Bill Review/Audit Services. 1. INITIAL TERM (Years 1 through 3) A. Proposed Total Fees and Costs for Initial Term (Years 1 through 3): The proposed total fees and costs shall include all fees, including one-time and recurring, and value added options, for Part II Services only. (Total fees and costs should be the aggregate price for the initial three years) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The Proposer shall break down its price for providing the Managed Care:Medical Bill Review/Audit Services as specified in Section 3, Specifications/Scope of Work. The proposed fees shall be based on: a) the three (3) year initial term Agreement; b) flat fee broken down on an annual basis for the three (3) year term; c) the cost for anticipated staffing levels, based on the Proposer's proposal; and d) the implementation costs. 1. Pr000sed Staffin Positions FTE Annual Salary Total Costs 1 Supervisor S ' $ 2 $ #$ 3 $ $ 4 $ $ $ 1$ 6 $ $ 7 $ $ 8 I$ $ 9 $ $ 10 $ $ 11 $ $ 12 $ $ Proposed Total Fees and Costs Third Patty Ciai:rs .' dmini tration City of Miami, Florida RFP No.605386 2. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (%) Total Costs Year 1 Year 2 $ Year 3 $ Proposed Grand Total (Years 1 through 3) 3. Proposed One -Time Implementation Costs Item Description Total Costs I $ 2 $ 3 $ 4 S 5 I$ Proposed Total Fees and Costs s Notes: 1) The City reserves the right to correct and re -calculate any errors found in Proposer's calculation.. 2) Total Fees and Costs from Tables 1, 2, and 3, In Section 16 above, should equal the aggregate costs in Section 1A above. 2. OPTION TO RENEW YEARS (Two, One -Year Periods - Years 4 and 5) The Proposer shall state its proposed price below for the costs during the optional renewal years. This Price Proposal Schedule is for Part II Services Only: Managed Care/Medical Bill Review Services A. Proposed Total Fees and Costs for Initial Term (Years 1 through 3): The proposed total fees and costs shall include all fees, and value added options, for Part II Services Only. (Total fees and costs should be the aggregate price for the two renewal years) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The Proposer shall break down its price for providing the Managed Care/Medical Bill Review Services as specified in Section 3, Specifications/Scope of Work, during the option to renew years. The proposed fees shall be based on: a) the two (2) additional years of the Agreement; b) flat fee broken down an an annual basis for the two years; and c) the cost for anticipated staffing levels, based on the Proposer's proposal. City of Miami, Florida RFP No.605386 4. Proposed Staffing Positions FTE Annual Salary -total Costs 1 Supervisor $ S '2 $ S 1 $ S 4 �. $ $ $ 1 $ 6 $ :$ 7 $ $ 8 $ S 9 S S roposed total Fees and Costs *Use additional paper if required 5. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (%) Total Costs Year 1 $ Year 2 $ Proposed Grand Total (Years 4 and 5) $ Notes: 1) The City reserves the right to correct and re -calculate any errors found in Proposer's calculation. 2) Total Fees and Costs from tables 4 and 5, in Section 2B above, should equal the aggregate costs in Section 2A above. 3. ADDITIONAL SERVICES (Initial Term and Option to Renew Years) The Scope of Work outlined herein identifies the work that the selected Proposer shall perform under the Agreement. To address future City requests for any additional work: modifications, or changes outside of the scope of work, please provide not -to -exceed hourly rates for personnel who will be assigned to this contract. 6. Additional Services Personnel Proposed Not -To -Exceed Hourly Rates iS S 3 City of Miami, Florida RFP No.605386 *Use additional paper if required Notes: 1) The proposed prices above in Sections 1 A, shall be fixed and firm for the initial term of the Agreement. The proposed prices for the option to renew years, in Sections 2A, may be negotiated prior to the renewal of the contract for each option to renew period, at the sole discretion of the City. Any extensions to the Agreement beyond the five year period, will be at the then current rates. 2) All out-of-pocket expenses, including employee travel, per diem and miscellaneous costs and fees, should be included in the Proposer's proposed price, as they will not be reimbursed separately by the City. Refer to CH.112.061 of the Florida Statutes regarding adherence to travel expenses. 3) Notwithstanding the proposed hourly rates in Sections 3, Additional Services, above, the City reserves the right to negotiate the not -to -exceed pricing on a year by year basis, at the City's sole discretion. 4) The positions identified in the table above shall be the same as the key positions identified in the Proposer's proposal. The City expects that the personnel in those positions will be performing the services. 4. BREAKDOWN OF MANAGED CARE/MEDICAL REVIEW/AUDIT SERVICES The Proposer shall state the not to exceed charges in the columns provided in Tables 7 and 8, for the itemized Managed Care Services listed on the follovving pages: 4 City of Miami. Florida RFP No.605386 A. MANAGED CARE/BILL REVIEW/AUDIT SERVICES - ITEMIZED Proposer shall list the not -to -exceed charge for each Service itemized below in Table 7: 7. Itemized Managed Care/Bill Review/Audit Services Services Charges Fee Schedule (Bill Review / UCR / System Savings) All Other Savings • Clinical Validation/Nurse Review (CV) • Preferred Provider Networks (PPO) • Out Of Network (OON) • Specialty Networks) Physical Therapy (PT) Electronic Receipt of Medical Bills Telephonic Case Management Hospital Certification Program Utilization Review Program Physician Review/Peer 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 Medical Case Management and Vocational Rehabilitation — Hourly Priority Care 365 Durable Medical Equipment (DME) Proclram- First Script Medical Cost Projection (MCP) and Clinical Recommendations Pharmacy Benefit Management (PBM) — First Script Rx Peer to Peer Review (P2P) Drug Utilization A Rx Drug Utilization Assessment (DUA) Return to Work Coordinator (Injury Coordinator) Durable Medical Equipment (DME) Program - First Script Dental Review Program OSHA Reporting Taxes (All applicable taxes will be added to the service fees where required) City of Miami. Florida RFP No.605386 B. OTHER SERVICES - ITEMIZED: Proposer shall list the not -to -exceed charge for each Service itemized below in Table 7: 8. Other Services SERVICES CHARGES On-line Access GB International Claims Services Consultative Services Loss Control Consulting Services Appraisal Services Fraud Prevention — Gallagher Bassett Investigative Services (GBIS) Special Fraud Investigations - SIU Surveillance Investigations Targeted Field Investigations Targeted Database Investigations MSA Workers Compensation Medicare Set -Aside Allocation (WCiv1SA) Rush Fees (MSA completed within 7 days) Revisions: Liability Medicare Set -Aside Allocation (LPv1SA) MSA Submission to CMS Compliance Services Conditional Payment Research (CPR) Conditional Payment Negotiations (CPN) Secure Final Demand for Settlement (SFD) Bundled CP Resolution Services Benefit Coordination & Recovery Contractor Notification Medicare Eliaibility Inouiry (MEl) SSDI Verification Release / Settlement Agreement Review Lien Resolution (Advantage Plan, Medicaid, Part D) Taxes (All applicable taxes will be added to the service fees where required) G QIittur f Tharni ANNIE PEREZ, CPPO DANIELJ, ALFONSO Procurement Director City Manager ADDENDUM NO. 3 DATE: October 24, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. The following are the inquiries as received and the corresponding responses: QI. Please provide the employee count for City of Miami's (City) full-time and part-time employees. Al . The City employs 3,985 full-time employees, and 152 part-time employees. Q2. What is the City's philosophy for Telephonic and Field Nurse Case Management? A2. The City must approve each assignment of Telephonic and Field Nurse Case Management. Q3. Will the City provide a performance guarantee? A3. The City reserves the right to request that the Successful Proposer enter into a mutually agreed upon performance guarantee at a future date. The addendum to the Professional Services Agreement would include, but not limited to, key performance indicators, target results, and any penalty or gain share amounts. Q4. What would happen to Pharmacy Management Services? A4. The City wishes to retain those claims currently assigned to Cypress Care. Q5. In reviewing the RFP, there is a reference to Auto losses. Should the proposing TPA be including Auto in the pricing options for Liability, or will the City look to the TPA for GL and WC claims handling? A5. The City will require the Successful Proposer to handle General Liability and Workers' Compensation claims, as well as the existing Auto Claims being handled by current Third Party Administrator (TPA). Q6. Please provide number of medical bills for each of the past five (5) years. A6. The breakdown of medical bills for the past five (5) fiscal years (10/1 through 9/30) are as follows: 2011 to 2012: 16,464 2012 to 2013: 16,198 2013 to 2014: 13,946 2014 to 2015: 14,712 2015 to YTD: 15,726 07. Please provide Medical Bill Savings Report for each of the past three (3) years A7. The Medical Bills Savings Report has been attached to the Header Section of the RFP in Oracle, 08. In attachment A, page 10, Pricing, Part 1, #1, it indicates that "All pricing should be on a life of claim basis..." a) Is the City seeking pricing an a lire of contract or life of claim basis? b) Will the City accept life of contract pricing proposals? A8. The City is seeking life of contract pricing Q9. Who are the City's excess insurance carriers? A9. The City's past and current excess insurance carriers are: • State National: 10/1/04 — 10/1/07 • Star Insurance Company: 10/1/07 - 10/1/09 • No carrier for WC: 10/26/09 — 10/26/10 • Midland: 10/26/10 to present 010. Provide a breakdown of all the open claims for takeover- by line of coverage and claim type. A10. See chart below: Open Claim Count Auto Liability - Bodily Injury 22 Auto Liabil'ly - Property Damage 1 Employee Benefit Liability 6 Employment Practices Liability 2 Errors & Omissions 12 General Liability Bodily Injury 207 Genera! Liability Property Damage 4 Police Professional Liability 86 7 011. For the open workers' compensation claims, identify how many are lost time/indemnity and how many are medical only (MO) claims? Alt See chart below: Open Claim Count WC — Indemnity WC— Medical 667 39 Q12. Will the new TPA take over the handling of all open auto liability claims? If so, how many, or will those continued to be handled in house? Al2. Please refer to the response to Question 11. Claims identified therein will be taken over by Successful Proposer. Q13. Does the City require or prefer a fully dedicated (only working on the City's claims) unit for all claims; Workers' Compensation and Liability? Or is the City only requiring that the position of Workers' Compensation Supervisor be dedicated, as stated in Section 3.3.1, number 5? A13. Yes, the City requires a fully dedicated (only working on the City's claims) unit for ail claims, Q14. How many claims annually require the services of a Field Adjuster? A14. This number should be determined by the Proposer as Field Ad;usters are encouraged to go in the field as they see fit, to conduct credible claim investigation. Q15. Are there any service concerns or issues with the current TPA? Is the City satisfied with the current level of services received, or are there areas of improvement the City is hoping to obtain? A15. There are no concerns at this time, however, continuous improvement is the City's goal. Q16. The solicitation is requesting separate price proposals for claims and managed care services, and indicated the price proposals will be evaluated and possibly awarded independent of each other. If a company is proposing both services, can it all be submitted in one proposal with sections specifically for claims and managed care services (and with separate pricing indicated), or is the City requiring two separate and distinct proposal document submissions? Please clarify, A16. No, Proposers must submit separate Proposals if proposing on both Part 1: Workers' Compensation Claims and Liability Claims Administration, and Part II - Managed CareAledical Bill Review. Proposers must clearly indicate for which Part(s) Proposer is submitting its Proposal for, and must provide all of the information and documentation, in addition to the Supplemental Proposer Questionnaire (Attachment A), which is attached in the Header Section of this Solicitation for each part. Q17. For Medical Claims Review Services, does the City require that cnly a flat annual ail -inclusive fee (aggregate total for three [31 years) be proposed? A17. Completion of the pricing sheet for Medical Claims Review in its entirety is required. Q 18. For Managed Care -Services. does the City require a fiat all-inclusive annual fee or are alternative - pricing proposals acceptable (such as medical bill review per bill fees, PPO savings fees, case management fees)? A18. Alternative pricing is acceptable, however, the pricing sheet requested for Managed Care Services must also be completed in its entirety and submitted. Q19. On Attachment B, Price Proposal Schedule, Part 1. A (Claims), if a total three (3) year fee amount is submitted. is it necessary to also complete Section C — Breakdown of total fees? A19. Yes. Q20. The pricing page indicates that pricing should be submitted for the "life of the claim." From the RFP, it appears that the new TPA will assume handling of the existing claims and I see that the number of open cairns was included in Addenda #1. a) Is the City requesting pricing for "fife of claim for the life of the contract?" b) Will the City move the "tail" claims to a new TPA at the end of this contract as well? A20. a) The City is requesting Price for life of the contract. b) Yes, the City will move the "tail" claims to the new TPA. Q21. What PPO network is currently used by the City's current TPA? A21. Gallagher Bassett Managed Care Services (Please refer to Addendum No.1, Q8). Q22, Section 2.8, Minimum Qualification Requirements, Sub -Section A. Item 5 requires TPA to have five continuous years of Florida municipal claims handling experience and with 1 employer of at least 1,500 employees. Our organization has 20 plus years of continuous Florida claim handling; and has been handling public entity claims outside of the State of Florida in numerous states across the US since 1987 for employers with over 100,000 employees including large city, county and state public entities. This requirement may eliminate viable candidates for the City which may be a disadvantage to the City. Will the City please reconsider this requirement or modify it so that potential TPA's with extensive public entity experience regard ess of the jurisdictional experience will be sufficient? A2.2. It is in the City's best interest to award to a Proposer who is experienced in handling Florida exposures, therefore the referenced minimum requirement of five (5) continuous years of experience, handling Florida municipal claims with at least one (1) client having a m nirnum of 1500 employees, will remain at this tirr;e. All other information remains the same. AP; to Date d / c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A, Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement (!Iit of refilianti ANNIE PEREZ, CPPO DANIELJ. ALFONSO -Irocuremert Di•ectar City Manage^ ADDENDUM NO. 4 DATE: October 26, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. A. The deadline for receipt of proposals for RFP605386 has been extended to Wednesday. November 30, 2016. at 2:00 PM (local time), to allow additional time for Proposers to respond. B. The following language has been added to the Certification Statement, which has been revised and attached to the Header Section of the Solicitation: Pease list and acknowledge all addendum/addenda received. List the addendum/addenda number and date of receipt (i.e.. Addendum No. 1, 7i1/15). If no addenda/addendum was/were issued. please insert 'IN/A". Has Proposer reviewed the attached Sarnpie Professional Services Agreement (PSA)? Does the Proposer acknowledge that the attached PSA is an example of the standard Agreement used in conjunction with the services related to this Solicitation and shall not be amended? C. Section 4, Submission Requirements, Subsection 4.1 has been amended to revise the following information: ALL RESPONSES SHALL BE SUBMITTED IN HARD COPY FORMAT ONLY TO INCLUDE ONE (1) ORIGINAL, SIX (6) COPIES. AND AN ELECTRONIC COPY (USB OR CD). NO ON-LINE SUBMITTALS WILL BE ACCEPTED. D. The following are the inquiries as received and the corresponding responses: Q1. Provide the RFP Attachments A and B in Word Format? Al. Attachment A, Proposer Supplemental Questionnaire has been attached to the Header Section of the Solicitation in Word Format. Attachment B, Price Proposal Schedule, has been revised (refer to Addendum No. 2, A) and have been attached to the Header Section of the Solicitation in Word Format, as B1, Claims Administration Price Proposal Schedule, and B2, Managed Care Price Proposal Schedule. Q2. How many claims per year for the past five (5) years had a Telephonic or Field Nu-se/Case Manager assigned to them? A2. Please refer to Addendum No. 1, response to question No. 10. Q3. Who is the current broker? A3. The current Third Party Administrator (TPA) is Gallagher Bassett Managed Care Services. Q4. Page 7 of 65, 1.4: Does the City want all addenda submitted with the proposal or just an acknowledgement of addenda, if any, satisfactory? A4. The Proposer shall acknowledge all addenda by indicating same on the Certification Statement that is attached to the Header Section of the Solicitation. See Item A above. Q5. Page 9 of 65, 1.11, Bid Bond/Bid Security: Please confirm that a Bid Bond is not required for proposal submission, and that there are no special conditions requiring this for the proposal. A5. Bid Bond,'Bid Security does not apply to this Solicitation. Q6. Who are the City's excess carriers? A6. Refer to Addendum No. 3, response to Question 9. Q7. Section 4, Submission Requirements, sub -section 4.1, Page 57 of 65, requires One Original and Six Hard Copies. Page 27 of 65 1.78: Requires submission electronically via the Oracle System. Page 57 of 65 4.1 indicates "NO ON-LINE SUBMITTALS WILL BE ACCEPTED". Please clarify. A7. See item C above. The instructions in Section 4, Submission Requirements applies to this Solicitation. The clause pertaining to electronic submission in the Oracle System does not apply.. 08. Please describe the performance guarantee currently used for Managed Care/Medical Bill Review (Part 11 services). A8. See response in Addendum No. 3, Question 3. All other information remains APPROVED: A AP:Io he sa le Perez, CPPO, Director of P rement Date /14/4 c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juiiachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement ANNIE PEREZ, CPPO Procurement director (Cite of ADDENDUM NO. 5 DATE: October 28, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.; 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. DANiEL J. ALFONSO City Manager A, Section 3.3.2, Liability Claims Administration, Item No. 3a, has been deleted in its entirety and corrected with the following language: a) Contact the claimant or the claimant's attorney within 24 hours of the time the accident report is received by the Successful Proposer. In the case of unrepresented claimants, personal contact is required the same day the claim is received. Alf claim files must contain adjuster's logs documenting al! contact and activity. B. The following are the inquiries as received and the corresponding responses: Q1. Please clarify what the City is requiring in Section 2.8, B, +11 regarding Official Disability Guide ("ODG") guidelines being integrated into the rule engine? Al. The City requires the Proposer to incorporate ODG guidelines into the Proposer's decision tree/rule engine, for medical status and progression for Telephonic Case Managers and Field Case Managers. Q2. The RFP references submission of SSAE 16 SOC 1 and 2, report with the proposal. This is not a current standard requirement in the industry. As a TPA approved by all major carriers in the US, there are not any carriers or regulatory agencies requiring more than SSAE 16 (SOC 1) Type II compliance. In fact, in our SOC 1 audit, in addition to testing of information systems against best practices, controls in place to provide security. confidentiality of stored information, processing integrity of transactions, system availability and privacy testing (required in SOC 2). our SOC 1 requires testing of many other internal controls with respect to human resources, accounting, claims management, and other critical internal controls. Given that this SOC 2 may be limited, not standard requirement in the industry, and could cost hundreds of thousands of dollars to change processes and audit requirements for qualified "Big Four" firms (vs. Industry Cottage firms) to update complex audit programs, would the City would accept SSAE 16 (SOC 1) Type it report? A2. Yes, the City would accept a SSAE 16 (SOC 1) Type II report. Q3. Will the City allow a reasonable and minimum time of twelve (12) business days after the release of answers to questions for submission? A3. Refer to Addendum No. 4. The deadline for submission of proposals has been extended until November 30, 2016, at 2:00 PM. Q4. Who are the current providers for the following managed care programs? a. Bill Review b. PPO Networks (which Networks) c. Medical Case Management A4. The current providers for the referenced managed care programs are as follows: a. Bill Review: Gallagher Bassett Services. Inc. ("Gallagher") b. PPO Networks: Gallagher — Aetna & First Health c. Medical Case Management: Gallagher Q5. Provide the following annual summary information: a. #of Bills b. Amount of Billed Charges c. Amount of Fee Schedule Reductions d. Amount of PPO Reductions e. Fees for Fee Schedule Reduction f. Fees for PPO Network Access g. Fee for Specialty Bill Review A.5. The annual summary is as follows: a. # of Bills: 15,726 b. Amount of Billed Charges: $18.815,104 c. Amount of Fee Schedule Reductions: $11.118.442 d. Amount of PPO Reductions: $791,361 e. Fees for Fee Schedule Reduction: $8.50 Per Bill f. Fees for PPO Network Access: 25% of Savings g. Fee for Specialty Bill Review: 25% of Savings Q6. Approximately how many audit -in network and out -network hospital,'provider bilis, are processed annually? A6, Approximately 150 audit in -network and out -network hospital/provider bills are processed annually, Q7. The City currently uses Cypress Care PBM for claims that are administered in-house. a) How many claims and what types of claims are administered in-house? b) Would the City consider the use of a different PBM for all claims administered by the TPA if it benefits the City (and in accordance to physician dispensed drug policy)? A7. The City desires to retain Cypress Care for the WC claims administered in-house from 2001 and prior, Q8. Will the City pay for specialized Loss Control services that may require the referral to a company specializing in certain loss control services? A8, Yes. The City is expecting a set number of hours to be provided within the Proposer's proposal. Any services needed in excess of the hours provided may have a predetermined rate. Q9. Are single or bi-directional interfaces required? Please explain? What is the RMIS used by the City for this interface(s)? A9. The City currently does not have a RMIS internally. The City is in the process of procuring a system. Upon acquisition of a RMIS, the City ideally would like the Successful Proposer to have bi-directional interface, Q10. Does the City desire access to the TPA claim system? If yes, for approximately how many Users? A10. Yes, the City requires access to the Successful Proposer's TPA claim system for approximately ten (10) Users. Q11. Does the City require a full time Medical Case Manager(s)? If yes, how many? Are medical case management services provided on an hourly or per case rate? Approximately how many cases are referred? a. To telephonic medical case management per year? b. For field case medical case management per year? c. For utilization review per year? Al 1. The City does not require full time Medical Case Managers. Medical case management is bought on an hourly rate, and cases are referred to Medical Case Managers by the City, as needed. Refer to responses to questions 10 and 11 in Addendum No. 1 for the number of cases. Q12. Section 3.3.1, Workers' Compensation Claims Administration, Page 42 of 65, Item 12: a. It appears a full claim status report has to be provided to the City every ninety days on any claim in which an employee is not working full duty. Approximately how many claims at any given time are on restricted duty? b. Approximately how many claim files require a full summary report (for the types of claims noted in Section 12 a), b), c), and d) every 90 days? Al2. a. The City currently is paying Temporary Total Disability ("TTD"), on 55 files; b. There are currently 1,031 files that meet the criteria, The report required is a claims summary format, which should be updated every 90 days for supervisory review. Q13. Please provide the approximate number of all open claims by claim type for all claim years including: a. GL b. Auto/BI/PD c. APA d. POL & ELL e. LEL f. Indemnity. Of the open indemnity approximately how many are Future medical, PD or Grover type claims that require limited / awarded payments per year? g. Medical A13. The approximate number of all open claims, by claim type. for all claim years. are as follows: a. GL: 204 b. Auto/Br/PD.143 c. APA: 140 d. POL & ELL: 86 e. LEL: 12 f. Indemnity. 1084. A report with a breakdown of the type of claims is not available at this time. g. Medical:37 Q14. Is a minimum of three (3) attempts to contact appropriate parties required on simple medical claims? Please clarify. A14. Yes, ideally the City requires three (3) attempts to contact parties, so that the City can gain as much information on the front side of the claim, in the event the claim changes direction unexpectedly. - Q15. Attachment B, Cost Proposal: Section B, Managed Care,'Medical Bill Review/Audit Services. Please provide: a. Clarification and volume of "Managed Care Services" (assuming this if for medical case management services). b. Number of bills processed for Fee Schedule annually. c. Number of bills processed as "Audit Services". d. Confirmation PPO Network Access fees are an allocated loss adjustment expense (ALAE). A15. Refer to response to question No. 5 above for the information requested for a, b. and c. d. Yes. the PPO access fees are included within the ALAE. Q16. Provide complete moss runs/reports for clams dada by line of coverage for each of the past five (5) years. A16. The Loss Runs Report for claims data has been attached to the Header Section of the Solicitation in Oracle, Q17. Does the current TPA utilize a subcontractor to meet any participation goals with a MBEJWBE or other business enterprise? If yes, who is the subcontractor(s) and for what services? If yes, for what percentage? A17. The current TPA does have subcontractors for parts of the services they provide, however, MBEIWBE's was not a criteria. Q18. Compliance with Federal, State and Local Laws, Item L: Please confirm bidders do not have to provide Prompt Payment discounts, A18. This clause is a part of the City's general terms and conditions. For more information on Prompt Payments refer to Florida Statutes, Sections 218.79 to 218.79. Q19. What its Gallagher's current staffing model for the City of Miami claims by Position and # of FTE(s)? A19 One (1) WC Supervisor; Four (4) WC Indemnity; One (1) WC Medical Only; and Two (2) Liability Adjusters. Q20. Please provide your incoming claim counts by coverage type for the last five (5) years for the following coverage types: a WC -Indemnity b. WC -Medical only c. Auto BI d. Auto PD e. General Liability BI f. General Liability PD g. Public Officials h. E&O i. EPLI - Law Enforcement Liability A20. Coverage Type Incoming Claims Count 2012 2013 2014 1 2015 2016 a 1 WC -Indemnity 460 553 1 416 613 532 b WC -Medical only 279 247 . 236 ! 215 121 c Auto BI 97 92 65 ; 49 58 d Auto PD 397 430 398 328 275 e I General Liability BI 208 202 1 221 235 168 f General Liability PD 231 212 198 163 149 g Public Officials 0 0 0 0 i 0 h E&O 0 0 5 2 1 1I IEPLI 0 1 2 1 0 j ! Law Enforcement Liability 44 30 33 21 5 Q21. Please provide your current open claim counts by coverage type. a WC -Indemnity b. WC -Medical only c. Auto BI d. Auto PD e. General Liability BI f. General Liability PD g. Public Officials h. E&0 I. EPLI j. Law Enforcement Liability A21. Refer to Addendum No. 1, responses to questions 2 and 3. Q22. Provide a break-out for the total number of legal claims for each of the coverages in question No. 21 above (provide those counts), A22. The City's current TPA is only tracking legal status within the Workers' Compensation Line of Coverage in a report format. The numbers are below: Coverage Type Current Claims Count a I WC -Indemnity 2012 2013 j 2014 2015 110 114 108 143 2016 67 Q23. Please provide the following for each of the last three (3) years: a. Total number of medical bills by type (DWC-9, DWC-10, DWC-11 and DWC-90) b. total billed (by bill type if that is available) c. total fee schedule paid d. total amount of PPO discounts e. all other UR savings f. total amount paid to providers (by bill type if that is available g. all fees paid for Bill Review services A23. Please see response to Question No. 5. Q24. Regarding Attachment A, Section 2, item 3b: Please define -"tape feed." We are able to accept file transfer via secure FTP in formats such as .xls and .txt. Is this acceptable to the City? A24. Yes, this is acceptable. 025. Does the City require any subcontractors to mirror the coverage requ:rements that the TPA must follow? A25. Yes, the City requires that subcontractors shall have equal or higher coverage requirements. Q26. Please provide your current TPA's staffing model, including the number of adtusters dedicated to the City's account. A26. Refer to response for question No. 5. Addendum No 1. Q27. The RFP mentions "scene investigations, and personal claimant contact on all lost time or light duty cases". Will our WC adjusters be housed on site at the City, or do we send our WC TPA adjusters out into the field, or do you want our field adjusters to make these visits? A27. It has not been determined if the Successful Proposer's adjuster will be situated on -site or not, but scene investigations will be needed on as requested basis by the City. The City does not anticipate this to be a high volume. The City will require that a thorough investigation be completed to interview all parties and witnesses at the scene, to get all the information available about the alleged accident. Q28. Section 3.3.2., Item No. 2 of the RFP mentions outside field adjusters for liability claims. Is this fee an allocated expense charged to the claim file, or is it to be included in the annual fee? A28. This should be included within the annual fee. Q29. Section 3.3.2., Item No. 3 of the RFP indicates all under -represented claimants are to be seen in person. How many field assignments have been made by year for the last three years? A20. For clarification purposes, refer to corrected language in A above. Personal contact shall be made by phone on all unrepresented claimants and in person contact will be only needed as requested. Q30. Section 3.5, Item No. 9 of, the RFP indicates the proposer will "maintain these maximum pending caseload levels'. What are the City's expected maximum pending caseloads? A30. The Proposer shall state their caseload recommendations. 031. Section 3.5, Item No. 10 of the RFP, indicates proposers should submit resumes. Will the City accept base -line qualifications of each position in lieu of a resume since we will have to hire adjusters to handle a program of this size? Is the City interested in a new TPA attempting to retain some or all of the current team of supervisors and adjusters? A31. Yes, base -line qualifications are acceptable with the Proposer's proposal. Upon hiring of the selected individuals however, the City will require a copy of the adjuster's resume. The City also has the right to select or reject the team proposed. The current adjusting team are employees of the current TPA, 032. Is there a requirement to have an office in Miami or Dade County? Would the City be interested in housing the adjusters on site at the City of Miami? A32. No, it is not required to have an office in the City of Miami or Miami -Dade County, The City has not decided if an on -site adjuster model would be needed at this time. The City has a right to discuss this at time of negotiation. Q33. Which MWBE-certified vendors are currently providing services for the City? Does the City wish to continue receiving services from these vendor partners? A33. Although, the current TPA does have subcontractors for parts of their services, it was not a criteria for inclusion of MV1BE/WBE, certified vendors. Q34. Will the City consider extending the deadline for proposals? A34. Yes. Please refer to Addendum No. 4. Q35. What is the current caseload by claim type for each adjuster? A35. R�er to Addendum No 2, response to question No 10. Q36. Regarding Attachment A, section 7 on page 7: Google Chrome -compatible or Firefox-compatible claims management system platform providing real-time interactive communication and claims management between nurses, adjusters, the City, and its business units. Our claims system is currently supported on IE 10 and 11. Does the city specifically require support for Chrome and/or Firefox? A36. Internet Explorer 10 and 11 are acceptable. All other information remains the same. APPROVED: AP:lo ie Perez, CPPO, Director of Procurement ///c2di 6 Date/ c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement ANNIE PEREZ, CPPO (tTituuf4Iixrni 1D1)I NDLi�I NO. 6 DATE: November 2, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. The following are the inquiries as received and the corresponding responses: Q1. Please provide your current contract for Bill Review and Case Management Services. Al. The City's contract for Bill Review and Case Management Services is a bund'e package with Gallagher Bassett Services, Inc. (Gallagher). The Contract is attached to the Header Section of the Solicitation, including the attached pricing schedule submitted by Gallagher, All other information renrins the same. APPROVED. `.- /�i _ r' - i"//- // Arnie Perez, CPPO, Director of Procurement Date AP:Io c. Ann -Marie Sharpe. Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadssa Calderon, CPPB, Senior Procurement Manager, Procurement i go beyond C'A L LAGo. EgAssEZf City of Miami 000757 2/15/2016 - 2/15/2017 PRICING OPTION: BUDGETED STAFFING (Based on utilizing GBMCS) , co beyond GALLAGI �A5sE Life of Partnership Annual Cost Plus Service FatIniated Year 3 r , ;. Workers Compensation Medical only All Fees included in sairies below Indemnity All tees included in salrres below Ind Tier II Florida, New York, Ohio and Texas All Fees included in sairies below All Fees included in sairies below Liability _ General Bodily Injury All Fees inr:luderI in sallies below General Property Damage All Fees included in sairies below Auto Bodily lnjury All Fees included in sallies below Auto Property Darrraye Ali Fees included in sairies below Auto Physical Damage All Fees included in sairies below Professional Liability All Fees included in sairies below Actual Salaries at Coinmencern Actual Salaries at Actual Salaries at ent of 2nd Conrmenceme Commencement Actual Salaries at Year of City nt of 3rd Year of 4th Year of Commencement of 5th Actual Salaries at Commencement of 1st Option - of City Option - City Option - Year of City Option - Total Salary Expense Year of City Option - $682,515 $641,114 $607.587 $716,274 $745,298 Total Estimated Service Fee (2.30 multiplier) $1,603,910 $1,474,562 $1,397,451 r I S1,454,049 $1,512,211 Annual Fee for Licensing of SysFacs (up to six users) $0 $17,500 $17,500 517,500 $17,500 Grand Total $1,603,910 $1,492,062 $1,414,951 $1,471,549 $1,529,711 Quoted as fifth 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 Service Period GB will perform normal salary administration pursuant to GB Procedures Budgeted Staffing Cost & Ierms (Revision date: 6/8/2015) Page 1 Ggo beyonc $nsseN-.‘ City of Miami 000757 2/15/2016 - 2/15/2017 GB MANAGED CARE SERVICES Fee Schedule (Bill Review / UCR / System Savings) All Other Savings • Clinical Validation/Nurse Review (CV) • Preferred Provider Networks (PPO) • Out Of Network (OON) • Specialty Networks/ Physical Therapy (PT) Electronic Receipt of Medical Bills Telephonic Case Management 25 % of Savings 25 % of Savings 25 % of Savings 25 % of Savings $2 additional per bill in all applicable states $75 Medical Triage $290 per Indemnity claim (each 30 days) $130 per Medical Only claim (one time) Hospital Certification Program Utilization Review Program Physician Review/Peer 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 Medical Case Management and Vocational Rehabilitation — Hourly Priority Care 365 Texas HCN Service Options $120 Inpatient Pre -Certification $105 Outpatient Pre -Certification $270 per Review $530 per assignment $705 per assignment $635 per assignment $590 per assignment $660 ($730 in CA) per assignment $92 per hour plus expenses $103 per hour— AK, CA, HI, NY Budgeted Staffing Cost & Terms (Revision date: 6/8/201S) Page 2 go be:yonM 4sE� City of Miami 000757 2/15/2016 - 2/15/2017 GB MANAGED CARE SERVICES SERVICES CHARGES" Other State Service Options: • California MPN Service Options • Illinois PPP Service Option • New York PPO Service Option • West Virginia MRCP Service Option Medical Cost Projection (MCP) and Clinical Recommendations Not applicable 5125 per hour Pharmacy Benefit Management (PBM)— First Script Rx Peer to Peer Review (P2P) Drug Utilization A Cost of prescriptions — no charge for Bill Review or PPO reductions for PBM transactions RX Peer to Peer Review Options: • No DUA Performed - $290 per review • DUA Performed in prior 60 days-$865 per review Rx Drug Utilization Assessment (DUA) Drug Utilization Assessment - $575. Return to Work Coordinator (Injury Coordinator) Durable Medical Equipment (DME) Program - First Script Dental Review Program OSHA Reporting Coordinator - S8,750 per month Cost of medical equipment — no charge for Bill Review or PPO reductions for Prospective DME trai'sections Charged on a per review basis $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 Gallaglier Bassett Managed Care Services is utilized, an administrative toe may apply in exchange for bona fide administrative services. 7 he administrative services may include, but not he limited to overhead costs tor 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, and onsuring proper mandatory state compliance and reporting. Budgeted Stalling Cost & Terms Revision dale: 6/8/2015) Page 3 G. go beyonc atILLAGHvIL gASSfI • SERVICES risxfacs.com - Additional Users GB International Claims Services Consultative Services City of Miami 000757 2/15/2016 - 2/15/2017 OTHER SERVICES $1,000 per user Varies by Country (pricing provided upon request) Loss Control Consulting Services Appraisal Services $140 per hour TBD Fraud Prevention — Gallagher Bassett Investigative Services (GBIS) Special Fraud Investigations SIU Surveillance Investigations $85 per hour plus expenses $70 per hour plus expenses Targeted Field Investigations $80 per hour plus expenses Targeted Database Investigations Rate per report Gallagher Bassett Litigation Management Program (GBLMP) Invoice and Matter Management platform for Resolution Manager/counsel 5 client licenses for Legal Analytics platform Attorney -led invoice compliance review 2%, of net legal invoice (invoice net of disbursements and invoice review savings). Charged as discount off total payment remitted to counsel unless client elects to fund. Medlnsights MSA (This pricing is for Medlnsights services only. If another vendor is selected, then other pricing applies) Workers Compensation Medicare Set -Aside Allocation (WCMSA) Rush Fees (MSA completed within 7 days) Revisions: Liability Medicare Set -Aside Allocation (LMSA) MSA Submission to CMS Gallagher Bassett Compliance Services (GBCS) (The following pricing is for GBCS services only. If another vendor is selected, then other pricing applies) $2,300 per allocation $450 per case $150 per hour (One free revision within six months of submission) Conditional Payment Research (CPR) Conditional Payment Negotiations (CPN) Secure Final Demand for Settlement (SFD) Bundled CP Resolution Services $2,300 Fee $850 Fee $200 Flat Rate $375 Flat Rale $250 Flat Rate $700 Flat Rate Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page4 o beyoric City of Miami 000757 2/15/2016 - 2/15/2017 Benefit Coordination & Recovery Contractor Notification Medicare Eligibility Inquiry (MEI) SSDI Verification Release / Settlement Agreement Review Lien Resolution (Advantage Plan, Medicaid, Part D) Taxes All applicable taxes will be added to the service fees $45 Flat Rate No Charge $175 Flat Rate $250 Flat Rate--- $500 Hat Rate per Lien Resolution where required Budgeted Staffing Cost & terms (Revision date: 6/8/2015) Page 5 go beyonr. G laAs$EA ' 1. Audit Terms: Actual: • Actual — No true -ups will occur City of Miami 000757 2/15/2016 - 2/15/2017 PROGRAM SPECIFIC TERMS AND CONDITIONS Ggo beyond AI,LAat asset 2. 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. 3. 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: ► 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-FAGS" ), risxfacs.com users, Administration, Banking fees and monthly reports for as long as GB handles claims. 4) Account Administration includes the following: a. Designated Account Manager b. Detailed Status Reports © $50,000 c. Settlement Authority L $10,000 (WC)/$3,000 (Liability) d. Banking Administration (SIMMS) e. Two Claim Reviews a Year or One Performance 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) or Medlnsights for Bill Review, PPO, out -of -network, utilization review, telephonic case management, MSA and field case management. Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 6 goeyonc G ',4sse. - City of Miami 000757 2/15/2016 - 2/15/2017 �� go beyond 'liLLAGH $ASsk�q 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 Administration included in the cost-plus fee. 7. The pricing of specific service offerings is the proprietary, confidential property of Gallagher Bassett Services, Inc. It has been provided to you for the sole purpose of considering a quote for claims administration services. It is not to be duplicated or shared in any form with anyone other than the individuals of such prospective client that have a business need to know the information_ It must be destroyed or returned to Gallagher Bassett Services, Inc. after its intended use. $_ 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. Budgeted Staffing Cost & Terms (Revision dale: 6/8/2015) Page 7 Ggo tieyoF-ic: 'gLLAG►� �' $ASSe ' City of Miami 000757 2/15/2016 - 2/15/2017 GENERAL CONTRACT TERMS AND CONDITIONS G. go beyond %ARLLAGH�¢ Q4SSES S 1. Independent resolution managers for Catastrophes - If applicable, following 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 (resolution managers) 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 (GO) 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 Court reports r Medical records Accident reconstruction r Experts' rehabilitation costs Chemist ;- Fees for service of process Collection cost payable to third parties on subrogation • Architects, contractors Engineer Any other similar cost, fee or expense reasonably chargeable to the investigation, negotiation, settlement or defense of a claim or Toss 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 rose investigation Official documents and transcripts Pre- and post -judgment interest paid Y 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 ili. Automated state fee scheduling iv. Light duty/return-to-work programs v. vi. Medical case management and Vocational rehabilitation network Prospective injury management services vii. Hospital bill audit services Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 8 G'- go beyonO �Qass�. City of Miami 000757 2/15/2016 - 2/15/2017 DEFINITIONS go beyond 4iLLAGHti� �ASSE� 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 CraimL.ine 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 all 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)IProperty 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 Staffing Cost & Terms (Revision date: 6/8/2015) Page 9 City of Miami Procurement ❑epartment Miami Riverside Center 444 SW 2^d Avenue, 6,, Floor Miami, Florida 33130 Web Site Address Number: Title: Issue Date/Time: Closing Date/Time: Pre-Bid/Pre-Proposal Conference: Pre-Bid/Pre-Proposal Date/Time: Pre-Bid/Pre-Proposal Location: Deadline for Request for Clarification: Contracting Officer: Hard Copy Submittal Location: Contracting Officer E-Mail Address: Contracting Officer Facsimile: 605386,6 Request for Proposals for Third Party Claims Adm. & Managed Care Services 02-NOV-2016 30-NOV-2016 @ 14:00:00 Voluntary Wednesday, October 12, 2016, at 2:00 PM 444 SW 2nd Avenue, 6th Floor South Conference Room, Miami, Florida Tuesday, November 1, 2016 at 5:00 PM Calderon, Yadissa City of Miami - City Clerk 3500 Pan American Drive Miami FL 33133 US yealderon@miamigov.com 305-400-5369 Page I of 56 Certification Statement Please quote on this form. if applicable. net prices for the item(s) listed. Return signed original and retain a copy for your files. Prices should include all costs. including transportation to destination. The City reserves the right to accept or reject all or any part of this submission. Prices should be firm for a minimum of 180 days following the time set for closing of the submissions. In the event of errors in extension of totals, the unit prices shall govern in determining the quoted prices. We (I) certify that we have read Your solicitation. completed the necessary documents, and propose to furnish and deliver, F.O.B. DESTINATION, the items or services specified herein. The undersigned hereby certifies that neither the contractual party nor any of its principal owners or personnel have been convicted of any of the violations. or debarred or suspended as set in section 18-107 or Ordinance No. 12271. All exceptions to this submission have been documented in the section below (refer to paragraph and section) . EXCEPTIONS: We (I) certify that any and all information contained in this submission is true: and we (1) further certify that this submission is made without prior understanding. agreement, or connection with any corporation. firm. or person submitting a submission for the same materials. supplies. equipment. or service. and is in all respects fair and without collusion or fraud. We (I) agree to abide by all terms and conditions of this solicitation and certify that I am authorized to sign this submission for the submitter. Please print the following and sign your name: PROPOSER NAME - ADDRESS: PHONE: FAX' EMAIL- CELL(Optional): SIGNED BY: TITLE: DATE: FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM SHALL DISQUALIFY THIS RESPONSE. Page 2 of 66 Certifications Legal Name of Firin: FEIN No.: Entity Type; Partnership, Sole Proprietorship. Corporation, etc. Year Established: Business Address: City, State, and Zip Code: Telephone Number; Fax Number: E-mail Address: Office Location: City of Miami, Miami -Dade County. or Other Business Tax Receipt/Occupational License Number: Business Tax Receipt/Occupational License Issuing Agency: Business Tax Receipt/Occupational License Expiration Date: Will Subcontractor or Sub consultant (s) be used? Sub consultant shall mean the sante thing as a Page 3 of 66 Subcontractor in these documents. (Yes or No) (if yes for what and what percentage of such work) Will furnish and provide professional services to the City, at minimum. in compliance with all contract documents and in compliance with all applicable laws, rules and regulations. Certifies that neither the Proposer nor any of its principal owners or personnel or any subsidiary of the Proposer, have been convicted of any of the violation(s) or crimes or actions and conduct involving moral turpitude as defined by applicable laws. or debarred or suspendedas set forth in Section 18-107, City Code, or as provided by 287.133. Florida Statutes. The Proposer further certifies that the Proposer has not been debarred or suspended by the United States Government. the State of Florida. any political subdivision of the State of Florida or any Special District or Public School Board in the State of Florida. Proposer understands that exceptions not timely or correctly taken are waived. Please list and acknowledge all addendum/addenda received. List the addendum/addenda number and date of receipt (i.e. Addendum No. 1, 7/1/07). If no addendum/addenda \vas/were issued. please insert Has Proposer reviewed the attached Sample Professional Services Agreement (PSA)? Does the Proposer acknowledge that the attached PSA is an example of the standard Agreement used in conjunction with the services related to this Solicitation and shall not be amended.? Page 4 of 66 Line: 1 Description: Disregard this line item. Please refer to Attachment A, attached to the Header Section of this solicitation. Proposer shall clearly indicate in proposal if providing a response for Part I andfor Part II Services. Category: 95327-00 Unit of Measure: Year Unit Price: $ Number of units: 3 Total: S Page 5 of 66 605386.6 Table of Contents Terms and Conditions 7 1. Genera] Conditions 7 1.1. GENERAL TERMS AND CONDITIONS 7 2. SPECIAL CONDITIONS 29 2.1. PURPOSE 99 2.2. DEADLINE FOR RECEIPT OF REQUEST FOR .ADDITIONAL INFOR\IATION 29 2.3. VOLUNTARY PRE -PROPOSAL CONFERENCE 99 2.4. DEFINITIONS 29 3. Specifications 39 3.1. SPECIFICATIONS/SCOPE OF WORK 39 4, Submission Requirements 57 4.1. CMIA Submission Requirements 57 5. Evaluation Criteria 65 5.1. CI\IHA Evaluation Criteria 65 Page 6 of 66 605386,6 Terms and Conditions 1. General Conditions 1.1. GENERAL TERMS AND CONDITIONS References to goods only apply insofar as thev are applicable to "Goods" as defined in Section 18-73 of the City Code. References to "Professional and Personal Services" are as defined in Section 18-73 of the City Code, Intent: The General Terms and Conditions described herein apply to the acquisition of goods,equipment'services with an estimated aggregate cost of S25,000.00 or more. Definition: A formal solicitation is defined as issuance of an Invitation for Bids. Request for Proposals. Request for Qualifications, or Request for Letters of Interest pursuant to the City of Irliarni Procurement Code and, or Florida Law. as amended. Formal Solicitation and Solicitation shall be defined in the same manner herein. 1.1. ACCEPTANCE OF GOODS OR EQUIPMENT- Any good(s) or services delivered under this formal solicitation. if applicable, shall remain the property of the seller until a physical inspection and actual usage of the good is made. and thereafter is accepted as satisfactory to the City. It must comply with the terms herein and be full in accordance with specifications and of the highest quality. In the event the goods equipment supplied to the City are found to be defective or does not conform to specifications, the Cite reserves the right to cancel the order upon written notice to the Successful Proposer and return the product to the Successful Proposer at the Successful Proposer's expense. 1.2. ACCEPTANCE OF OFFER- The signed or electronic submission of your proposal shall be considered an offer on the part of the Successful Proposer: such offer shall he deemed accepted upon issuance by the Cita of a purchase order. 1.3. ACCEPTANCE/REJECTION L The City reserves the right to accept or reject any or all responses or parts of after opening/closing date and request re -issuance on the goods/services described in the formal solicitation. In the event of such rtjectirm. the Director of Procurement shall notify all affected bidders. proposers and make available a written explanation for the rejection. The City also reserves the right to reject the response of any Successful Proposer who has previously railed to properly perform under the terms and conditions of a contract. to deliver on time contracts of a similar nature. and who is not in a position to perform the requirements defined in this formal solicitation. The City further reserves the right to waive any irregularities or minor informalities or technicalities in any or all responses and may. at its discretion. re -issue this formal solicitation. 1.4. ADDENDA - It is the bidder's/proposer's responsibility to ensure receipt of all Addenda. Addenda are available at the Citv's wehsite at: http:-'www.ci.miatni.fl.us'procurement 1.5. ALTERNATE RESPONSES WILL NOT BE CONSIDERED. 1.6. ASSIGNMENT - Successful Proposer agrees not to subcontract. assign. transfer, convey. sublet. transfer, pledge. encumber. or otherwise dispose of the resulting Contract. in whole or in part or any or all of its right. title or interest herein, without City of Miami's prior written consent. These particular services are considered unique in nature and specialized in training and experience and the City will select a Proposer in reliance on such training and experience. 1.7.. ATTORVEY'S FEES- In connection with any litigation. in trial and appellate levels. mediation and arbitration Page 7 of 66 605386.6 arising out of this Contract. each parts shall bear their own attorneys fees through and including appellate litigation and any post judgment proceedings. 1.8. AUDIT RIGHTS AND RECORDS RETENTION- The Successful Proposer agrees to provide access at all reasonable times to the City. or to any of its duly authorized representatives. to any books, documents, papers. and records of Successful Proposer which are directly pertinent to this formal solicitation, for the purpose of audit. examination, excerpts. and transcriptions, The Successful Proposer shall maintain and retain any and all of the books, documents. papers and records pertinent to the Contract for three (3) years after the City makes final payment and all other pending matters are closed. SuccessfulProposer's failure to or refusal to comply with this condition shall result in the immediate cancellation of this contract by the City. The Audit Rights set forth in Section 18-102 of the City Code apply- as supplemental terms and are deemed as being incorporated by reference herein. 1.9. AVAILABILITY OF CONTRACT STATE-WIDE- Any Governmental. not -for -profit or quasi - governmental entity in the State of Florida. may avail itself of this contract and purchase any and all goods. services. specified herein from the Successful Proposer at the contract price(s) established Herein. when permissible by federal. state. and local laws. rules. and regulations. Each Gov ernmental. not -for -profit or quasi -governmental entity which uses this formal solicitation and resulting bid contract or agreement tvill establish its own contract. agreement, place its own orders. issue its own purchase orders. be invoiced there from and make its own payments. determine shipping terns and issue its own exemption certificates as required by the Successful Proposer. 1.I0. AWARD OF CONTRACT: A. The Formal Solicitation. Proposer's response. am addenda issued.. the Professional Services ,agreement ("PS.\") attached hereto as an Exhibit, and the purchase order shall constitute the entire contract. unless modified in accordance with any ensuing contract agreement" amendment or addenda. B. The award of a contract where there are Tie Bids will be decided by the Director of Procurement or designee in the instance that Tie Bids can't be determined bs applying Florida Statute Section. 287.087. Preference to Businesses With Drug -Free Workplace Programs. C. The award of this contract may he preconditioned on the subsequent submission of other documents as specified in the Special Conditions or Technical Specifications, Proposer shall be in default of its contractual obligation if such documents are not submitted in a timely manner and in the form required by the Cite. Where Proposer is in default of these contractual requirements. the City. through action taken by the Procurement Department. will void its acceptance of the Proposer's Response and may accept the Response from the next lowest responsive. responsible Proposal most ads antageous to the City or re -solicit the City's requirements. The City. at its sole discretion. may seek monetary restitution from Successful Proposer and its proposal bond or guaranty. if applicable. as a result of damages or increased costs sustained as a result of the Proposer's default. D. The term of the contract shall be specified in one cif three documents which shall be issued to the Successful Proposer. These documents rnav either be a purchase order. notice of award and/or contract award sheet. E. The City" reserves the right to automatically extend this contract for up to one hundred twenty (120) calendar days beyond the stated contract term in order to provide City departments with continual service and supplies while a new contract is being solicited. evaluated. and 'or awarded. If the right is exercised. the City shall notify the Successful Proposer. in writing. of its intent to extend the contract at the saute price. terms and conditions for a specific number of days. Additional extensions over the first one hundred twenty (120) day extension may occur. if. the City and the Successful Proposer are in mutual agreement of such extensions. F. \Where the contract involves a single shipment of goods to the City. the contract term shall conclude upon Page 8 of 66 605386,6 completion of the expressed or implied warranty periods. G. The City reserves the right to award the contract on a split -order. lump sum or individual -item basis. or such combination as shall best serve the interests of the Cis; unless otherwise specified. H. A Contract: Agreement niav be awarded to the Successful Proposer by the City Commission based upon the minimum qualification requirements reflected herein. As a result of a RFP. RFQ. or RFLI. the City reserves the right to execute, a Professional Services Agreement ("PSA" or "Agreement') in substantially the form attached to the Solicitation, with the Proposer. whichever is determined to be in the City's best interests. Such agreement will be furnished by the City. \\ill contain certain terms as are in the Citv's best interests. and trill be subject to approval as to legal form by the City Attorney. Certain terms. including. without limitation. the cancellation for convenience and the hold harmless/ duty to defend and indemnify are long standing City requirenicnts and may not be modified. 1.11. BID BOND/ BID SECURITY -A cashier's or certified check issued by a bank authorized to transact banking business in Florida. or a Bid Bond signed hr.' a recognized surety company that is licensed to do business in the State of Florida, parable to the City- of Miami, for the amount bid is required from all Proposers. if so indicated under the Special Conditions. This check or bond guarantees that a Successful Proposer will accept the order or Agreement, as proposed, if it is awarded to Successful Proposer. Successful Proposer shall forfeit hid deposit to the City should City award Agreement to Successful Proposer and Successful Proposer fails to accept the award. The City reserves the right to reject any and all surety tendered to the City. Bid deposits are returned to unsuccessful Proposers within ton (10i days after the award and Successful Proposer's acceptance of award. If one hundred eight- (l 80) days have passed after the date of the formal solicitation closing date. and no contract has been awarded. all bid deposits will be returned on demand. 1.12. RESPONSE FORM (HARDCOPY FORMAT)- All formes should he completed. signed axed submitted accordingly. 1.13. BID SECURITY FORFEITED LIQUIDATED DAMAGES- Failure to execute an .Agreement and or file an acceptable Bid Payment, Performance Bond. when required. as provided herein, shall be just cause for the rescission of the award and the forfeiture of the Bid Security to the Cit. tthich forfeiture shall be considered, not as a penalty. but in mitigation of damages sustained. Award may then be made to the next lowest responsive, responsible Proposer most advantageous to the City or all responses mar be rejected. 1.14. BRAND NAMES- If and wherever in the specifications brand names. makes, models. names of any manufacturers. trade names. or Successful Proposer catalog numbers are specified, it is for the purpose of establishing the type. function. minimum standard of design, efficiency. grade or quality of goods only. \Viten the City does not wish to rule out other competitors' brands or makes. the phrase "OR EQUAL" is added. When proposing an approved equal. Proposers will submit, with their response. complete sets of necessary data (factory information sheets. specifications. brochures. etc.) in order fur the City to evaluate and determine the equality of the item(s) proposed. The Citv shall be the sole judge of equality and its decision shall be final. Unless otherwise specified, evidence in the form of samples may be requested if the proposed brand is other than specified br the City. Such samples are to be furnished after formal solicitation opening/closing only upon request of the City. If samples should be requested. such samples must be received by the City no later than seven (7) calendar days after a formal request is made. 1.15. CANCELLATION- The Citv reserves the right to cancel all formal solicitations before it's opening dosing. In the event of bid proposal cancellation. the Director of Procurement shall notify all prospective bidders'proposers and make available a written explanation for the cancellation. 1.16. CAPITAL EXPENDITURES . Successful Proposer understands that any capital expenditures that the firm makes. or prepares to make, in order to deliver'perfornt the goods,'ser•ices required by the City, is a business risk Page 9 of 66 605386.6 which the Proposer roust assume. The Cite yyill not he obligated to reimburse amortized or unamortized capital expenditures. or to maintain the approved status of any Proposer. If Proposer has been unable to recoup its capital expenditures during the time it is rendering such goods/services, it shall not have arty claim upon the City. 1,17, CITY NOT LIABLE FOR DELAYS- It is further expressly agreed that in no event shall the City be liable for. or responsible to. the Successful Proposer. anv sub- contractor 'sub -consultant, or to any other person for. or on account of. anv stoppages or delay in the work herein provided for by injunction or other legal or equitable proceedings or on account of any dclav for any cause over which the City has no control. 1.18. COLLUSION - Proposer. by submitting a response. certifies that its response is made yy ithout previous understanding, agreement or connection either with any person, firm or corporation submitting a response for the same items/services or with the City of Nliaini's Procurement Department or initiating department. The Proposer certifies that its response is fair. tyithout control. collusion. fraud or other illegal action. Proposer certifies that it is in compliance with the Conflict of Interest and Code of Ethics Laws. The City will investigate all potential situations where collusion may have occurred and the City reserves the right to reject any and all responses yvhere collusion may have occurred+ 1.19. COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS - Successful Proposer understands that contracts between private entities and local governments are subject to certain laws and regulations. including laws pertaining to public records. conflict of interest. records keeping. etc, City. and Successful Proposer agree to comply with and observe all applicable laws. codes and ordinances as that may in any way affect the goods or equipment offered. including but not limited to: A.Executive Order 11246. \yhich prohibits discrimination against any employee, applicant, or client because of race. creed. color. national origin. sex. or age yvith regard to. but not limited to, the following- employment practices. rate of pav or other compensation methods, and training selection. B.Occupational, Safety and Health Act (OSHA). as applicable to this Formal Solicitation. C.Tlre State of Florida Statutes. Section 287.1330 on Public Entity Crimes. D.Environment Protection .agency (EPA), as applicable to this Formal Solicitation. E.L'inform Commercial Code (Florida Statutes. Chapters 672-679). F.Americans with Disabilities Act of 1990, as amended. G,National Institute of Occupational Safety: Hazards (N IOSH). as applicable to this Formal Solicitation. H.Natinnal Forest Products Association (NFPA), as applicable to this Formal Solicitation. +City Procurement Ordinance City Code Section 18. Article III. J.C.onflict of Interest. City. Code Section 2-611: 61. K.Cone of Silence, City Code Section 18-74. L.The Florida Statutes Sections 218.70 to 218.79 on Prompt Payments. Lack of knowledge by the Successful Proposer will in no yvay be a cause for relief from responsibility. Non-compliance with all applicable local. state. and federal directives-. orders. codes. rules, regulations, and laws may be considered grounds for termination of contract(s) at the option of the City Manager. Copies of the City Ordinances may be obtained from the City Clerk's Office. 1.20. CONE OF SILENCE - Pursuant to Section 18-74 of the City of Miami Code, a "Cone of Silence" is imposed Page 10 of 66 605386.6 upon each RFP. RFQ. RFLI. or IFB after advertisement and terminates at the time the City Manager issues a written recommendation to the Miami City Commission. The Cone of Silence shall he applicable only to Contracts for the provision of goods and services and public works or improvements for amounts greater than S200.000. The Cone of Silence prohibits any communication regarding RFPs, RFQs, RFLI or IFBs (bids) between. among others: Potential vendors, service providers. bidders, lobbyists or consultants and the City's professional staff including, but not limited to. the City lllanager and the City Manager's staff: the Mayor. City Commissioners. or their respective staffs and any member of the respective selection/"evaluation committee. The provision does not apply to. among other communications: oral communications with the City Procurement staff. provided the communication is limited strictly to matters of process or procedure already contained itt the formal solicitation document: the provisions of the Cone of Silence do not apply to oral cotnmunications at duly noticed site visits inspections. pre -proposal or pre -bid conferences. oral presentations before selection/evaluation committees. contract negotiations during any dult noticed public meeting. or public presentations made to the Miami Citv Commission during a duly noticed public meeting: or communications in writing or by email at any time with anv Citv employee. official or member of the City Commission unless specifically prohibited by the applicable RFP. RFQ. RFLI or II B (bid) documents (See Section 2.2. of the Special Conditions): or communications in connection with the collection of industry comments or the performance of market research regarding a particular RFP. RFQ. RFLI OR IFB by City Procurement staff. Proposers or bidders must file a copy of any written communications with the Office of the City Clark. which shall ix made available to any person upon request, The City shall respond in writing and file a copy with the Office of the City Clerk. ~,vhich shall he made available to any person upon request. Written communications may he in the form of e-mail, \1 ith a copy to die Office of the Citv Clerk. In addition to anv other penalties provided by law, violation of the Cone of Silence by anv Proposer shall render anv award voidable. A violation by a particular Proposer. Offeror, Respondent. lobbyist or consultant shall subject same to potential penalties pursuant to the City Code. Any person having personal knowledge of a violation of these provisions shall report such violation to the State Attorney and/or may file a complaint with the Ethics Commission. Proposers should reference Section 18-74 of the City of Miami Code for further clarification. This language is only a summary of the ket provisions of the Cone of Silence. Please review City of Miami Code Section 18-74 for a complete and thorough description of the Cone of Silence. You may contact the City Clerk at 305-250-5360. to obtain a copy of same. 1.21. CONFIDENTIALITY- As a political subdivision. the Citv of Mianti is subject to the Florida Sunshine Law and Public Records Law. If this Contract Agreement contains a confidentiality provision, it shall have no application when disclosure is required by Florida law or upon court order. 1.22. CONFLICT OF INTEREST - Proposers, by responding to this Formal Solicitation. certify that to the best of their knowledge or belief. no elected appointed official or employee of the City of ?Miami is financially interested, directly or indirectly. itt the purchase of goods/services specified in this Formal Solicitation. Anv such interests on the part of the Successful Proposer or its employees must be disclosed in writing to the City. Further. you must disclose the name of anv City employee who owns. directly or indirectly. an interest of five percent (5'0) or more of the total assets of capital stock in your firth. Page 11 of 66 605386.6 A. Successful Proposer further agrees not to use or attempt to use anv knowledge. property or resource \vhich may be within his/her/its trust, or perform his/her/its duties. to secure a special privilege, benefit. or exemption for hiinsclf'herself'itself. or others. Successful Proposer may not disclose or use information not available to members of the general public and gained by reason of his'herlits position. except for information relating exclusively to governmental practices. for his,'her/its personal gain or benefit or for the personal gain or benefit of any other person or business entity. B. Successful Proposer hereby acknowledges that he.'shelit has not contracted or transacted any business with the City or any person or agency acting for the City. and has not appeared in representation of any third party before any board, commission oragency of the City within the past two years. Successful Proposer further warrants that he/she/it is not related, specifically the spouse. son. daughter. parent, brother or sister. to: (i) any member of the commission: (ii) the Mayor: (iii) any City employee: or (iy) any member- of any board or agency of the City. C. A violation of this section may subject the Successful Proposer to immediate termination of any professional services agreement with the -City, imposition of the maximum fine and 'or anv penalties allowed by law. Additionally. violations may be considered by and subject to action by the Miami -Dade County Commission on Ethics. 1.23. COPYRIGHT OR PATENT RIGHTS - Proposers «arrant that there has been no violation of copyright or patent rights in manufacturing. producing. or selling the goods shipped or ordered and. or services provided as a result of this formal solicitation, and Proposers agree to hold the City harmless from any and all liability. loss. or expense occasioned by any such violation. 1.24. COST INCURRED BY SUCCESSFUL PROPOSER- All expenses involved with the preparation and submission of Responses to the City. or anv work performed in connection therewith shall be borne by the Proposer(s). 1.25. DEBARMENT AND SUSPENSIONS (Sec 18-107, City Code) (a) Authority and requirement to debar and suspend. After reasonable notice. to an actual or prospective Contractual Party. and after reasonable opportunity for such parry to be heard, the City ?Manager, after consultation with the Chief Procurement Officer and the City Attorney. shall have the authority to debar a Contractual Party. for the causes listed below. from consideration for award of City Contracts. The debarment sha.Il be for a period of not fewer than three years. The City Manager shall also have the authority to suspend a Contractual Party from consideration for award of City Contracts if there is probable cause for debarment. pending the debarment determination. The authority to debar and suspend Proposer s shall be exercised in accordance with regulations which shall be issued by the Chief Procurement Officer after approval by the City Manager, the City attorney, and the City Commission. (b) Causes for debarment or suspension. Causes fur debarment or suspension include the following: (1) Conviction for commission of a criminal offense incident to obtaining or attempting to obtain a public or private Contract or subcontract. or incident to the performance of such Contract or subcontract. (2) Conviction under state or federal statutes of embezzlement. theft. forgery, bribery. falsification or destruction of records. receiving stolen property, or any other offense indicating a lack of business integrity or business honesty. (3) Conviction under state or federal antitrust statutes arising out of the submission of Bids or Proposals. (4) Violation of Contract provisions, which is regarded by the Chief Procurement Officer to be indicative of non - Page 12 of 66 605386.6 responsibility. Such violation may include failure without good cause to perform in accordance with the terms and conditions of a Contract or to perform svithin the time limits provided in a Contract. provided that failure to perform caused by acts beyond the control of a party shall not he considered a basis for debarment or suspension. (5) Debarment or suspension of the Contractual Party by anv federal. state or other governmental entity. (6) False certification pursuant to paragraph (e) below. (7) Found in violation of a zoning ordinance nr anv other City ordinance or regulation and for which the violation remains noncompliant. (8) Found in iotation of a zoning ordinance or any other City ordinance or regulation and for,vhich a civil penalty or fine is due and owing to the City. (9) Any other cause judged by the City Manager to be so serious and compelling as to affect the responsibility of the Contractual Part, performing City Contracts. (e) Certification. All Contracts for goods and services. sales. and leases by the City shall contain a certification that neither the Contractual Party- nor anv of its principal owners or personnel have been convicted of anv of the violations set forth above or debarred or suspended as set forth in paragraph (b) )5). (d) Debarment and suspension decisions. Subject to the provisions of paragraph (a). the City Manager shall render a written decision staling the reasons for the debarment or suspension. A copy of the decision shall be provided promptly to the Contractual Party, along with a notice of said partv's right to seek judicial relief. 1.26. DEBARRED/SUSPENDED VENDORS - An entity or affiliate Nvho has been placed on the State of Florida debarred or suspended Vendor list may not submit a response on a contract to provide goods or services to a public entity. ilia, not subunit a response on a contract with a public entity for the construction or repair of a public building or public ssork. may not submit response on leases of real property to a public entity. may not award or perform work as a Proposer . supplier. subcontractor. or consultant under contract ,with anv public entity. and 'nay not transact business with any public entity. 1.27. DEFAULT/FAILURE TO PERFORM -The City shall be the sole judge of nonperformance. which shall include anv failure on the part oldie Successful Proposer to accept the awvard. to furnish required documents. and or to fulfill anv portion of this Contract within the time stipulated. Upon default by the Successful Proposer to meet anv terms of this agreement. the City will notify the Successful Proposer of the default and will provide the Successful Proposer three (3) days (weekends and holidays excluded) to remedy the default. Failure on the Successful Proposer's part to correct the default within the required three (3) days shall result in the Contract being terminated and upon the Ciiv notifying in writing the Successful Proposer of its intentions and the effective date of the termination. The following shall constitute default: A. Failure to perform the work or deliver the goodsrsers ices required under the Contract andior t\ ithin the time required or failing to use the sub Proposer s. entities and personnel as identified and set forth. and to the degree specified in the Contract. B. Failure to begin the work under this Contract, within the time specified. C. Failure to perform the ,work with sufficient workers and equipment or ,with sufficient materials to ensure timely completion. D. Neglecting or refusing to remove materials or perform new work where prior work has been rejected as nonconforming ,with the terms of the Contract. Page 13 of 66 605386,6 E. Becoming insolvent. being declared bankrupt, or committing any act of bankruptcy or insolvency. or making an assignment for the benefit of creditors. if the insolvency. bankruptcy. or assignment renders the Successful Proposer incapable of performing the work in accordance with and as required by the Contract. F. Failure to comply with any of the terms of the Contract in any material respect. All costs and charges incurred by the City as a result of a default or a default incurred beyond the time limits stated, together with the cost of completing the work. shall be deducted from any monies due or which may become clue on this Contract. 1.28. DETERMINATION OF RESPONSIVENESS -Each Response will be reviewed to determine if it is responsive to the submission requirements outlined in the Formal Solicitation. A "responsive" response is one which follows the requirements of the formal solicitation. includes all documentation. is submitted in the format outlined in the formal solicitation. is of timely submission. and has appropriate signatures as required on each document. Failure to comply with these requirements may deem a Response non -responsive. Responsible Proposer shall mean a Proposer who has submitted a Proposal and who has the capability. as determined under the City Procurement Ordinance, in all respects to fully perform the contract requirements, and the integrity and reliability of which give reasonable assurance of good faith and performance. 1.29. DISCOUNTS OFFERED DURING TERM OF CONTRACT -Discount Prices offered in the response shall be fixed after the award bv the Commission. unless otherwise specified in the Special Terms and Conditions. Price discounts off the original prices quoted in the response twill be accepted from Successful Proposer(s) during the term of the contract. Such discounts shall remain in effect for a minimum of 120 days from approval bv the City Commission Anv discounts offered bv a manufacturer to Successful Proposer will be passed on to the City. 1.30. DISCREPANCIES. ERRORS. AND OMISSIONS -Any discrepancies. errors. or ambiguities in the Formal Solicitation or addenda (if an-) should be reported in writing to the Citys Procurement Department. Should it be found necessary a written addendum will be incorporated in the Formal Solicitation and will become part of the purchase agreement (contract documents). The City will not he responsible for any oral instructions. clarifications. or other communications. A. Order of Precedence �, Any. inconsistency in this formal solicitation shall be resolved by giving precedence to the following documents. the first of such list being the goy erning documents, I) Addenda (as applicable) 2) Specifications 3) Special Conditions •1) General Terms and Conditions 1.31. EMERGENCY / DISASTER PERFORMANCE - In the event of a hurricane or other emergency or disaster situation. the successful vendor shall provide the City with the commodities/services defined within the scope of this formal solicitation at the price contained within vendors response. Further. successful vendor shall deliverperform for the City on a priority basis during such tithes of emergency. 1.32. ENTIRE BID CONTRACT OR AGREEMENT -The Agreement consists of this City of Miami Formal Solicitation and specifically- this General Conditions Section. Proposer 's Response and any written agreement Page 14 of 66 605386,6 entered into by the City of Miami and Proposer in cases involving RFPs. RFQs. and RFLIs. and represents the entire understanding and agreement between the parties with respect to the subject matter hereof and supersedes all other negotiations. understanding and representations. if any. made by and between the parties. To the extent that the agreement conflicts yvith. modifies, alters or changes any of the terms and conditions contained in the Formal Solicitation and/or Response, the Formal Solicitation and then the Response shall control. This Contract may he modified only by a written agreement signed by the City of ]Miami and Proposer. 1.33. ESTIMATED QUANTITIES LEstimated quantities or estimated dollars are provided for your guidance only. No guarantee is expressed or implied as to quantities that will be purchased during the contract period. The City is not obligated to place an order for any given amount subsequent to the award of this contract. Said estimates may be used by the City for purposes of determining the most advantageous proposer meeting specifications. The City reserves the right to acquire additional quantities at the prices proposed or at lower prices in this Formal Solicitation. 1.34. EVALUATION OF RESPONSES A. Rejection of Responses The City ma v reject a Response for anv of the following reasons: 1)Succcssfu] Proposer fails to acknowledge receipt of addenda: 2)Succcssful Proposer misstates or conceals any material fact in the Response: 3)Response does not conform to the requirements of the Formal Solicitation: 4)Response requires a conditional award that conflicts with the method of award: 5)Response does not include required samples. certificates. licenses as required: and. 6)Response was not executed by the Pruposer(s) authorized agent. The foregoing is not an all-inclusi e list of reasons for which a Response may be rejected. The City ntav reject and re -advertise for all or anv part of the Formal Solicitation \vhencver it is deemed in the best interest of the City. B. Elimination from Consideration 1) A contract shall not he awarded to anv person or firm which is in arrears to the City upon anv debt or contractor which is a defaulter as surety or otherwise upon any obligation to the City. 2) A contract may not. he awarded to am- person or firm yvho has failed to perform under the terms and conditions of anv previous contract with the City or deliver on time contracts of a similar nature. 3) A contract may not be awarded to anv person or firm who has been debarred by the City in accordance with the City's Debarment and Suspension Ordinance. C. Determination of Responsibility 1) Responses will only be considered from entities yvho are regularly engaged in the business of providing the goods/equipment:services required by the Formal Solicitation. Successful Proposer must be able to demonstrate a satisfactory record of performance and integrity: and, have sufficient financial. material. equipment. facility. personnel resources. and expertise to meet all contractual requirements. The terms "equipment and organization" as used herein shall be construed to mean a fully equipped and well established entity in line with the hest industry practices in the industry as determined by the City. 2) The City may consider anv evidence available regarding the financial, technical and other qualifications and Page 15 of 66 605386,6 abilities of a Successful Proposer. including past performance (experience) tvith the City or any other gotiernmental entity in making the award. 3) The City tnav require the Proposerfs) to show proof that they have been designated as an authorized representative of a manufacturer or Proposer which is the actual source of supply. if required by the Formal Solicitation. 1.35. EXCEPTIONS TO GENERAL AND/OR SPECIAL CONDITIONS OR SPECIFICATIONS Exceptions to the specifications shall be listed on the Response and shall reference the section. Any exceptions to the General or Special Conditions shall be cause for the Proposal to be considered non -responsive. It also may be cause for a REP, RFC/ or RFLI to be considered nonresponsive: and, if exceptions are taken to the terms and conditions of the resulting agreement it may lead to terminating negotiations. 1.36. F.O.B. DESTINATION -Unless otherwise specified in the Formal Solicitation. al] prices quoted/proposed by the Successful Proposer must be F.O.B. DESTINATION. inside delivery. with all delivery costs and charges included. in the bid,"proposal price, unless otherwise specified in this Formal Solicitation. Failure to do so may be cause for rejection of proposal. 1.37. FIRM PRICES - The Successful Proposer warrants that prices. terms, and conditions quoted in its response will he firm throughout the duration of die contract unless otherwise specified in the Formal Solicitation. Such prices will remain firm for the period of performance or resulting purchase orders or contracts. which are to be performed or supplied over a period of time. 1.38. FLORIDA MINIMUM WAGE -The Constitution of the State of Florida, Article X. Section 24. states that employers shall pat. emplotee wages no less than the minimum wage fur al] hours worked in Florida. Accordingly. it is the Proposer's and its' subcontractor(s) responsibility to understand and comply with this Florida constitutional minimum stage requirement and pay its enrplu\ees the current established hourly minimum wage rate. which is subject to change or adjusted by the rate of inflation using the consumer price index for urban wage earners and clerical ttorkers. CPI-W. or a successor index as calculated by the United States Department of Labor, Each adjusted minimum wage rate calculated shall be determined and published by the Agency Workforce Innovation on September 30th of each year and take effect on the following January 1st, At the time of responding, it is the Proposer and his/her subcontractor(s), if applicable. full. responsibility to determine whether any of its ernplovees may be impacted by this Florida Law at any given point in time during the term of the contract. If impacted. Proposer must furnish employee name(s). job title(s). job desc:ription(s). and current pay rate(s). Failure to submit this information at the time of submitting a response constitute Proposer's acknowledgement and understanding that the Florida'.1linimum Wage Law will not impact its prices throughout the term of contract and waiver of any contractual price increase request(s). The City reserves the right to request. and Successful Proposer must provide for any and al] information to make a wage and contractual price increase(s) determination. In the event a City of Miami "Lit ink; Wage" Ordinance is enacted prior to the award of an Agreement its provisions may be applicable to the employees of the Proposer. 1.39. GOVERNING LAW AND VENUE -The validity and effect of this Contract shall be governed by the laws of the State of Florida. The parties agree that any action, proceeding. mediation or arbitration arising out of this Contract shall take place in Miami -Dade County, Florida. In any action or proceeding each party shall bear their own respective attorney s fees. Page 16 of 66 O0538€ .6 1.40. HEADINGS AND TERMS -The headings to the various paragraphs of this Contract have been inserted for convenient reference only and shall not in anv manner be construed as modifying. amending, or affecting in any tvav the expressed terms and provisions hereof. 1.41. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)- Any person or entity that performs or assists the City of Miami with a function or activity involving the use or disclosure of " individually identifiable health information (IIH1) andor Protected Health Information (PHI) shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the City of Miami Privacy Standards. HIPA-\ mandates for privacv, security and electronic transfer standards, which include but are not limited to: A. Use of information only for perforating services required by the contract or as required by law: B. Use of appropriate safeguards to prevent non -permitted disclosures: C. Reporting to the City of Miami of any non -permitted use or disclosure: D. Assurances that any agents and sub Proposer s agree to the same restrictions and conditions that apply to the Successful Propuser and reasonable assurances that IIHI'PHI tvi11 be held confidential: E. Itlaking Protected Health Information (PHI) available to the customer; F. Making PHI available to the customer for review and amendment: and incorporating any amendments requested by the customer: G. Making PHI available to the City of Miami for an accounting of disclosures: and H. slaking internal practices. books and records related to PHI available to the Clty ofNIiami for compliance audits. PHI shall maintain its protected status regardless of the form and method of transmission (paper records. and;or electronic transfer of data). The Proposer must give its customers written notice of its privacy information practices including specifically. a description of the types cif uses and disclosures that would be made with protected health information. 1.42 INDEMNIFICATION - Successful Proposer shall indemnify. hold save harmless and defend at its own costs and expense the Cin. its officials. officers. agents, directors, and employees. from liabilities, damages, losses, and costs. including. but not limited to reasonable attorney's fees. to the extent caused by the negligence. recklessness or intentional wrongful misconduct of Successful Proposer and persons employed or utilized by Successful Proposer in the performance of this Contract and will indemnify, hold harmless and defend the City, its officials. officers. agents. directors and employees against. airy civil actions. statutory or similar claims. injuries or damages arising or resulting from the permitted work. even if it is alleged that the City, its officials anci;or employees were negligent. These indemnifications shall survive the term of this Contract. In the event that anv action or proceeding is brought against the City by reason of any such claim or demand. Successful Proposer shall; upon written notice from the City, resist and defend such action or proceeding by counsel satisfactory to the City. The Successful Propuser expressly understands and agrees that any insurance protection required by this Contract or otherwise provided by Proposer shall in no vvay limit the responsibility to indemnify. keep and save harmless and defend the City or its officers. employees. agents and instrumentalities as herein provided. The indemnification provided above shall obligate Successful Proposer to defend at its own expense to and through appellate. supplentental or bankruptcy proceeding. or to provide for such defense, at the City's option. any and all claims of liability artd all suits and actions of every name and description which may be brought against the City whether perforated by Successful Proposer, or persons employed or utilized by Proposer. This indemnity. hold harmless and duty to defend will survive the cancellation or expiration of the Contract. This indemnity twill he interpreted under the laws of the State of Florida. including without limitation and \\inch conforms to the limitations of §725.O6 and'or §725.08. Fla. Statutes, as amended from time to time as applicable. Page 17 of 66 605386,6 Successful Proposer shall require all Subcontractor agreements to include a provision that they \vill indemnify the City. The Successful Proposer agrees and recognizes that the City shall not be held Kahle or responsible for any claims which may result from any actions or omissions of the Successful Proposer in which the City participated either through review or concurrence of the Successful Proposer's actions. In reviewing, approving or rejecting any submissions by the Successful Proposer or other acts of the Successful Proposer. the City in no way assumes or shares any responsibility or liability of the Successful Proposer or Subcontractor. under this Agreement. 1.43. FORMATION AND DESCRIPTIVE LITERATURE - Proposer must furnish all information requested in the spaces provided in the Formal Solicitation. Further. as may be specified elsewhere, each Proposer must submit for evaluation. cuts. sketches. descriptive literature. technical specifications, and Material Safety Data Sheets ('vISDS) as required. covering the products offered. Reference to literature submitted with a previous response or on file \vith the Buyer will not satisfy this provision. 1.44. INSPECTIONS -The City may. at reasonable tines during the term hereof. inspect Successful Proposer's facilities and perform such tests. as the City deems reasonable necessary. to determine whether the goods and; or services required to be provided be the Successful Proposer under this Contract conform to the terms and conditions of the Formal Solicitation. Successful Proposer shall make available to the City all reasonable facilities and assistance to facilitate the performance of tests or inspections by City representatives. Ali tests and inspections shall be subject to, and made in accordance with. the provisions of the City of Miami Procurement Ordinance Section 18-70, City Cocle ). as same may be amended or supplemented from time to time. 1.45. INSPECTION OF RESPONSE -Responses received by the City pursuant to a Formal Solicitation will not be made available until such time as the Cite provides notice of a decision or intended decision or within 30 days after bid closing. whichever is earlier, Proposal results will he tabulated and may be furnished upon request via fax or e-mail to the Sr. Procurement Specialist issuing the Solicitation. Tabulations also are available on the Citv's Web Site following recommendation for award. 1.46. INSURANCE -Within ten (10) days after receipt of Notice of Award, the Successful Proposer. shall furnish Evidence of Insurance to the Procurement Department, if applicable. Submitted evidence of coverage shall demonstrate strict compliance to all requirements listed on the Special Conditions entitled "Insurance Requirements". The City shall be listed as an "Additional Insured.'° Issuance of a Purchase Order is contingent upon the receipt of proper insurance documents. If the insurance certificate is received within the specified time frame but not in the manner prescribed in this Solicitation the Successful Proposer shall be verbally notified of such deficiency and shall have an additional five (5) calendar days to submit a corrected certificate to the Cite. If the Successful Proposer fails to submit the required insurance documents in the manner prescribed in this Solicitation within fifteen (15) calendar days after receipt Notice of Award. the Successful Proposer shall be in default of the contractual terms and conditions and shall not be awarded the contract, Under such circumstances, the Successful Proposer may be prohibited from submitting future responses to the City. Information regarding any insurance requirements shall be directed to the Risk :Management Director r, Department of Risk !Management, at 444 SW 2nd Avenue. 9th Floor, Miami, Florida 33130, 305-416-1604. The Successful Proposer shall be responsible for assuring that the insurance certificates required in conjunction with this Section remain in effect for the duration of the contractual period: including any and all option terms that mav Page 18 of 66 605386.6 be granted to the Successful Proposer. 1.47. INVOICES -Invoices shall contain purchase order number and details of goods and/or services delivered (i.e. quantity. unit price. extended price. etc.): and in compliance with Chapter 218 of the Florida Statutes (The Local Government Prompt Payment Act). 1.48. LOCAL PREFERENCE A. City Code Section 18-86, states, the RFP, RFLI or RFQ. as applicable. may. in the exercise of the reasonable professional discretion of the City Manager, director of the using agency-. and the Chief Procurement Officer. include a five (5°0) percent evaluation criterion in favor of Proposers who maintain a local office. as defined in Section 18-73. In such cases. this five (5"6) percent evaluation criterion in favor of Proposers who maintain a local office will be specifically defined in the RFP. RFLI or RFQ. as applicable: otherwise, it will not apply. 1.49. MANUFACTURER'S CERTIFICATION -The City reserves the right to request from Proposers a separate 11anufacturer's Certification of all statements made in the proposal. Failure to provide such certification may result in the rejection of proposal or termination of Agreement. for n hich the Successful Proposer must bear full liability. 1.50. MODIFICATIONS OR CHANGES IN PURCHASE ORDERS AND CONTRACTS -No contract or understanding to modify this Formal Solicitation and resultant purchase orders or contracts. if applicable. shall be binding upon the City unless made in writing by the Director of Procurement of the City of Miami. Florida through the issuance of a change order, addendum. amendment. or supplement to the contract. purchase order or award sheet as appropriate. 1.51. NO PARTNERSHIP OR JOINT VENTURE -Nothing contained in the Agreetnetn will be deemed or construed to create a partnership or joint venture between the City of Miami and Successful Proposer. or to create any other similar relationship between the parties. 1.52. NONCONFORMANCE TO CONTRACT CONDITIONS -Items may be tested for compliance with specifications under the direction of the Florida Department of Agriculture and Consumer Services or by other appropriate testing Laboratories as determined by the City_ The data derived from any test for compliance with specifications is public record and open to examination thereto in accordance with Chapter I19. Florida Statutes. Items delivered not conforming to specifications may be rejected and returned at Proposers expense. These non -conforming items not delivered as per delivery date in the response and'or Purchase Order may result in Successful Proposer being found in default in which event anv and all re -procurement costs may be charged against the defaulted Proposer . Any violation of these stipulations may also result in the supplier's name being removed from the City of Miami's Supplier's list. 1.53. NONDISCRIMINATION - Successful Proposer agrees that it shall not discriminate as to race. sex. color. age. religion. national origin. marital status, or disability in connection with its performance under this formal solicitation. Furthermore. Successful Proposer agrees that no otherwise qualified individual shall solely by reason of his'her race, sex, color. age. religion. national origin. marital status or disability be excluded from the participation in, be denied benefits of. or be subjected to. discrimination under any program or activity. In connection with the conduct of its business, including performance of services and employment of personnel. Successful Proposer shall not discriminate against any person on the basis of race, color. religion. disability. age, sex. marital status or national origin. All persons having appropriate qualifications shall be afforded equal opportunity for employment. 1.54. NON-EXCLUSIVE CONTRACT/ PIGGYBACK PROVISION -At such times as may serve its best interest. the City of Miami reserves the right to advertise for, receive, and award additional contracts for these herein Page 19 of 66 605386.6 goods and: or services. and to make use of other competitively bid (governmental) contracts. agreements. or other similar sources for the purchase of these goods and/or services as may he available in accordance with the applicable provisions of the City of \liami Procurement Ordinance. it is hereby agreed and understood that this formal solicitation does not constitute the exclusive rights of the Successful Proposer(s) to receive all orders that may he generated by the City in conjunction with this Formal Solicitation. In addition. any and all commodities. equipment, and services required by the City in conjunction with construction projects are solicited under a distinctly different solicitation process and shall not be purchased under the terms. conditions and wards rendered under this solicitation, unless such purchases are determined to he in the best interest of the City. 1.55. OCCUPATIONAL LICENSE -.anti person. firm. corporation or joint venture. with a business location in the City of Miami and is submitting a Response under this Formal Solicitation shall meet the City's Occupational. License Tax requirements in accordance with Chapter 31.1, Article I of the City of \lianii Charter. Others with a location outside the City of lUiami shall meet their local Occupational License Tax requirements. A copy of the license must be submitted with the response: however, the City may at its sole option and in its best interest allow the Successful Proposer to supply the license to the City during the evaluation period, but prior to award. 1.56. ONE PROPOSAL -Only one (1) Response front an individual. firm. partnership. corporation or joint venture will be considered in response to this Formal Solicitation. 1.57. OWNERSHIP OF DOCUMENTS -it is understood by and between the parties that any. documents. records. files. or any other matter whatsoever which is given by the City to the Successful Proposer pursuant to this formal solicitation shall at all times remain the property of the City and shall not be used bs the Successful Proposer for any other purposes IA hatsoever without the written consent of the C its-. 1.58. PARTIAL INVALIDITY -If any provision of this Contract or the application thereof to any person or circumstance shall to anv extent be held invalid. then the remainder of this Contract or the application of such provision to persons or circumstances other than those as to which it is held invalid shall not be affected thereby, and each provision of this Contract shall be valid and enforced to the fullest extent permitted by law. 1.59. PERFORMANCE;PAYMENT BOND zA Successful Proposer may be required to furnish a Performance/Payment Bond as part of the requirements of this Contract. in an amount equal to one hundred percent (100°0) of the contract price. Any bond furnished st ill comply with Florida Lass- and be in a form acceptable to the City of Miami Risk I1[anagement Director. 1.60. PREPARATION OF RESPONSES (HARDCOPY FORMAT) - Proposers are expected to examine the specifications. required delivery, drawings, and all special and general conditions. All proposed amounts. if required. shall be either typewritten or entered inrn the space provided with ink. Failure to do so will be at the Proposer's risk. A. Each Proposer shall furnish the information required in the Formal Solicitation. The Proposer shall sign the Response and print in ink or type the name of the Proposer, address, and telephone number on the face page and on each continuation sheet thereof on which he, she makes an entry. as required. B. If so required, the unit price for each unit offered shall be shown. and such price shall include packaging. handling and shipping. and F.O.B. Miami delivery inside City premises unless otherwise specified. Proposer shall include in the response all taxes. insurance. social security. workmen's compensation. and anv other benefits Page 20 of 66 605386.6 normally paid by the Proposer to its employees. If applicable. a unit price shall be entered in the "Unit Price" column for each item, Based upon estimated quantity. an extended price shall be entered in the "Extended Price" column for each item offered. In case of a discrepancy between the unit price and extended price. the unit price will he presumed correct, C. Proposer must state a definite time. if required, in calendar days for delivery of goods and or services. D. Proposer should retain a copy of all response documents for future reference, E. All responses. as described. must he fully completed and typed or printed in ink and must be signed in ink with the firm's name and by an officer or employee having authority to bind the company or firm by his.'her signature. Proposals having any erasures or corrections must be initialed in ink by person signing the response or the response may be rejected. F. Responses are to remain valid for at least 180 days. Upon award of a contract. the content of the Proposer's response may be included as part of the contract. at the Citv's discretion. G. The Citv's Response Forms. shall be used when Proposer is submitting its response in hardropv format. Use of any other forms will result in the rejection of the response. IF SUBMITTING HARDCOPY FORMAT. THE ORIGINAL AND SIX (6) COPIES OF THESE SETS OF FOR\IS. UNLESS OTHERWISE SPECIFIED. AND ANY REQUIRED ATTACH\IFNTS MUST BE RETURNED TO THE CITY OR YOUR RESPONSE \IAY BE DEEMED NON -RESPONSIVE 1.61. PRICE ADJUSTMENTS - Any price decrease effectuated during the contract period either by reason of market change or on the part of the Successful Proposer to other customers shall be passed on to the City of Nliami. 1.62. PRODUCT SUBSTITUTES -In the evert a particular awarded and approved manufacturer's product becomes unavailable during the term of the Contract. the Successful Proposer awarded that item may arrange with the Citv's authorized representative(s) to supply a substitute product at the awarded price or lower. provided that a sample is approved in advance of delivery and that the new product tweets or exceeds all quality. requirements. 1.63. CONFLICT OF INTEREST, AND UNETHICAL BUSINESS PRACTICE PROHIBITIONS Successful Proposer represents and warrants to the City that it has not employed or retained any person or company employed by the City to solicit or secure this Contract and that it has not offered to pay, paid, or agreed to pay any person any fee, commission. percentage, brokerage fee, or gift of any kind contingent upon or in connection with, the award of this Contract. 1.64. PROMPT PAYMENT - Proposers may offer a cash discount for prompt payment: however. discounts shall not be considered in determining the lowest net cost for response evaluation purposes. Proposers are required to provide their prompt payment terms in the space provided on the Formal Solicitation. If no prompt payment discount is being offered. the Proposer attest enter zero (0) for the percentage discount to indicate no discount. If the Proposer fails to enter a percentage. it is understood and agreed that the terms shall be 2% 20 days. effective after receipt of invoice or final acceptance by the City, whichever is later. When the City is entitled to a cash discount. the period of computation will commence on the date of delivery. or receipt of a correctly completed invoice. whichever is later. If an adjustment in pad -meta is necessary due to damage. the cash discount period shall continence on the date final approval for payment is authorized. If a discount is part of the contract. but the invoice does not reflect the existence of a cash discount. the City is entitled to a cash discount with the period commencing on the date it is determined by the City that a cash discount applies. Price discounts off the original prices quoted on the Price Sheet will be accepted from Successful Proposers during Page 21 of 66 605386,6 the term of the contract. 1.65. PROPERTY -Property owned by the City of \liaini is the responsibility of' the City of Miami. Such property furnished to a Successful Proposer for repair. modification, study. etc.. shall remain the property of the City of Miami. Damages to such property occurring while in the possession of the Successful Proposer shall be the responsibility of the Successful Proposer. Damages occurring to such property while in route to the City of Miami shall be the responsibility of the Successful Proposer. In the event that such property is destroyed or declared a total loss, the Successful Proposer shall be responsible for replacement value of the property at the current market value. less depreciation of the property, if any. 1.66, PROVISIONS BINDING -Except as otherwise expressly provided in the resulting Contract. all covenants, conditions and provisions of the resulting Contract shall be binding upon and shall inure to the benefit of the parties hereto and their respective heirs. legal representatives. successors and assigns. 1.67. PUBLIC ENTITY CRIMES -A person or affiliate who has been placed on the cony icted vendor list following a conviction for a public entity crime ntav not submit a response on a contract to provide any goods or services to a public entity. may not submit a response on a contract with a public entity for the construction or repair of a public building or public work. may not submit responses on leases of real property to a puhlic entity. may not be awarded or perform work as a Proposer. supplier. subcontractor. or subconsultant under a contract with any public entity. and may not transact business tvith any public entity in excess of the threshold amount provided in Section 287.017, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. 1.68. PUBLIC RECORDS - Successful Proposer understands that the public shall have access. at all reasonable times. to all documents and information pertaining to Citv contracts. subject to the provisions of Chapter 119. Florida Statutes. and Citv of Miami Code. Section 18, Article III. and agrees to allow access by the City and the public to all documents subject to disclosure under applicable lady. Successful Proposer shall additionally comply with the provisions of Section 119.0701. Florida Statutes. entitled 'Contracts: puhlic records". 119.071 Florida Statutes is deemed as being incorporated bv reference herein. In summation it provides: Successful Proposer shall additionally comply with Section 119.0701. Florida Statutes. inc luding without limitation: (1) keep and maintain public records that ordinarily and necessarily would be required by the City to perform this service: (2) provide the public with access to public records on the same terms and conditions as the Cite would at the cost provided bv Chapter 119. Florida Statutes. or as otherwise provided by law: (3) ensure that public records that are exempt or confidential and exempt from disclosure are not disclosed except as authorized by law: (4) meet all requirements for retaining public records and transfer , at no cost. to the City all public records in its possession upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from disclosure requirements: (5) All electronically stored public records must be provided to the City in a format compatible with the Citv's information technology systems Successful Proposer's failure or refusal to comply' with the provision of this section shall result in the immediate cancellation of this Contract bv the Cirv. 1.69. QUALITY OF GOODS, MATERIALS, SUPPLIES, PRODUCTS. AND EQUIPMENT- All materials used in the manufacturing or construction of supplies. materials, or equipment covered by this solicitation shall be new. The items proposed must be of the latest make or model. of the best quality. and of the highest grade of vorktnanship. unless as otherwise specified in this Solicitation, Page 22 of 66 605386,6 1.70, QUALITY OF WORK/SERVICES- The work services performed roust be of the highest quality and workmanship. Materials furnished to complete the service shall be new and of the highest quality except as otherwise specified in this Solicitation. 1.71. REMEDIES PRIOR TO AWARD (Sec. 18-106)- If prior to Contract award it is determined that a formal solicitation or proposed award is in violation of law. then the solicitation or proposed award shall be cancelled b\ the City Commission. the City Manager or the Chief Procurement Officer, as may be applicable. or revised to comply with the law. 1.72. RESOLUTION OF CONTRACT DISPUTES (Sec. 18-105) (a) Authority to resolve Contract disputes. The City Manager. after obtaining the approval of the City attorney, shall have the authority ro resolve controversies between the Contractual Party and the Cit1 tyhich arise under. or by virtue of. a Contract between them; provided that. in cases involving an amount greater than $25.000. the City Commission must approve the City 1\lanager's decision. Such authority extends. without limitation. to controversies based upon breach of Contract. mistake. misrepresentation or lack of complete performance, and shall be invoked by a Contractual Party by submission of a protest to the City Manager. (b) Contract dispute decisions. If a dispute is not resolved by mutual consent. the City Manager shall promptly render a written report stating the reasons for the action taken by the City Commission or the City Manager \which shall be final and conclusive. A copy of the decision shall be immediately provided to the protesting party, along with a notice of such party's right to seek judicial relief, provided that the protesting party shall not be entitled to such judicial relief without first having followed the procedure set forth in this section. 1.73. RESOLUTION OF PROTESTED SOLICITATIONS AND AWARDS (Sec. 18-10. City Code) (a) Right to protest. The following pro edures shall be used for resolution of protested solicitations and awards except for purchases of goods. supplies. equipment. and services. the estimated cost of which dues not exceed $25.000. Protests thereon shall be governed by the Administrative Policies and Procedures of Procurement. 1. Protest of Solicitation. i, Any prospective Proposer who perceives itself aggrieved in connection with the solicitation of a Contract may protest to the Chief Procurement Officer. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within three days after the Request for Proposals. Request for Qualifications or Request for Leiters of Interest is published in a newspaper of general circulation. A notice of intent to file a protest is considered filed 4vhen receiv ed by the Chief Procurement Officer: or ii. Any prospecli\e Proposer who intends to contest the Solicitation Specifications or a solicitation may protest to the Chief Procurement Officer. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within three days after the solicitation is published in a newspaper of general circulation.A notice of intent to file a protest is considered filed when received by the Chief Procurement Officer. 2. Protest of Award. i. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within two clays after receipt by the Proposer of the notice of the City Manager's recommendation for award of Contract. which will be posted on the City of Miami Procurement Department website, in the Supplier Corner. Current Solicitations and Page 23 of 66 605386,6 Notice of Recommendation of Award Section. The notice of the City Manager's recommendation can be found by selecting the details of the solicitation and is listed as Recommendation of Award Posting Date and Recommendation of award To fields. If "various.' is indicated in the Recommendation of Award To field. the Successful Proposer must contact the buyer for that solicitation to obtain the suppliers name. It shall be the responsibility of the Successful Proposer to check this section of the wehsite daily after responses are submitted to receive the notice: or ii. Any actual Responsive and Responsible Bidder whose Bid is lower than that of the recommended bidder may protest to the Chief Procurement Officer. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within rwo days after receipt by the bidder of the notice of the City's determination of non - responsiveness or non -responsibility. The receipt by bidder of such notice shall be confirmed by the City by facsimile or electronic mail or L.S. mail, return receipt requested. A notice of intent to file a protest is considered filed when received by the Chief Procurement Officer. iii. A written protest based on any of the foregoing must he submitted to the Chief Procurement Officer within five (5) days after the date the notice of protest was filed. A written protest is considered filed when received by the Chief Procurement Officer. The written protest may not challenge the relative weight of the evaluation criteria or the formula for assigning points in making an award determination. The written protest shall state with particularity the specific facts and law upon which the protest of the solicitation or the award is based. and shall include all pertinent documents and evidence and shall be accompanied by the required Filing Fee as provided in subsection (D. This shall form the basis for review of the written protest and no facts. grounds. documentation or evidence not contained in the protester's submission to the Chief Procurement Officer at the time of filing the protest shall be permitted in the consideration of the vv ritten protest. No time will be added to the above limits for service by mail. In computing anv period of time prescribed or allowed by this section, the day of the act. CA ent or default from which the designated period of time begins to run shall not be included. The last day of the period so computed shall be included unless it is a Saturday, Sunday or legal holiday in which event the period shall run until the end of the nett day which is neither a Saturday, Sunday or legal holiday. Intermediate Saturdays. Sundays and legal holidays shall be excluded in the computation of the time for filing. (b) Authority to resolve protests: hearing officer (s). Hearing officers appointed by the City shall have authority to resolve protests filed under this Chapter of the Ciry Code. The City !tanager shall appoint a hearing officer. from a separate list of potential hearing officers pre -approved by the City Commission. to resolve protests filed in accordance with this Section. no later than five (5) working days following the filing of a bid protest. The hearing officer shall have the authority. to settle and resolve any written protest. The hearing officer shall submit said decision to the protesting party and to the other persons specified within ten (10) days after hclshc holds a hearing under the protest. (1) Hearing officer. The hearing officer tnav be a Special Master as defined in Chapter 2, Article X. Sec. 2-811 of the City Code. or a lawyer in good standing with the Florida Bar for a minimum of ten (10) years with a preference given to a lawyer who has served as an appellate or trial judge. The hearing officer may be appointed from alternative sources (e.g. expert consulting agreements, pigg}back contracts, etc.) where the Cite Commission adopts a recommendation of the City Attorney that such action is necessary to achieve fairness in the proceedings. The engagement of hearing officers is excluded from the Procurement Ordinance as legal services. The hearing officers appointed in the pre -qualified group should be scheduled to hear protests on a rotational basis. (2) Right of Protest, Any actual bidder or proposer who has standing under Florida law dissatisfied and aggrieved Page 24 of 66 605386.6 w ith the decision of the City regarding the protest of a solicitation or the protest of an award as set forth above in this Section may request a protest hearing. Such a written request for a protest must be initiated with a notice of intent to protest followed by an actual protest as provided in Section 18-101(a). The notice of intent to protest and the actual protest must each he timely received bv- the Chief Procurement Officer and must comply with all requirements set forth in Section 18-104 (a). Failure to submit the required notice of intent to protest and the actual protest within the specified tinieframes will result in an administrative dismissal of the protest. (3) Hearing Date. Within thirty (30) clays of receipt of the notice of protest the Chief Procurement Officer shall schedule a hearing before a hearing officer, at which time the person protesting shall he given the opportunity to demonstrate IA by the decision of the City relative to the solicitation or the award. which may include a recommendation for award by the City :Manager to the City Commission. as applicable. should he overturned. The party recommended for award. if it is a protest of award. shall have a right to intervene and be heard. (4) Hearing Procedure. The procedure for any such hearing conducted under this .Article shall be as follows: (i) The Cite shall cause to he served by certified mail a notice of hearing stating the time. date. and place of the hearing. The notice of hearing shall be sent by certified mail return receipt requested. to the mailing address of the protester. (ii) The party, any intervenor and the City shall each have the right to be represented by counsel. to call and examine witnesses, t0 introduce evidence. to examine opposing or rebuttal witnesses on any relevant matter related t0 the protest even though the marter was not covered in the direct examination. and to impeach anv witness regardless of which party first called him 'her to testify. The hearing officer may extend the deadline for completion of the protest hearing for good cause shown. but such an extension shall not exceed an additional five 15) business clays. The hearing officer shall consider the written protest and supporting documents and evidence appended thereto, supporting documents or evidence from anv inters enor. and the decision or recommendation as to the solicitation or award being protested. as applicable. The protesting party. and any intervenor. must file all pertinent documents supporting his/her protest or motion to intervene at least five (5) business days before the hearing. as applicable. The hearing officer shall allow a maximum of two (2) hours for the protest presentation and a maximum of two (2) hours for the City response. When there is an intervenor. a maximum of two (2) hours will he added for the intervenor. In the event of multiple protests for the same project. the hearing officer shall allocate time as necessary to ensure that the hearing shall not exceed a total of one (1) day. (iii) The hearing officer shall consider the evidence presented at the hearing. In any hearing before the hearing officer. irrelevant. immaterial. repetitious. scandalous or frivolous evidence shall he excluded. All other evidence of a type commonly relied upon by reasonably prudent persons in the conduct of their affairs shall be admissible Ivhether or not si[ch evidence would he admissible in trial in the courts of Florida. The hearing officer may also require written summaries. proffers. affidavits . and other documents the hearing officer determines to he necessary to conclude the hearing and issue a final order within the time limits set forth by this section.. (iy} The hearing officer shall determine whether procedural due process has been afforded. whether the essential requirements of law have been observed. whether the decision was arbitrary, capricious, an abuse of discretion. in accordance with the lacy or unsupported by substantial evidence as a whole: substantial evidence means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. (v) Within ten (10( days from the date of the hearing. the hearing officer shall complete and submit to the City Nlanager. the City Attorney, anv intervenor, the Chief Procurement Officer and the person requesting said hearing a final order consisting of his/her findings of fact and conclusions of law as to the denial or granting of the protest. as applicable. (vi) The decisions of the hearing officer are final in terms of Citv decisions relative to the protest. Page 25 of 66 605386.6 Any appeal from the decision of the hearing officer shall be in accordance with the Florida Rules of Appellate Procedure. (c) Compliance with filing requirements. Failure of a party to timely file either the notice of intent to file a protest or the written protest. together with the required Filing Fee as provided in subsection (f). with the Chief Procurement Officer within the time provided in subsection (a). above. shall constitute a forfeiture of such partv's right to file a protest pursuant t0 this section. The protesting party shall not be entitled to seek judicial relief kvithnut first having followed the procedure set forth in this section (d) Stay of Procurements during protests, Upon receipt of a written protest filed pursuant to the requirements of this section, the City- shall not proceed further with the solicitation or with the award of the Contract until the protest is resolved by the Chief Procurement Officer or the City Commission as provided in subsection (b) above. unless the City Manager makes a written determination that the solicitation process or the Contract award must be continued without delay- in order to avoid an immediate and serious danger to the public health. safety or welfare. (e) Costs. All costs accruing from a protest shall be assumed by the protestor. (f) Filing Fee. The written protest must be accompanied by a filing fee in the form of a money order or cashier's check payable to the City in an amount equal to one percent of the amount of the Bid or proposed Contract. or S5000.00. whichever is less, which filing fee shall guarantee the payment of all costs which rnav be adjudged against the protestor in anv administrative or court proceeding. If a protest is upheld by the Chief Procurement Officer and.ar the City Commission. as applicable. the filing fee shall be refunded to the protestor less any costs assessed under subsection (e) above. If the protest is denied. the filing fee shall be forfeited to the City in lieu of payment of costs for the administrative proceedings as prescribed by subsection (e) above. 1.74. SAMPLES -Samples of items. when required. must he submitted within the time specified at no expense to the City. If tut destroyed by testing. Proposer(s) yyill he notified to remote samples. at their expanse. within 30 days after notification. Failure to remos e the samples yt ill result in the samples becoming the property of the City. 1.75. SELLING. TRANSFERRING OR ASSIGNING RESPONSIBILITIES , SuccessfulProposer shall not sell. assign. transfer or subcontract at any time during the term of the Contract. the Agreement itself or anv portion thereof. or any part of its operations. or assign, sell, pledge. dispose . convey or encumber any portion of the Agreement or its performance . t required by this contract. except under and by virtue of prior written permission granted by the City Manager. which mav be withheld or conditioned. in the City Nlanager's sole discretion. As this Agreement is considered unique in nature such permission may be refused. withheld or conditioned by the City itanager. 1.76. SERVICE AND 1VARRANTY i\lhen specified. the Successful Proposer shall define all warranty service and replacements tliat v ill be provided. Proposer must explain on the Response to yvlrat extent warranty and service facilities are available. A copy of the manufacturer's warranty. if applicable. should be submitted with your response. 1.77. SILENCE OF SPECIFICATIONS -The apparent silence of these specifications ancl anv supplemental specification as to any detail or the omission from it of detailed description concerning any point shall be regarded as meaning that only the best commercial practices are to prevail and that only materials of first quality and correct type, size and design are to be used. All yvorkntanship and services is to be first quality. All interpretations of these specifications shall be made upon the basis of this statement. if your firm has a current contract with the State of Florida. Department of General Services, to supply the items on this solicitation. the Successful Proposer shall quote not more than the contract price: failure to comply with this request will result in disqualification of Proposal. Page 26 of 66 605386,6 1,78. SUBMISSION AND RECEIPT OF RESPONSES -Responses shall be submitted electronically via the Oracle System and additionally, responsesshall be submitted in hardcopy format to the City Clerk, City Hall. 3500 Pan American Drive. !Miami. Florida 33133-5504. at or before. the specified closing date and time as designated in the IFB. REP. RFQ. or RFLI. NO EXCEPTIONS. Proposers are welconic to attend the solicitation closing: however. no award will be made at that time. A. Hardcopy responses shall be enclosed in a sealed envelope. box package. The face of the envelope, box or package must shots the hour and date specified for receipt of responses, the solicitation number and title, and the name and return address of the Proposer. Hardcopy responses not submitted on the requisite Response Forms may be rejected. Hardcopy responses received at any other location than the specified shall be deemed non -responsive. Directions to City Hall: FROM THE NORTH: I-95 SOUTH UNTIL IT TURNS INTO L'Sl. US1 SOUTH TO 27TH AVE., TURN LEFT, PROCEED SOUTH TO SO. BAYSHORE DR. (3RD TRAFFIC LIGHT), TURN LEFT, 1 BLOCK TURN RIGHT ON PAN AMERICAN DR, CITY HALL IS AT THE END OF PAN AMERICAN DR, PARKING IS ON RIGHT. FROM THE SOUTH: US l NORTH TO 27TH AVENUE. TURN RIGHT, PROCEED SOUTH TO S0. BA `SHORE DR. (3RD TRAFFIC LIGHT), TURN LEFT, 1 BLOCK TURN RIGHT ON PAN AAIERICAN DR. CITY HALL IS AT THE END OF PAN All IERICAN DR. PARKING IS ON RIGHT. B. Facsimile responses will not be considered. C. Failure to follow these procedures is cause for rejection of bid proposal. D. The responsibility for obtaining and submitting a response on or before the close date is solely and strictly the responsibility of Successful Proposer. The City of Miami is not responsible for delays caused by the United States mail delivery or caused by any other occurrence. Responses received after the solicitation closing date and time wilt be returned unopened. and will not be considered for award. E. Late or mis-delivered or incorrectly addressed responses be rejected. F. All responses are subject. to the conditions specified herein. Those which do not comply with these conditions are subject to rejection. G. Modification of responses already submitted will be considered only if received at the City before the time and date set for closing of solicitation responses. All modifications must be submitted via the Oracle System or in writing. Once a solicitation closes (closed date and/or time expires). the City will not consider any subsequent submission which alters the responses. H. If hardcopy responses are submitted at the same time for different solicitations. each response trust be placed in a separate envelope, box, or package and each envelope, box or package must contain the information previously stated in 1.82.A, 1.79. TAXES -The City of Miami is exempt from any taxes imposed by the State and 'or Federal Government. Exemption certificates will be provided upon request. Notwithstanding, Bidders/Proposers should be aware of the fact that all materials and supplies which are purchased by the Successful Proposer for the completion of the contract is subject to the Florida State Sales Tax in accordance with Section 212.08. Florida Statutes. as amended and alt amendments thereto and shall he paid solely by the Successful Proposer. 1.80, TERMINATION - The City Manager on behalf of the City of Miami reserves the right to terminate this contract by written notice to the Successful Proposer effective the date specified in the notice should any of the Page 27 of 66 605386.6 following apply: A. A Successful Proposer is determined by the City,. to be in breach of any of the terms and conditions of the contract. B. The City has determined that such termination will he in the best interest of the City to terminate the contract for its own convenience: C. Funds are not available to cover the cost of the goods andior services. The City's obligation is contingent upon the availability of appropriate funds. 1.81. TERMS OF PAYMENT -Payment will be made by the City after the goods arrd'or services awarded to a Successful Proposer have been received. inspected. and found to comply with award specifications. free of damage or defect. and properly invoiced. No advance payments of any kind will be made by the City of Miami. Payment shall be made after delivery, within 45 days of receipt of an invoice and authorized inspection and acceptance of the goods services and pursuant to Section 218.71. Florida Statutes and other applicable law. 1.82. TIMELY DELIVERY -Time will be of the essence for any orders placed as a result of this solicitation. The City reserves the right to cancel such orders. or any part thereof. without obligation. if delivery is not made within the time(si specified on their Response. Deliveries are to be made during regular City business hours unless otherwise specified in the Special Conditions. 1.83. TITLE -Title to the goods or equipment shall not pass to the City until after the City has accepted the goods. equipment or used the goods. whichever comes first. An exception may he made for "trade secrets," If the Response contains information that constitutes a "trade secret". all material that qualifies for exemption from Chapter 119 must he submitted in a separate em elope. clearlti identified as "TRADE SECRETS EXCEPTION." with your firm's name and the Solicitation number and title marked on the outside. Please be aware that the designation of an item as a trade secret by you may be challenged in court by an person. E< your designation of material in your Response as a "trade secret" you agree to indemnify and hold harmless the City for any award to a plaintiff for damages, costs or attorneys fees and for costs and attwrne''s fees incurred by the City by reason of any legal action challenging your claim. 1,84. UNAUTHORIZED WORK OR DELIVERY OF GOODS -Neither the Successful Proposer(s) nor any of his 'her employees shall perform any xvork or deliver any goods unless a change order or purchase order is issued and received by the Successful Proposer. The Successful Proposer(s) shall not be paid for any work performed or goods delivered outside the scope of the contract or any work performed by an emploxce not otherwise previously authorized. 1.85. USE OF NAME -The City is not engaged in research for advertising. sales promotion, or other publicity purposes. No advertising. sales promotion or other publicity materials containing information obtained from this Solicitation are to be mentioned. or imply the name of the City, without prior express written permission of the City Manager or the City Commission. 1.86. VARIATIONS OF SPECIFICATIONS -For purposes of solicitation evaluation. Proposers must indicate any variances from the solicitation specifications and;or conditions. no matter how slight. If variations are not stated on their Response. it will be assumed that the product fully complies with the City's specifications. Page 28of66 605386.6 2. SPECIAL CONDITIONS 2.1. PURPOSE The purpose of this Solicitation is to establish a contract(s). for the provision of Third Party Claims Administration anclior Managed Care Services. with a Third Party- Claims Administrator. hereinafter referred to as "Successful Proposer". as specified herein. from a source(s). fully compliant wvith the terms. conditions. and stipulations of the solicitation. 2.2. DEADLINE FOR RECEIPT OF REQUEST FOR ADDITIONAL INFORMATION/ Any questions or clarifications concerning this solicitation shall be submitted by email or facsimile to the Procurement Department, Attn: Yaclissa Calderon: fax: (305) 400-5369 or email: V calderonf-ci.miami.fl.us. and a copy filed with the Office of the Cite Clerk at clerksgmiarnigov.com. pursuant to Section 1.20. Cone of Silence. The solicitation title and number shall he referenced on all correspondence. All questions must he received no later than Tuesday. Not ember 1. 2016 at 5:00 PM. All responses to questions yyill he sent to all prospective Proposers in the form of an addendum. NO QUESTIONS \\ILL BE RECEIVED VERBALLY OR AFTER SAID DEADLINE. 2.3. VOLUNTARY PRE -PROPOSAL CONFERENCE Proposers are strongly encouraged to attend theVoluntary Pre -Proposal Conference, wvltich wvill occur on Wednesday. October 12. 2016, at 2:00 PM (local time), at 444 SW 2nd Avenue. 6th Floor South Conference Room. 11liami, Florida. A discussion of the requirements of the Solicitation yv911 occur at that time. Each Proposer is required. priorto submitting a Proposal. to acquaint themselves thoroughly with any and all conditions and'or requirements that may in any manner affect the work to be performed. No allowances will be made because of lack of know ledge of these conditions. The purpose of the Pre -Proposal Conference is to allow Proposers an opportunity to present questions to staff and obtain clarification of die requirements of the Solicitation documents. Because the City considers the conference to be critical to understanding the solicitation requirements, attendance is highly recommended. 2.4. DEFINITIONS "City :Manager" shall mean the City Manager of the City of Miami who is the Chief Administrative Officer of the City. Whenever the word "City" is used, unless another body or board or commission is mentioned by name in decisions made by the City relative to this Agreement, the City shall mean the "City Manager." "Director" for purposes of this Agreement shall mean the Director of the City of Miami Risk Management Department. The Citv' Project Manager. may at her discretion consult with the Director about any matter regarding die Agreement. and the Director will provide her input if so requested. "City Commission" shall mean the Nliami City Commission. the municipal legislative body. who will consider the award of this Agreement and would be required to approve this Agreement. The City Commission is the only entity who may increase the funding. the budget or the moneys paid under this Agreement. 2.4.TERM OF AGREEMENT Page 29 of 66 605386,6 The Proposer(s) qualified to provide the services requested herein. shall be required to execute a Professional Services Agreement (".agreement") with the City, which shall include. but not be limited to, the following terms: 1)The term of the Agreement shall be for three (3) Fears. with an option to renew far two (2) additional one (1) year periods. 2)The City I\ )anager shall have the option to extend al terminate the Agreement. Continuation of the Agreement beyond the initial three (3) year period is a City prerogative: not a right of the Successful Proposer(s). This prerogative will he exercised only when such continuation is clearly in the best interest of the City. 3/The City ]Manager ntav cancel the Agreement for convenience on thirty (30) days prior written notice to the Successful Proposer(s). and the Successful Proposerls) \\ill have no recourse except to be paid its direct fees and costs incurred prior to the effective date of cancelation. 41The Hold Harmless. Duty to Defend. Indemnity and Insurance terms and requirements provided for in this RFP. 2.5. EXECUTION OF AN AGREEMENT The Successful Proposer(s) evaluated and ranked in accordance with the requirements of this Solicitation. shall be awarded an opportunity to negotiate a Professional Services Agreement (Agreement) \with the Cirv. The City reserves the right to execute, or not execute, as applicable. an Agreement \yith the Successful Proposer(s) in substantially the same form as the draft Agreement attached to the Header Section of [his Solicitation. Such .Agreement which \will be furnished by the City. will contain certain terms as are in the: Citv's best interest. and will be subject to approval as to legal form by die City Attorney. 2.6. CONDITIONS FOR RENEWAL Each renewal of the .agreement is subject to the following: 1) Continued satisfactory performance compliance with the specifications, terms and conditions established herein. 2) Availability of funds 2.7.NON-APPROPRIATION OF FUNDS In the event no funds or insufficient funds are appropriated and budgeted or are otherwise unavailable in any fiscal period for payments clue under this :agreement. then [he Cin. upon \yrittcn notice to the Successful Proposer(s) or his assignee of such occurrence, shall have the unqualified right to terminate the Agreement ywithout anv penalty or expense to the City. No guaranteei warranty or representation is made that anv projects) \will be awarded to any frrm(s). 2.8. MINIMUM QUALIFICATION REQUIREMENTS Proposer(s) shall satisfy each of the following requirements cited below. Failure to do so \will result in the Proposal being deemed non -responsive. Page30of66 605386.6 A.Workers' Compensation Claims and Liability Claims Administration Proposer shall: 1)Be authorized (licensed) as a Claims Administrator by the State of Florida. as of proposal due date: 2)Have dedicated/designated adjusters in the State of Florida with a minimum of three (3) years' experience, directed bya dedicated Supervisor. \with at least five (5) years' recent experience. 3)Be approved by all of the City's excess carriers: 4)Be compliant throughout the life of the Agreement and must be compliant at the time of proposal submittal. in Statement on Auditing Standard No. 70 (SAS70)I Statement on Standards for Attestation Engagement 16 (SSAE16) ; 5)Have a minimum of five (5) continuous years of experience. handling Florida municipal claims. with at least one (1) client having a minimum of 1500 employees: 6)Be in full compliance \with the federally -mandated State Children's Health Insurance Program (SCHIP) and Florida Electronic Data Interchange (EDI) requirements: 7)Have electronic capabilities to provide electronic reporting. transfer of data to anv!all platforms as directed. and connectivity to Proposer's information system: 8)Have no record of judgments, bankruptcies. pending lawsuits against the City. criminal activities involving moral turpitude. and not have any conflicts of interest that have not been waived by the City Commission: and 9)Not be in arrears or in default of any debt or contract involving the City (as a party to a contract. or otherwise): nor have failed to perform faithfully on any previous contract with the City. This requirement applies to Proposer's principals. officers. or stockholders. B.Managed Care/Medical Bill Review/Audit Services Proposers shall: ])Administer one or more national Preferred Provider Organizations (PPO) that have negotiated contract rates with hospitals and providers. in an order or priority acceptable to Risk Management. Risk Management may, at its sole discretion, disallow the use of any PPO: 2)Have a National pharmacy network: 3)Have the ability to interface with Risk Management Information System (R\IIS): 4)Be available twenty-four (24) hours, seven (7) days a week: 5)Proposer's staff nurses (telephonic and onsite) shall have a minimum of five (5) to seven (7) years of experience; 6)1\fust comply with Florida Agency for Health Care Administration guidelines: Rule Chapter 59A-23: 7)Be required to have Utilization Review Accreditation Commission (URAC) accreditation, as of the proposal due date: 8)Telephonic Case Manager (TCM) Nurse Case Manager (NCM)are subject to continuing education: 9)Own. management and control PPO networks (can add. remove provider at will): 10) Have a mechanism to oversee physician/provider performance via scorecard: 11)Offirial Disability Guidelines (ODG),-American College of Occupational and Environmental Medicine ( ACOEM) schedules must be integrated into the rule engine of the Proposer; and Page 31 of 66 605386.6 12)Own. manage. and control Utilization Review (L R) services. 2.9.FAILURE TO PERFORM Should it not be possible to reach the Successful Proposer or representative. and/or should remedial action not be taken within 18 hours of any failure to perform according to specifications, the City reserves the right to declare Successful Proposer in default of the contract or make appropriate reductions in the contract payment, 2.10.INSURANCE REQUIREMENTS INDEMNIFICAATION Successful Proposer shall pay on behalf of, indemnify and save City and its officials harmless. from and against any and all claims, liabilities. losses. and causes of action. which may arise out of Successful Proposer's performance under the provisions of the Agreement. including all acts or omissions to act on the part of Successful Proposer. including any person performing under this Agreement for or on Successful Proposer's behalf. provided that anv such claims. liabilities. losses and causes of such action are not attributable to the negligence or misconduct of the City and, from and against any orders. judgments or decrees which'nav he entered and which may result from this Agreement. unless attributable to the negligence or misconduct of the City, and from and against all costs, attorneys' fees. expenses and liabilities incurred in the defense of any such claim, or the investigation thereof. The Successful Proposer shall furnish to the City of Miami, c/o Procurement Department, -141 SW 2nd Avenue. 6th Floor, Nlianri, Florida 33130, Certificate(s) of Insurance which indicate that insurance coverage has been obtained which meets the requirements as outlined below: The Successful Proposer shall. at its oven cost and expense. acquire and maintain during the term of the Agreement. vvith carriers having an ANT Best Rating of A-VII or better, sufficient insurance to adequately protect the respective interests of the parties, including the Successful Proposer's indemnity obligations. Specifically. the Successful Proposer must carry the following minimum types and amounts of insurance on an occurrence basis or in the case of coverage that cannot he obtained on an occurrence basis. then coverage can he obtained on a. claims -made basis with a three (3) year tail following the termination or expiration of this Agreement: a) Commercial General Liability:WVritten on an occurrence form. including but not limited to premises -operations. broad form property damage. products /completed operations. contingent and contractual exposures. personal injury and advertising injury. vvith limits of at least $1,000,000 per occurrence and S2.000.000 general aggregate. This coverage should be written on a primary and non-contributory basis. and should list the City as an additional insured: b) Workers' Compensation Insurance:Statutory Workers' Compensation Insurance and Employers' Liability Insurance in the minimum amount of S1.000.000 each employee by accident. S1,000.000 each employee by disease and S1.000.000 aggregate by disease with benefits afforded under the laws of the state or country in which the services are to be performed. Policy will include an alternate employer endorsement providing coverage in the event anv employee of the Successful Proposer sustains a cnrnpensable accidental injury while on vvork assignment with Company. Insurer for Vendor will be responsible for the Workers' Compensation benefits due such injured employee: c) Commercial Automobile Liability: if an automobile is used by the Successful Proposer in connection with the performance of its obligations under this Agreement. there Comprehensive Automobile Liability Insurance for anv owned. non -owned. hired. or borrowed automobile used in the performance of Successful Proposer's obligations under this Agreement is required in the minimum amount of $1.000.000 each accident combined for bodily injury and property damage. City of I\liami should be listed as an additional insured: d) Professional Errors and Omissions Liability: Insurance in the ntinirnum amount of S10.000.000 per claim and Page 32 of 66 605386.6 policy aggregate. protecting the City against Successful Proposer's professional negligence. failure to perform professional duties and breach of contractual obligations under this Agreement. including but not limited to. coverage for claims services and certification that there is no security breach or unauthorized use exclusion on this policy: e) Network Security/Privacy Liability (Cyber Liability): Insurance in the minimum amount of S5.000,000 per occurrence including but not limited to protection of private or confidential information whether electronic or non -electronic: network security and privacy liability: protection against liability for systems attacks: denial or loss of service: introduction. implantation or spread of malicious software code: security breach: unauthorized access and use: including regulatory action expenses: cvber extortion coverage: and notification and credit monitoring expenses ij Employee Dishonesty/Fidelity: Insurance including 3rd Party Liability in the minimum amounts ofS1,000.000 each occurrence for acts of all Staff: and g) Excess Umbrella Liability (Excess Follow Forrn):\litiimum limits of $10.000.000 per occurrence aggregate. This coverage is excess over all applicable liability policies. The above insurance limits may he achieved by a combination of primary and umbrella"excess liability policies. I. Prior to the execution of this Agreement (or seven (7) calendar days prior to the start of work under this A greement) and annually upon the anniversary dates) of the insurance policy's renewal date(s), the Successful Proposer will furnish the City with a Certificate of Insurance evidencing the coverages set forth above and naming the City. its subsidiaries. affiliates. authorized distributors. directors. officers. employees. partners and agents as an "Additional Insured" on the Successful Proposer's Commercial General Liability and Commercial Auto Liability policies listed ahoy c and name the Cin-, its subsidiaries. affiliates. authorized distributors. directors. officers. employees. partners and agents as a "Loss Payee" on the Successful Proposer's Fidelity Policy ?. The Successful Proposer shall provide the City- thirty (30) calendar days written notice of any cancellation. non -renewal, termination. material change nr reduction in coverage. 3. The Successful Proposer's insurance as outlined above shall he primary and non-contributory coverage. 4. The coverage territory for the stipulated insurance shall be on a worldwide basis. 6. The Successful Proposer must ensure that am- subcontractors or other service providers the Successful Proposer engages to provide the services required under this Agreement. acquire and maintain at all times. with insurance companies with a minimum A..\1. Best Rating A -\'II. the same levels of insurance coverage as are outlined above. The Successful Proposer and subcontractors of the Successful Proposer. will cause their insurance companies to waive their right of recovery against the Cin-, 6. The stipulated limits of coverage above shall not be construed as a limitation of any potential liability to Company. and failure to request evidence of this insurance shall not be construed as a waiver of the Successful Proposer's obligation to provide the insurance coverage specified. BINDERS ARE UNACCEPTABLE. The insurance coverage required shall include those classifications. as listed in standard liability insurance manuals, which most nearly reflect the operations of the Successful Proposer. Al! insurance policies required above shall be issued by companies authorized to do business under the laws of the State of Florida. with the following qualifications: Certificates will indicate no modification or change in insurance shall be made without thirty (30) days written advance notice to the certificate holder. Page 33 of 66 605386.6 NOTE: CIT1 RFP NUMBER AND/OR TITLE OF RFP iMMLST APPEAR ON EACH CERTIFICATE. AND THE CITY NIUST BE LISTED AS THE INSLRED ANDOR ADDITIONAL INSURED. Compliance with the foregoing requirements shall not relieve the Successful Proposer of his liability and obligation under this section or under anv other section of this Agreement. --If insurance certificates are scheduled to expire during the contractual period. the Successful Proposer shall be responsible for submitting new or renewed insurance certificates to the City- at a minimum of ten (I0) calendar days in advance of such expiration. --In the event that expired certificates are not replaced with new or renewed certificates tivhich cover the contractual period. the City shall: (a) Suspend the Agreement until such time as the new or renewed certificates are received by the City in the manner prescribed in the RFP. (b) The City may. at its sole discretion. terminate tins Agreement for cause and seek re -procurement damages from the Successful Proposer in conjunction with the General and Special Terms and Conditions of the solicitation. The Successfu] Proposer shall be responsible for assuring that the insurance certificates required in conjunction with this Section remain in force for the duration of the contractual period: including anv and all option terms that may be granted to the Successful Proposer. 2.11.PROJECT MANAGER, CITY MANGER, DIRECTOR. CITY COMMISSION Upon award. Successful Proposer shall report and work directly with !11s. Angella Breadwood. Claims 'Manager. Risk 'llanagemcru Department. \vho shall be designated as the City Project :Manager, for purposes of day to day administration of this Agreement. 2.I2.SUI3CONTRACTOR(S) OR SUBCONSULTANT(S) A subconsultant. herein referred to as subcontractor. is an individual or firm contracted by the Successful Proposer or Successful Proposer s firm to assist in the performance of services required under this Solicitation. A subcontractor shall be paid through Successful Proposer or Successful Proposer's firm and not paid directly by the City. Subcontractors are allowed by the City in the performance of the services delineated within this Solicitation. Proposer must clearly reflect in its Proposal the major subcontractor(s) to be utilized in the performance of required services. The City retains the right to accept or reject any subcontractor(s) proposed at time of proposal submittal or prior to contract execution. Any and all liabilities regarding the use of subcontractors shall be borne solely by the Successful Proposer and insurance for each subcontractor must be maintained in good standing and approved by the City throughout the duration of the Agreement. Neither Successful Proposer nor anv of its subcontractors are considered to be employees or agents of the City. Failure to list all subcontractors, and provide the required information, may disqualify any proposed subcontractor(s) from performing work under this Solicitation. Proposers shall include in their proposal the requested subcontractor(s) information and include all relevant information required of the Proposer. In addition. within five 15) working days after the identification of the award to the Successful Proposer(s). the Successfu] Proposer(s) shall provide a list confirming the subcontractors that the Successful Proposer(s) intends to utilize in the Agreement. if applicable. The list shall include, at a minimum. the name. location of the place of business for each subcontractor. the services subcontractor will provide relative to any contract that may result from this Solicitation. anv applicable licenses. references, ownership, and other information required of Successfu] Proposer(s). 2.13.TERMINATION Page 34 of 66 605386.6 A. FOR DEFAULT If the Successful Proposer defaults in its performance under the Agreement and does not cure the default within thirty (30) days after written notice of default. the City Manager may terminate the Agreement. in whole or in part. upon written notice without penalty to the City of Miami. In such event the Successful Proposer shall he liable for damages including the excess cost of procuring similar supplies or services: provided that if. (1) it is determined for any reason that the Successful Proposer was not in default or (2) the Successful Proposer failure to perform is tivithout his or his subcontractor's control, fault or negligence. the termination will be deemed to be a termination for the convenience of the City of Miami. B. FOR CONVENIENCE The Ciry Manager may terminate this Agreement. in whole or in part. upon thirty (30) days prior written notice. when it is in the best interest of the City. If the Agreement is for supplies. products. equipment. or software. and so terminated for the convenience by the Cit\ the Successful Proposer will be compensated in accordance with an agreed upon adjustment of cost. To the extent that the Agreement is for services and so terminated. the City of Miami shall be liable only for payment in accordance with the payment provisions of the Agreement for those services rendered prior to termination. 2.14. PRIMARY CLIENT (FIRST PRIORITY) The Successful Proposer(s) agree upon award of this Agreement that the City shall be its primary client, and shall be serviced first during a schedule conflict arising between this Agreement. and any other contracts Successful Proposer(s) rnav have with anv other cities and:or counties to perform similar services. as a result of anv catastrophic events such as tornadoes. hurricanes. severe storms or anv other public emergency impacting various areas during or approximately the satnic time. 2.15. UNAUTHORIZED WORK The Successful Proposers) shall not begin work until a Purchase Order and or a Notice to Proceed is received. 2.16.CHANGES/ALTERATIONS Proposer ma\ change or withdraw a proposal at anv time prior to proposal submission deadline: hoot er er. no oral modifications will be allowed. Written modifications shall not be allowed following the proposal submission deadline. 2.17. COMPENSATION PROPOSAL Price must be submitted on the Price Proposal Form. Attachment B. as provided. See Header Section of the RFP for the form. Proposer(s) may submit a proposal for one and 'or both category of services. Refer to Section 3.1, Background. hi the event a Proposer is submitting a proposal for both categories of services. a separate Price Pro posal Form is required for each category of service, Proposer shall detail any and all fees and costs to provide the required services as listed below. and in accordance with the Submission Requirement for each of the category of service Proposer is submitting a proposal for. Part I - Third Party Claims Adrninistratiun a.\vorkers compensation claims b.liability claims including: i.Automobile (AL) ii. General liability (GL) iii. Employment practice liability iv. Law enforcement liability Page 35 of 66 605386.6 v. Public Officials liability Part II - NIanaged Care 'Medical Bill Review Services Proposer shall additionally provide a detailed list of all costs to provide all services as detailed in Section 3. Scope of Services. as proposed. Failure to submit compensation proposal as required.mav disqualify Proposer from consideration. Proposer shall submit a guaranteed. all-inclusive annual fee as previously detailed. This fee is to represent all claims. administrative, and loss data fees. Proposed rates are to be guaranteed annual fees for the initial three (3) years, and for the two (2) option to renew years. as opposed to per claim time and expense or any other fee proposal. Proposals not containing an all-inclusive guaranteed annual fee for initial three (3) years and two option to renew years, for all specified services, vvill not be considered. The pursuit of subrogation and recovery from the Special Disability Fund is to be included in the Proposer's annual fee. Clearly indicate anv charge not included in the proposed annual fee. A flat rate is desirable. with nn charges for duplicates and for hill review at fee schedule or L'C only for reductions after. Proposer shall provide prices in L..S dollars for the required services. It is important that Proposer outline features of the Proposal. such as value-added product(s) and/or service(s) that would not normally be addressed in a pricing evaluation. as they are of a non -monetary nature. As such. Proposer should include anv relevant services or products Mat will be provided to the City which are not priced in its Proposal. but which will enhance the acquisition process. Proposer shall be responsible for indicating in its Proposal the cost, if any. of assuming these prior claims and data conversion and whether it is a one-time charge or an annual charge. .As the current Proposer utilizes an on-line claim processing system where all data is maintained. updated and payments are issued. the Successful Proposer(s) must provide the Citv with a bank reconciliation tape and a tape to interface with the Citv's financial information. The Successful Proposer(s) will include in its costs for the provision of an enhanced system and for the conversion of any data necessary. The Citv's proposed performance guarantee may be negotiated with the City. Provide any and all additional costs. item by item. as identified by Proposer in any other area not previously discussed and detail what those additional costs, if applicable, would entail. Include which entity (Proposer or City) that will be responsible for payment of those costs. 2.18.EVALUATIONISELECTION PROCESS AND CONTRACT AWARD The procedure for response evaluation, selection. and award is as follows: (1) Solicitation issued: (2) Receipt of proposals: (3) Opening and listing of all proposals received: Page 36 of 66 605386.6 (4) The Department of Procurement (Procurement) staff twill review each proposal for compliance with the proposal submission requirements of the solicitation. including verifying that each proposal includes all documents required: (5) An Evaluation Committee. appointed by the Ciry Manager, comprised of appropriate City staff and members of the community. as deemed necessary, 1vith the appropriate technical expertise and or knowledge. shall meet to evaluate each proposal in accordance with the requirements of this solicitation and based upon the evaluation criteria as specified herein: (6) The Evaluation Committee (Committee) reserves the right, in its sole discretion. to request Proposers to make oral presentations before the Committee as part of the evaluation process. The presentation may be scheduled at the convenience of the Committee and shall he recorded: (7) The Committee reserves the right to rank the proposals and shall submit its recommendation to the Cite Manager for acceptance. If the City Manager accepts the Committee's recommendation. the City Manager's recommendation for award of contract will be posted on the City of Miami Procurement Department wyt•bsite, in the Supplier Corner. Current Solicitations and Notice of Recommendation of Award Section. The notice of the City \tanager's recommendation can he found by selecting the details of the solicitation and is listed as Recommendation of Award Posting Date and Recommendation of "Award To.' fields. If "various" is indicated in the Recommendation of Award To" field. the Proposer must contact the Procurement Contracting Officer for that solicitation to obtain the suppliers names. The City \tanager shall make his recommendation to the City Commission requesting the authorization to negotiate and or execute an Agreement vital the recommended Proposer(s). No Proposer(s) shall have any rights against the City arising from such negotiations or termination thereof: (8) The City Manager reserves the right to reject the Committee's recommendation. and instruct the Committee to re-evaluate and make another recommendation, reject all proposals. or recommend that the City Commission reject all proposals: (9i The City \[anager cyi11 negotiate a final Agreement with the Successful Proposer. which will be presented to the City Commission: (10) The City Commission may review, consider and approve the negotiated Agreement with the Successful Proposer(s). 2.19.ADDITIONAL SERVICES Services not specifically identified in this request may be added to any resultant Agreement upon successful negotiation and mutual consent of the contracting parties. The Citk reserves the right to add or delete any service (s). at any time. Should the City determine to add an additional service(s) for which pricing was not previously secured. the City shall ask the Successful Proposer to provide reasonable cost(s) for same. Should the City determine the pricing unreasonable, the City reserves the right to negotiate cost(s) or seek another firm entity for the provision of said service (s). 2.20. RECORDS During the Agreement period. and for a least five (5) subsequent tears thereafter, Successful provide City access to all files and records maintained on the Citt's behalf. 2.21.AMENDMENTS TO THE CONTRACT The City Manager shall have the right and authority to amend and execute any necessary modifications to this Agreement on behalf of the City. in a form acceptable to the Office of the may be necessary For said purpose. Proposers) shall amendments and City .attorney. as Page 37 of 66 605386.6 2.22. TRUTH IN NEGOTIATION CERTIFICATE Execution of the resulting Agreement by the Successful Proposer shall act as the execution of truth -in -negotiation certificate staling that wage rates and other factual unit costs supporting the compensation of the resulting Agreement are accurate. complete. and current at the time of contracting,. The original contract price and any additions thereto shall be adjusted to exclude any significant sums by which Girt- determines the contract price was increased due to inaccurate. incomplete. or non -current wage rates and other factual unit costs. All such contract adjustments shall be made within One (1) year following the end of the Agreement term. 2.23.ADDITIONAL TERMS AND CONDITIONS No additional terms and conditions included as part of tour solicitation response shall be evaluated or considered, and any and all such additional terms and conditions shall have no force or effect and are inapplicable to this solicitation. If submitted either purposely, through intent or design. or inadvertently. appearing separately in transmittal letters. specifications. literature. price lists or warranties. it is understood and agreed that the General Conditions and Special Conditions in this solicitation are the only conditions applicable to this solicitation and that the Proposer's authorized signature affixed to the Proposer's acknowledgment form attests to this. If a Professional Services Agreement (PS,\) or other Agreement is provided by the City and is expressly included as part of this solicitation. no additional terms or conditions which materially or substantially vats. modify or alter the terms or conditions of the PS.\ or Agreement. in the sole opinion and reasonable discretion of the City will be considered. Any and al] such additional terms and conditions shall have no force or effect and are inapplicable to this PSA or Agreement. 2.24.ATTACHMENTS TO RFP A.Exhibit I: Third Party Claire Administration Contract with current Claim Administrator, Gallagher Bassett Services. Inc. (Gallagher): and $.Exhibit 2: Labor Agreements with the follow ing: I la) Fraternal Order of Police (FOP): lib) International Association Of Fire Fighters {IAFF): 1 (c) American Federation of State. County and Municipal Employees 79 I,.AFSCME): 1(d) American Federation of State County and Municipal Employees (AFSC\IE). All attachments can be found in the Header Section of this Solicitation. Page 38 of 66 605386.6 3. Specifications 3.1. SPECIFICATIONS/SCOPE OF WORK 3..1BACKGROUND The Department of Risk Management (Risk Management} prop ides optimum service to employees and the public through a variety of interrelated health. safety and liabilityloss control programs. The pro }lion of these crucial prevention -oriented programs greatly- enhances the working environment and serves as an incentive for employee recruitment. retention and satisfaction, while protecting the City's assets. employees and citizens. 1ts objectives include goals to eliminate. where possible. the threat of accident and other forms of liability. and kvhere it is possihle to eliminate the risk. to at the very least. reduce the possibility of an accident or risk occurring. Currently. the City has approximately 4.1-11 full time employees. which include Law Enforcement officers. fire personnel. solid waste collectors, parks personnel. and does not include seasonal employees. There are four (4) Labor Unions in the City: 1 }Fraternal Order of Police (FOP): ?}American Federation of State County and ?Municipal Employees (AFSC\IE}: 3I International Association of Fire Fighters (TAFF): and -fiAmerican Federation of State. County and Nunicipal Ewplovees 79 (.-\FSC\1E}. Labor Unions represent eighty-five percent 185°0 of the City's yyorkforce. The City has created and maintains a Se]f-insurance program stihich provides protection to the City for all property and casualty loss exposures. workers' compensation claims. and provides group health benefits to active and retired employees. In addition, Risk ]Management monitors the City's injured yynrkers.Attention is focused in the areas of safety awareness. pre ention. treatment of injured workers, rehabilitation. job placement, education. and communications with the employees and the departments. Guidelines for the treatment and care of injured employees are based on Chapter 4-10. Florida Statutes. which governs the State's requirements for the prevision of 1Vorkers' Compensation benefits. However. as a result of bargaining agreements. additional benefits may be clue depending on the bargaining unit. The Successful Proposer(s) most became familiar with the existing labor agreements (attached in the Header Section of this Solicitation). The City's current Third Party Claims administrator. Gallagher Bassett Services, Inc. (Gallagher}, utilizes Risx Facs claim processing system where all data is maintained. updated. and payments are issued. The adjudication of workers' compensation medical bills and payments to the City's providers are performed through this system. Claims administration under this RFP. will include the takeover of current claims from Gallagher. The City seeks a Claims Administrator to provide the hest quality claims services and the most reliable and valid data possible using the most useful. user-friendly claim systems mailable. The City uses in-house counsel on all litigated claims. as necessary. Risk Management works closely with the City's Attorney Office in a hest -practices approach to manage litigated claims, The City is focused on the management of all claims, but has a Laser focus on Workers Compensation claims as they represent approximately 80% of the City's annual claims cost. A Return to Work program is being implemented as the City recognizes that prompt return to work aids in controlling claims costs. Individual department heads are directly responsible for claims occurring in their departments. as claims cost are allocated by department. Therefore. each department is highly motivated to support effective loss control. safety. and liability and workers compensation claim management. Page 39 of 66 605386.6 The City utilizes a 24,7 claims intake center. This type of system facilitates expedited handling. in order to process and close claims in the most efficient manner. for the benefit of the employees. Due to the City s Fire and Police operations. the City has devoted significant resources and has been and remains focused on managing presumption -related Workers Compensation claims. The City has never lost a litigated presumption case. and the rate of presumption claim denial is eighty-five percent (85"o1. Close attention is also paid to closure rates and sound reserving practices. The partnership between Risk Management. the Cin's legal department. and outside counsel where needed, is unique and also quite effective. Case law is closely monitored and utilized to 111os1 effectively handle each situation. The City experiences approximately 756 claims per year on average. The ratio of medical only to loss rime case is 40:60. i.e. forty percent 110' ,} medical nnlv. and sixty percent (60"0) loss time. Of the approximate 4.141 full-time City employees, the following generallw represents the location of their residences: REGION 1 REGION 2 COLAT (`) Broward FL 606 Collier Fl. 1 Lee FL ., Leon FL I iartin FL 1 N 1iami-Dude FL 3509 Palm BK1c11 FL 16 Seminole FL 1 St. Lucie fl 3 Bronx FL 1 The City is soliciting for two (2) Category of Services: Part I - Workers' Compensation Claims and Liability Claims Administration: and Part Ili., Managed Careil\ledical Bill Review. Proposers may submit a proposal for either Part 1: Workers' Compensation Claims and Liability Claims Administration. and, or Part 11 - 'Managed Care'\ledical Bill Review. Proposals will receive a separate score. in each Category of Ser\ ice for ww-11ich a proposal is submitted. Proposals will be ranked on a Category of Services basis. For example. proposals submitted for Part 1. Workers' Compensation Claims and Liability Claims Administration, will only be ranked against other proposals submitted for the Workers' Compensation Claims and Liability Claims Administration. 3.2 CITY'S CLAIM EXPERIENCE Below Is the Citw s Claims experience by Gears: Page 40 of 66 605386.6 Table No. 1 Policy Year GL Auto HL'PD APD POL & ELL WC I_F.L Total 1011r10 - 930/ 11 300 355 113 8 821 12 1 r; ,<< 101: 1 1 - 9?30r 12 410 421 84 2 748 39 1 , 10 1 12 - 9•'30/ 13 419 433 87 0 795 3-1 1 J, 10 1 13 - 9'30r 14 412 355 109 3 680 26 1 585 lit I. 14 - 9.30,15 351 270 68 1 765 14 1469 2010 - 2014 (.Al.eragel 378 367 92 4 762 31 1633 Table No. 2 Policy Year GL Auto LI. PfJ AP[) POL & ELL WC LEL Total 10,1 10 - 9 30,11 $566.237 S659.129 8201.201 S618.715 86.848.12 7 $2.490.514 S11.383.923 It), 1. I1 - 930/12 8712.157 S1,725,636 $147.499 SI 86.215.610 S235.809 $9.036,711 10/1 12 - 9i30/13 S1.154.438 $707.976 $134.866 80 S6.6(36.574 S512.050 $9.175.903 101. 13 - 9'30r 14 S664,786 8610,034. $218.272 $38.000 S6.43.5.261 $331.468 S8.297.820 10. 114 - 930.13 $546.951 S 1.052.972 $122.527 S 1.00t1 S4.773.880 S 101,681) SS6.599.0101 — 2010-2014(Aveerage) $728.91-1 8951.149 8164.873 8164.429 86.187,890 8734.304 $8.898.673 Table No. 3 Policy Year Indemnity 1ledical Total 19 1 1 1 - 9'30/ 11 147 37-1 821 10, 1. 11 - 9 30r 12 144 304 748 1 0. 1 12 - 9.30r 13 549 246 795 10,1 13 - 9. 30/ 14 445 235 680 1 0/ 1 1-1- 9' 30; 1 5 504 261 765 2010 - 2014 (Average) 478 284 762 3.3 PART 1 - WORKERS COMPENSATION CLAIMS AND LIABILITY CLAIMS ADMIINISTRATION 3.3.1:WORKERS COMPENSATION CLAIMS ADMINISTRATION The Successful Pruposer(s1 shall be responsible for performing at a minimum, die following services: 1. Establish reporting procedures 11.hich are compatible I-rith the needs and organisational structure of the City as determined by Risk 'Management, Notice of injury report ‘vi11 be submitted by the City. to the Successful Proposer in paperless format (i.e. internet or email). 2. Establish claims acknoiedgement procedures to the City's satisfaction. 3. Provide all necessary forms and instructions for use. Such forms shall include appropriate first reports of injure tvhh mailing address of claim administrator pre-printed thereon. These forms shall be provided electronically if requested. The cost of providing these forms shall be included within the proposed price. 4 Develop a cost effective staffing structure to include the number of adjusters. designated to appropriately Page 41 of 66 605386.6 handle the City's claims. The City reserves the right to negotiate and approve the final staffing plan and any cost associated with the changes. In addition. the City will have the right to request removal of personnel assigned to the City's Agreement. Removal will take effect within thirty (30) days of written request by the City. 5. Provide a dedicated Claims Supervisor to he assigned exclusively to the City's contract. 6. Receive and examine on behalf of the City all reports of employee injury claims. 7. Establish and maintain complete files on each claim. 8. Accept or denv all reported claims for employees' injuries on behalf of the City in accordance with the applicable workers compensation law. The decision to controvert a claim must first be discussed with and approved by Risk Management and. or the Office of the City Attorney, 9. Conduct the required investigations deemed necessary, as it relates to k orkers Compensation. including scene investigations. and personal claimant contact on all lost time or light duty cases. Contact rvitlt claimants must be attempted within twenty --four (24) hours of the Successful Proposer's receipt of the claim. Field investigations and claimant contact must be performed by employees of the Successful Proposer. Independent adjusters shall not be used to provide this service. 10. Perform jnh site visits_ to become familiar with exposures unique to the City. 11. Provide a report to the City's Project Manager. every thirty (30) days. indicating all employees who are losing time or working in a light duty or restricted capacity. 12. Submit a full summary to Risk ?Management and/or the office of the City Attorney [whore legal review or litigation has commencedl. eyery ninety (90) days. on all claims of the following types: a.anv claim in which an employee is not working full dutv: b.total incurred claim value exceeding S2,000: c.potentiall\ controverted cases: d.cardiovascular claims: and e.claims in which settlement (washout) is recommended. 13. Prepare. and maintain files necessary for legal defense of claims and'or other litigation (such as actions for suhrogatiotil. or other proceedings. 14. Pay in a timely fashion(within 30 days) all claims and expenses from the loss fund account established by the City. which will be maintained by the Successful Proposer. Fees and civil penalties for late payments are to be paid by the Successful Proposer unless caused due to late reporting by the City. 15. Pursue all possibilities of subrogation from third parties and recovery from Special Disability Trust Fund ISDTFJ and report such activities in the time. manner and method. as deemed necessary by the City and!or the Office of the City Attorney [where legal review or litigation has commenced'. 16. While the Office of the City Attorney will designate the attornev(s) that provide the defense of claims. as well as litigation strategy. the Successful Proposer shall provide the City's defense anornev(s1 a complete copy of the file in question and monitor and actively participate in the activities of the City's defense attorneys). 17. The Successful Proposershall attend Workers Compensation hearings. mediations. and pension board hearings involving work -related injuries. as requested by the City. 18. Make written recommendations to Risk Management regarding any procedures rtr condition that should be examined to prevent future claims. which are revealed during the Successful Proposers investigation of a claim. 19. Contact Risk Management by telephone on all claims where the compensability or the relatedness of the medical expenses on the claim is in question. and conduct such investigation. or such additional investigation. as deemed necessary by Risk \lanagetnent or the Office of the City Attorney. Page 42 of 66 605386.6 20. Contact employees who experience loss time at least every two (2) \seeks, for the duration of temporary total disability payments. When an employee is represented. the City attorney shall be contacted when appropriate. If City attorney contact is appropriate. that contact should be on a sixty (60)-day basis. 21. Report all lost time and,'or questionable cases to the Index Bureau. All lost time shall be re -indexed every six (6) months. 22. Establish initial reserves within ten (10) days of the first report of the claims being reported. All files must be reserved adequately to extend through the expected life of the claim. Although all the necessary facts may not be available at the onset of a claim. reserves should be adjusted when medical information or investigation indicates the existing reserve is inadequate or overstated. The following factors shall be considered when establishing reserve: a,the injury: lithe investigation: c.medical treatment and costs: d.projected temporary total disability benefits to be paid: e+projected permanent partial disability and impairment benefits: and f.potential use of outside experts (rehabilitation service providers. attorneys. etc.).: 23. The Successful Proposer shall review the adequacy of reserves at least every three (3) months. and document the file accordingly. 2-1. Present in writing all settlements to Risk lanagement and the Office of the City Attorney for approval. regardless of the amount. The injured employee will not be contacted regarding settlement until approval of proposed settlement is obtained from Risk Alanagement and/or the Office of the City Attorney. 25. Follow all Division of Workers' Compensation (D11 C) rules when compensation. medical. or other benefits are being controverted. The case must he discussed with Risk Management before the claim is denied and/or the Office of the City Attorney. where legal review or litigation has commenced. 26. Obtain medical reports as necessary. in such manner as approved by Risk \ianagement and the Office of the City Attorney to determine the status of die employee's injury and to verify disability. 27. Report all claims inyol\mg a fatality to Risk Management and the Office of the CityAttcorney inulnediately, Payments on these and all other Workers' Compensation matters shall he made in accordance with the Florida Workers' Compensation lass and or governing contractual agreements. Periodic activits!status checks shall be performed to ensure that dependents tvho receive survivor's benefits are still eligible to receive them. and notify Risk Management regarding those activity checks. The Office of the City Attorney shall be notified on litigated cases, or cases where legal review has commenced. 28. Prepare and file with the appropriate State agency all applications required for the Citv's qualification as a self -insurer. 29. Prepare. maintain and file all records and reports as may he required by legal authorities (State. local and Federal). Attach copies of reports. 30. Prepare. maintain and file statistical information required by Workers' Compensation Rating Bureaus. including all required data necessary for the promulgation of experience modifications. 31. Review for accuracy and approve the appropriateness of State assessments. prior to the due date of the assessment. 32, Establish an interest bearing hank account to make claim. indemnity. expense, and legal payments on checks drawn from this account. It is understood that all funds in this account are City funds and shall be returned upon the City's request or the termination of the Agreement. Regarding this account. the Successful Proposer shall: Page 43 of 66 605386.6 a.Reconcile on a monthly basis. the account and provide all monthly hank statements to the City, along with a request for a deposit from the City to maintain the balance needed in the account. as determined by the City. h.Ensure that anv interest earned on the account be applied to reducing the subsequent monthly deposit by the City. c.Suhmit a monthly statement including the following: i. balance at inception: ii. total disbursements by date and claimant: iii. balance at closing: and iv. amount of deposit required. d.List all checks along with all statements supplied to the City. 33. SuccessfuI Proposer shall provide to the City, hank account transactions and other information. additionally or in lieu of. on-line or via other means for "real-time" access by the City 34. Ensure that all adjusters handling City's cases are kept abreast of the Workers' Compensations Statutes. DWC rules. and applicable laws. 35. Ensure that the minimum standards of performance of Successful Proposer's personnel conform to the Florida statutes and administrative rules or future changes. if anv. 36. Ensure all D\VC filings. including compromise settlement agreement payments. are made in a correct and timely manner. 37. Provide notification of suit being filed against the City for any reason. to the Office of the City Attorney. and to Risk \lanagement evith twenty-four (24) hours of suit being filed. 38. Aggressively pursue recoveries to the satisfaction of the City. including recoveries based on subrogation and SDTF. As regards to subrogation recoveries involving injuries to the claimant caused by third parties. the Successful Proposer acknowledges that such recoveries mad include reductions in future +vorkers' compensation benefits as provided by Florida Workers' Compensation Law based on formulas provided in Chapter 440 and case law interpreting such law. and shall be responsible for documenting and collecting such recoveries from health care providers and the claimant as mutually agreed upon by the claimant and the Cite upon the claimant's recovery from the third partvjiesj. 39. The Successful Proposer evill pursue. track. and provide quarterly reports on all SDTF. as well as subrogation recoveries in such manner as deemed necessary by the City Attorney or designee. -10. Be responsible for data integrity. This includes properly inputting all cause codes. location codes. Loss description. and other claims information. If a data conversion is involved the Successful Proposer must attest to the integrity of the combined data. 41. Obtain the approval of Risk Management and'or the Office of the City attorney [inhere legal review or litigation have commenced] to hire experts in connection with claims against the City. Experts include. but are not limited to, accident reconstruction engineers and experts. medical and rehabilitation vendors and private investigators. 42, Provide the means for the City to perform claims status inquiries. 43. Provide training for supervisory personnel of the City for those individuals responsible for %Porkers Compensation activities. 44. Comply with all applicable laws and regulations regarding the administration of Workers Compensation benefits. 45. Provide and integrate successfully. an online claims management system that interfaces with all other existing systems to be utilized in the performance of this scope of work. Page 41 of 66 605386.6 46. Work closely +vith the "safety team" to enhance the Safety Program to reduce claims on an annual basis. 47. Assist in the implementation of the City's Return to Work Program. 48. Provide to the City a performance guarantee. to be negotiated with the City, A.HEARINGS CONFERENCES/TRIALS The Successful Proposer shall ensure that the following requirements for hearing conferences, trials are followed: 1. Pre -hearing or pre-trial reports shall be submitted by the Successful Proposer to the Office of the City Attorney at least two weeks prior to the hearing confcrcnce'trial or whenever requested by the Office of the City .attorney. Periodic up -dates on ongoing litigation. as well as provision and inspection of file materials kept by the Successful Proposer by the City Attorney or designee. will be scheduled by the Office of the City Att7rne\ as needed. 2. Reports must contain all information pertinent to the file including transcribed statements and depositions. 3. The Successful Proposer shall obtain settlement authority from the City prior to any hearing conference' trial. 4. Any recommendations made by the Successful Proposer. pertaining to die file should be carried out or referred to Office of the Citv .attorney. B.REPORTING REQUIREMENTS 1. Successful Proposer shall make an itnnwdiate report to the Risk Management Director or designee on: a.fatalities: and b.catastrophic occurrences with potential exposure $50.000 for more. ?. Submit "full captioned reports" within thirty (301 days of setting reserves at or above S25.000. The content of the "full captioned reports" shall include. not limited tu. the following: a.coverage items: b.etnployee's background: c.dependents: d.etnployee's job description: e.occurrence: [injury: g.medical. management: Image and compensation rates: i.dates and periods of disability: j.rehabilitation: k.other employee benefits: 1.1itigation: m.index'state filings: n.subrogation: o.rertrarks and or recommended actions: and p.strategy for resolution. 3. Submit "full -captioned report" on all files in litigation. Provide copies of all pleadings along with the report. 4. Ensure that follow-up reports are received within ninety (90) days of the "full -captioned report". 5. Submit monthly experience'statistical reports vhich shall include. but are not limited to, a summary of experience bv department stating cause of accident. frequency and cost. Open and closed claims shall include specific information on the accident date. claimant's name. cause of accident. injury type. amount paid and reserved. and state if the claim is open or has been finalized. These reports must be delivered by the loth of each month. and trust provide summary information by department, bv participant. and by total program. Page 45 of 66 605386.6 b. Become familiar with existing labor agreements. and report all activities pursuant to those .-agreement to the Risk Management Director or designee as requested. at least on a monthly basis. or as required bv the City. 7. Provide the necessary reports and or data to satisfy Florida's self-insurance requirements. Required forms shall be completed bv the Successful Proposer and sett to the City for review and appropriate signatures. Required self-insurance reports shall be provided on a timely basis so that the City will have sufficient time to review and execute [he documents before the due date. 8. Provide any report(s) requested by the Risk Management Director. Successful Proposers system shall have the ability to run ad hoc queries. C. "BAD FAITH" PROCEDURES The following procedures shall be followed to avoid potential actions for breach of good faith and fair dealings: 1. Termination ofvycckly benefits: Weekly benefits may be terminated only upon written or verbal notification by the treating physician or the City when employee returns to work. If return to work information is obtained verbally. the Successful Proposer must fallow up in writing with a request for written verification. If treating physician releases the employee to modified work. the Successful Proposer must promptly determine if modified work is available and offered to the employee before benefits are terminated. 2. Controverting claims: The Successful Proposer shall contact the City prior to formally denying a claim. This will not be necessary when controverting the reasonableness and necessity of medical bills. 3. Judgments,'sculcnienis: Judgments. settlements should release potential future "bad faith" actions. 4. Penalties and fines: Penalties and fines assessed by the DWC shall be paid by the Successful Proposer if such fines and penalties result from negligent performance of its duties D. PERFORMANCE STANDARDS: WORKERS' COMPENSATION The City performs annual performance standards audit based on the following: 1. Successful Proposer will document all new claim information received from the City. and this information will be available within one (1) hour of receipt. it' received during normal business hours. or within the first business hour of the next business day, if received less than one (1) hour before the close of a business day. File shall include First Report of Injury form. 2. A minimum of "three (3) attempts" by the Successful Proposer. to contact the appropriate parties. will be considered a "contact". if followed with the appropriate correspondence within the measurement period. For a workers' compensation claim. three (3) point contacts will be required (claimant, supervisor and treating provider). For a liability claim. two (2) point contacts will be required (claimant and reporting City Supervisor. if applicable). 3. Successful Proposer shall document. and provide Risk Management written notice of,subrogation. contribution, and/or coordination of benefits recovery potential, as they develop, if a Successful Proposer decides not to pursue any, such recovery. Successful Proposer must give written notice to Risk Management of its decision within fourteen (14) days of claim receipt. 4. For Workers' Compensation claim, within fourteen (14) days of receipt of the claim. the claims adjuster will perform a three point contact. send appropriate notification packages to the claimant. as required by Chapter 440. review. the claimant's pre -employment physical. and document the Successful Proposer's analysis of the compensability of the clairn. Page 46 of 66 605386.6 For liability claims. within fourteen (14) days of receipt of the claim. the Successful Proposer will document appropriate specific directions for the investigation and handling of the case. 5. Within 72 hours of receipt of the claim. initial reserves for the file \vil1 be set. thereafter, reserves \\ill he reviewed on an on -going basis. as follows: a.30 days from 72 hour review: b.30 days from 30 day review: c.60 days from last 60 day review: and d.Every 6 months thereafter. Increase or decrease of reserves by $10.000 or more. requires notification to Risk \lanagement. Subsequent to notification. Risk Management reserves the right to discuss the case and request a reconsideration of the reserve of the Successful Proposer. G.Successful Proposer shall "address" litigation within two (2) days of receipt of litigation notification. or less than ma f2) days as requested by the Office of the City Attorney if a shorter deadline is deemed legally necessary by the Office of the City Attorney. This will mean notice of to Risk \lanagement. and referral to the Office of the City :attorney for assignment, within two (2) class. or perhaps less than twtu (2) dams, if requested by the Office of the City Attorney. 7. Required status reports shall be provided to the Risk \lanafement Administrator or designee. Required status reports are outlined in Attachment A. Proposer Supplemental Questionnaire. 8. Settlement evaluation shall be provided to the Office of the Ciry .attorney and Risk h[anagcntent 30 days prior to mediation. The Successful Proposer shall evaluate, nr cause. a third party expert. as deemed necessary. to esaIuate the neat for a Medicare Set Aside ]\ISA], and this shall he determined and documented in all settlement evaluations. 9. File/System documentation shall include documentation of return phone calls to injured worker and the City within twents -four (24) hours or the next business day. 10. File/System documentation shall include documentation that referral appointment was made for a claimant to a network provider specialist (i.e.: Diagnostic testing. Neurologist. Orthopedic) so that claimant was seen by specialist within two (2) weeks of the elate of receipt of the referral from the primary treating physician. unless it is clearly documented that. despite Successful Proposer's best efforts, no specialist was available to see claimant within the requisite ttvn weeks period_ 3.3.2:LIABILITY CLAI\IS ADMINISTRATION Upon receipt of all liability claims, the Successful Proposer. on behalf of the City. stall perform. at a minimum, the following services: 1. Review all first notices of claim reports received from the City. svhich will consist of loss reports. claim letters and suits. or claims that are phoned. nailed. or faxed in bv the City, prior to an assignment to the Successful Proposer's adjuster. approved bv the City. 2. Designate the necessary number of outside field adjusters to handle all City claims and also designate an alternate in their absence. The designation of these persons is subject to the approval of the Citv. Page -17 of 66 605386,6 3. Conduct a thorough and complete investigation of the accident. according to the requirements of the Citv.. Investigations shrill include, but not limited to. the following: al Contact the claimant or the claimant's attorney within 24 hours of the time the accident report is received by the Successful Proposer. In the case of underrepresented claimants. personal contact is required the same day the claim is received. All claim files must contain adjuster's logs documenting all contact and activity. h)Obtain recorded statements from the claimant. witnesses. and the City personnel. Personal contact of all underrepresented claimants by outside adjusters is required. c) Complete a timely scene investigation consisting of photos and diagrams. This is required within two (2) days of receipt of any serious AL or GL claim assignment. d)Ubtain the police and/or fire rescue report. e)Ohtain and review all medical reports and bills submitted by the claimant or their attorney. f)Obtain and review all estimates and appraisals for property damage claims. g)Estahlish appropriate reserves on all claims, and revise the reserves as needed. h)Submit a report to the Ciry within 30 days of receipt of the claim, summarizing: i.Date'timellocarion of loss: ii.Claimant information: iii.Description of accident: iv.lnjuries or damages: v.Wiuresses' version: vi.Liahility analysis:and vii.Evaluation of claim (i.e. amount of recommended settlement. denial. reserves, attorney demand), If a settlement recommendation cannot be made at this initial report (due to lack of information), indicate same and reason, However. remainder of investigation should be completed. 4. Submit a status report every 90 days thereafter to the City until the claim is resolved. The City prefers the above reporting requirements to he accomplished via the on-line claims management system for "real-time" viewing. 5. The Successful Proposer has the authority to settle cases on behalf of the City up to $3.000 per claim for propert\ damage and $3.000 for bodily injury. For any settlement in excess of the above, the Successful Proposer must receive authorization from the City. The request for this authorization must be presented in writing. including the adjuster's evaluation and recommendation in a format required by the City.. After authorization is granted. the Successful Proposer will settle the claim and obtain the appropriate release. Additionally- the Successful Proposer shall provide a quarterly report to the City on all settlements above and below S10.000. 6. The Citv will assign an attorney for the legal defense of any claims that goes into suit. The Successful Proposer will assist the City's attorneys NA ith arty additional investigations. as deemed necessary by the City or its attorneys. The Successful Proposer will continue to monitor the file in lit igatian.Successful Proposer vv ill provide a monthly report of all litigated claims in the format specified by the City, 7 Upon notification from the City, the Successful Proposer shall forward a copy- of the file in suit. to the Citv's attorney with a transcription of all settlements. 8. The Successful Proposer shall attend ail mediations and trials as requested by the City. With respect to claims with impending trial dates, the designated Successful Proposer's Supervisor or designee. shall take an active and aggressive role in settlement or preparation for trial. 9. The Successful Proposer. after apprus al of the City. can assign the necessary auto appraiser for property damage claims. These expenses shall be paid as an allocated expense by the Successful Proposer from the Citv's Toss fund. Page 48 of 66 605386.6 10. Any other claim expense must be approved by the City prior to being incurred. However. expenses for normal claim activities. such as photographs, tapes. supplies, postage, etc., are the responsibility of the Successful Proposer. 11. The Successful Proposer shall meet quarterly (or more frequently if required by the City) with the City \tanager. and or authorized representative, to review all large exposure (over $25,000) incurred cases and report on their status. 12. All claim files are at all times the property of the City. The City has the right to inspect any and all files vvhenever the City deems necessary. If the Agreement is terminated. the City will receive all original claim files. 13. The Successful Proposer shall make recommendations to the City as to actions that ran be taken to prevent future claims. These loss prevention recommendations can be included in the status report. 14. All work must be performed by the employees of the Successful Proposer. The use of any contracted or independent adjuster is prohibited. unless prior approv al is granted by the City. 15. The Successful Proposer shall reimburse the City for payments made in error that are non-recoverahie from third parties by the Successful Proposer. 16. The Successful Proposer shall provide to the City a performance guarantee. to be negotiated with the City in the provision of Managed Care'i`+Iedical Bill Review tPart II services) as cited herein. to improve its effect eness and efficiency while maximizing City resources. 17. The Successful Proposer shall continue to monitor the file in litigation. and obtain updates from the City Attorney s office. in an effort to prepare reports to the Citv's excess carriers as required. A.PERFORMANCE STANDARDS: LIABILITY The City performs annual performance standards audit based on the following: 1. Successful Proposer shall document all new claim information received from the City. and this information will he available electronically within one (1) hour of receipt. if received during normal business hours. or vs ithin the first business hour of the next business day. if received less than one (1) hour before the close of a business day. File will include First Report of Injury form. 2. A minimum of "three (3) attempts" by the Successful Proposer's claims adjuster to contact the appropriate parties will be considered a "contact", if follosyed up with appropriate correspondence within the measurement period. 3. Successful Proposer shall document. and give City's Project !\lanager. written notice of. subrogation. contribution, and.'or coordination of benefits recovery potential. If Successful Proposer decides not to pursue any such recovery. it must give written notice to Risk Nlanagement of its decision within fourteen (14) days of claim receipt 4. For liability claims. within fourteen (14) days of receipt of the claim. the Successful Proposer shall document appropriate specific direction for the investigation and handling of the case. 5. Within 72 hours of receipt of the claim, initial reserves for the file shall be set. thereafter, reserves will he reviewed on an on -going basis. as follows: a.30 days from 72 hour review: b.30 days from 30 day review; c.60 days from last 60 day review; and d.Every 6 months thereafter. 6. Successful Proposer shall "address" litigation within two (2) days of receipt of litigation notification. This will mean notice to Risk Management. and referral to the City Attorney's office for assignment, within two (2) days. 7. Required status reports are outlined in Attachment A. Proposer Supplemental Questionnaire. Page49of66 605386,6 The City desires prompt. personal contact of all claimants. Evaluations of each claim shall be made as soon as the necessary information is received by the Successful Proposer. The investigation and evaluation of all claims should be completed prior to suit being filed. since F.S. 768.28 (sovereign immunity statute) requires the claimant provide six months' notice of intention to file suit. The Successful Proposer must have up-to-date policy and procedure manual(s) on hand in the work place. These ntanual(s) shall describe and discuss the day to day procedures for adjusting files, and shall be kept in accordance with statutory requirements. The Successful Proposer shall provide adequate toll -free telephone access to the claims office. The Successful Proposer shall provide claims personnel. ivho shall be available on a 7 day. 24 hour basis. for investigating claims. and must have an maintain an 800 or toll -free number for emergency service. The Successful Proposer shall provide its own office space or facilitv(s) for its adjuster or staff of adjusters. The Successful Proposer must agree to be responsible to manage liability claims to be opened within the vear(s) following contract execution. along with the current inventory of open files. The Successful Proposer shall provide claims administration on a "life of relationship basis.'" 3.5 STAFFING. QUALITY CONTROL, AND SUPERVISION The Successful Proposer shall render high -quality claims management and adjusting services throughout the term of the Agreement. The Successful Proposers personnel shall have. as a minimum. the following levels of experience and licensing: 1. Supervisor or Supervising Adjuster shall have five to seven (5-7) years of related experience: 2. Adjusters shall have three (3) years of experience: 3. Medical -only processor(sl shall have one (1) year of experience. and must hold a current Florida Adjuster License: 4. The Successful Proposer's files must reflect evidence of supervisory direction and in olvement at es ery level. All files must be kept current. File review should he performed on 30. 60, 90 or 120 day cycles. as appropriate. Periodic review by the handling adjuster and all supervisors should be reflected in the file. 5. Successful Proposer's Supervisors shall receive all First Reports of Injury and outline investigative needs for the adjusters to follow through. Supervisors should assign the most difficult files to the most qualified adjuster. �. Successful Proposer shall perform monthly claims review with Risk Management. to include the adjusters. and City .-Attorney. 7. It is the Cirs-'s claims management philosophy that the proper and most cost-effective method to handle claims and thereby reduce and control the C itv's self -insured loss payments. is to ensure the Successful Proposer hires and retains the appropriately qualified professionals to handle the CiWs claims. Additionally, the adequate number of adjusters and a manageable caseload enables qualified adjusters to perform the required services. The City therefore requires that the Successful Proposer agree to staffing. qualifications. and caseload criteria established by the City. 8. The City' reserves the right to the final prior approval of the hiring and'or assignment of the claims manager. supervisors. and adjusters that will handle the Citv's claims. 9. The Successful Proposer agrees to add staff as necessary, to maintain these maximum pending caseload levels. The Proposer in its response to the RFP, must explain how its office or unit will be staffed, and the level of supervision that will be provided. Page 50 of 66 605386.6 10. Claims personnel must be employees of the Successful Proposer. The use of independent adjusters. sub contractors. or temporary adjusters will not be acceptable without prior approval of the City. Successful Proposer's .Adjuster trainees are not acceptable for handling of the City's claims. The Proposer must submit vi[h its proposal. the resumes of all claims professionals specifically to be assigned to this account. All Successful Proposer's claims professionals must possess a current Florida adjuster's license. 11. In addition to those services previously discussed. the Successful Proposer will additionally perform the following related services: a.State required filings: b, Loss fund management: c.Computer generated loss runs and other management reports, preferably on-line: and d.Provide an annual SAS 70 audit report. 12. The Successful Proposer shall have the ability to provide full customer service to English. Spanish, and Haitian -Creole speaking individuals, when needed. 13. The Successful Proposer shall make available to the City an individual \ ith management authority to meet with the Risk I\lanagement Director. or the designee, upon reasonable notice. This individual shall have the authority t0 make "agreed to changes," The Successful Proposer's employees shall meet with Risk Management on a quarterly or as -needed basis to discuss claims of interest. Sufficient advance notice will be given by Risk y.lanaement to allow adequate preparation and data collection. The Successful Proposer's personnel. including the adjuster or Supervisor. must also be available to attend mediation conferences, as necessary. 3.6 PART II; MANAGED CARE/MEDICAL BILL REVIEW/AUDIT SERVICES The City supports management of the medical component. which is kev to returning employees back to \York and facilitation of %Yorkers' Compensation claim resolution. The City has the following expectations relating to medical: •.\ provider who actively and aggressively manages medical, •.a network of physicians specializing in Return to Work •_A claims management team approach whereby the team understands and \works as partners in the RTW Transitional -duty efforts. The CRY is very interested in the Successful Proposers philosophy on utilization of TC\I & FCM within their claims management model with the understanding that the City may elect to use a separate managed care vendor. The City's current Claims Administrator (Gallagher). utilizes on-line claims processing system where all data is maintained. updated. and payments are issued. The adjudication of ll orkers' Compensation medical bills and payments to the City's prodders are performed through this system. On a monthly basis, Gallagher provides the City, with a hank reconciliation report to interface with the City's financial system. The Successful Proposer shall be responsible for the provision of an on-line claim processing system and the conversion of any data necessary for successful integration with any and all other sysielns. including following the termination of the Contract. Any procedures. equipment, and'or costs necessary to connect with Gallagher's hardware and software. shall be the sole responsibility of the Successful Proposer. A. MANAGED CARE SERVICES The Successful Proposer shall render high -quality claims management services throughout the entire Contract terra. The Successful Proposer's personnel shall have. as a minimum. the following levels of experience and licensing: a)Supervisor shall have five to ten (5-10) sears of relevant experience: Page 51 of 66 605386.6 b)Nurse Case Manager shall have five to seven (5-7) Years of relevant experience: c) account Representative shall be fully qualified and responsible for the performance of Provider's responsibilities under the Agreement. The Account Representative's responsibilities include. but are not limited to: i.Aci as Successful Proposer's representative on any claims issue or problems: ii. act as a liaison between the City, medical network. Successful Proposer, and any other parties as deemed necessary by the City: and iii.Participate with and assist the Risk I\lanagenlent in the performance reviews, as required under the Agreement. and review other claims as requested by Risk Ivlanagement under the Agreement. d)The Successful Proposers files must reflect evidence of supervisory direction. and involvement at every level. All files must he kept current. File review should be performed on 30. 60, 90. 120 day cycles as appropriate. Periodic review by the handling Nurse Case Manager and Supervisors should he reflected in the file. e)Successful Proposer's Supervisors) shall receive all First Report of Injury and outline investigative needs for the Nurse Case !1lanager to follow through. Supervisor(s) should assign the most difficulty files to the most qualified Nurse Case Manager. f)Successful Proposer shall perform monthly claims review ys ith Risk Management. to include the adjusters, Risk !\lanagement and City Attorney. g)The City reserves the right to the final prior approval of the hiring and, or assignment of the Nurse Case Manager. and Supervisor(s) to handle the City"s claims. h)The Successful Proposer agrees to add staff, as necessary. to maintain the maximum pending caseload levels. The Proposer. in its response. shall explain how its office, or unit will be staffed. and the level of supervision that will be provided. i)Claims personnel must he employees of the Successful Proposer. The use of Nurse Case Manager. subcontractor, or temporary Nurse Case Manager. will not he acceptable without prior approval of the City. The Proposer must submit with its proposal. the resumes of all Proposer's claims professionals specifically to be assigned to this account. All claims professionals must possess a current Florida adjuster's license. j)The Successful Proposer shall have the ability to provide full service to English. Spanish, and Haitian - Creole speaking individuals, when needed. kiThe Successful Proposer shall make available to the City. an individual ss ith management authority, to meet with Risk Management Director or the designee upon reasonable notice. This individual shall have the authority to make "agreed to changes." The Provider will meet Risk Management or the designee on a quarterly or as -needed basis to discuss claims of interest. Sufficient advance notice will be gi\ en to allow adequate preparation and data collection. The Successful Proposer's personnel. including the Case Manager or supervisor. must be available to attend mediation conferences as necessary. B. MEDICAL BILL REVIEW AND AUDIT SERVICES Proposers are requested to provide the following medical hill r'cview and audit services: A)Medical Bill Review: 1. Promptly review medicalsurgical bills (in and out of network) for accuracy. including. but not limited to, as they relate to the following: a) Duplicate billings: b) Unbundling of charges: c) Up -coding of charges: and d) Approval and appropriate pre -certification Page 52 of 66 605386 6 2. Review all medical bills that: a) Are not subject to fee schedule coding; b) -1re for services not specifically addressed in the fee schedule: c)Need an in-depth medical interpretation of the rules and regulations: and d)In the exercise of professional judgment. specifically warrant review 3. Process. pay. and mail bills within 20 days of receipt. 4. Reimburse the City for anv overpayments made in the bill review process. within 30 days of identification of overpayment. Reimburse the City for anv penalties and or interest associated with inaccurate payments. B]Medieal Auditing Services: 1. Audit -in network and out -network hospital provider bills: a)Exceeding $5.000: b)` Vhcre a departmental charge exceeds IO"o of the total bill. excluding room and hoard charges: and c)Others al the Successful Proposer's direction or specific request by the City for accuracy and appropriateness. 2. Develop and follow written policies on how law charges. no show charges. and special arrangements shall he handled. 3.Devefop and provide communication materials to explain the policies and procedures of the Medical Bill Review and Audi Services to the City of Miami's Medical providers. 4. Process. pay and mail bills within 20 days of receipt. 5. Develop and follow written grim once procedures for provider concerns. C. PHARMACEUTICAL NIANAGEMENT SERVICES The City currenth uses Cypress Care PBNI services for claims that are administered in-house. The City desires to retain this relationship_ Successful Proposer shall pursue subrogation recoveries pursuant to )Workers Compensation lien recovery settlement agreement. Details regarding the PBMS's services should he provided. including access, utilization review services. coordination of claims data and reporting. Sonic physicians were dispensing drugs directly to injured workers: the Citv's current Claims Administrator (Gallagher). has taken steps to curtail excessive costs. and evill reprice the prescriptions. Fees for pharmaceuticals or pharmaceutical services shall be reimbursable at the applicable fee schedule amount (F.S> 440.13(12c). except where the employer/carrier has contracted for a lower amount. )Where the emplover`carrier has contracted for such services and the employee elects to obtain them through a provider not a party to the contract. the reimbursement shall he at the scheduled. negotiated. or contract price. whichever is lover. Successful Proposers are requested to address the issue of physician dispensing and the high cost of repackaged drugs. D. LOSS CONTROL SERVICES When requested by the City to do so. the Successful Proposer shall consult with the Citt. its emplovees. agents and others. concerning workplaces. operations. work procedures. and equipment owned or operated by the City, and make recommendations to the City regarding same. for the purpose of establishing loss control systems to mitigate and. or control losses. damage. and claims: provided. however. it is understood and agreed. that neither tht' rights of Page 53 of 66 605386.6 the Successful Proposer to make inspections. nor its recommendations or reports as to loss control. shall constitute an undertaking on behalf of. or for the benefit of the City, or its employees or otters. to determine. warrant. or guarantee that such work places. operations. procedures. or equipment are free and safe from defects and or hazards. E. IRS FILING REQUIREMENTS OF CLAIMS ADMINISTRATOR (SUCCESSFUL PROPOSER) The Successful Proposer shall: 1. Furnish required tax information for the internal Revenue Service including 1099s with a copy of the 1099s submitted to the IRS. 2. Prepare. maintain and file all records and reports as may be required by legal authorities (State. local and Federal). 3. Prepare. maintain and file statistical information required by the Division of Workers' Compensation and Rating Bureaus, including all data necessary for the promulgation of experience modification. and as required by any other legal entitv(s). F. STATE REQUIRED FILINGS At a minimum. the Successful Proposer shall be required to provide the following services: 1. Prepare and file. on behalf of the City. with the appropriate state agency. all applications required for the City's continued qualification as a self -insurer. 2. Prepare. maintain. and file all records and reports. as may be required by legal State or Federal. 3. Prepare. maintain. and file statistical data. records. or reports. as required by excess insurers. City actuaries. and the State. 4. Prepare. maintain. and file statistical information required by worker's compensation rating bureaus. including all data required for the promulgation of the City's experience modification and state assessment. 5. Prepare and file any other reports as required by the City and the State relating to claims experience. payments, etc. (such as D\VC-51. etc.) G. LOSS FUND MANAGEMENT 1. The Interest Bearing Account will be maintained at the City's commercial banking institution. The account will be classified as pan of the analysis group of the City's accounts. The Cite will pay all service fees that are normal and customary in this account. All interest earned or service credits generated will accrue to the benefit of the City. 2. The Successful Proposer is required to follow Florida law concerning public deposits. Specifically. the Successful Proposer shall adhere to F.S. 237.211(6) and F.S. 280 Security of Public Deposits. Failure to comply \vith these laws is sufficient cause for the City to terminate the .Agreement %kith the Successful Proposer. 3. all claims. expense and legal payment will be made by the Successful Proposer on checks drawn on an Page 54 of 66 605386.6 account set up by the Successful Proposer. and funded monthly by the City. It is understood that all funds in this account are City funds. and shall be returned to the City upon request or at termination of the contract. 4. The Successful Proposer is responsible for the monthly reconciliation of this account and shall provide bank statements to the Cits monthly. along with a request for a deposit from the City to maintain the monthly balance in the loss fund. as determined by the City. 5. The monthly reconciliation statement submitted by the Successful Proposer to the City shall, at minimum. include the following: a,Balance at inception of statement period: h.Total disbursements v hich cleared. by date and claimant'payee: c.Balance at close of statement period: d.Amount of deposit required: and e.A list of all checks shall be submitted on a monthly basis, H. COMPUTER LOSS INFORMATION All charges related to these services are to be included in the annual claims administration fee. Any costs associated with programming changes that are necessary to create a report required by the City are the responsibility of the Successful Proposer. In its proposal. Proposer should indicate any fees to be charged for the creation of any special reports requested by the City. as necessary. All reports currently provided to the City are required from the Successful Proposer. I. Successful Proposer must ensure conductivity with the current system and software used bv Risk itlanagemcnt and the Department of Finance. and all other involved departments. Successful Proposer shall continue to ensure. at its cost. that its system remains a viable solution for on-line claims administration. should the City upgrade or replace any aspect of its risk and. or financial system throughout the term of the Contract. 2. All claims data is the property of the Citv and any data and media will be provided to the City upon request and, or upon termination of the contract. All computer notes will be printed out and placed in We files prior to file transfer to a successor Claims Administrator. 3. The Successful Proposer. at its own expense. shall ensure all claims and payment data is included in their loss runs. by a elate as determined bv the City. Historical data from the current Claims .Administrator's database cannot be purged. Claims data for all open and closed claims must be transferred. .1. Loss runs shall he provided by the Successful Proposer. on a monthly basis, sorted separately bv line of coverage (11 C. GL. AL). policy year. and department 'location. Loss runs should list each claim separately. Specific suntntar' reports must also be provided. This requirement may be satisfied by utilizing the Successful Proposer's on -litre system. The following reports, at a minimum, are required: a.Claiins list (lists all claims alphabetically): b.Check register:: c.Cumulati\e report byline of coverage by year: d.Annual summary reports: e.Location report: f.Large Toss or severity report: g.Safety report li.Excess insurance report Page 55 of 66 605386.6 i.Litigation report j.Legal payments report k.SAF 200 (OSHA log) 5. Workers Compensation claims. involving no payment or no medical treatment. are reported by the Cit\ for inclusion in the database as reporting purpose only (RPO) or first aid or no pay cases and should he identified in the system that same way. 6. The Successful Proposer shall provide the City access via Internet to the system for file review. e-mail, or other purposes. at no additional cost to the City. An 800 or other toll -free number is necessary for on-line connections and faxes if the call is outside :Miami -Dade County. I. FEE BILLING The City desires to pay claims administration fees monthly in arrears for claim files established in the previous month. A summary in\ oicc should be broken down by line of co\ erage and tic to month -end figures as shown on the loss runs. Page 56 of 66 605386,6 4. Submission Requirements 4.1. CMIA Submission Requirements 4.1. SUBMISSION REQUIREMENTS The following documentation shall be included, as a minimum. in the Proposal and submitted to the City. Instructions to Proposers: Proposers should carefully follow the Format and instructions outlined below, observing format requirements ‘ here indicated. Proposals should contain the information itemized below and in the order indicated. This information should be provided for the Proposer for the work contemplated by this RFP. Proposals submitted which do not include the following items. may be deemed non -responsive, and may not be considered for contract award. ALL RESPONSES SHALL BE SUBMTITTED IN HARD COPY FORMAT ONLY TO INCLUDE ONE (1) ORIGINAL, SIX (6) COPIES, AND AN ELECTRONIC COPY (USB OR CD). NO ON-LINE SUBMITTALS WILL BE ACCEPTED. The response to this Solicitation shall be presented in the following format. Failure to do so may deem your Proposal non -responsive. Proposers may submit a Proposal for either Part 1: Workers' Compensation Claims and Liability Claims Administration, and/or Part II - Managed Care1111edical Bill Review.Proposers must clearly indicate for which Parts) Proposer is submitting its Proposal for. and must provide all of the following for each Part, in addition to the Supplemental Proposer Questionnaire (Attachment A). which is attached in the Header Section of this Solicitation. Proposals will be ranked on a Category of Services basis. For example. Proposals submitted for Part T. Workers' Compensation Claims and Liability Claims Administration will only be ranked against other Proposals submitted for the Workers' Compensation Claims and Liability Claims Administration. 1. COVER PAGE The Cover Page should include the Proposer's name: Contact Person for the RFP: Firms Liaison for the Contract: Primary Office Location: Local Business Address, if applicable: Business Phone and Fax Numbers: Title of RFP: RFP Number: Federal Employer Identification Number or Social Security- Number. 2. TABLE OF CONTENTS The Table of Contents should outline. in sequential order. the major sections of the proposal as listed below, including all other relevant documents requested for submission. All pages of the proposal, including the enclosures, should be clearly and consecutively numbered and correspond to the table of contents. 3. EXECUTIVE SUMMARY Page 57 of 66 605386.6 A signed and dated summary of not more than two (2) pages containing the Proposer's Qualifications and Experience. Ability- to Perform Required Services. and Overall Approach and Methodology to Scope of Work as contained in the submittal. Include the name of the organization. business phone and contact person. Provide a summary of the work to he performed by Proposer. Proposer must meet all requirements and or criteria in Section 2.6. Minimum Qualification Requirements. and elsewhere in the RFP. including responding to and the following information in Sections 4 through 9. and providing all documents as required. With Proposer's response to this RFP. Attachment A. Proposer Supplemental Questionnaire must also be completed in its entirety. Failure to comply with the above. niav deem your proposal non -responsive. 4,PROPOSER'S GENERAL EXPERIENCE. PAST PERFORMANCE AND EXCEPTIONS I)Descrihe the Proposer's past performance and experience and state the number of years that the Proposer has been in existence. the current number of employees. and the primary markets served. 2)List all contracts «hick the Proposer has performed for the City of :Nliatni, describe all work performed for the City and include for each project: (i) naive of the City Department Ilhich administers or administered the contract. (ii) description of work. (iii) total dollar value of the contract. (iv) dates covering the term of the contract. (v) City contact person and phone number. (vi) statement of whether Proposer Was the prime contractor or subcontractor, and (vii) the results of the project, 3)Provide information concerning any prior or pending litigation. either civil or criminal. involving a governmental agency or which may affect the performance of the services to he rendered herein. in which the Proposer. any of its employees or subcontractors is or has been involved within the last five (5) years. Provide letters of reference from law firths which currently handle your litigation. Provide contact person and phone number for each. -/)Identify if Proposer has taken any exception to the tenors of this Solicitation. If so. indicate what alternative is being offered and the cost implications of the exception(s). 5. PROPOSER'S CATEGORY SPECIFIC EXPERIENCE, PAST PERFORMANCE Note: Any Proposer submitting a Proposal for both categories of Service. Part I- Workers' Compensation Claims Administration AND Part II: Medical Bill Review and Audit Services (Part I and II) must provide in its proposal, complete and separate responses for applicable Items 5 through 15 below for each Part (Part I or II). 5)Descrihe Proposer's past performance and experience with regard to the particular service category (Part I and/or Part II), and state the number of years that the Proposer has worked in this area providing a similar type of service, the current number of employees working in this area. and the primary markets served. Provide organizational history and structure. and indicate whether the City has previously awarded any contracts to the Proposer (a list of these Citv contracts shall be provided in item 2 above). Page 58 of 66 605386.6 6)Provide a detailed description of five (5) comparable contracts (similar in scope of services to those requested herein). which the Proposer has either ongoing or completed within the past five (5) years in the capacity as a Third Party Claims .Administrator. The description should identify for each project: (i) client. (ii) client contact person. phone number and email address. (iii) description of work. iv) total dollar value of the contract. (vi) dates covering the terns of the contract, (vii) statement of whether- Proposer was the prince contractor or subcontractor, Include the Proposer's role and any value added. (viii) Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Where possible. list and describe those projects performed for government clients or similar size private entities (excluding any ssork perforated for the City). In the event that the Proposer has not performed five (5) comparable contracts in the particular category (Part I or - Part II), the Proposer should provide information that demonstrated its ahilits to perform the required services. 7)Descrihe any relevant industrv'subject matter expertise. including any experience in the particular services. and any unique or proprietary project methodologies relevant to the requested services. 81Proyidc a list of clients that hare. for whatever reason. discontinued the use of your services svithin the past it1 o 12) rears. and indicate the reasons for the same. The City reserves the right to contact arts clients listed as part of the evaluation process. 9)Provide two (2) Letters of Reference. on letterhead, from two different. similar sized governmental entities (as the Citv). and for which similar services (Part I or Part I1) have been performed within the past five (5) Years. This information is subject to verification as part of the evaluation process. 10)Provide a complete List of all current Florida clients for which Proposer administers claims in a Workers' Compensation. self-insurance. or retention program. The description should identify,- for each client: (i) client, and type of entity: (ii) client contact person. phone number. and entail address. (iii) description of work. iv) total dollar value of the contract. (vi) dates covering the term of the contract. (yii) statement of whether Proposer was the prime contractor or subcontractor, Specificall\ identify clients for whom a similar service has been pros ided. particular) to governmental entities similar in size to the Citv. Trust. or other similar rope as the City. Indicate whether Proposer assisted in disability. safety program. Light duty return -to -work program. etc. 111Discuss in detail Proposer's qualifications and experience to provide general liability and automobile liability claims administration. Include, in the description. the Proposer's thorough knowledge of all State Statutes and other applicable laws governing this RFP. to demonstrate a complete understanding of the work to be performed. 12lDiscuss in detail Proposer's qualifications and experience to provide managed care services, include the Page 59of66 605386.6 Proposer's thorough knowledge of all State Statutes and other applicable laws governing this RFP, to demonstrate a complete understanding of the w ork to be perforated. 13)Prnvide detailed background on the Proposer's proposed \lanager'Supervisor to be assigned the Citv's account throughout the duration of the contract terns. and whether Proposer agrees to City's terms for approval of future Maiiager'Super-isnr, shnulti proposed representative leave Proposer's firm during the contract term. Protiide copies of current applicable licenses for work to he performed in the State of Florida. 1 llDescribe the experience. qualifications and other vital information.. including relevant experience on previous similar projects (Part 1 or Part II). of all key personnel. who tv ilI he assigned to the City's contract. This information shall include the functions to be performed by the key individuals. and the caseload of each person assigned to service the account. Include copies of all licenses held In each individual. as all claims professionals must possess a current Florida adjuster's license. Provide cops ties} of each adjuster's and Supervisor's Florida Adjusiing License. or any other relevant licenses. if applicahle. In addition. provide resumes. if available, with job descriptions and other detailed qualification information on all kev personnel who wilt be assigned to the City contract. 15tProv ide a complete list of all licensed claim's personnel that will handle Citv's claims. aiidior managed care ser\ ices. including the Proposer's proposed i•lanager:'Super isor. Supervising Adjuster. Adjusters. Supervising nurse Case Manager. Case Nlana;er. Aledical-only processors. or other individuals including clerical and or support staff detailing education. experience in the area of workers' compensation claims. in the area of managed care. and type of licensefsl. Include copies of all licenses held by each individual. Note: After qualification submission, but prior to the award of any contract or work order issued, as a result of [his RFP, the Proposer has a continuing obligation to advise the City of any changes, intended or otherwise to the key -personnel in its proposal submission. 6. PROPOSER'S ABILITY TO PERFORM REQUIRED SERVICES ID1Provide a complete list of all claims office locations and territorv(ies) serviced svith Proposer's current personnel. indicating the number of personnel of Proposer. and Proposer's ability to provide required services to the City. 1 i)Describe where your main office is located, and the location where the primary work will be performed. Indicate location where the Successful Proposer. the Successful Proposer's Manager:Supervisor tvill be located. I81Discuss how the Proposer's office or unit tvill be staffed. and the level of supervision that will be provided. Discuss case assignments, including pending case load for each designated Adjuster and current number of monthly new assignments to each Adjuster. if applicable. Discuss case assignments, including pending case load for each designated nurse Case Manager and current number of monthly new assignments to each nurse Case Manager. if applicable. Page 60 of 66 605386.6 l9)Desctibe how Proposer will ensure managed care services by City employees residing in Miami -Dade. Broward. Patin Beach. and Monroe Counties, among other locales. 20)Discuss whether the award of this contract necessitates an increase in Proposer's staff size to meet the City's staffing and caseload requirements_ and whether staff Nvil1 he in place by the start of the contract, \vhich is estimated to be February 1. 2017. 21)Explain the percentage of time the Proposer's proposed Adjusters will be out of the office doing field work. If all of Proposer's proposed Adjusters are telephone Adjusters. indicate as such. Explain whether Proposer will utilize independent contracted Adjusters, and under what circumstances. Provide the name, address, phone. and contact person for independents you currently utilize. 22)Identify language capabilities (spoken or \v ritten) of Proposer's employees and those of the subcontractors or suhconsultants. 7. PROPOSED OVERALL APPROACH TO PERFORMING THE SERVICES 23)Discuss in detail Proposer's overall approach to the work to be performed. Describe Proposers specific project plan and procedures to be used in providing the services. and how Proposer has applied the proposed project approach in comparable contracts. \ 2d)Describe Proposer's ability to perform the services described in the Scope of Ser\ ices,.and describe Proposer 's specific policies, plans, procedures or techniques to be used in providing the services requested. The Proposer shall describe its approach to project organization and management. responsibilities of Proposer's management and staff personnel that will perform work in this Solicitation. 25)Provide projected caseloads per employee of Proposer assigned to City account. 26)Dcscribe Proposer's staffing plan to demonstrate that Proposer can be adequately staffed with trained personnel to handle the City's full caseload and have the capability to recruit such staff. 27)Include a statement that at east thirty (30) days prior to replacement of key personnel. Proposer will notify the Citv's Project Manager. in writing. that replacement employees will possess qualifications and experience equal to or greater than personnel being replaced. 28)Provide a detailed timetable identifying significant milestones for the smooth transition of the operations. Proposer shall identify the necessary support that shall be required from City staff during that transition. 29}Discuss in detail exactly how all services reflected in the Scope of Work will be accomplished. Include a complete approach Proposer will take to meet all responsibilities expected of Proposer by the City. Include any Page 61 of 66 605386.6 and all information regarding affiliated physicians. other medical personnel. locations to provide said services. and other related information regarding the provision of such services for the Citv. 30)Provide a description of the standard loss reports. as well as provide a sample and descriptions of any additional reports to he utilized. 31)Explain whether Proposer currently file state and excess insurance forms on behalf of Proposer's clients. and attach copies of the forms used. 32)Describe Proposer's methodology for evaluating and determining savings as expected tivithin this RFP. Include in detail the mechanisms Proposer would use to track whether proposed savings goal has been met, and methods to meet those goals. Indicate if Proposer is willing to accept the incentive or penalty as indicated, should savings not result. 33)If proposed. describe in detail Proposer's computerized on-line claims management system and software to be utilized during the performance of the scope of work reflected herein. Detail functionality, transition from current system, and if a cost is proposed. indicate in Proposer's Fee Proposal. 34)Detail anv procedures. equipment. and'or costs necessary to connect with the Citv's hardware and software. particularly related to conductivity with Risk and Finance, at the time of this RFP and should the Citv's system he modified or replaced during the Contract term. Should there be associated costs: indicate those costs. the reasons for the same. and who will pay those costs. Costs. if anv. shall be detailed in the Fee Proposal Section. 355)Estitttate Proposer's minimum start-up time from date of contract award to the date Proposer's network would be available to Risk Management, What specific requirements does the Proposer have to initiate set-up. and please explain any additional costs involved. 36)Explain anv options which the Proposer's system has that will permit the City to generate reports from. and to make direct inquiries into the Administrator's data base by on-line access. Proposer must clearly identify in its Proposal the costs of providing anv special conversion systems. license and software costs for accessing the system. and the part`(s) responsible for the payment of those costs. if any, (Costs shall be fully detailed in Fee Proposal Section). 37)Provide sample reports describing information such as type of accident. accident site. department. dale and time. cause of accident. injury. and part of body. Proposer shall describe in detail any safetv'loss control reports that are provided by the system. and shall submit a listing of the variety of claims reports available. and provide sample copies of formats that may be requested by the Citv.. 38) Provide the ntethodulogv and list of allocated or anticipated expenses to employ outside professionals such Page 62 of 66 605386.6 as surveillance. rehabilitation, experts. attorneys and otliers to assist in the investigation and adjustment of claims. 39)Provider shall provide its most recent audited certified business financial statements (or unaudited if audited is not available) as of a date not earlier than the end of the Proposer's preceding official tax accounting period. together with a statement in writing, signed by a duly authorized represerrtati‘ e, stating that die present financial condition is materially the same as that shown on the balance sheet and income statement submitted. or with an explanation for a material change in the financial condition. A copy of the most recent business income tax return will be accepted if certified financial statements are unavailable. 8. FEE PROPOSAL (Provide prices in U.S dollars) dfllSuhmit a guaranteed. all-inclusive annual fee as previously detailed in Section 2.17. This fee shall represent all claims. administrative. and loss data fees. and shall be guaranteed annual fees for the initial three (3) years, and the two option to renew years. as opposed to per claim time and expense or any other fee proposal. Proposals not containing an all-inclusive guaranteed annual fee For three (3) years, and the two option to renew years. for all specified services. will not be considered. The pursuit of subrogation and recovery from the Special Disability Fund is to be included in the Proposer's .Annual Fee. Clearly indicate anv charge not included in the proposed annual fee. -111,as the City is interested in a program which will generate savings over the current expenditures in the tt orkers' compensation area. the proposed fee structure should address the mechanism for achiet ing a minimum of net sax ings with an escalating incentive bonus for savings that exceed the minimum and a penalty for a shortfall in the desire net savings. d21Submit a separate quotes) for existing claims, and a separate quote(s) for prospective claims: pricing an a "per claim" bask for both existing claims and prospective claims. and a breakdox n of the cost between lost time vs. medical. In addition. provide a per claim cost vs. flat dollar cost. Include any other charges not included in pricing. Price Proposal must contain rates based on the "life of relationship basis," namely- for those prospective claims. and the City's inventory of open files. Provide separate quotes for the assumption of prior claims and for prospective claims commencing on the commencement date of the Contract. -13)lnclude any relevant services or products that will be provided to the Citv which are not priced in Proposer's Proposal. but which will entrance the acquisition process. •1.1 }Indicate the cost. if any. of assuming prior claims and data conversion and tti hether it is a one-time charge or an arntuaI charge. Include in Proposer's proposed price. costs for the provision of an enhanced system and for the conversion of any data necessary. 45)Provide a performance guarantee (may be negotiated with the City). d6)Provide any. and all additional costs, item by item. as identified by Proposer, in any other area not previously discussed herein. and detail what those additional costs. if applicable. would entail. Include Gvhether Proposer, or the City will be responsible for payment of those additional costs. Page 63 of 66 605386.6 Page 64 of 66 605386.6 5. Evaluation Criteria 5.1. CMIA Evaluation Criteria 5.1. EVALUATION CRITERIA Proposals wil] he reviewed to determine if the proposal is responsive to the submission requirements outlined in this Solicitation. A responsive proposal is one which follows the requirements of this Solicitation. includes all documentation. is submitted in the format outlined in this Solicitation. is of timely submission, and has the appropriate signatures as required. Failure to comply may result in the Proposal being deemed non -responsive. Proposals 4vill be evaluated by an Evaluation Committee (Committee) tvhich will evaluate and rank proposals based upon the following criteria and weight. The Committee will be comprised of appropriate Citv personnel and members of the Conmmunin-, as deemed necessary, with the appropriate experience and knowledge. The criteria are itemized with their respective weight for a maximum total of one -hundred (100) points. per Committee member, CRITERIA PERCENTAGE Technical Criteria and Points 1.Proposer's General Experience. Qualifications. and Past Performance 10 2. Proposer(s Category Specific Experience. Qualifications, and Past Performance 25 3. Proposer(s and Proposer(s Keti Persrnnel's Ability to Perform Required Services 1.t) 4. Proposer s'1lethodolugv and Overall Approach to Scope of ,I Price Criteria and Points 5. Fee Proposal Total: 100 Proposals will receive a separate score in each category of service (Part I or Part II). for which proposal is submitted. Proposals xyill be ranked %n a category by category basis. For example proposals submitted for Part I. IA ill only be ranked against other proposals submitted for Part I. 5.2Ora1 Presentations Upon completion of the technical criteria evaluation indicated above, rating and ranking. the Committee niay choose to conduct an oral presentation with the Proposer(s) which the Committee deems to warrant further consideration. Upon completion of the oral p'esentation(s), the Committee will re-evaluate, re -rate and re -rank the proposals remaining in consideration. based upon the written documents combined Evith the oral presentation.. 5.3Price Evaluation Page 65 of 66 605386.6 After the evaluation of the technical proposal. in light of the oral presentation(s) if necessary. the Committee wi11 evaluate the price proposals of those Proposers remaining in consideration. The price proposal will be evaluated subjectively in combination with the technical proposal, including an evaluation of how \vel1 it matches Proposers understanding of the City's needs described in this Solicitation, the Proposer's assumptions. and the value of the proposed services. The pricing evaluation is used as part of the evaluation process to determine the highest ranked Proposer, The City reserves the right to negotiate the final terms, conditions and pricing of the contract as may he in the hest interest of the City. Page 66 of 66 City of Miami, Florida Contract No. RFP 605386 EXHIBIT B SCOPE OF WORK THIRD PARTY CLAIMS ADMINISTRATION SERVICES 23 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 EXHIBIT B SCOPE OF SERVICES THIRD PARTY CLAIMS ADMINISTRATION SERVICES 1. OVERVIEW The City of Miami (City) is contracting with USIS, Inc. (TPA) to provide third party claims administration services for full time employees. The TPA shall provide the best quality claims services for Workers' compensation and liability claims and the most reliable and valid data possible, using the most useful and user-friendly claims system available. 2. BACKGROUND The City's Department of Risk Management (Risk) provides optimum service to employees and the public through a variety of interrelated health, safety and liability/loss control programs. The provision of these crucial prevention -oriented programs greatly enhances the working environment and serves as an incentive for employee recruitment, retention and satisfaction, while protecting the City's assets, employees and citizens. Its objectives include goals to eliminate, where possible, the threat of accident and other forms of liability, and where it is possible to eliminate the risk, to at the very least, reduce the possibility of an accident or risk occurring. Currently, the City has approximately 4,141 full time employees, which include Law Enforcement officers, fire personnel, solid waste collectors, parks personnel, and does not include seasonal employees. There are four (4) Labor Unions in the City: 1) Fraternal Order of Police (FOP); 2) American Federation of State County and Municipal Employees (AFSCME); 3) International Association of Fire Fighters (IAFF); and 4) American Federation of State, County and Municipal Employees 79 (AFSCME). Labor Unions represent eighty-five percent (85%) of the City's workforce. The City has created and maintains a Self -Insurance Program, which provides protection to the City for all property and casualty loss exposures, Workers' compensation claims, and provides group health benefits to active, and retired employees. In addition, Risk monitors the City's injured workers. Attention is focused in the areas of safety awareness, prevention, treatment of injured workers, rehabilitation, job placement, education, and communications with the employees and the departments. Guidelines for the treatment and care of injured employees are based on Chapter 440, Florida Statutes, which governs the State's requirements for the provision of Workers' Compensation benefits. However, as a result of bargaining agreements, additional benefits may be due depending on the bargaining unit. The TPA must become familiar with the existing labor agreements). The City's current Third Party Claims Administrator, utilizes Risx Facs claim processing system where all data is maintained, updated, and payments are issued. The adjudication of Workers' compensation medical bills and payments to the City's providers are performed through this system. Claims administration under this Contract, will include the takeover of current claims from the current Third Party Claims Administrator. The City uses in-house counsel on all litigated claims, 1 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 as necessary. Risk works closely with the Office of the City Attorney in a best -practices approach to manage litigated claims. The City is focused on the management of all claims, but has a laser focus on Workers' Compensation claims as they represent approximately eighty percent (80%) of the City's annual claims cost. A Return to Work program is being implemented as the City recognizes that prompt return to work aids in controlling claims costs. Individual department heads are directly responsible for claims occurring in their departments, as claims cost are allocated by department. Therefore, each department is highly motivated to support effective loss control, safety, and liability and Workers' compensation claim management. The City utilizes a 24/7 claims intake center. This type of system facilitates expedited handling, in order to process and close claims in the most efficient manner, for the benefit of the employees. Due to the City's Fire and Police operations, the City has devoted significant resources and has been and remains focused on managing presumption -related Workers' Compensation claims. The City has never lost a litigated presumption case, and the rate of presumption claim denial is eighty-five percent (85%). Close attention is also paid to closure rates and sound reserving practices. The partnership between Risk, the Office of the City Attorney, and outside counsel where needed, is unique and also quite effective. Case law is closely monitored and utilized to most effectively handle each situation. The City experiences approximately 756 claims per year on average. The ratio of medical only to loss time case is 40:60, i.e. forty percent (40%) medical only, and sixty percent (60%) Toss time. Of the approximate 4,141 full-time City employees, the following generally represents the location of their residences: REGION 1 REGION 2 COUNT (*) Broward FL 606 Collier FL 1 Lee FL 2 Leon FL _ 1 Martin FL 1 Miami -Dade FL 3509 Palm Beach FL 16 Seminole FL 1 St. Lucie FL 3 Bronx FL 1 3. CITY'S CLAIM EXPERIENCE Below is the City's Claims experience by years: Table No. 1 Policy Year GL Auto Bl/PD APD POL & ELL WC LEL Total 10/1/10 - 9/30/11 300 355 113 8 821 42 1639 10/1/11 - 9/30/12 410 421 84 2 748 39 1704 10/1/12 - 9/30/13 419 433 87 0 795 34 1768 10/1/13 - 9/30/14 412 355 109 3 680 26 1585 10/1/14 - 9/30/15 351 270 68 1 765 14 1469 2010 - 2014 (Average) 378 367 92 4 762 31 1633 2 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 Table No. 2 _ Policy Year GL Auto BI/PD APD POL & ELL WC LEL Total 10/1/10 - 9/30/11 $566,237 $659,129 $201,201 $618,715 $6,848,127 $2,490,514 $11,383,923 10/1/11 - 9/30/12 $712,157 $1,725,636 $147,499 $0 $6,215,610 $235,809 $9,036,711 10/1/12 - 9/30/13 $1,154,438 $707,976 $134,866 $0 $6,666,574 $512,050 $9,175,903 10/1/13 - 9/30/14 $664,786 $610,034 $218,272 $38,000 $6,435,261 $331,468 $8,297,820 10/1/14 - 9/30/15 $546,951 $1,052,972 $122,527 $1,000 $4,773,880 $101,680 $6,599,010 2010 - 2014 (Average) $728,914 $951,149 $164,873 $164,429 $6,187,890 $734,304 $8,898,673 Table No. 3 Policy Year Indemnity Medical Total 10/1/10 - 9/30/11 447 374 821 10/1/11 - 9/30/12 444 304 748 10/1/12 - 9/30/13 549 246 795 10/1/13 - 9/30/14 445 235 680 10/1/14 - 9/30/15 504 261 765 2010 - 2014 (Average) 478 284 762 4. WORKERS' COMPENSATION AND LIABILITY CLAIMS ADMINISTRATION A. THIRD PARTY CLAIMS ADMINISTRATION SERVICES The TPA shall be responsible for performing at a minimum, the following services: Establish reporting procedures which are compatible with the needs and organizational structure of the City as determined by Risk, Notice of injury report will be submitted by the City, to the TPA in paperless format (i.e. Internet or email). 2. Establish claims acknowledgement procedures to the City's satisfaction. 3. Provide all necessary forms and instructions for use. Such forms shall include appropriate first reports of injury with mailing address of claim administrator pre-printed thereon. These forms shall be provided electronically if requested. The cost of providing these forms shall be included within the proposed price. 4. Develop a cost effective staffing structure to include the number of adjusters, designated to appropriately handle the City's claims. The City reserves the right to negotiate and approve the final staffing plan and any cost associated with the changes. In addition, the 3 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 City will have the right to request removal of personnel assigned to the City's Agreement. Removal will take effect within thirty (30) days of written request by the City. 5. Provide a dedicated Claims Supervisor to be assigned exclusively to the City's contract. 6. Receive and examine on behalf of the City all reports of employee injury claims. 7. Establish and maintain complete files on each claim. 8. Accept or deny all reported claims for employees' injuries on behalf of the City in accordance with the applicable Workers' compensation law. The decision to controvert a claim must first be discussed with and approved by Risk and/or the Office of the City Attorney. 9. Conduct the required investigations deemed necessary, as it relates to Workers' Compensation, including scene investigations, and personal claimant contact on all lost time or Tight duty cases. Contact with claimants must be attempted within twenty-four (24) hours of the TPA's receipt of the claim. Field investigations and claimant contact must be performed by employees of the TPA. Independent adjusters shall not be used to provide this service. 10. Perform job site visits, to become familiar with exposures unique to the City. 11. Provide a report to the City's Project Manager, every thirty (30) days, indicating all employees who are losing time or working in a light duty or restricted capacity. 12. Submit a full summary to Risk and/or the Office of the City Attorney [where legal review or litigation has commenced], every ninety (90) days, on all claims of the following types; a. any claim in which an employee is not working full duty; b. total incurred claim value exceeding $2,000; c. potentially controverted cases; d. cardiovascular claims; and e. claims in which settlement (washout) is recommended. 13. Prepare, and maintain files necessary for legal defense of claims and/or other litigation (such as actions for subrogation), or other proceedings. 14. Pay in a timely fashion (within 30 days) all claims and expenses from the loss fund account established by the City, which will be maintained by the TPA. Fees and civil penalties for late payments are to be paid by the TPA unless caused due to late reporting by the City. 15. Pursue all possibilities of subrogation from third parties and recovery from Special Disability Trust Fund [SDTF] and report such activities in the time, manner and method, as deemed necessary by the City and/or the Office of the City Attorney [where legal review or litigation has commenced]. 16. While the Office of the City Attorney will designate the attorney(s) that provide the defense of claims, as well as litigation strategy, the TPA shall provide the City's defense attorney(s) a complete copy of the file in question and monitor and actively participate in the activities of the City's defense attorney(s). 4 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 17. Attend Workers' Compensation hearings, mediations, and pension board hearings involving work -related injuries, as requested by the City. 18. Make written recommendations to Risk regarding any procedures or condition that should be examined to prevent future claims, which are revealed during the TPA's investigation of a claim. 19. Contact Risk by telephone on all claims where the compensability or the relatedness of the medical expenses on the claim is in question, and conduct such investigation, or such additional investigation, as deemed necessary by Risk or the Office of the City Attorney. 20. Contact employees who experience loss time at least every two (2) weeks, for the duration of temporary total disability payments. When an employee is represented, the Office of the City Attorney shall be contacted when appropriate. If City's attorney contact is appropriate, that contact should be on a sixty (60)-day basis. 21. Report all lost time and/or questionable cases to the Index Bureau. All lost time shall be re -indexed every six (6) months. 22. Establish initial reserves within ten (10) days of the first report of the claims being reported. All files must be reserved adequately to extend through the expected life of the claim. Although all the necessary facts may not be available at the onset of a claim, reserves should be adjusted when medical information or investigation indicates the existing reserve is inadequate or overstated. The following factors shall be considered when establishing reserve: a. the injury; b. the investigation; c. medical treatment and costs; d. projected temporary total disability benefits to be paid; e. projected permanent partial disability and impairment benefits; and f. potential use of outside experts (rehabilitation service TPAs, attorneys, etc.).; 23. Review the adequacy of reserves at least every three (3) months, and document the file accordingly. 24. Present in writing all settlements to Risk and the Office of the City Attorney for approval, regardless of the amount. The injured employee will not be contacted regarding settlement until approval of proposed settlement is obtained from Risk and/or the Office of the City Attorney. 25. Follow all Division of Workers' Compensation (DWC) rules when compensation, medical, or other benefits are being controverted. The case must be discussed with Risk before the claim is denied and/or the Office of the City Attorney, where legal review or litigation has commenced. 26. Obtain medical reports as necessary, in such manner as approved by Risk and the Office of the City Attorney to determine the status of the employee's injury and to verify disability. 27. Report all claims involving a fatality to Risk and the Office of the City Attorney 5 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 immediately. Payments on these and all other Workers' Compensation matters shall be made in accordance with the Florida Workers' Compensation law and or governing contractual agreements. Periodic activity/status checks shall be performed to ensure that dependents who receive survivor's benefits are still eligible to receive them, and notify Risk regarding those activity checks. The Office of the City Attorney shall be notified on litigated cases, or cases where legal review has commenced. 28. Prepare and file with the appropriate State agency all applications required for the City's qualification as a self -insurer. 29. Prepare, maintain and file all records and reports as may be required by legal authorities (State, local and Federal). 30. Prepare, maintain and file statistical information required by Workers' Compensation Rating Bureaus, including all required data necessary for the promulgation of experience modifications. 31. Review for accuracy and approve the appropriateness of State assessments, prior to the due date of the assessment. 32. Establish an interest bearing bank account to make claim, indemnity, expense, and legal payments on checks drawn from this account. It is understood that all funds in this account are City funds and shall be returned upon the City's request or the termination of the Agreement. Regarding this account, the TPA shall: a. Reconcile on a monthly basis, the account and provide all monthly bank statements to the City, along with a request for a deposit from the City to maintain the balance needed in the account, as determined by the City. b. Ensure that any interest earned on the account be applied to reducing the subsequent monthly deposit by the City. c. Submit a monthly statement including the following: i. balance at inception; ii. total disbursements by date and claimant; iii. balance at closing; and iv. amount of deposit required. d. List all checks along with all statements supplied to the City. 33. Provide to the City, bank account transactions and other information, additionally or in lieu of, on-line or via other means for "real-time" access by the City 34. Ensure that all adjusters handling City's cases are kept abreast of the Workers' Compensation Statutes, DWC rules, and applicable laws. 35. Ensure that the minimum standards of performance of TPA's personnel conform to the Florida statutes and administrative rules or future changes, if any. 36, Ensure all DWC filings, including compromise settlement agreement payments, are made in a correct and timely manner. 37. Provide notification of suit being filed against the City for any reason, to the Office of the City Attorney, and Risk with twenty-four (24) hours of suit being filed. 6 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 38. Aggressively pursue recoveries to the satisfaction of the City, including recoveries based on subrogation and special disability trust fund (SDTF). As regards to subrogation recoveries involving injuries to the claimant caused by third parties, the TPA acknowledges that such recoveries may include reductions in future Workers' Compensation benefits as provided by Florida Workers' Compensation Law based on formulas provided in Chapter 440 and case law interpreting such law, and shall be responsible for documenting and collecting such recoveries from health care TPAs and the claimant as mutually agreed upon by the claimant and the City upon the claimant's recovery from the third party[iesj. 39. Pursue, track, and provide quarterly reports on all SDTF, as well as subrogation recoveries in such manner as deemed necessary by the City Attorney or designee. 40. Be responsible for data integrity. This includes properly inputting all cause codes, location codes, loss description, and other claims information. If a data conversion is involved the TPA must attest to the integrity of the combined data. 41. Obtain the approval of Risk and/or the Office of the City Attorney [where legal review or litigation have commenced] to hire experts in connection with claims against the City. Experts include, but are not limited to, accident reconstruction engineers and experts, medical and rehabilitation vendors and private investigators. 42. Provide the means for the City to perform claims status inquiries. 43. Provide training for supervisory personnel of the City for those individuals responsible for Workers' Compensation activities. 44. Comply with all applicable laws and regulations regarding the administration of Workers' Compensation benefits. 45. Provide and integrate successfully, an online claims management system that interfaces with all other existing systems to be utilized in the performance of this scope of work. 46. Work closely with the "safety team" to enhance the Safety Program to reduce claims on an annual basis. 47. Assist in the implementation of the City's Return to Work Program. 48. Provide to the City a performance guarantee, to be negotiated with the City. B. HEARINGS CONFERENCES/TRIALS The TPA shall ensure that the following requirements for hearing conferences/trials are followed: 1. Pre -hearing or pre-trial reports shall be submitted by the TPA to the Office of the City Attorney at least two weeks prior to the hearing conference/trial or whenever requested by the Office of the City Attorney. Periodic up -dates on ongoing litigation, as well as provision and inspection of file materials kept by the TPA, by the Office of the City 7 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 Attorney or designee, will be scheduled by the Office of the City Attorney as needed. 2. Reports must contain all information pertinent to the file including transcribed statements and depositions. 3. The TPA shall obtain settlement authority from the City prior to any hearing conference/trial. 4. Any recommendations made by the Office of the City Attorney, pertaining to the file should be carried out or referred to the TPA. C. REPORTING REQUIREMENTS The TPA Shall: Make an immediate report to the Risk Director or designee on: a. fatalities; and b. catastrophic occurrences with potential exposure $50,000 for more. 2. Submit "full captioned reports" within thirty (30) days of setting reserves at or above $25,000. The content of the "full captioned reports" shall include, not limited to, the following; a. coverage items; b. employee's background; c. dependents; d. employee's job description; e. occurrence; f. injury; g. medical management; h. wage and compensation rates; i. dates and periods of disability; j. rehabilitation; k. other employee benefits; 1. litigation; m. index/state filings; n. subrogation; o. remarks and/or recommended actions; and p. strategy for resolution. 3. Submit "full -captioned report" on all files in litigation. Provide copies of all pleadings along with the report. 4. Ensure that follow-up reports are received within ninety (90) days of the "full -captioned report". 5. Submit monthly experience/statistical reports which shall include, but are not limited to, a summary of experience by department stating cause of accident, frequency and cost. Open and closed claims shall include specific information on the accident date, claimant's name, cause of accident, injury type, amount paid and reserved, and state if the claim is open or has been finalized. These reports must be delivered by the 10th of each month, and must provide summary information by department, by participant, and 8 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 by total program. 6. Become familiar with existing labor agreements, and report all activities pursuant to those agreement to the Risk Director or designee as requested, at least on a monthly basis, or as required by the City. 7. Provide the necessary reports and/or data to satisfy Florida's self-insurance requirements. Required forms shall be completed by the TPA and sent to the City for review and appropriate signatures. Required self-insurance reports shall be provided on a timely basis so that the City will have sufficient time to review and execute the documents before the due date. 8. Provide any report(s) requested by the Risk Director. TPA's system shall have the ability to run ad hoc queries. D. "BAD FAITH" PROCEDURES The following procedures shall be followed to avoid potential actions for breach of good faith and fair dealings: 1. Termination of weekly benefits: Weekly benefits may be terminated only upon written or verbal notification by the treating physician or the City when employee returns to work. If return to work information is obtained verbally, the TPA must follow up in writing with a request for written verification. If treating physician releases the employee to modified work, the TPA must promptly determine if modified work is available and offered to the employee before benefits are terminated. 2. Controverting claims: The TPA shall contact the City prior to formally denying a claim. This will not be necessary when controverting the reasonableness and necessity of medical bills. 3. Judgments/settlements: Judgments/settlements should release potential future "bad faith" actions. 4. Penalties and fines: Penalties and fines assessed by the DWC shall be paid by the TPA if such fines and penalties result from negligent performance of its duties E. PERFORMANCE STANDARDS: WORKERS' COMPENSATION The City will perform annual performance standards audit based on the following: 1. TPA will document all new claim information received from the City, and this information will be available within one (1) hour of receipt, if received during normal business hours, or within the first business hour of the next business day, if received less than one (1) hour before the close of a business day. File shall include First Report of Injury form. 2. A minimum of "three (3) attempts" by the TPA, to contact the appropriate parties, will be considered a "contact", if followed with the appropriate correspondence within the measurement period. For a Workers' compensation claim, three (3) point contacts will be required (claimant, supervisor and treating TPA). For a liability claim, two (2) point contacts will be required (claimant and reporting City Supervisor, if applicable). 9 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 3. TPA shall document, and provide Risk written notice of, subrogation, contribution, and/or coordination of benefits recovery potential, as they develop. If a TPA decides not to pursue any such recovery, TPA must give written notice to Risk of its decision within fourteen (14) days of claim receipt. 4. For Workers' Compensation claims, within fourteen (14) days of receipt of a claim, the claims adjuster will perform a three point contact, send appropriate notification packages to the claimant, as required by Chapter 440, review the claimant's pre -employment physical, and document the TPA's analysis of the compensability of the claim. For liability claims, within fourteen (14) days of receipt of the claim, the TPA will document appropriate specific directions for the investigation and handling of the case. 5. Within 72 hours of receipt of the claim, initial reserves for the file will be set, thereafter, reserves will be reviewed on an on -going basis, as follows: a. 30 days from 72 hour review; b. 30 days from 30 day review; c. 60 days from last 60 day review; and d. Every 6 months thereafter. Increase or decrease of reserves by $10,000 or more, requires notification to Risk. Subsequent to notification, Risk reserves the right to discuss the case and request a reconsideration of the reserve of the TPA. 6. TPA shall "address" litigation within two (2) days of receipt of litigation notification, or less than two (2) days as requested by the Office of the City Attorney if a shorter deadline is deemed legally necessary by the Office of the City Attorney. This will mean notice of to Risk, and referral to the Office of the City Attorney for assignment, within two (2) days, or perhaps less than two (2) days, if requested by the Office of the City Attorney. 7. Required status reports shall be provided to the Risk Management Administrator or designee. 8. Settlement evaluation shall be provided to the Office of the City Attorney and Risk 30 days prior to mediation. The TPA shall evaluate, or cause, a third party expert, as deemed necessary, to evaluate the need for a Medicare Set Aside [MSA], and this shall be determined and documented in all settlement evaluations. File/System documentation shall include documentation of return phone calls to injured worker and the City within twenty-four (24) hours or the next business day. 10. File/System documentation shall include documentation that referral appointment was made for a claimant to a network TPA specialist (i.e.; Diagnostic testing, Neurologist, Orthopedic) so that claimant was seen by specialist within two (2) weeks of the date of receipt of the referral from the primary treating physician, unless it is clearly documented that, despite TPA's best efforts, no specialist was available to see claimant within the requisite two weeks period. F. LIABILITY CLAIMS ADMINISTRATION 10 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 Upon receipt of all liability claims, the TPA, on behalf of the City, shall perform, at minimum, the following services: 1. Review all first notices of claim reports received from the City, which will consist of loss reports, claim letters and suits, or claims that are phoned, mailed, or faxed in by the City, prior to an assignment to the TPA's adjuster, approved by the City. Designate the necessary number of outside field adjusters to handle all City claims and also designate an alternate in their absence. The designation of these persons is subject to the approval of the City. 3. Conduct a thorough and complete investigation of the accident, according to the requirements of the City. Investigations shall include, but not limited to, the following: a) Contact the claimant or the claimant's attorney within 24 hours of the time the accident report is received by the TPA. In the case of underrepresented claimants, personal contact is required the same day the claim is received. All claim files must contain adjuster's logs documenting all contact and activity. b) Obtain recorded statements from the claimant, witnesses, and the City personnel. Personal contact of all underrepresented claimants by outside adjusters is required. c) Complete a timely scene investigation consisting of photos and diagrams. This is required within two (2) days of receipt of any serious AL or GL claim assignment. d) Obtain the police and/or fire rescue report. e) Obtain and review all medical reports and bills submitted by the claimant or their attorney. f) Obtain and review all estimates and appraisals for property damage claims. g) Establish appropriate reserves on all claims, and revise the reserves as needed. h) Submit a report to the City within 30 days of receipt of the claim, summarizing: I. Date/time/location of loss; II. Claimant information; III. Description of accident; IV. Injuries or damages; V. Witnesses' version; VI. Liability analysis; and VII. Evaluation of claim (i.e. amount of recommended settlement, denial, reserves, attorney demand). If a settlement recommendation cannot be made at this initial report (due to lack of information), indicate same and reason. However, remainder of investigation should be completed. 4. Submit a status report every ninety (90) days thereafter to the City until the claim is resolved. The City prefers the above reporting requirements to be accomplished via the on-line claims management system for "real-time" viewing. 5. The TPA has the authority to settle cases on behalf of the City up to $3,000 per claim for property damage and $3,000 for bodily injury. For any settlement in excess of the above, the TPA must receive authorization from the City. The request for this authorization must be presented in writing, including the 11 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 adjusters evaluation and recommendation in a format required by the City. After authorization is granted, the TPA will settle the claim and obtain the appropriate release. Additionally the TPA shall provide a quarterly report to the City on all settlements above and below $10,000. 6. The City will assign an attorney for the legal defense of any claims that goes into suit. The TPA will assist the City's attorneys with any additional investigations, as deemed necessary by the City or its attorneys. The TPA will continue to monitor the file in litigation. TPA will provide a monthly report of all litigated claims in the format specified by the City. 7. Upon notification from the City, the TPA shall forward a copy of the file in suit, to the City's attorney with a transcription of all settlements. 8. The TPA shall attend all mediations and trials as requested by the City. With respect to claims with impending trial dates, the designated TPA's Supervisor or designee, shall take an active and aggressive role in settlement or preparation for trial. 9. The TPA, after approval of the City, can assign the necessary auto appraiser for property damage claims. These expenses shall be paid as an allocated expense by the TPA from the City's loss fund. 10. Any other claim expense must be approved by the City prior to being incurred. However, expenses for normal claim activities, such as photographs, tapes, supplies, postage, etc., are the responsibility of the TPA. 11. The TPA shall meet quarterly (or more frequently if required by the City) with the City Manager, and/or authorized representative, to review all large exposure (over $25,000) incurred cases and report on their status. 12. All claim files are at all times the property of the City. The City has the right to inspect any and all files whenever the City deems necessary. If the Agreement is terminated, the City will receive all original claim files. 13. The TPA shall make recommendations to the City as to actions that can be taken to prevent future claims. These loss prevention recommendations can be included in the status report. 14. All work must be performed by the employees of the TPA. The use of any contracted or independent adjuster is prohibited, unless prior approval is granted by the City. 15. The TPA shall reimburse the City for payments made in error that are non -recoverable from third parties by the TPA. 16. The TPA shall provide to the City a performance guarantee, to be negotiated with the City in the provision of Managed Care/Medical Bill Review, as cited herein, to improve its effectiveness and efficiency while maximizing City resources. 17. The TPA shall continue to monitor the file in litigation, and obtain updates from the City Attorney's office, in an effort to prepare reports to the City's excess carriers as required. 12 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 G. PERFORMANCE STANDARDS: LIABILITY The City performs annual performance standards audit based on the following: 1. TPA shall document all new claim information received from the City, and this information will be available electronically within one (1) hour of receipt, if received during normal business hours, or within the first business hour of the next business day, if received less than one (1) hour before the close of a business day. File will include First Report of injury Form. 2. A minimum of "three (3) attempts" by the TPA's claims adjuster to contact the appropriate parties will be considered a "contact", if followed up with appropriate correspondence within the measurement period. 3. TPA shall document, and give City's Project Manager, written notice of, subrogation, contribution, and/or coordination of benefits recovery potential. If TPA decides not to pursue any such recovery, it must give written notice to Risk of its decision within fourteen (14) days of claim receipt. 4. For liability claims, within fourteen (14) days of receipt of the claim, the TPA shall document appropriate specific direction for the investigation and handling of the case. Within 72 hours of receipt of the claim, initial reserves for the file shall be set, thereafter, reserves will be reviewed on an on -going basis, as follows: a. 30 days from 72 hour review; b. 30 days from 30 day review; c. 60 days from last 60 day review; and d. Every 6 months thereafter. 6. TPA shall "address" litigation within two (2) days of receipt of litigation notification. This will mean notice to Risk, and referral to the Office of the City Attorney for assignment, within two (2) days. 7. Submit required status reports as outlined by the Risk Management Director or designee. The City desires prompt, personal contact of all claimants. Evaluations of each claim shall be made as soon as the necessary information is received by the TPA. The investigation and evaluation of all claims should be completed prior to suit being filed, since F.S. 768.28 (sovereign immunity statute) requires the claimant provide six months' notice of intention to file suit. The TPA must have up-to-date policy and procedure manual(s) on hand in the work place. These manual(s) shall describe and discuss the day to day procedures for adjusting files, and shall be kept in accordance with statutory requirements. The TPA shall provide adequate toll -free telephone access to the claims office. The TPA shall provide claims personnel, who shall be available on a 7 day, 24 hour basis, for investigating claims, and must have an maintain an 800 or toll -free number for emergency service. The TPA shall provide its own office space or facility(s) for its 13 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 adjuster or staff of adjusters. The TPA must agree to be responsible to manage liability claims to be opened within the year(s) following contract execution, along with the current inventory of open files. The TPA shall provide claims administration on a "life of relationship basis." H. STAFFING, QUALITY CONTROL, AND SUPERVISION The TPA shall render high -quality claims management and adjusting services throughout the term of the Agreement. The City relied upon the TPA's proposal to determine that the TPA's personnel shall have, as a minimum, the following levels of experience and licensing: 1. Supervisor or Supervising Adjuster shall have five (5) to seven (7) years of related experience; 2. Adjusters shall have three (3) years of experience; 3. Medical -only processor(s) shall have one (1) year of experience, and must hold a current Florida Adjuster License; 4. The TPA's files must reflect evidence of supervisory direction and involvement at every level. All files must be kept current. File review should be performed on 30, 60, 90 or 120 day cycles, as appropriate. Periodic review by the handling adjuster and all supervisors should be reflected in the file. 5. TPA's Supervisors shall receive all First Reports of injury and outline investigative needs for the adjusters to follow through. Supervisors should assign the most difficult files to the most qualified adjuster. 6. TPA shall perform monthly claims review with Risk, to include the adjusters, and City Attorney. 7. It is the City's claims management philosophy that the proper and most cost-effective method to handle claims and thereby reduce and control the City's self -insured loss payments, is to ensure the TPA hires and retains the appropriately qualified professionals to handle the City's claims. Additionally, the adequate number of adjusters and a manageable caseload enables qualified adjusters to perform the required services. The City therefore requires that the TPA agree to staffing, qualifications, and caseload criteria established by the City. 8. The City reserves the right to the final prior approval of the hiring and/or assignment of the claims manager, supervisors, and adjusters that will handle the City's claims. 9. The TPA agrees to add staff as necessary, to maintain these maximum pending caseload levels. 10. Claims personnel must be employees of the TPA. The use of independent adjusters, subcontractors, or temporary adjusters will not be acceptable without prior approval of the City. TPA's Adjuster trainees are not acceptable for handling of the City's claims. All TPA's claims professionals must possess a current Florida adjuster's license. 14 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 11. In addition to those services previously discussed, the TPA will additionally perform the following related services: a. State required filings; b. Loss fund management; c. Computer generated loss runs and other management reports, preferably on-line; and d. Provide an annual SAS 70 audit report. 12. The TPA shall have the ability to provide full customer service to English, Spanish, and Haitian -Creole speaking individuals, when needed. 13. The TPA shall make available to the City an individual with management authority to meet with the Risk Director, or the designee, upon reasonable notice. This individual shall have the authority to make "agreed to changes." The TPA's employees shall meet with Risk on a quarterly or as -needed basis to discuss claims of interest. Sufficient advance notice will be given by Risk to allow adequate preparation and data collection. The TPA's personnel, including the adjuster or Supervisor, must also be available to attend mediation conferences, as necessary. 14. The City will provide office space in its Risk Department to house two (2) claim adjusters. At the City's discretion, the City may increase or decrease the number of stations provided. I. FEE BILLING The City will pay fees monthly in arrears for claim files established in the previous month. A summary invoice should be broken down by line of coverage and tie to month -end figures as shown on the loss runs. 15 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 EXHIBIT C PROPOSAL AND COMPENSATION 24 Third Party Claims Administration Services Request For Proposals.. PART I: WORKERS' COMPENSATION CLAIMS AND LIABILITY CLAIMS ADMINISTRATION RFP #605386 Opening November 30th, 2016 at 2: 00 p.m. EST LRV1Cf K[vuhu 1 1 i I CONTRACT USIS, Inc. Contact Person: Ron Warble, Executive Vice President Firm's Liaison: Terri Snapp 5728 Major Blvd_, Suite 450 Orlando, Florida 32819 Phone: 800.444.9098 ext. 6503 Fax: 407.949.3140 Federal Employer Identification Number: 204580645 TABLE OF CONTENTS Part I — Workers' Compensation Claims and Liability Claims Administration ITEM PAGE/ATTACHMENTS Executive Summary Pages 1-2 • Insurance Certificate Page 3 Certification Statement Page 4 Certifications Pages 5-6 Proposer's General Experience, Past Performance, and Exceptions Pages 7-9 • Brown & Brown, Inc. Annual Report Attachment 1 Proposer's Category Specific Experience, Past Performance Pages 10-27 • Cardiac -Exposure Protocol Attachment 2 • Innovative Programs Attachment 3 • USISiNet and AmeriSysiNet Attachment 4 • USIS Sample Reports Attachment 5 • Reference Letters Attachment 6 • Resumes/Licenses, Job Descriptions Attachment 7 Proposer's Ability to Perform Required Services ...... Pages 28-30 Proposed Overall Approach to Performing the Services Pages 31-47 • SSAE 16 excerpt Attachment 8 • Transition Plan Attachment 9 • Implementation Check List Attachment 10 Fee Proposal Pages 48-49 Supplemental Proposer Questionnaire Attachment A Pages 50-166 • myMatrixx Attachment 11 • Risk and Insurance, Revitalizing the Program - Teddy Award Winner Attachment 12 • Claims Handling Practices and Liability Claim Procedure Manual Attachment 13 Claims Administration Price Proposal Schedule Attachment B1 �� USIS November 28, 2016 Yadissa A. Calderon, CPPB Procurement Contracting Manager City of Miami Procurement Department 444 SW 2 Ave, 6th Floor Miami, Florida 33130 Reference: Third Party Claims Administration — RFP #605386 Executive Summary Dear Ms. Calderon: PO Box 616648 Orlando, Florida 32861 800A44.9098 ext. 6503 Ron Warble USIS is interested in and excited about the opportunity of providing Third Party Administrator services to and on behalf of the City of Miami. We believe our experience dealing with public entities for the core services requested makes USIS an excellent potential partner for the City and its injured employees. We are prepared to begin working with you and your team to design a workers' compensation program plan that meets the unique needs and requests of the City. We recognize that each employer/insured is unique in systems and philosophies and we stand ready to customize our services to best complement the current program. We also recognize that these services and programs are dynamic and require ongoing assessment, evaluation and modifications to remain current with statute and rule as well as technology, medical advances and other efficiency -related information and techniques. As an organization we understand and are ready to implement all services that are necessary to meet all of the components identified and required as a part of this RFP. Having provided services to you previously as your Managed Care Partner from 2003 — 2011: AmeriSys, USIS' Medical Management division, is familiar with your various Agencies and Departments. AmeriSys worked closely with the City's Fire and Police with excellent satisfaction expressed. We are familiar with the number of Presumption claims the City historically incurred which represents a significant part of your overall exposure. We have developed unique Case Management programs for first responders covered under the Presumption Bill. We believe our BADGE program will assist the City in minimizing exposure to future costs of expensive cardiac events. • Our flexibility allows us to deliver a complete claims administration program that will be tailored to the unique needs of the City of Miami. • There is a commitment in our organization to security. Our software system as well as our firewalls protect both medical provider information and claimant protected health information in accordance with HIPAA standards (even though Workers' Compensation claims are not subject to H1PPA compliance). Our organization is subject to Sarbanes-Oxley and as a result we have developed highly secured systems and protocols. Our systems are frequently audited and reviewed, both internally and by third party reviewers including annual SSAE16 (formerly SAS-70) audits. Though this process seems expensive and burdensome at times, we believe that it provides our customer partners confidence that we will handle their resources with great care. • Innovation and efficiencies are critical to any successful program and as a result USIS encourages new ideas from employees and sets improvement goals annually. Our primary office of operation will be in the Orlando area which has a rich labor pool allowing us to recruit and maintain exemplary staffing for this program. Ron Warble, Executive Vice President Authorized to legally bind and authorized to make representations in regard to this procurement on behalf of USIS, Inc. USIS Inc. PO Box 616648 Orlando, FL 32861 mn.w'arble(a usis-tpa.com 407.949.3 50 We are able to provide all Core services internally, partnering with PGCS to provide certain specialty liability claims services, in accordance with the requirements of the RFP. USIS and PGCS are both wholly owned organizations of Brown & Brown, Inc., operating within the same division (Services) that specializes in the services requested under this RFP. We understand that the services we would be providing on your behalf are for your employees, your colleagues, your citizens and very often friends. We recognize that we must treat each injured employee with respect and genuine interest in his/her well-being and recovery. We do this while also making sure that we protect the financial and human resources that are paid for by the hard earned tax dollars of your City's citizens. We have a stewardship obligation and commitment to the injured employees and the City of Miami. We look forward to oral presentations where we can provide additional information and/or answer any questions about how our organization can assist you in providing a superior workers' compensation claims program for City of Miami. Respectfully, Ron Warble Executive Vice President USIS, Inc. Paz .r-"At BROWN-3 OP ID: JW A�C�RLa CERTIFICATE OF LIABILITY INSURANCE °A;1; e,7s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FOLDER. THIS CERTIFICATE DOES NOT AFFIRMA€IVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_ THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERISI, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER_ IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed- It SUBROGATION IS WAIVED. subject to Hie terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in IieU of such en dorsementisj PRCDUCER "*.TACT LAURIE KOHLER 416095 NAME Brown & Brown of Florida. Inc. ffi Daytona Beach Office PHONE c N. ant. 386-239-7242 I IA c, Itor. 386-323-9159 P.O.Box 5 wreaa Ikohlel bbdaytona.com Daytona Beach, FL 32115-2412 frI Decker Youngman MSIURERISI AFFORDING COVERAGE NAM* INSURER A . Travelers Prop & Cas of Amer 25674 NSUREo BROWN & BROWN INC ETAL sex URER 3- Continental Casualty Co 20443 P0BOX 2412 DAYTONA BEACH, FL 32115 INWWRER0:Travelers Indemnity 25658 INSURER 0:XL. Specialty Ins Inc. 37885 INac/RER E INSURER E COVERAGES CERTIFICATE NUMBER_ REVISION NUMBER: THS IS TO CEPTEI THAT THE POLICIES C F INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TEE POIJCY PERICO INDICATED NOTWf-HSTANDING ANY RECUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH i CERTIFICATE MAY BE ISSUED OR MAY FTAIN, IHE INSURANCE AFECRDED BY THE POLICIES DESCRIBED HERE -A! IS SIBJECT TO ALL THE TERSE, EXCLU :/EN5 AND GCNDITICAG OF SUCH POLICIES. OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS MISS LTA TYPE 4?F INSURANCE IDOL MD SUER IWO POLICY NUMBER POLICY EFF faOS.00,YYrn POLICY ECP LIMITS A X COMMERCIAL G@IERAL LL4eILMTY ,1MM'ODITf5YI EACH CCCIARENCE i 1,000,000 1 :lA±u5•M cE I ^ 1 XCLR. TC2JGL5A95271387415 01101f2016 01l01F2017 a 3Ev Ea xcurrere,1 i 1,000,000 _ UEo EXP ....fly wu o TS.... s 5,000 ,ERECNNA,SAC., NjURY 1 1,000,000 GENE. AGG EsS-E _MAT -EC FE 5ENERAL AGGREGATE_ S 2,000,000 POL,C'r ;.Eg LOC FACCUCT3 •C.UF 5 AGO I 2,000,000 GT-IFr AUTOMOBILE u5BUTY :C. BibED SINGLE _MI- Ea seribreti i 1,600,000 ' A ANY,I..T[) TC2JCAPS52TB86216 Of/01/2016 01101t2017 E°OILY IN -AIRY; FerrermFi i — N_L D!NNED AITroa — 3C, ULED Wren 3'.3DILY LN,ORY Pe, arc, i X MI i A ae X yCA{+hFED .AAT23 .R:PERTY DASIN3E Per a-_ [M.1 i i I( UMBRELLA LAB rX ,SCCLR EACH 7C _RRENCE S 5,000,000 5 EXCESS LIAR MAI.i0-41ADE 601164429 01l01,2016 0110tt2017 ,uraFG,,,m s 5,000,000 DED I I R€TEN^CI: S i WORKERS COMPENSATION X 13'i4T11 c I I cRTH- A AND ESIPLOYERS' Llt.$ILIT Y: M .w: Fa:Amiwraa, Ns=e,=ct---.E N A TC2JUB9517B58016 0110112016 ONNO1rz017 _ _ EAcr-,corer i 1,000,000 c tAi.� ally ��`d+� `xC Lcr . TRKU1 9518876116 0110112016 otiou2o17 E _ :,,,,a,z,e . Lk EmgLoyEES 1,000,000 ` /es. demove uTdel 5E2CS:.:..CA :IF JPECATMN3 Se!3A -.-.51 ELE-- RDUC. LIMIT 1 1,000,000 D INS AGENTS E&O ELU142465-16 01/01/2016 01101/2017 LIMIT 5,000,000 AGGREGATE 25,000.000 DESCRIPTION OF OPERATIONS ' LOCATIONS VEHICLES [AWARD tat. Adatem Mal Pefabflt1 1101w74O1 , may be afts5Aea 3 mare spade Is requMre91 NAMED INSURED: USIS, INC. RFP NUMBER 605386 WORKERS' COMPENSATION CLAIMS AND LIABILITY CLAIMS ADMINISTRATION CERT1FK:ATE HOLDER CANCELLATION CITYM-1 CITY OF MIAMI PROCUREMENT DEPARTMENT. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS 444 N.W. 2ND AVE. 6TH FLOOR MIAMI. FL 33130 AUTHORIZED REPRESEarTAIvE I -7/ 'E' 1988-2014 ACORD CORPORATION_ All rights reserved- ACORD 25 /2014/01) The ACORD name and logo are registered marks of ACORD Page 3 Certification Statement Please quote on this form. if applicable, net prices for the item(s) listed. Return signed original and retain a copy for your files. Prices should include all costs, including transportation to destination. The City reserves the right to accept or reject all or any part of this submission. Prices should be limn for a minimum of 180 days following the time set for closing of the submissions. In the event of errors in extension of totals, the unit prices shall govern in determining the quoted prices. We (I) certify that we have read your solicitation, completed the necessary documents, and propose to furnish and deliver, F.O.B. DESTINATION, the items or services specified herein. The undersigned hereby certifies that neither the contractual party nor any of its principal owners or personnel have been convicted of any of the violations, or debarred or suspended as set in section 18-107 or Ordinance No. 12271. All exceptions to this subtnission have been documented in the section below (refer to paragraph and section). USIS has no exceptions to this .suhnrrsslon. We (I) certify that any and all information contained in this submission is true; and we (I) further certify that this submission is made without prior understanding, agreement, or connection with any corporation, finn, or person submitting a submission for the same materials, supplies, equipment, or service, and is in all respects fair and without collusion or fraud. We (I) agree to abide by all terns and conditions of this solicitation and certify that I am authorized to sign this submission for the submitter. Please print the following and sign your name: PROPOSER NAME: USIS, Inc. ADDRESS: 5728 Major Blvd., Suite 450 PHONE: 800.444.9098 FAX: 407.949.3140 EMAIL: ron.warble a usis-tpa.com CELL(Optional): 407.810.2684 SIGNED BY: TITLE: Executive Vice President DATE: November 28, 2016 FAILURE TO COMPLETE. SIGN. AND RETURN THIS FORM SHALL DISQUALIFY THIS RESPONSE. page 4 Certifications Legal Name of Finn: USIS, Inc. FEIN No.: 204580645 Entity Type: Partnership, Sole Proprietorship, Corporation, etc. - Corporation USIS, Inc. is a wholly owned subsidiary of Brown & Brown, Inc. Year Established: Established in 1982. Business Address: 5728 Major Blvd.. Suite 450 City, State, and Zip Code: Orlando, Florida 32819 Telephone Number: 800.444.9098 Fax Number: 407.949.3140 E-mail Address: ron.warble(ciusis-tpa.com Office Location: City of Miami, Miami -Dade County, or Other Orlando, Florida Business Tax Receipt/Occupational License Number: Orlando #500-0520375 — Case Number BUS0000795-016 Business Tax Receipt/Occupational License [ssuine Agency: City of Oviedo, Cit Scott Randolph, tax Collector local Business Tax Receipt Orange County, Flcdde .:.;..;..-o:.,o.,r.0•Mar, a�N EXPIRES 2362017 11C0041393n • Naftiiil.l0 1.3. TOTAL fAA NON OPNV tlgrAw ND ae SAL caR N3) ✓ pm %PASO IRAQ OM A • ONNICIO UPI r.o - a 193• ^mono T..yaa. to m....r ., w. s. fx..a. RIC k .Om are y of Orlando, Orange County le (_in IJFOU..kNix> Business Tax Receipt/Occupational License Expiration Date: 9/30/2017 Page 5 Will Subcontractor or Sub consultant (s) be used? Sub consultant shall mean the same thing as a Subcontractor in these documents. (Yes or No) (if yes for what and what percentage of such work) USIS may partner with Preferred Governmental Claim Solutions, Inc. (PGCS) to provide certain specialty liability claims services. USIS and PGCS are both wholly owned organizations of Brown & Brown. Inc., operating within the same division (Services) that specializes in the services requested under this RFP. Will furnish and provide professional services to the City, at minimum, in compliance with all contract documents and in compliance with all applicable laws, rules and regulations. USIS agrees. Certifies that neither the Proposer nor any of its principal owners or personnel or any subsidiary of the Proposer, have been convicted of any of the violation(s) or crimes or actions and conduct involving moral turpitude as defined by applicable laws, or debarred or suspended as set forth in Section 18-107, City Code, or as provided by 287.133, Florida Statutes. The Proposer further certifies that the Proposer has not been debarred or suspended by the United States Government, the State of Florida, any political subdivision of the State of Florida or any Special District or Public School Board in the State of Florida. USIS certifies to the above statement. Proposer understands that exceptions not timely or correctly taken are waived. USIS understands that exception not timely or correctly taken are waived. Please list and acknowledge all addendum/addenda received. List the addendum/addenda number and date of receipt (i.e. Addendum No, 1, 7/1/07). If no addendum/addenda was/were issued, please insert N/A. Addendum No., 1 10/13/20 i 6 Addendum No., 2 10/17/2016 Addendum No., 3 10/24/2016 Addendum No., 4 10/26/2016 Addendum No., 5 10/28/2016 Addendum No., 6 l 1/2/2016 Has Proposer reviewed the attached Sample Professional Services Agreement (PSA)? Yes, USIS has reviewed the attached Sample Professional Services Agreement. Does the Proposer acknowledge that the attached PSA is an example of the standard Agreement used in conjunction with the services related to this Solicitation and shall not be amended? Yes, USIS acknowledges and agrees to above. Page 6 Proposer's General Experience, Past Performance, and Exceptions 1) Describe the Proposers past performance and experience and state the number of years that the Proposer has been in existence, the current number of employees, and the primary markets served, USIS. Inc. was established in Orlando, Florida, in June of 1982. USIS is a full service Third -Party Administrator (TPA) providing specialized, client designed, professional service programs for All -Lines Claims Administration as well as Total Care Management Systems and Loss Prevention Services. AmeriSys is the medical management division of USIS, Inc. and is a dba of USIS. (USIS, Inc. clba AmeriSys) USIS is a wholly owned subsidiary of Brown & Brown Inc., one of the nation's largest insurance agency/brokerage organizations. The financial and management depth and resources afforded by our affiliation with Brown & Brown assures our customers that we will be there for them even during the most troubling times. Please reference Attachment 1 — Brown & Brown, Inc. Annual Report. Parent Company Corporate Office Brown & Brown, Inc. PO Box 2412 Daytona Beach, Florida 32115 Home Office (City of Miami Service Office) USIS, Inc. PO Box 616648 Orlando, FL 32861-6648 Previously operated under United Self Insured Services AmeriSys Office AmeriSys 140 AIexandria Blvd, Suite H Oviedo, FL 32765 dha of USIS, Inc. USIS provides services throughout the Southeast while Florida and Georgia are the primary markets served. We provide our services to commercial carriers, self-insurance funds, risk pools and trusts, as well as serf -insured employers in the private and public sectors of the market. USIS management and claim technical teams are composed of high level, dynamic claim and medical professionals. These teams thoroughly understand the challenges related to the unique operational needs of individual clients. Our staff of almost 250 personnel includes a dynamic and experienced leadership and management team, experienced adjusters in All Lines of claims management, RN medical case -managers and other support professionals to promote efficient, timely and technically -sound claims and medical management. The culture statement for B&B is as follows: "Brown & Brown is a lean, decentralized highly competitive sales and service organization comprised of people of the highest integrity and quality. bound together by clearly defined goals and prideful relationships. Although we are decentralized by design, that culture permeates USIS/AmeriSys. Page 7 AineriSys is a regional medical management/managed care organization founded in 1985, and operated under its previous name ERS until 1995, a regional disability management company which had built a ten year success in Florida, Georgia, the Carolinas, and other southeastern states. As of April I, 2000, AineriSys was acquired by Brown & Brown Insurance Services, Inc., and folded into USIS, Inc. as its medical management division. AineriSys is URAC Workers' Compensation Utilization Management certified. URAC is the nationally recognized certifying body for these programs and services. ACCREDITED €:,InEs€a03 Of USIS, the claims handling side of our organization, is completely integrated with AineriSys. AineriSys is a division of USIS rather than a separate company. As such, we have common executive leadership assuring continuity and compliance, while having separate technical leadership making certain that we excel professionally in all aspects of the claims adjudication service to our customer partners. Our organization is customer -centric. Our excellent reputation comes from recognizing that each employer/insured is unique in systems and philosophies. We stand ready to customize our services to best complement the cun-ent program by designing unique and customized service programs that allow our customers to "own" their claims service program. This incorporates our customers' strengths while augmenting their programs with design, support and expertise in the areas that will drive the greatest improvement in outcomes. We also recognize that these services and programs are dynamic and require ongoing assessment, evaluation and modifications to remain current with statute and rule as well as technology, medical advances and other efficiency -related information and techniques. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards. Our innovative, quality administrative services Multi -Line Claim Administration Medical Management and Certified Managed Care Programs Third Party Recoveries Full Spectrum Risk Management include: Progressive Claim -Reporting Procedures Cost Containment/Medical Bill Auditing and Review/EDI transmission State -of -the -Art Information Systems Multi -State Capabilities With a solid reputation borne of commitment to service, our team is dedicated to serving the client. Our focus is on quality, professional, superior service. This service -driven philosophy, conveyed throughout the organization, means dedicated individuals with the client's best interests at heart, constantly reinforcing the corporate mission — Service Beyond the Contract®. We have a team of talented, responsive people with a desire to share their knowledge and understanding of the insurance arena for the client's benefit — experienced in all types of Workers' Compensation claims. We establish designated and/or dedicated teams to each account allowing for maximum customization to the needs of our customer partners. Our approach is inventive and creative with the client's needs in mind. Pace 8 2) 3) 4) Our goal is to keep the employee at work. But if that is not possible, the adjuster and the employer work as a team to facilitate a quick return -to -work in a modified/transitional duty position as soon as a release to Return to Work (RTW) and restrictions are received. We have found that RTW in a modified duty position helps keep the employee's morale high and the claims costs low. The ultimate goal is to bring the claim to conclusion in the most economical way possible while still providing quality medical care for the injured employee. Internal claims handling guidelines are essential to providing excellent claims administration services. Our flexibility allows us to deliver a complete claims administration program that is tailored to the unique needs of the client. All or part of our services may be utilized, depending on the client's individual requirements. We understand that the services we would be providing on your behalf are for your employees, your colleagues. and very often friends. We recognize that we must treat each injured employee with respect and genuine interest in his/her well-being and recovery. We do this while also making sure that we protect the financial and human resources that are paid for by the hard earned tax dollars of your City's citizens. We have a stewardship obligation and commitment to the City of Miami and its injured employees. List all contracts which the Proposer has performed for the City of Miami, describe all work performed for the City and include for each project: (i) name of the City Department which administers or administered the contract, (ii) description of work, (iii) total dollar value of the contract, (iv) dates covering the term of the contract, (v) City contact person and phone number, (vi) statement of whether Proposer was the prime contractor or subcontractor, and (vii) the results of the project. USIS, Inc., through its medical management division AmeriSys, contracted with the City of Miami for Managed Care services from 2003 — 2011. Name of the city of department Risk Management Description of work Workers' Compensation Managed Care Services Total dollar value of the contract Approximately $200.000 annually Dates covering the term of the contract 2003-201 1 City contact person and phone number Angella Breadwood, 305.416.1751 Prime contractor or Subcontractor Prime Contractor Results of the project Successfully completed Provide information concerning any prior or pending litigation, either civil or criminal, involving a governmental agency or which may affect the performance of the services to be rendered herein, in which the Proposer, any of its employees or subcontractors is or has been involved within the last five (5) years. Provide letters of reference from law firms which currently handle your litigation. Provide contact person and phone number for each. USIS/AmeriSys has not been party to lawsuits, administrative actions or litigation related to fraud. theft. breach of contract, misrepresentation, safety, or wrongful death. However in the nonnal course of doing business related to workers' compensation claims handling, USIS/AmeriSys was made party to litigation related to the servicing of workers' compensation claims (5) on behalf of its clients. All but one was resolved in our favor, and one is current and pending. Brown & Brown, Inc. (the parent of USIS, Inc.) is publicly traded on the NYSE, is regularly subject to suits and claims that arise in the ordinary course of its business, and is required by law to make periodic filings with the Securities and Exchange Commission, which are publicly available and which contain additional information concerning legal matters. Identify if Proposer has taken any exception to the terms of this Solicitation. If so, indicate what alternative is being offered and the cost implications of the exception(s). USIS has no exceptions to this submission. Page 9 Proposer's Category Specific Experience, Past Performance Note: Any Proposer submitting a Proposal for both categories of Service, Part I- Workers' Compensation Claims Administration AND Part II: Medical Bill Review and Audit Services (Part I and II) must provide in its proposal, complete and separate responses for applicable Items 5 through 15 below for each Part (Part I or II). USIS, Inc. is submitting two proposals; Part I is proposed under USIS, Inc. and Part II is proposed under USIS, Inc. cfba AmeriSys. 5) Describe Proposer's past performance and experience with regard to the particular service category (Part I and/or Part II), and state the number of years that the Proposer has worked in this area providing a similar type of service, the current number of employees working in this area, and the primary markets served. Provide organizational history and structure, and indicate whether the City has previously awarded any contracts to the Proposer (a list of these City contracts shall be provided in item 2 above). USIS, Inc. is a full service Third -Parry Administrator (TPA) providing specialized, client designed, professional service programs for All -Lines Claims Administration as well as Medical Management Systems/Programs and Loss Prevention Services and Programs. USIS provides services throughout the Southeast while Florida and Georgia are the primary markets served. USIS, Inc. has been in business for 34 years and was established in June of 1982 as a division of Brown & Brown, Inc. In April of 2006 USIS was incorporated as a wholly owned subsidiary of Brown & Brown, Inc. (NYSE stock symbol BRO). B&B is one of the nation's largest insurance brokerage organizations. This provides our organization with the size and economic strength, stability and resources to handle a program such as the City of Miami's Workers' Compensation program. Our staff of almost 250 personnel includes a dynamic and experienced leadership and management team, experienced adjusters in All Lines of claims management, RN medical case -managers and other support professionals to promote efficient, timely and technically -sound claims and medical management. USIS, Inc. (corporation) ciba AmeriSys is a wholly owned subsidiary of Brown & Brown Inc., one of the nation's largest insurance agency'brokerage organizations. The financial and management depth and resources afforded by our affiliation with Brown & Brown assures our customers that we will be there for them even during the most troubling times. USIS is dedicated to long-term client satisfaction. Most of our customers have been with us for many, many years and even through mandated-RFP processes, still remain with USIS. With Service Beyond the Contract its motto, USIS has a team approach, a partnership with our clients that will ensure there is always someone looking out for your best interests. Beyond the day to day claims handling by the adjuster, the following team members own the relationship. The Management/Supervisory team (30) has been with USIS an average of 13 years. The Management team (l l) has been with USIS an average of 17.6 years. The leadership philosophy at USIS is a customer -centric team approach and always one of respect. From the top down, leaders are always expected to behave in a respectful, courteous manner across all ranks of Page 10 the team. up and down. We expect that of our teammates and it is expected of our leaders. We strive to offer our teammates a pleasant place to work which passes through to our customers. All leaders are an active part of the team — we do not develop managers; we develop leaders. We strive to ensure that our teammates are fully trained and part of the team — from the initial "Welcome" posting to the introductions around the office to detailed training in customer service, and constant check -ins to strive to keep happy, engaged teammates. Company leaders eschew the vertical pronoun "I." encouraging their teams to opt for the encompassing "we." vxa pn.tl.nt APewra���daFvau PeoRea w ' aNlytiC ova. Some i ltu.. Medical u..a to.s ,.rA uma We..Ira t ICYSCai Supniscra �SGY.rCMa AWN iltdf..alm. Re.M Um* UM Spodallats aaal 0.0061 BUIRWR tjt RIAFI:lmcal rat Ce.ntatairmet SY6VYga. hum., 11.11 Revetxvr, It@R 4VaYIY CaW4..r RON WARBLE EXECUTIVE VICE PRESIDENT AOnnna Airy. Assnlanl H.A. re.yr a rHarWt Relational Coordinator 3 rwe.r .Nan Mr Unit Assam. �"Wai La.np LIWn. Warr Craw. Un..I craun. Accae.dtno,OC Clain. Salran.arl I Claims Sopmiiar Aalu.nn Ln.CaM.el CI� MO AquMF1 Mown Clas al U W. Srm lead P Wnal9uppM �__ AR YIN 57R&SP.IIK*ER ILmager Ilunirees 12.0•Rwarte We. Coca CL..s VMRE cl..�. ■.r•nta CYma unit Clans Sus...iron Yrt. at...d..d *ens G.... Cum. Vac ry vlt� w.r.rn. C.a.m un. tI am Sadµy.lat. MO RYIINan i1R A..ate,l RK.Wwnnn CYRA Lan. e of talpn. IWne.a.aatl.. A.a..bnt USIS, Inc. has not been previously awarded any contracts to the City of Miami for Workers' Compensation Claims Administration. USIS was awarded a contract for Workers' Compensation Managed Care Services (2003 — 2011) through its Medical Management division AmeriSys. Page I I 6) Provide a detailed description of five (5) comparable contracts (similar in scope of services to those requested herein), which the Proposer has either ongoing or completed within the past five (5) years in the capacity as a Third Party Claims Administrator. The description should identify for each project: (i) client, (ii) client contact person, phone number and email address, (iii) description of work, iv) total dollar value of the contract, (vi) dates covering the term of the contract, (vii) statement of whether Proposer was the prime contractor or subcontractor. Include the Proposer's role and any value added. (viii) Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Where possible, list and describe those projects performed for government clients or similar size private entities (excluding any work performed for the City). Client Palm Beach County Sheriff's Office (PBSO) Client contact person Hilda Gonzalez Phone number 561.688.3550 Email address gonzalezH@pbso.org Description of work WC Claims TPA, Medical Bill Review, Medical Management Total dollar value S800,000+ annually Dates covering the teen of the contract Established 2000 and remains active Prime contractor or subcontractor Prime Contractor Proposer's role and any value added. Weekly staffing on cardiac claims. Dedicated Adjusters. Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Active contract with performance standards being met. Client Orange County Public Schools (OOPS) Client contact person Regina Cochrane Phone number 407.317.3918 Email address regina,cochrane@ocps.net Description of work WC Claims TPA, Medical Bill Review, Medical. Management Total dollar value $400,000+ annually Dates covering the term of the contract Established 1995 and remains active Prime contractor or subcontractor Prime Contractor Proposer's role and any value added. Monthly and yearly claim reviews. Helped establish a Return to work program. Yearly review of physician panel. Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Active contract with performance standards being met. Page 12 Client Orlando Health Client contact person Richard Tunno Phone number 321 841 8641 Email address richard.tunnoui orlandohealth.com Description of work WC Claims TPA, Medical Bill Review Total dollar value Confidential Dates covering the term of the contract Established 1996 and remains active Prime contractor or subcontractor Prime Contractor Proposer's role and any value added. Quarterly claim reviews. Assisted with choice of vendors. Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Active contract with performance standards being met, Client Volusia County School Board Client contact person Sandra Higginbotharn, Phone number 386.734.7190 Email address skhigginaiNolusia.kl2.tl.us Description of work WC Claims TPA, Medical Bill Review, Medical Management _ Total dollar value $250,000+ Dates covering the term of the contract Established 2007 and remains active Prime contractor or subcontractor Prime Contractor _ Proposer's role and any value added. Return to work program. Assisted with physician panel. Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Active contract with performance standards being met. Client Columbus Consolidated Government Client contact person Anne -Marie Amiel Phone number 706.225.3113 Email address aamiel@colurnbusga.org Description of work WC Claims TPA, Bill Review, Managed Care Organization Total dollar value $350.000+ annually Dates covering the term of the contract Established 2014 and remains active Prime contractor or subcontractor Prime Contractor Proposer's role and any value added. Helped establish a Return to Work program and saved CCG approximately $ 1,000,000 per year in Workers' Compensation expenses Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Active contract with perforrnance standards being met. Page 13 In the event that the Proposer has not performed five (5) comparable contracts in the particular category (Part I or Part 11), the Proposer should provide information that demonstrated its ability to perform the required services. N/A 7) Describe any relevant industry/subject matter expertise, including any experience in the particular services, and any unique or proprietary project methodologies relevant to the requested services. USIS has built an outstanding reputation as a claims administrator for Workers' Compensation programs. Our clients appreciate our philosophy of personal service, dedicated commitment and team approach. • Properly licensed, experienced multi -line claims professionals • Case counts below the industry average allow for proper claim management and personal service • Rapid assessment and investigation of claims to help control medical and indemnity costs, and discourage attorney involvement • Timely, successful conclusion of claims, with strict diary system control • Focus on claim -reserving practices initial reserve determined only after careful review by the licensed adjuster and the claims supervisor • Timely vocational case -management intervention, as necessary, to enhance successful file closure and reduce exposure to prolonged disability payments • Licensed specialists review each claim tile for subrogation potential, seeking maximum recovery of client claim expenses — with a track record of reaping substantial recoveries • Although opportunities to recover from SDTF are rapidly disappearing, we maintain a dedicated claims unit to assure recovery to the extent possible from the various Trust Funds • Aggressive investigation of potentially fraudulent claims • Progressive claim -reporting procedures - May be reported online using the USIS web site, or via email, fax or telephone. - One contact from the employer establishes a record of the claim and initiates all required State filings and review procedures • Ability to electronically register each claim with a national claims index service It is our understanding that the City has first responders/badged officials that are in your employment which experience presumption and cardiac claims. Please reference BADGE Program. Attachment 2 - Cardiac -Exposure Protocol. We believe that the Heart/Lung public presumption claims represent one of the most significant economic exposures to closing claims and the anticipation that most of those claims will deteriorate as the employee ages. David E. Perloff, MD, FACC, FACP, is the AmeriSys BADGE Program Cardiac Medical Director. He has many years of experience in Cardiology and over 10 years of that in dealing with workers' compensation related to the Heart/Lung Presumption Bill. It is also our assumption that the City has injured employees who are prescribed opioids. Please reference Attachment 3 - Innovative Programs for information related to the SECURE program. AmeriSys has developed unique protocols and criteria for managing these complex and cost -driving claims. The program's goals are to improve/enhance return -to -work outcomes, reduce disability duration; prevent unnecessary, dangerous and costly consequences of inappropriate or prolonged utilization of opioid medications while reducing the costs of handling pain management claims. Page 14 It is this position and approach of innovation and efficiency that characterizes our organization. Whether it is unique types of claims, unusual working conditions or locations with special information needs, we strive to customize our program to address those unique and individual needs. Our commitment to innovation and efficiency is also coupled with 30+ years of proven experience in providing cost effective and quality -oriented medical care management. It is the careful blend of innovation with proven, tested experience and success that allows for the best in functional and economic outcomes. USIS stands ready to work with your leadership team to identify, develop and implement a program that is hest suited to your claims and informational needs. The City of Miami will have real-time access to our USISoNet Web Portal. Upon registration, users may have access to claims, reports, notes, payment information, dashboards, and more depending on assigned level of access. There is no charge for access. Access is granted to clients based on authority level and permissions dictated by the client via user ID/password. Please reference Attachment 4 — USISiNet and AmeriSysiNet. Please reference Attachment 5 - USIS, Inc. Sample Reports which are available at any time through the web -portal. We have 8 on staff and on -site programmers who will be able to build ad hoc reports and/or data extracts that you desire in a reasonable time frame. If the report is available, you can customize dates, etc. We host and control source code and all of the data files that make up the workers° compensation application. Reports may be downloaded in Excel and can be customized upon request. 8) Provide a list of clients that have, for whatever reason, discontinued the use of your services within the past two (2) years, and indicate the reasons for the same. The City reserves the right to contact any clients listed as part of the evaluation process. Miami Jewish Health Systems 5200 NE 2nd Avenue Miami, Florida 33137 Shaniqua Smith, 305.762.1526 Loss of account due to a complete changeover in leadership and the new leadership moved in a different direction. Florida Roofers and Sheet Metal Association SIF 4099 Metric Drive Winter Park, Florida 32792 Brett Stiegel, 407.671.3772 FRSA is a Self -Insured Trust which made a decision to create its own Claims Department and began administering claims in-house. The Medical Management portion of FRSA went to a third party for one year and came back to USIS/AmeriSvs. 9) Provide two (2) Letters of Reference, on letterhead, from two different, similar sized governmental entities (as the City), and for which similar services (Part I or Part II) have been performed within the past five (5) years. This information is subject to verification as part of the evaluation process. Please reference Attachment 6 — Reference Letters. 10) Provide a complete list of all current Florida clients for which Proposer administers claims in a Workers' Compensation, self-insurance, or retention program. The description should identify for each client: (i) client, and type of entity; (ii) client contact person, phone number, and email address, (iii) description of work, iv) total dollar value of the contract, (vi) dates covering the term of the contract, (vii) statement of whether Proposer was the prime contractor or subcontractor. Specifically identify clients for whom a similar service has been provided, particularly to governmental entities similar in size to the City, Trust, or Page 15 other similar type as the City. Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Bay County Board of County Commissioners Type of Entity Public Client contact person Eve Tooley Phone number 850.248.8231 Email address etooly@baycountyfl.gov Description of work WC Claims TPA Medical Bill Review Total dollar value $15,000+ annually Dates covering the term of the contract Established 1993 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / retum-to-work program, etc. RTW Client Broward County BOCC Type of Entity Public Client contact person Jeff O'Connor Phone number 954.357.7230 Email address JCOCONNOkcijbroward.org Description of work Network Access/Bill Review/Intake Total dollar value $50,000+ annually Dates covering the term of the contract I Established 2007 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client City of Cocoa Type of Entity Public Client contact person John Titkanich Phone number 321.433.8686 Email address jtitkanicha,cocoafl.org Description of work WC Claims TPA, Medical Bill Review Total dollar value $50,000+annually Dates covering the term of the contract Established 2009 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW I' i_ I i, Client Citv of Jacksonville Type of Entity Public Client contact person Twane Duckworth Phone number 904.630.2777 Email address twanedf ccoj.net Description of work Network Access, Medical Bill Review and Medical Only Claims Handling on an as needed basis Total dollar value $275,000± annually Dates covering the term of the contract Established 2013 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / retum-to-work program, etc. Client Orange County Public Schools Type of Entity Public Client contact person _ Regina Cochrane Phone number 407.317.3918 Email address regina.cochranet(,ocps.net Description of work WC Claims TPA. Bill Review and Medical Management Total dollar value $400,000+ annually Dates covering the term_of the contract Established 1996 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty % return -to -work program, etc. - - RTW, Light Duty, Loss Control Client Palm Beach County Sheriffs Office Type of Entity Public Client contact person Hilda Gonzalez Phone number 561.688.3550 Email address gonzalezH.cipbso.org Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value _ $750,000+ annually Dates covering the term of the contract Established 2000 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program. etc. RTW, Light Duty Page 17 Client _ - State of Florida (DRM) J. Type of Entity Public Client contact erson Candy Janes Phone number 850.413.4827 Email address Candy.Janes@myfloridactb.com Description of work Intake/Triage Medical Management Total dollar value S9,000,000+ Annually Dates covering the tern of the contract Established 2014 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Volusia County Public Schools Type of Entity Public Client contact person Sandra Higginbotham _ Phone number 386.734.7190 Email address skhiggin(zrvolusia.k12.fl.us Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value S250,000+ Annually Dates covering the tern of the contract Established 2007 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Client Preferred Governmental Insurance Trust Type of Entity Public Client contact person Ann Hansen _ Phone number 321.832.1510 Email address ahansen ;publicrisk.com Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value Confidential Dates covering the term of the contract Established 1999 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp TPA Indicate whether Proposer assisted in disability, safety program, tight duty / return -to -work program, etc. Page 1 Client Brevard County BOCC Type of Entity _ Public Client contact person Julie Jones Phone number 321.637.5446 Email address Julie.Jones@brevardcounty.us Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Coinp TPA (PGCS) Total dollar value S250,000+ annually Dates coveri the term of the contract Established 2003 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp TPA Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Charlotte County Type of Entity Public Client contact person Raymond Carter Phone number 941.743.1334 Email address Raymond. Carter(ctscharlottecountyll.gov Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value $40.000+ annually Dates covering the term of the contract Established 2010+and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability, safety program, light duty i return -to -work program, etc. Client City of Delay Beach Type of Entity Public Client contact person Eddie DeMicco Phone number 561.243.7150 Email address demicco@:rnydelraybeach.com Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value $50,000+ annually Dates covering the term of the contract Established 2013 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability, safety _program, light duty / return -to -work program, etc. Client Leon County BOCC Type of Entity Public CIient contact person Karen Melton Phone number 850.606.5120 address Meltonk �cleoncountyfl.gov - _Email Description of work Medical Bill Review, Medical Managernent (USIS /ArneriSys) Liability and Work Comp TPA (PGCS) Total dollar value $50,000+ annually _ Dates covering the term of the contract Established 201 l and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability. safety program, light duty / return -to -work program, etc. Client Preferred Governmental Claims Services Type of Entity Private Client contact person_ Ken Picton Phone number 800237.6617 Email address kpictongpgcs-tpa.com Description of work Medical Managernent, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 2005 and remains active Prime contractor or subcontractor Prime Contractor for \ ledical Bill Review and Medical Managernent Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Ferman Motor Car Company Type of Entity Private Client contact person _ Webb Bond Phone number 831.251.2765 Ernail address webb.bond(4ferman.com Description of work WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 201 1 and remains active Prime contractor or subcontractor Prime Contractor - Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Page 20 Client Halifax Health Type of Entity Private Client contact person Terry Martin Phone number 386.254.4048 Email address Terry.martin@;halifax.org Description of work WC Claims TPA, Bill Review Total dollar value $75,000+ Annually Dates covering the term of the contract Established 2012 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Client Health First, Inc. Type of Entity Private Client contact person Nancy Johnson Phone number 321.868.7248 Email address Nancy.johnson(Thealth-first.org Description of work WC Claims TPA, Bill Review Total dollar value $125,000+ Annually Dates covering the terrn of the contract Established mid 1980's and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program. etc. RTW, Light Duty Client Orland© Health Type of Entity Private Client contact person Christy Pearson Phone number 321.841.6104 Email address christy.pearson@orhs.org Description of work WC Claims TPA, Bill Review Total dollar value $175,000+ Annually Dates covering the term of the contract Established 1996 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Page 21 Client Parrish Medical Center Type of Entity Private Client contact person Roberta Chaildin Phone number 321.268.6333 Email address roberta.chaildin<<lparrisluned.corn Description of work WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 201 1 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Client Ring Power Corporation Type of Entity Private Client contact person Cindy Acosta Phone number 904,737,7730 Email address Cindy.Acosta@ringpower.com Description of work _ WC Claims TPA, Bill Review Total dollar value $40,000+ Annually Dates covering the tern of the contract Established 2011 and remains active Prime contractor or subcontractor Prune Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Client FHM Insurance Company Type of Entity Private Client contact person Jack Lemine Phone number 800.329.4340 Email address jlemine@thmic.com Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value Confidential Dates covering the term of the contract Established 2003 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, ete. Page 22 Client Florida Citrus, Business Industries Fund Type of Entity Private Client contact person Jim Emerson Phone number 863.660.5943 Email address jim.emerson48@gmail.com Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value Confidential Dates covering the term of the contract Established 2002 and remains open Prime contractor or subcontractor Prune Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Florida Rural Electric Self Insurers Fund Type of Entity Private Client contact person William Willingham Phone number 850.877.6166 Email address Bill{ritFECA.Com Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value _ Confidential Dates covering the term of the contract Established 2002 and remains active Prime contractor or subcontractor Prime Contractor I Indicate whether Proposer assisted in disability, safety program,light duty / retum-to-work program, etc. Client Florida Workers' Compensation Insurance Guaranty Association Type of Entity Private Client contact person Sandra Robinson Phone number 850.386.9200 Email address srobinson@agfgrotty.org Description of work WC Claims TPA, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 1998 and remains active Prime contractor or subcontractor Piirne Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Run off claims Page 23 Client Type of Entity Sugar Cane Growers Cooperative of Florida Private Client contact person Carmen Abercrombi Phone number Email address Description of work Total dollar value 561.996.E-751 cabercrombi (scgc.org WC Claims TPA, Bill Review Confidential Dates covering the term of the contract Prime contractor or subcontractor Established 2010 and remains active Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program. etc. 11) Discuss in detail Proposers qualifications and experience to provide general liability and automobile liability claims administration. Include, in the description, the Proposer's thorough knowledge of all State Statutes and other applicable laws governing this RFP, to demonstrate a complete understanding of the work to be performed. USIS will partner with Preferred Governmental Claim Solutions, Inc. (PGCS) to provide some specialty liability services. We are a single organization (Brown & Brown, Inc.) operating within the same division that specializes in the services requested under this RFP. PGCS has been licensed to operate as a third party claims administrator since 1956 (60 Years). PGCS was formed in 1956 in Miami, Florida under the naive of Insurance Servicing and Adjusting Company (ISAC). The governmental entity division of ISAC later changed its name to Preferred Governmental Claim Solutions. PGCS has been located in central Florida for twenty- four 24 years and is currently located in Lake Mary, FL and maintains a dedicated claim unit at the Risk Management Department of Palm Beach County. PGCS was acquired by the Public Entity Division of Brown & Brown, Inc. in 2001 PGCS provides third party claims administration service to thirteen (13) self -insured municipalities. In addition, PGCS administers claims for over one -hundred (100) municipal members of the Preferred Governmental Insurance Trust (PGIT) With 60 years of Florida claims administration experience, PGCS has a thorough knowledge of all State Statutes and other applicable laws governing this RFP. Page 24 12) Discuss in detail Proposer's qualifications and experience to provide managed care services. Include the Proposer's thorough knowledge of all State Statutes and other applicable laws governing this RFP, to demonstrate a complete understanding of the work to be performed. AmeriSys is the medical and cost containment division of USIS. AmeriSys provides a complete selection of medical management and managed care programs. Our experience in handling large public entity employers, such as your own organization, the City of Miami (2003 — 2011), as well as the Palm Beach County Sheriff's Office, Broward County Government and the State of Florida, makes us uniquely qualified to assist the City with its managed care program. Our experience providing the Occupational Medical Management program for Preferred Governmental Claim Services and Preferred Governmental Insurance Trust brings over 200 Florida public entity employers into our service program. Each of these custorners has benefited from highly customized approaches developed by AmeriSys to meet its unique occupational medical management needs. AmeriSys has a thorough knowledge of all State Statutes and other laws governing this RFP from its 30 years of experience in the Florida Medical Management marketplace. 13) Provide detailed background on the Proposer's proposed Manager/Supervisor to be assigned the City's account throughout the duration of the contract term, and whether Proposer agrees to City's terms for approval of future Manager/Supervisor, should proposed representative leave Proposer's firm during the contract term. Provide copies of current applicable licenses for work to be performed in the State of Florida. Jenny Ross, will be the Account Executive. She will be the City's main point of contact for Claims Reviews and Service Issues ensuring a high quality of service and support. It will be the responsibility of the Account Executive, Jenny Ross, to identify and resolve any issues brought forth during the project duration. The Account Executive has been responsible for multiple large clients and is experienced in dealing with and resolving any issues. She will be accessible to the City by keeping the lines of conununication open. USES strives for an excellent customer service relationship. If there are any concerns, they will be immediately handled. Our goal is to build and ensure excellent rapport between our staff and the City's for a superior working relationship. The Account Executive will remain fully involved in the day to day claims handling process in order to ensure that all critical decisions being made by the staff are in the best interest of the City and its injured employees. Any concerns will be discussed with Risk Management as needed. Jenny Ross, Account Executive, Ext. 6302 ienny.rosski usis-tpa.com Jenny Ross has been in the claims industry for over 20 years. Joining USIS 16 years ago, Jenny has been steadily promoted throughout her career. She started as an adjuster, handling a large volume of workers' compensation claims, conducting client visits and claims reviews: and has become an integral part of our claims management team. Jenny's customer service, dedication and commitment to our clients, along with claims knowledge and analysis, make her a top notch Project Manager. Prior to joining USIS, Jenny was employed at Executive Risk Consultants as a lost time claims adjuster. Jenny was the proud recipient of the 2011 Nationwide Brown & Brown Claims Professional of the Year Award, as well as USIS's Employee of the Year in 2007. Page 25 Terri Snapp, WC Claims Manager, Ext. 6409 terri.snapp i usis-tpa.com Terri Snapp has over 28 years of experience in the workers- compensation insurance claims industry. Beginning her career as a file clerk with Leatherby Insurance Co., she was steadily promoted within the industry and has been with USIS, a leading Third Party Administrator, since 1988. Terri is currently a Claims Manager with USIS, supervising the work product of over 18 adjusters and supervisors. One key component of her job is dealing directly with clients, a lot of which are public entities, to ensure a high quality of service and support. Her knowledge and experience in the insurance claims industry has been significant in ensuring the continued success of US1S as a TPA. Yarixa Etiason, Liability Supervisor, Yarixa.eliason(ivusis-tpa.coni Yarixa Etiason has over 20 years of experience in the liability insurance claims industry. Beginning her career in Miami with John's Eastern as a liability adjuster, she was steadily promoted within the industry. She has her all lines adjuster license with experience in handling claims for commercial auto, general liability, employment liability and governmental entities. One key component of her job is dealing directly with public entity clients. Please reference Attachment 6 - Resumes/Licenses, Job Descriptions. Since USIS will be the employer and USIS/Brown & Brown could potentially be at risk for any perceived liability of wrongdoing in the hiring process, it would not be standard practice to accept an outside entity into our hiring processes. It is our intent to positively ensure that our equal employment opportunity philosophy, in accordance with federal, state, and local law, applies to all aspects of employment with USIS including recruiting, hiring, training, transfer/promotions, compensation and benefits, and termination. At USIS, handled through our own Human Resources Department we must ensure that our employment practices are free of discriminatory practices and that employment decisions are made on the basis of job -related qualifications, experience, including personal competence and potential for advancement. With that stated, we will be open and pleased to strongly consider any recommendations or referrals of properly qualified staff that the Cite might provide or request. We will also be willing to share the resumes of the employee(s) hired or transfen-ed internally to handle the City of Miami account. Once into the contract, should there be any staffing changes necessary, USIS would communicate with the City of Miami as soon as known. It should be noted that at USIS we are committed to ensuring equal employment opportunity for all employees and applicants for employment. It is our goal to recruit, hire and develop the best employees using only job -related qualifications. We know that our people are the heart and soul of our enterprise and we recognize that our continued success depends on the full and effective recruitment, hiring and development of the very best employees, taking into consideration only job -related qualifications, regardless of race, color, religion. sex, age, national origin, marital status, disability, veteran status, genetic information and any other category protected by state or federal laws. AmeriSys strives to recognize the talents and job performance of all employees, and values the contributions that come from people with different backgrounds and perspectives. It is AmeriSys' desire to promote an environment that maximizes the potential of all of our employees, and to promote diversity throughout the Company because we believe that diversity is important to our ability to continue to excel in an increasingly diverse and dynamic marketplace. Page 26 The Company does not permit discrimination or retaliation against qualified individuals with disabilities in regard to application procedures, hiring, advancement, discharge, compensation, training, or other terms, conditions, and privileges of employment. The Company- will reasonably accommodate qualified individuals with a temporary or long-term disability so that they can perform the essential functions of a job. A job applicant who can be reasonably accommodated for a job, without undue hardship, is given the same consideration for that position as any other applicant. 14) Describe the experience, qualifications and other vital information, including relevant experience on previous similar projects (Part I or Part II), of all key personnel, who will be assigned to the City's contract. This information shall include the functions to be performed by the key individuals, and the caseload of each person assigned to service the account. Include copies of all licenses held by each individual, as all claims professionals must possess a current Florida adjuster's license, Provide copy(ies) of each adjuster's and Supervisor's Florida Adjusting License, or any other relevant licenses, if applicable. In addition, provide resumes, if available, with job descriptions and other detailed qualification information on all key personnel who will be assigned to the City contract. Jenny Ross Account Executive Terri Snapp Claims Manager Yarixa Eliason Liability Supervisor Please reference Attachment 7 - Resumes/Licenses, Job Descriptions. i 5) Provide a complete list of all licensed claim's personnel that will handle City's claims, and/or managed care services, including the Proposer's proposed Manager/Supervisor, Supervising Adjuster, Adjusters, Supervising nurse Case Manager, Case Manager, Medical -only processors, or other individuals including clerical and or support staff detailing education, experience in the area of workers' compensation claims, in the area of managed care, and type of license(s). Include copies of all licenses held by each individual. Jenny Ross Account Executive Terri Snapp Work Comp Claims Manager Yarixa Eliason Liability Supervisor TBD* Work Comp Supervisor TBD* (5) Lost Time Adjusters TBD* (l) Medical Only Adjuster TBD* (2) Liability Adjusters Please reference Attachment 7 — Resumes/Licenses, Joh Descriptions*. Note: After qualification submission, but prior to the award of any contract or work order issued, as a result of this RFP, the Proposer has a continuing obligation to advise the City of any changes, intended or otherwise, to the key personnel in its proposal submission. USIS agrees to the above statement. Page 27 Proposer's Ability to Perform Required Services 16) Provide a complete list of all claims office locations and territory(ies) serviced with Proposers current personnel, indicating the number of personnel of Proposer, and Proposer's ability to provide required services to the City. Parent Company Corporate Office Brown & Brown, Inc. PO Box 2412 Daytona Beach, FL 321 15 # of Employees: 8,600 Home Office City of Miami Servicing Office USIS, Inc. PO Box 616648 Orlando, FL 32861-6648 Previously- operated under United Self Insured Ser l ic4s # of Employees: 88 USIS provides services in Florida, Georgia, South Carolina, North Carolina, Virginia, Kentucky and Alabama. USIS currently provides the required services to Florida Public Entity clients. USIS has the ability to provide the required services to the City of Miami. 17) Describe where your main office is located, and the location where the primary work will be performed. Indicate location where the Successful Proposer, the Successful Proposer's Manager/Supervisor will be located. USIS main office which is listed below is the location where the primary work will be performed. The Account Executive will also be located at the main office. USIS, Inc. 5728 Major Blvd., Suite 450 Orlando, Florida 32819 I8) Discuss how the Proposer's office or unit will be staffed, and the level of supervision that will be provided. Discuss case assignments, including pending case load for each designated Adjuster and current number of monthly new assignments to each Adjuster, if applicable. Discuss case assignments, including pending case load for each designated nurse Case Manager and current number of monthly new assignments to each nurse Case Manager, if applicable. USIS proposes to provide a dedicated unit with (1) Work Comp Supervisor and (6) Work Comp Adjusters (5 Lost Time and I Medical Only). The Liability Unit will have (1) working Supervisor and (2) Liability Adjusters. The designated Workers' Compensation Claims Manager will also manage the USIS Florida Independent Unit. Lost Time adjusters will handle a maximum case load of 160 claims and the Medical Only adjuster 350 claims. To maintain the Lost Time caseload below the maximum, USIS would move non -litigated Lost Time files not receiving indemnity payments to the Medical Only adjuster. Page 28 The Liability adjusters will have a maximum caseload of 160 claims. Caseloads are monitored via weekly claim count reports — system -generated for claim supervisors and managers. The City can access this report through USISiNet. This report is a tool that allows the supervisor to make case load adjustments as necessary. US1S Current Caseload Average Pending Caseload Average New Assignments per Month Lost Time Adjuster 127 10 Medical Only Adjuster 294 152 WC' Supervisor WC Supervisors do not handle a caseload The following staffing assumes USIS. Inc. clba AmeriSys receives the Medical Management contract. Under the overall direction of the Vice President of AmeriSys, the City of Miami will be directly supervised by a registered nurse who is also a certified case -manager. The Program Manager/Supervisor is responsible for the day to day activities on all claims. She is also responsible to ensure the standards set forth by the AHCA are upheld and maintained. Some of the standards include but are not limited to the monitoring of caseloads and ensuring diary protocols are followed. The supervisory duties also include the reviewing of internal audit scores, identifying issues pertinent to the City of Miami that require education and need reporting to the quality assurance committee. She will also track and trend the activity involved in the quality initiatives in which the City of Miami is participating. The Program Manager/Supervisor acts as an advisor and mentor to her staff members, and is the direct point of contact for both the claims adjusting team and the City of Miami Risk Management Department for any issues that are escalated and require an immediate response. It is our intention to staff the City of Miami designated unit with two (2) registered nurse case -managers. The team lead nurse case -manager will handle Medical Only and Lost Time files assigned by the adjusters. The second case -manager will be the cardiac case -manager, assigned to the oversight and management of the claims covered by the Heart and Lung Bill, specifically following the protocol of the BADGE program. The Telephonic Case Manager caseload average is 72 files and their maximum is 80 files. These numbers are dependent on severity and complexity. While it is our intention to maintain this number of cases for the City of Miami ease -managers, we understand this may fluctuate at times dependent on seasonal activity as well as any incidents involving multiple claims at one time. AmeriSys averages 10-12 new files opened per Telephonic Case Manager per month. We also recognize that the number of new monthly assignments is directly affected by the number and type of newly reported injuries each month. We will distribute each type of claim to the appropriate case -manager. r.,gt l", 19) Describe how Proposer will ensure managed care services by City employees residing in Miami -Dade, Broward, Palm Beach, and Monroe Counties, among other locales. Ame.riSys, USIS" Medical Management division, currently has approximately 200 employees who service our customers. Those customers include Broward County Government and Palm Beach County Sheriffs Department as two large self -insured employers in the south east Florida area. In addition, the State of Florida is a customer with a Large southeast Florida presence. We also have a number of smaller public entities as well as several insurance companies and three self-insurance funds, all of which have claims within the counties identified above. 20) Discuss whether the award of this contract necessitates an increase in Proposer's staff size to meet the City's staffing and caseload requirements, and whether staff will be in place by the start of the contract, which is estimated to be February 1, 2017. USIS will need to hire staff to meet the requirements of the City of Miami's RFP. The staff will be in place by the start of the contract. 2 l) Explain the percentage of time the Proposer's proposed Adjusters will be out of the office doing field work. If all of Proposer's proposed Adjusters are telephone Adjusters, indicate as such. Explain whether Proposer will utilize independent contracted Adjusters, and under what circumstances. Provide the name, address, phone, and contact person for independents you currently utilize. Liability - We intend to hire one of the two adjusters in the Greater Miami area as an adjuster whom will perform field work. Based on information provided by the City of Miami, it is assumed that the adjuster would spend 20% of his/her time doing field work. 22) Identify language capabilities (spoken or written) of Proposer's employees and those of the subcontractors or subconsultants. USIS will have employees within the unit who are bi-lingual. Page 30 Proposed Overall Approach to Performing the Services 23) Discuss in detail Proposers overall approach to the work to be performed. Describe Proposer's specific project plan and procedures to be used in providing the services, and how Proposer has applied the proposed project approach in comparable contracts. Our goal is to keep the employee at work (Stay at Work). But if that is not possible, the adjuster and the City of Miami will work as a team to facilitate a quick return -to -work in a modified/transitional duty position, taking into account reasonable accommodations, as soon as a release to return to work (RTW) and restrictions are received. We have numerous customers with Stay -at -Work or Return -to -Work (SAW or RTW) programs in place. We can assist the City with designing and implementing a SAW or RTW program but in reality this must be "your" program. It is essential that there is buy -in from the City of Miami at the top. The number of employees and job positions available overall within the City has a great deal to do with the program design and efficacy. USIS prides itself on customization of programs to maximize utilization management. It begins with ensuring compensability of the injury and the treatments being prescribed are related to the reported injury. Once that has been determined, then all measures are taken to return the injured employee back to gainful employment. Is the disability time in accordance to ODG standards, if not, why? Questions are posed to the Authorized Treating Physician (ATP) regarding functional limitations rather than blanket off work statements. This allows employers to maximize modified duty positions by focusing on what the injured employee can do, rather than what they cannot do. All ATP's treatment requests are compared to evidenced based guidelines. It is our goal to have and maintain an excellent rapport with the provider community. USIS utilizes peer to peer contact to help resolve any issues regarding medical necessity. It is in this way we ensure a strong relationship with the provider community that understands the intentions and goals of the City to provide an expedited and safe return to work for its employees, thereby lowering costs. While ATP's treatments are compared to evidenced based guidelines, so are ancillary services such as therapies and diagnostics. USIS has put together a panel of preferred ancillary providers. These organizations have been put through a stringent process that includes providing services in accordance to evidenced based guidelines and performance guarantees to ensure the guidelines are being adhered to. Finally, our bill review process involves high levels of technology to allow for the deepest discounts that are compliance with state statute and rule. USIS prides itself on proactive claims management in a team approach with the injured worker, the employer, and medical case manager if applicable. Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. An efficient claims system allows for effective claims administration. Software from leading vendors within the Workers' Compensation and medical management field, supplemented with programs and components developed by in-house programmers, provides an environment tailored to the special needs of the client. Page 31 • Employers have online access to all claim information through database and document utilities. • Support services include all up-to-date office management tools • Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as internet or VPN • In-house programmers are able to develop customized reports where special client needs exist • Claims data is available via the USIS website for use in client spreadsheets. word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure. state-of-the-art web portal warehouse. All claim data within the system is viewable online and able to be downloaded into an Excel format directly from the website. Features include First Report of Injury reporting; check registers; loss reports; all account and injured worker statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall costs and to provide cost- effective solutions best suited to the client's situation. Our service commitment is to make our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes- Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the telephonic case -managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case - manager (when assigned) and cost containment. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost contairunent and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. Ongoing Claims Management Supervisors will review claims after the initial review, every 30. 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness ofreserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may become litigated. The supervisor will also review the quality of all documentation, paying close attention to the medical documentation to ensure that a treatment plan is in place, that the employee is compliant with appointments and testing and that the adjuster has a current action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 days will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. Page 32 The adjusters are welt trained on when to recognize when a ease is deteriorating and are instructed to control these claims as quickly aspossible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Utilization Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with the injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee, to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to full duty, restricted duty, and the employers' ability to accommodate the injured employee's restrictions. USES is acutely aware that an employee's status cannot remain at modified duty for an indefinite period of time. The treating physician is routinely asked to identify the injured employee's progress as it is related to the decreasing of functional limitations. Issues such as the decreasing of weight lifting restrictions are tracked, documented and communicated to the employer. When a failure to progress with limitations is noted in comparison to the guidelines, the treating physician is asked to address this area in the treatment plan, and a physician advisor may be called upon to opine on the situation. Catastrophic or large losses seldom occur but when they do they have a chilling impact on claims expense. Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and burns. These claims are complex from beginning to end. Rapid response in claims investigation, assignment of Catastrophic Case Management Providers and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. AmeriSys, our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized many times on large and catastrophic claims bringing the City of Miami the experience, when necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to maintain the highest degree of compassion and service to that employee and his/her family. Liability The claims adjusters are responsible for providing thorough, accurate, timely communication and advice to the City in order to resolve any and all claim related issues. The claims adjuster will handle all cases professionally in order to assure a mutually beneficial resolution in a timely and cost effective manner. The handling of the claims will involve, but not be restricted to: 3 A) Initial investigation to determine liability. B) Investigation to determine the damages. C) Identify and pursue any and all third party (subrogation) possibilities. D) Establish, monitor and assure the accuracy of any reserves. E) Notify the excess carrier of any claim that is catastrophic or has excess potential. F) Adhere to all recommendations provided through the claim review process. G) Prepare and manage all litigation. H) Adhere to the timely filing of any and all legal documents. I) Close all files as deemed appropriate on a timely basis. It is policy that all reported claims will be investigated to fullest extent warranted. The adjuster will perform the investigation to include all available information from the claimant, the account, witnesses, medical providers and experts if warranted. All determinations of liability and the damages owed will be made in accordance with the laws The adjuster will perform all investigation warranted including obtaining information from the claimant. the account, witnesses, medical providers and experts. The adjuster will gather documentation and obtain any estimates needed to properly evaluate the claim. This will include but not be limited to: I. Recorded statement where warranted by liability and / or damages. A summary of this statement should be included with the tape. ?. Verification of any physical injuries will be made. With any claim involving a physical injury, a medical release form will be obtained. 3. The police and incident reports will be obtained on all claims. 4. The tire department reports will be obtained on all property claims. 5. Photographs will be taken on all property claims. Photographs will be dated and carry a description. 6. Estimates and/or appraisals will be obtained on all automobile physicallproperty damage claims. Photographs will be obtained on all automobile claims. Page 34 24) Describe Proposer's ability to perform the services described in the Scope of Services, and describe Proposer's specific policies, plans, procedures or techniques to be used in providing the services requested. The Proposer shall describe its approach to project organization and management, responsibilities of Proposer's management and staff personnel that will perform work in this Solicitation, Be authorized (licensed) as a Claims Administrator by the State of Florida, as of proposal due date; USIS, Inc. is authorized as an administrator in the State of Florida — current annual update through February 28, 2017. £r ta ,xrste JEFFATWATER EVE ry HAW., rciivaq• 11, 2016 Mr. Non ikarhle Fxeetnive Vice President USIS. Inc. Post Office Bret 616648 Orlando, Flnrida.i2861.6648 Re: Qualified Servicing Entity iSmoral Report Caw Mr. Warble The Qualified Servicing Entity Annual Report Fotm for your company has been received. 1 have reviewed this report and timed that your company is in compliance with Rule 69L-S..7&111) (Retaining Amhorizaliaa as a Qualified Sv^rvicilg Entity). This letter will confirm thst your company Ina been recertified fix the period March 1. 2016 thrmagh February 28, 2017. Attached is a copy of Form tJFS-F2 SI-2.3 (Qualified Servicing Entity Annual Report Form), to be tool for fount filing as we no longer mall thr firms prior In she Joe date. Also attaches) os a Form DF'-F2-5I-(9 (CMifiuvimn of Servicing for Self -Warm). this farm is in be axnplerwl thew (30) days or emer,ng eat. a coroner for servicing,. 'rear nest annual report is due io our office no liner than March 1. 201'r. Should you have art) yuextauw or need fhrher assistance. please coronet me at (SW 11J-1784_ Wetly. 41100r. `1 wayi Mant[Ina llntirrw)0! Asiminiu(ntlur Attachments MAMA err laaxrl,t' or n1.410dIki rratv1:es Misfoo.rw.r.,.- r:.n.ana•ke • (1111 . n[Amual Aemafda) ±au €ma s n,nu x.su• T011gunco. Hunk (LgM4t8t • rd. 1WM1a11-17ax• Fea1a-.414.2i44 t'aua. • 7i,wymNmarA. 1JN1o.•tadr:Vm' Perul.•itch ACM. • aw`M. 04,1•XiMnawf4em. • Have dedicated/designated adjusters in the State of Florida with a minimum of three (3) years' experience, directed by a dedicated Supervisor, with at least five (5) years' recent experience. We hire adjusters with a minimum of 3-5 years of experience; most of our adjusters have 10+ years of experience. We require them to have extensive knowledge of accepted industry standards and practices including case law; the ability to successfully negotiate the settlement and disposition of serious claims: those who are technically competent with systems, etc. We seek out those adjusters who have come highly recommended by trusted attorneys, successful employees, etc. Experience, capabilities and work ethic are checked with as many sources as possible. The dedicated supervisor will have a minimum of Live (5) years' experience. Paee 35 • Be approved by all of the City's excess carriers; USIS is approved by all of the City's excess carriers with the exception of State National. USIS has not had any issues getting approved by excess carriers and expects to be approved by State National. • Be compliant throughout the life of the Agreement and must be compliant at the time of proposal submittal, in Statement on Auditing Standard No. 70 (SAS70)/ Statement on Standards for Attestation Engagement 16 (SSAE16); USIS undergoes an annual SSAE 16 audit (formerly known as SAS 70) and is currently in compliance with all items. A copy of the report can be provided upon completion of an executed contract between USIS and Sarasota County Schools. Please reference Attachment 8 - SSAE 16 excerpt. • Have a minimum of five (5) continuous years of experience, handling Florida municipal claims, with at least one (1) client having a minimum of 1500 employees: USIS has provided Florida public entity claims services for more than (5) continuous years to Bay County, Palm Beach County Sheriffs Office, Orange County Public Schools and Volusia County Public Schools, the latter 3 who have in excess of 1,500 employees. (current clients) • Be in full compliance with the federally -mandated State Children's Health Insurance Program (SCHIP) and Florida Electronic Data Interchange (EDI) requirements; USIS reports all claim data to the State of Florida via electronic data interchange (EDI) according to and complying with the standards of IAIABC current requirements. Claim forms are transmitted to the State daily. The adjusters review the State forms the next business day in the online data warehouse. Any rejected forms are resubmitted immediately. USIS has not had any major deficiencies or issues with State audit compliance. USIS currently provides CMS reporting in compliance with MMSEA I 1 I . This reporting is identified for Medicaid (State Benefits) and Medicare (Federal Benefits). Currently there are no guidelines or directives for Medicaid reporting. but we are reporting to CMS for Coordination of Benefits Center (COBC) for those individuals receiving or likely to receive Medicare and/or Social Security benefits. Our system contains a COBC' CMS module that allows for direct data reporting for the Section 11 1 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA). • Have electronic capabilities to provide electronic reporting, transfer of data to any/all platforms as directed, and connectivity to Proposer's information system; USIS has the capability to provide and to receive electronic data to any/all platforms as directed by the City. • Have no record of judgments, bankruptcies, pending lawsuits against the City, criminal activities involving moral turpitude, and not have any conflicts of interest that have not been waived by the City Commission; and USIS has not been party to lawsuits, administrative actions or litigation related to fraud, theft, breach of contract, misrepresentation, safety, or wrongful death. However in the normal course of doing business related to workers' compensation claims handling, USIS was made party to litigation related to the servicing of workers' compensation claims (5) on behalf of its clients. All but one was resolved in our favor. and that one is recent and still pending. 36 Brown & Brown, Inc. (the parent of USIS, Inc.) is publicly traded on the NYSE, is regularly subject to suits and claims that arise in the ordinary course of its business, and is required by law to make periodic filings with the Securities and Exchange Commission, which are publicly available and which contain additional information concerning legal matters. In the normal course of doing business related to workers' compensation claims handling, USIS has been occasionally named in individual suits, however has not been found at fault or apportioned liability. • Not be in arrears or in default of any debt or contract involving the City (as a party to a contract, or otherwise) nor have failed to perform faithfully on any previous contract with the City. This requirement applies to Proposer's principals, officers, or stockholders, USES and Brown & Brown, Inc., USIS' parent company, are not in default on any contract or financing agreement with any bank, financial institution or other entity. USIS is unaware of any team member that is in default on any contract agreement or financing agreement with any bank, financial institution or other entity. 25. Provide projected caseloads per employee of Proposer assigned to City account. Lost Time adjusters will handle a maximum case load of 160 claims and the Medical Only adjuster 350 claims. To maintain the caseload below the maximum, USIS would move non -litigated Lost Time files not receiving indemnity payments to the Medical Only adjuster. The Liability adjusters will have a maximum caseload of 160 claims. Caseloads are monitored via weekly claim count reports — system -generated for claim supervisors and managers. The City can access this report through USISiNet. This report is a tool that allows the supervisor to make case load adjustments as necessary. 26) Describe Proposer's staffing plan to demonstrate that Proposer can be adequately staffed with trained personnel to handle the City's full caseload and have the capability to recruit such staff. USIS proposes to provide a dedicated unit with (1) Work Comp Supervisor and (6) Work Comp Adjusters (5 Lost Time and 1 Medical Only). The Liability Unit will have (1) working Supervisor and (2) Liability Adjusters. The designated Workers' Compensation Claims Manager will also manage the USIS Florida Independent Unit. USIS is experienced in recruiting and adequately staffing large accounts in a short period of time. In late 2014, USISIAmeriSys was awarded the State of Florida Medical Management contract. Within a 2 month period USIS/AmeriSys hired and trained approximately 70 employees. 27) Include a statement that at east thirty (30) days prior to replacement of key personnel, Proposer will notify the City's Project Manager, in writing, that replacement employees will possess qualifications and experience equal to or greater than personnel being replaced. USIS will notify the City's Project Manager at least thirty (30) days prior to replacement of key personnel. in writing, that replacement employees will possess qualifications and experience equal to or greater than personnel being replaced. 28) Provide a detailed timetable identifying significant milestones for the smooth transition of the operations. Proposer shall identify the necessary support that shall be required from City staff during that transition. USIS recognizes that the Transition Plan is an extremely important and complex process and therefore we have created an attachment to reference each phase of the implementation plan. Please reference Attachment 9 — Transition Plan. Page 37 29) Discuss in detail exactly how all services reflected in the Scope of Work will be accomplished. Include a complete approach Proposer will take to meet all responsibilities expected of Proposer by the City. Include any and all information regarding affiliated physicians, other medical personnel, locations to provide said services, and other related information regarding the provision of such services for the City. Our goal is to keep the employee at work (Stay at Work). But if that is not possible, the adjuster and the City of Miami will work as a team to facilitate a quick return -to -work in a modified/transitional duty position, taking into account reasonable accommodations, as soon as a release to return to work (RTW) and restrictions are received. We have numerous customers with Stay -at -Work or Return -to -Work (SAW or RTW) programs in place. We can assist the City with designing and implementing a SAW or RTW program but in reality this must be "your" program. It is essential that there is buy -in from the City of Miami at the top. The number of employees and job positions available overall within the City has a great deal to do with the program design and efficacy. USIS prides itself on customization of programs to maximize utilization management. It begins with ensuring compensability of the injury and the treatments being prescribed are related to the reported injury. Once that has been determined, then all measures are taken to return the injured employee back to gainful employment. Is the disability time in accordance to ODG standards, if not, why? Questions are posed to the Authorized Treating Physician (ATP) regarding functional limitations rather than blanket off work statements. This allows employers to maximize modified duty positions by focusing on what the injured employee can do, rather than what they cannot do. All ATP's treatment requests are compared to evidenced based guidelines. It is our goal to have and maintain an excellent rapport with the provider community. USIS utilizes peer to peer contact to help resolve any issues regarding. medical necessity. It is in this way we ensure a strong relationship with the provider community that understands the intentions and goals of the City to provide an expedited and safe return to work for its employees, thereby lowering costs. While the primary treating physician's treatments are compared to evidenced based guidelines, so are ancillary services such as therapies and diagnostics. USIS has put together a panel of preferred ancillary providers. These organizations have been put through a stringent process that includes providing services in accordance to evidenced based guidelines and performance guarantees to ensure the guidelines are being adhered to. Finally, our bill review process involves high levels of technology to allow for the deepest discounts that are compliance with state statute and rule. USIS prides itself on proactive claims management in a team approach with the injured worker, the employer, and medical case manager if applicable. Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. An efficient claims system allows for effective claims administration. Software from leading vendors within the Workers' Compensation and medical management field, supplemented with programs and components developed by in-house programmers, provides an environment tailored to the special needs of the client. Page 38 • Employers have online access to all claim information through database and document utilities. • Support services include all up-to-date office management tools • Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as intemet or VPN • 1n-house programmers are able to develop customized reports where special client needs exist • Claims data is available via the USIS website for use in client spreadsheets, word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure, state-of-the-art web portal warehouse. All claim data within the system is viewable online and able to be downloaded into an Excel format directly from the website. Features include First Report of Injury reporting; check registers; loss reports; all account and injured worker statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall costs and to provide cost- effective solutions best suited to the client's situation. Our service commitment is to make our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes- Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the telephonic case -managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case - manager (when assigned) and cost containment. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. Ongoing Claims Management Supervisors will review claims after the initial review, every 30, 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness of reserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may become litigated. The supervisor will also review the quality of all documentation, paying close attention to the medical documentation to ensure that a treatment plan is in place. that the employee is compliant with appointments and testing and that the adjuster has a current action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 days will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. Page 39 The adjusters are well trained on when to recognize when a case is deteriorating and are instructed to control these claims as quickly as possible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Utilization Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with the injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee. to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to full duty, restricted duty, and the employers' ability to accommodate the injured employee's restrictions. USES is acutely aware that an employee's status cannot remain at modified duty for an indefinite period of time. The treating physician is routinely asked to identify the injured employee's progress as it is related to the decreasing of functional limitations. Issues such as the decreasing of weight lifting restrictions are tracked, documented and communicated to the employer. When a failure to progress with limitations is noted in comparison to the guidelines, the treating physician is asked to address this area in the treatment plan, and a physician advisor may be called upon to opine on the situation. Catastrophic or large losses seldom occur but when they do they have a chilling impact on claims expense. Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and burns. These claims are complex from beginning to end. Rapid response in claims investigation, assignment of Catastrophic Case Management Providers and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. AmeriSys, our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized many times on large and catastrophic claims bringing the City of Miami the experience. when necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to maintain the highest degree of compassion and service to that employee and his/her family. Page 4( Liability The claims adjusters are responsible for providing thorough, accurate, timely communication and advice to the City in order to resolve any and all claim related issues. The claims adjuster will handle all cases professionally in order to assure a mutually beneficial resolution in a timely and cost effective manner. The handling ot'the claims will involve, but not be restricted to: A) Initial investigation to determine liability. 13) Investigation to determine the damages. C) Identify and pursue any and all third party (subrogation) possibilities. D) Establish, monitor and assure the accuracy of any reserves. E) Notify the excess carrier of any claim that is catastrophic or has excess potential F) Adhere to all recommendations provided through the claim review process. G) Prepare and manage all litigation. H) Adhere to the timely filing of any and all legal documents. I) Close all files as deemed appropriate on a timely basis. It is policy that all reported claims will be investigated to fullest extent warranted, The adjuster will perform the investigation to include all available information from the claimant, the account, witnesses, medical providers and experts if warranted. All determinations of liability and the damages owed will be made in accordance with the laws The adjuster will perform all investigation warranted including obtaining information from the claimant, the account. witnesses, medical providers and experts. The adjuster will gather documentation and obtain any estimates needed to properly evaluate the claim. This will include but not be limited to: 1. Recorded statement where warranted by liability and / or damages. A summaty of this statement should be included with the tape. 2. Verification of any physical injuries will be made. With any claim involving a physical injury, a medical release form will be obtained. 3. The police and incident reports will be obtained on all claims. 4. The fire department reports will be obtained on all property claims. 5. Photographs will be taken on all property claims. Photographs will be dated and carry a description. 6. Estimates and/or appraisals will be obtained on all automobile physical/property damage claims. Photographs will be obtained on all automobile claims. Page 4I 30) Provide a description of the standard Toss reports, as well as provide a sample and descriptions of any additional reports to be utilized. There are several types of loss reports. Loss reports can be generated by policy year, accident year, detailed version, summary version, by claim type, claim status, by an employer, or a particular location. Employer reports can be exported to Excel and to .PDF. Below is a list of other reports to be utilized, but not limited to: i. Check Registers (Payments) 1. Full Detail (By Individual Check/Transaction) 2. Totals by Year 3. Totals by Unit ii. Employer's Reports (Claim Payment, Reserve, Incurred Totals) 1. Full Detail (By Claim with Claim Details) 2. Totals by Year 3. Totals by Unit 4. By Policy, Accident Year, Employer b. Claim SummaryReports c. Reserve Reports d. Payment Histories e. Interactive Grids exportable f. Clain Lists g. Presumption h. Litigation Please reference Attachment 5— USIS Sample Reports. Page 42 31) Explain whether Proposer currently file state and excess insurance forms an behalf of Proposer's clients, and attach copies of the forms used. USIS has a designated Excess Adjuster who is responsible for the reports to the excess insurers. She is assigned to report all claims meeting the criteria to the excess insurers. The handling adjuster refers the claim to the Excess adjuster who in turn files the initial report and all follow up reports based on the reporting requirements regarding frequency as set forth by the excess insurer until the conclusion of the file. Quarterly loss runs are provided to each excess reinsurer showing all claims reported with paid to date, reserves and total incurred noted for each claim. Access to these reports can be obtained from the USIS website if needed on a more frequent basis once a username and password is requested and obtained by the excess insurer usls ExcessC,fnee Feral Repod pusslael: C4 mad. ' °' RR a:.,,rlHcurtentE: _ Emrka9nr. Paicy Period: Came Clam 1: ,nor. ofAcvdc.J.a, C4t,mane Inlom.ogn :w,0ro401'0n / SOF Pis&bekrr.s :e4a! I PTO as • k W: Expected RTW dal*: CR Anaves Balance Pare to Data Total mdair lfedcxlal Ex} w.e Led..: Torsi Ofrsetsla Waxen' ComPern:09. R1nabonabo i. Senlmunt C.atibant 1tabatt .y. fea'asa care rmr-=+er.iw `err Oue.tpnWN Claaa W6 SJA . excwdd Cornrrwnla. Cofla01.4ad by. Daft CMS. 1u. PO Bat 616441 Oda.A IL J361-6611 to,Ts..of'J 1,3PS,Ti ANa USIS Excess Carper Supplemental Report Petry Pentad: SIR DOB: S C gem el: Date of Occurrence: Canter clam a: Employer: Polley ATW dace: P7D as el: Expected RIW dace: AWW_ CR: Reserve. Illdell1Pry MFdical .penaa L o-dal Tobb Seisms Paid to Dole Total Oirsels ea Wotan,' Crmpensado. Ranabilliation '.moment Claimant Altumey Questionable Clasp 1 Will SIR be axreelfed Cornnlent5 Completed by Date USES, Tu. PO Box 616615 Orlando FL 3.16I-661S JO':3?..aisJ I.99).9J14W6 a1 rune emenc aR-'emu ...a 1 Pape 4. 32) Describe Proposer's methodology for evaluating and determining savings as expected within this RFP. Include in detail the mechanisms Proposer would use to track whether proposed savings goal has been met, and methods to meet those goals. Indicate if Proposer is willing to accept the incentive or penalty as indicated, should savings not result. To determine the potential savings achieved on behalf of the City, USIS/AmeriSys would first reference our Medical Bill Review Activity reports from 2011.when AmeriSys performed these services for the City. We would also reference performance reports for other clients in the same geographic area. We make every effort to achieve the highest level of savings possible within the Florida Statutes and Rules, while establishing and ensuring rapport within the provider community. We recognize the potential significance of the City's claims due to the occupational hazards the employees possess. Quality physicians must be available to render care. USIS is agreeable to accepting a mutually agreeable incentive or penalty as indicated, should savings not result. 33) If proposed, describe in detail Proposer's computerized on-line claims management system and software to be utilized during the performance of the scope of work reflected herein. Detail functionality, transition from current system, and if a cost is proposed, indicate in Proposer's Fee Proposal. USISiNet is the on-line claims I� Dashboard management system as USIS which will be fully available to the City of Miami. `l¢'° 'Status Tfe a ua 58 Mt There is no charge for access, and it does . -_ i 411 � not require special software. Access is ' granted to users based on authority level and permissions dictated by the client via r� » user id/password. The web portal contains %� * a „ MEW. reports that be directly accessed by the client. 111 • The City of Miami will have 24/7 on-line access to claims information via the USISiNet. The USISiNet is available through the internet requiring no additional hardware or special software. The USISiNet has customizable dashboards which allow for real-time data detailing information that is important to track. Please reference Attachment 4 - USISiNet and .AmeriSvsiNet ,....rs.., ,..Cram„... 1IMt.____-- 11 i l...... M.r_. cr.. The USISiNet provides secured access to claims information, claim notes (including imaged documents), medical bills, financial reports, and more, via individual user security level. New reports can also be requested and will be made available online as needed by the City. Our web interface is a true reflection of our claim system wherein clients have access to all claim data. The City will be provided full access to the financial information of all claims including reserve totals by reserve category, total payments by category, outstanding reserves, total incurred. USIS works along with our in-house application, Risk Manager. Risk Manager is an integrated suite of programs designed for the day-to-day administration of workers' compensation, property & casualty, professional liability, and general liability claims. It is an Internet capable, multi -state, client -server application designed to maximize performance in high volume environments. It is supported by a Microsoft SQL database and a .NET platform. Our in-house staff uses ERIC and the transactions are available real-time on our web portal. Our team of programmers have experience with data conversions and are prepared to transition from the City's current system into our Risk Managers Database. As part of the transition, we ensure that all transactions are successfully converted to a test database, all documents are available, and all financials are fully balanced. 34) Detail any procedures, equipment, and/or costs necessary to connect with the City's hardware and software, particularly related to conductivity with Risk and Finance, at the time of this RFP and should the City's system be modified or replaced during the Contract term. Should there be associated costs; indicate those costs, the reasons for the same, and who will pay those costs. Costs, if any, shall be detailed in the Fee Proposal Section. Data interfaces are implemented as a means to connect to the City's system. There is no need for additional hardware. Interfaces are normally done in the form of data transfers uploaded/downloaded to a Secure FTP that USES will to provide. If the City changes system, USIS would be prepared to assist in the process by making any modifications necessary to the interfaces. There should be no cost associated. 35) Estimate Proposer's minimum start-up time from date of contract award to the date Proposer's network would be available to Risk Management. What specific requirements does the Proposer have to initiate set-up, and please explain any additional costs involved. USIS ideally requests 60 days minimum start up time from date of contract award to the date USIS' network would be available to Risk Management. USIS will submit a conversion, implementation plan which includes a list of required data elements for conversion. • Initial Load of Electronic data files matching all file layouts • Claim/ claimant demographics • Claim Detailed historical reserve / payment transaction • Claim notes data file/ attachments thru • EDI & CMS 111 Data • Claim level loss runs • Any other Files • Bill Review / EOB History Data In addition, please review Attachment 10 — Implementation Cheek List. 36) Explain any options which the Proposer's system has that will permit the City to generate reports from, and to make direct inquiries into the Administrator's data base by on-line access. Proposer must clearly identify in its Proposal the costs of providing any special conversion systems, license and software costs for accessing the system, and the party(s) responsible for the payment of those costs, if any. (Costs shall be fully detailed in Fee Proposal Section). The City will have access to generate reports from USISiNet at their convenience, along with having the ability to make direct inquiry in various areas of the web portal. There is no cost for this service and no special software. The only requirement is a web -browser. Page 45 37) Provide sample reports describing information such as type of accident, accident site, department, date and time, cause of accident, injury, and part of body. Proposer shall describe in detail any safety/loss control reports that are provided by the system, and shall submit a listing of the variety of claims reports available, and provide sample copies of formats that may be requested by the City. The USISiNet application houses multiple printer -friendly stock and custom reports as well as data dumps into Excel format, all on demand, 7 days a week 24 hours a day. We currently staff 7 in-house programmers who can create client -defined purpose -specific reports or data extracts in a client -specified format. USIS can accommodate numerous report types as part of our web services site. Our user friendly site allows you to pull reports straight to your printer or download claims data directly to your PC. There is no special license or software to run these reports. They are part of the USISiNet portal. Please reference Attachment 5 - USIS Sample Reports. 38) Provide the methodology and list of allocated or anticipated expenses to employ outside professionals such as surveillance, rehabilitation, experts, attorneys and others to assist in the investigation and adjustment of claims. During the course of a claim the adjuster will need to employ outside professionals to obtain information that will assist in moving the claim closer to closure. Examples of items that would be allocated to the claim file, though not an exhaustive list, would be as follows: # Index Bureau Reporting 4 Surveillance Vocational Services # Court Reporters # Medical Records # Legal Services # IMEs # Expert Witnesses # MSAs The City will be responsible for payment of these additional costs. # Transcripts # Investigators # Translation Services for legal proceedings Life Care Plans Page 46 39) Provider shall provide its most recent audited certified business financial statements (or unaudited if audited is not available) as of a date not earlier than the end of the Proposer's preceding official tax accounting period, together with a statement in writing, signed by a duly authorized representative, stating that the present financial condition is materially the same as that shown on the balance sheet and income statement submitted, or with an explanation for a material change in the financial condition. A copy of the most recent business income tax return will be accepted if certified financial statements are unavailable. Please reference Attachment E — Brown & Brown, Enc. Annual Report. f own & ro=n INSURANCE; ROBERr w. LLOYD ..:set -nave ticePresicie.0 et General Counsel Daniel J. Alfonso City Manager City of Miami 444 S W 2"`I Avenue Miami, FL 33130 Brown & Brown, Inc. 220 South Ridgewood Avenue (32114) P.O. Box 2412 + Daytona Beach, FL 321 t.5 386/252-9601 • FAX 386/239-5729 Direct Line: S 3861 239 5752 • 11OO 877.2769 t•:xl. :. Direct Fax: (386133h."_: November 18, 2016 Re: USIS, Inc. - Request for Proposal Dear Mr. Al fonso: Pursuant to the RIP request. USIS, a subsidiary of Brown & Brown, Inc., provides its current financial statement on www.bbinsurancc.com. In addition, we have provided you with Brown & Brown, Inc.'s most recent Annual Report. This will confirm that the present financial condition of the company is materially the same as that shown on the balance sheet and income statement submitted. if you have any questions, please contact me. Sincerely, Robert W. Lloyd RWL/slp Page 47 Fee Proposal 40) Submit a guaranteed, all-inclusive annual fee as previously detailed in Section 2.17. This fee shall represent all claims, administrative, and loss data fees, and shall be guaranteed annual fees for the initial three (3) years, and the two option to renew years, as opposed to per claim time and expense or any other fee proposal. Proposals not containing an all-inclusive guaranteed annual fee for three (3) years, and the two option to renew years, for all specified services, will not be considered. The pursuit of subrogation and recovery from the Special Disability Fund is to be included in the Proposer's Annual Fee. Clearly indicate any charge not included in the proposed annual fee. Please reference Attachment BI Claims Administration Price Proposal. 41) As the City is interested in a program which will generate savings over the current expenditures in the workers' compensation area, the proposed fee structure should address the mechanism for achieving a minimum of 15% net savings with an escalating incentive bonus for savings that exceed the minimum and a penalty for a shortfall in the desire net savings. USES is agreeable to accepting a mutually agreeable incentive or penalty as indicated. should savings not result. 42) Submit a separate quote(s) for existing claims, and a separate quote(s) for prospective claims; pricing on a "per claim" basis for both existing claims and prospective claims, and a breakdown of the cost between lost time vs. medical. In addition, provide a per claim cost vs. flat dollar cost. Include any other charges not included in pricing. Price Proposal must contain rates based on the "life of relationship basis," namely for those prospective claims, and the City's inventory of open files. Provide separate quotes for the assumption of prior claims and for prospective claims commencing on the commencement date of the Contract. USIS is not prepared to offer a quote on a per claim basis due to the size and complexity of the City of Miami's Claims Administration Program. Please reference Attachment BI Claims Administration Price Proposal which includes Life of Contract pricing. 43) Include any relevant services or products that will be provided to the City which are not priced in Proposer's Proposal, but which will enhance the acquisition process. If USES / AmeriSys is selected for both Part I and Part II, USIS will provide our BADGE and SECURE programs. It is our assumption that the City has first responders/badged officials that are in your employment which experience presumption and cardiac claims. Please reference BADGE Program Attachment 2 - Cardiac - Exposure Protocol. We believe that the Heart/Lung public presumption claims represent one of the most significant economic exposures to closing claims and the anticipation that most of those claims will deteriorate as the employee ages. David E. Perlotf, MD, FACC, FACP, is the AmeriSys BADGE Program Cardiac Medical Director. He has many years of experience in Cardiology and over 10 years of that in dealing with workers' compensation related to the Heart/Lung Presumption Bill. It is also our assumption that the City has injured employees who are prescribed opioids. Please reference Page 48 Attachment 3 - innovative Programs for information related to the SECURE program. AmeriSys has developed unique protocols and criteria for managing these complex and cost -driving claims. The program's goals are to improve/enhance return -to -work outcomes, reduce disability duration; prevent unnecessary, dangerous and costly consequences of inappropriate or prolonged utilization of opioid medications while reducing the costs of handling pain management claims. It is this position and approach of innovation and efficiency that characterizes our organization. Whether it is unique types of claims, unusual working conditions or locations with special information needs, we strive to customize our program to address those unique and individual needs. Our commitment to innovation and efficiency is also coupled with 30 years of proven experience in providing cost effective and quality -oriented medical care management. It is the careful blend of innovation with proven, tested experience and success that allows for the best in functional and economic outcomes. USIS stands ready to work with your leadership team to identify, develop and implement a program that is best suited to your claims and informational needs. 44) Indicate the cost, if any, of assuming prior claims and data conversion and whether it is a one-time charge or an annual charge. include in Proposer's proposed price, costs for the provision of an enhanced system and for the conversion of any data necessary. There is no additional cost beyond that proposed in Attachment Bl Claims Administration Price Proposal. 45) Provide a performance guarantee (may be negotiated with the City). USIS is agrees to negotiate a mutually agreeable performance guarantee with the City of Miami. 46) Provide any, and all additional costs, item by item, as identified by Proposer, in any other area not previously discussed herein, and detail what those additional costs, if applicable, would entail. Include whether Proposer, or the City will be responsible for payment of those additional costs. Examples of items that would be allocated to the claim file. though not an exhaustive list, would be as follows: 1 Index Bureau Reporting + Surveillance / Vocational Services 4 Court Reporters 1 Medical Records -+ Legal Services / IMEs 1 Expert Witnesses $ MSAs The City will be responsible for payment of these additional costs. l Transcripts 4 Investigators 4 Translation Services for legal proceedings 1 Life Care Plans Pay*: 49 ATTACHMENT A Supplemental Proposer Questionnaire ATTACHMENT A SUPPLMENTAL PROPOSAL QUESIONNAIRE Proposer shall respond to each Section in its entirety, in the same format presented. A copy of Attachment A may be requested in Word Format. 1. INFORMATION ABOUT THE PROPOSER Please include the following in your response: I . Demonstrate your expertise and experience in claims handling that would relate directly to the City's operation. USIS, Inc. is a full service Third -Party Administrator (TPA) providing specialized, client designed, professional service programs for All -Lines Claims Administration as well as Medical Management Systems/Programs and Loss Prevention Services and Programs. USIS. Inc. has been in business for 34 years and was established in June of 1982 as a division of Brown & Brown, Inc. USIS has always been a technologically progressive company, as well as progressive in the development of programs for our clients and their injured workers. We are a regional TPA and Medical Management company that is diverse in the size and type of the clients with which we work. We are large enough to handle Workers' Compensation programs such as the State of Florida and State of Georgia. but also have smaller sized clients such as the City of Cocoa. We believe in a customer -centric model in which we will customize our services to meet the City of Miami's needs, values and culture. We will meet with the City during the transition phase to develop customized protocols and systems that will lead to quality care for your injured workers in a cost effective manner. USIS has a team of 8 programmers who are continually developing systems to meet the needs of our customer- partners. The USIS web -portal. USISiNet, has customizable dashboards which allow for real-time data detailing information that is important to track. The web portal also has an analytics module that will allow for detailed analysis - an important tool in the tracking and trending of your workers' compensation program. The USISiNet provides secured access to claims information, claim notes (including imaged documents), medical bills, financial reports, and more, via individual user security level. USIS will meet with the City during the transition phase to develop customized dashboards and reports that will assist the City to best manage its Claims Administration program. Please reference Attachment 4 — USISiNet and ArneriSysiNet for screenshots of the customizable dashboards and reports. Pagc 50 USIS/AmeriSys has been proactive in developing specialized programs as the Workers' Compensation landscape continues to change. Below is information on three programs that have been developed to give additional cost containment benefits while providing excellent medical outcomes. The SECURE program's goals are to improve/enhance return -to -work outcomes, reduce disability duration; prevent unnecessary, dangerous and costly consequences of inappropriate or prolonged utilization of opioid medications while reducing the costs of handling pain management claims. (Not included in the flat rate fee due to the specialized nature and costs associated with the SECURE proQ_Tain ) AmerzSl's 4C The AmeriSys 4C mission is to provide exceptional care in a cost-effective manner to severely injured or critically ill employees. USIS/AmeriSys will ease the burden of cost and management in dealing with these very challenging claims on behalf of employers and carriers. * BADGE AmeriSys developed a medical team and program approach in addressing the uniqueness and special needs of handling "Presumption" claims of the "Heart and Lung Bill". This program also addresses the exposures addressed in the bill. Please reference Attachment 3 — Innovative Programs for information related to these programs. We have a history of becoming a seamless part of our customers' programs, sitting as advisors on their Boards, serving on their select committees and otherwise being recognized as part of their own organizations. When we are able to earn the trust and confidence of our customer partners, we are best able to assist them in identifying, designing and implementing systems and programs allowing them to more effectively meet their objectives and missions. Our partnership with contracted ancillary vendors is to ensure quality of service is being rendered following evidence based clinical guidelines along with competitive pricing for our customers. Every ancillary vendor is accountable to follow performance guarantees that focus on the delivery of quality medical care while using utilization review processes when needed to address medical necessity of requested treatment. By using the ancillary vendor network, we are able to capture cost savings, compliance with performance guarantees for services rendered, and compliance with billing practices. Our system is integrated with our PBM provider, myMatrixx. This integration allows the adjuster and Nurse Case -Manager real time access to injured workers' information, along with tools needed to control pharmacy costs. The USIS/myMatrixx partnership has existed 10+ years since the inception of myMatrixx. Together we have provided quality medical management and pharmacy services to customers in the entire south-east region. USIS/AmeriSys and myMatrixx, through their relationship, have joined forces to face multiple challenges in the Workers' Compensation arena, and currently we are working together on the AmeriSys Pain Management initiative called SECURE. The Vice President of AmeriSys is currently a member of the myMatrixx pharmacy and therapeutics committee which establishes the general protocols and formularies for this PBM. Please reference Attachment II — myMatrixx. We understand that the services we would be providing on your behalf are for your employees, your colleagues, and very often friends. We recognize that we must treat each injured employee with respect and genuine interest in his/her well-being and recovery. We do this while also making sure that we protect the financial and human resources that are paid for by the hard earned tax dollars of your city's citizens. We have a stewardship obligation and commitment to the injured employees and the City of Miami. Page 51 2. List all external providers/vendors your company's partners with to provide adjusting, managed care, bill review, or other required services on an ongoing or occasional basis. Describe these services and the exact relationship between your company and those providers vendor. Liability Claims Administration Preferred Governmental Claims Solutions (PGCS) A Brown & Brown Company Since its founding in 1956, PGCS Claim Services has provided claims administration for public and private entities, carriers, and trusts. SIU Company Command Investigations, LLC is the preferred provider of Surveillance, SIU & Anti -Fraud Programming to P&C Carriers, Self -Insured Entities and Third -Party Administrators. Command is not a traditional vendor...but rather a strategic resource and committed investigative partner. Command has successfully blended the most sophisticated technology platforms with the finest staff to create a unique combination that leverages man, woman and machine. Their founding principles remain consistent with our 20 years of investigative experience: • Consistently deliver the best service and results ■ Develop. maintain and nurture rewarding customer relationships ■ Maintain a healthy, challenging, rewarding and fun work environment ■ Identify, develop and mentor new Command employees • Utilize and employ the finest technology available • Operate as a profitable and socially conscious business Managed Care External Providers: Preferred Provider Network USIS/AmeriSys is proposing DimensionComp for hospital and provider access, the AmeriSys Preferred Provider network for ancillary providers, and myMatrixx as the Pharmacy Benefit Manager. In addition to using DimensionComp as the primary network due to its South Florida specific geography; USIS/AmeriSys is prepared to offer the Coventry Preferred Provider network, which is a national provider, as a wraparound network to DimensionComp to capture the claims that do not fall within the primary network. USIS/AmeriSys employs a Director of Provider Services who will work closely with the City, DimensionComp, the adjuster and the case -manager. The Director of Provider Services will make recommendations as to what outcomes would be monitored as well as work with the City to determine the criteria that are important. DimensionComp is an affiliate of Dimension Health, Inc. DimensionComp provides clients access to the one of the largest Workers' Compensation networks in South Florida. By maintaining strong relationships with the provider community, DimensionComp is able to offer clients superior network savings and greater access. Coventry Health Care Workers' Compensation, Inc. Coventry provides clients access to the largest national provider network offering in the workers' compensation industry. By maintaining strong relationships with the provider community, Coventry is able to offer clients superior network savings and greater access. Page 52 Pharmacy° Benefit Nlana2er USIS/AmeriSys contracts with myMatrixx for PBM services. Matrix Healthcare Services, Inc., d/b/a. myMatrixx, is a full -service pharmacy benefit management (PBM) and ancillary services company focused on workers' compensation. Please reference Attachment 11 — Overview of myMatrixx PBM Services. The AmeriSys/myMatrixx partnership has existed 10+ years since the inception of myMatrixx. Together we have provided quality medical management and pharmacy services to customers in the entire south-east region. USIS/AmeriSys and myMatrixx through their relationship have joined forces to face multiple challenges in the Workers' Compensation arena such as the escalation of the need for cardiac medications (BADGE Program), and currently we are working together on the AmeriSys Pain Management initiative called SECURE. The Vice President of AmeriSys is currently a member of the myMatrixx pharmacy and therapeutics committee which establishes the general protocols and torrrularies for this PBM. Ancillary Network Access AmeriSys Preferred Provider network • The AmeriSys Preferred Provider Network is made up of a select group of vendors to perform the services referenced below. • Every three (3) years AmeriSys undergoes a very detailed RFP process for Ancillary Medical providers that include transportation, translation/languages, Physical Therapy, Diagnostics, Horne Health and Durable Medical Equipment. These organizations undergo due diligence and are then contracted. Contracting includes indemnification for customers. insurance coverage verification as well significant discounting for services. We believe this provides our customers with the best protection at the best price, creating best value. Page 53 AmeriSys Preferred Provider Network Spreemo Spreerno provides a diagnostic network through the AmeriSys Preferred Provider Network Orchid Medical Orchid Medical provides a Diagnostic, DME and Horne Health network services through the AmeriSys Preferred Provider Network Streamline Streamline provides a diagnostic network through the AmeriSys Preferred Provider Network One Call Care Management / Align Networks One Call / Align provides Diagnostic, DME and Home Health network and Physical Therapy services through the AmeriSys Preferred Provider Network Priority Care Solutions Priority Care Solutions provides DME and Horne Health network services through the AmeriSys Preferred Provider Network Speakeasy Translation & Transportation Speak Easy provides Transportation and Translation network services through the AmeriSys Preferred Provider Network ProCare ProCare provides Transportation and Translation network services through the AmeriSys Preferred Provider Network JNJ Services J&J provides Transportation and Translation network services through the AmeriSys Preferred Provider Network intrepreters Unlimited Intrepreters Unlimited provides Transportation and Translation network services through the AmeriSys Preferred Provider Network SPNet SPNet provides Physical Therapy services through the AmeriSys Preferred Provider Network Therapy Direct Therapy Direct provides Physical Therapy services through the AmeriSys Preferred Provider Network DentalWorks USA Dental Works provides dental network services through the AmeriSys Preferred Provider Network. NuQuest Bridge Point NuQuest provides Medical Set Aside services (a Brown & Brown, Inc. company) Field Case Management AmeriSys hires independent FCM subcontractors under the direction of AmeriSys' FCM Supervisor. All subcontracted FCM's are contracted to adhere to the standards of quality set forth by AmeriSys. Physician Advisor Services for UR Dane Street, LLC Debbie Hill, MSN, RN, CCM, Director of Account Management 891 Centre Street • Boston, MA • 02130 951.5413,1627 561.206.0659 (fax) dhill(a`.danestreet.com www.daneStreetcom Dane Street provides Workers' Compensation Peer Reviews to Managed Care Organizations, Third Party Administrators, Utilization Review Organizations and Employers. Licensed in all mandatory UR states, with an active Regulatory and Compliance group which interfaces with the appropriate State workers' compensation Boards and Departments of Insurance, Dane Street is a URAC-accredited review organization and the reviews are delivered according to all URAC, jurisdictional and client requirements. They understand the importance of state -specific medical treatment guidelines, turnaround times, match requirements —and track any changes across these categories in their rules -based PeerAccess platform. Page 54 3. List all external providers/vendors/governmental organizations your company has electronic data systems interface with. Describe the system interface in detail. USIS reports all claim data to the State of Florida via electronic data interchange (EDI) according to and complying with the standards of IAIABC current requirements. Claim forms are transmitted to the State daily. The adjusters review the State forms the next business day in the online data warehouse. Any rejected forms are resubmitted immediately. USIS has not had any major deficiencies or issues with State compliance. Additionally, USIS has electronic system interface with: • All ancillary vendors where we receive electronic bill records for adjudication and payment. and provide a file in return with the detailed data. • Several of our clients where we send/receive the following: claims data, bill data, electronic documents (.pdf, and tiff tiles), eligibility files, case notes, and more. Some of these clients include the State of Florida, Broward County, Palm Beach Sherriff s Office, City of Jacksonville and more. • We currently have interfaces with the following RMIS platforms: Risk Master, Stars, Origami, IVoss 4, Fully describe how your company perceives that your company's claims administration services differ and set your company apart from your companies' major competitors. Although USIS is located in the Greater Orlando area, USIS services many clients throughout Florida. We work with employers in the City of Miami area including State of Florida employees. The Claims Manager has worked at USIS for 28 years, most of this time handling self -insured public entity accounts. Terri is extremely involved in ensuring a culture of excellent customer service throughout the department. Terri and many of the adjusters have worked with Volusia County and Orange County school boards for over 20 years, taking great pride in their long term successful relationships. The adjusters handle each claim as though it is their money being spent. They live up to our motto -Service Beyond the Contract', and exemplify our s7'' E! campaign in the day to day claims handling process. S UPERIORITY T IMELINESS ESPONSIVENESS I NITIATIVE V IRTUE E NERGY BE BETTER THAN OUR COMPETITORS PROVIDE PROMPT CUSTOMER SERVICE SHOW SENSE OF URGENCY GO ABOVE AND BEYOND MAINTAIN ETHICAL COMPASS DEMONSTRATE PASSION AND ENTHUSIASM SERVICE BEYOND THE CONTRACT Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. Page 55 An efficient claims system allows for effective claims administration_ Software from leading vendors within the Claims Administration and medical management field, supplemented with programs and components developed by in-house programmers, provides an environment tailored to the special needs of the client. • Employers have online access to all claim information through database and document utilities. • Support services include all up-to-date office management tools • Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as internet or VPN • In-house programmers are able to develop customized reports where client special needs exist • Claims data is available via USISiNet for use in client spreadsheets, word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure, state-of-the-art web portal warehouse (USISiNet). All claim data within the system is viewable online and able to be downloaded into an Excel format directly from the website. Features include First Report of Injury reporting; check registers; loss reports; all account and claimant statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall insurance costs and to provide cost-effective solutions best suited to the client's situation. Our service commitment is to make our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional, superior service: with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management when required as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the TCMs work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case -manager (when assigned) and cost containment. AmeriSys also has contracts with PhysicianiHospital networks as well as Ancillary Providers (Physical Therapy. Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City's overall economic outcomes. Employee Performance Management System Staff performance evaluations are done quarterly and annually. The Core Values of the company are 'graded' on a quarterly basis, along with Key Performance indicators relative to each position. A more in-depth performance evaluation is also done annually. Of course, any time more training or direction is required; it is handled at that time. USIS promotes a team atmosphere in which employees can talk freely with members of leadership. Employees are encouraged to openly discuss with their Department Leader any issues so that appropriate action can be taken. Page 56 5. Provide a list of your company's current client within the public entity sector. USIS has over 30 years of experience working with Florida governmental entities. Public entities make up 30% of USIS total clients. Our extensive experience with public entities such as, city and county governments, tire and police districts, school districts, and two state governments provide us with unique experience and expertise to handle the City of Miami's Workers' Compensation program. USIS currently provides services to the following Florida governmental entities. Client Services Provided Bay County BOCC WC Claims TPA Medical Bill Review Broward County BOCC Intake / Triage Network Access Medical Bill Review City of Cocoa WC Claims TPA Medical Bill Review City of JacksonvilleMedical Network Access Bill Review Medical Only Claims Handling * * on an as needed basis Orange County Public Schools WC Claims TPA Medical Bill Review Medical Management Palm Beach County Sheriff's Office WC Claims TPA Medical Bill Review Medical Management Preferred Governmental Insurance Trust (200+ governmental members) Medical Bill Review Medical Management State of Florida Intake / Triage Medical Management Volusia County School Board WC Claims TP Medical Bill Review Medical Management Georgia Columbus Consolidated Government * WC Claims TPA Bill Review Managed Care Organization State of Georgia (DOAS) Triage Managed Care Organization *Reference Attachment 12— Risk and Insurance, Revitalizing the Program - Teddy Award Winner Page 57 PGCS currently provides services to the following Florida governmental entities, Client Brevard County BOCC Services Provided Liability Charlotte County Liability City of Delray Beach Liability City of Kissimmee Liability City of Naples Liability City of Titusville Liability Leon County BOCC Liability Leon County School Board Liability District School Board of Pasco County Liability Preferred Governmental Ins Trust Liability Page 58 6. Provide details including a brief summary and status of any pending claims, or lawsuits involving your company and/or its' subsidiaries, which may affect performance or bring about negative publicity for the City. USIS/AmeriSys has not been party to lawsuits, administrative actions or litigation related to fraud. theft, breach of contract, misrepresentation, safety, or wrongful death. However in the normal course of doing business related to workers' compensation claims handling, USIS/AmeriSys was made party to litigation related to the servicing of workers' compensation claims (5) on behalf of its clients. All but one was resolved in our favor. and that one is recent and still pending. Brown & Brown, Inc. (the parent of USIS, Inc.) is publicly traded on the NYSE, is regularly subject to suits and claims that arise in the ordinary course of its business, and is required by law to make periodic filings with the Securities and Exchange Commission, which are publicly available and which contain additional information concerning legal matters. 7. Provide a copy of your company's current SSAE 16/SOC 1 & SOC 2. USIS/AmeriSys receives an annual SSAE 16 audit and is currently in compliance with all items. A copy of the report will be provided upon completion of an executed contract between USIS and the City of Miami. Please reference Attachment 8 — SSAE 16 excerpt. AICPA SOC Org/sas 70 as 2. CLAIMS REPORTING The City desires Internet reporting capability, FAX, and a twenty-four (24) hour, seven (7) days -a- week, telephonic claims reporting service. Demonstrate your company's ability to meet the following criteria, detail how your company would meet the requirement, and any qualification or stipulation that applies to any response for the following: 1. Ability to answer a call routed from the City provided 1-800 number dedicated phone line with a customized the City script. USIS is able to have/provide a dedicated 1-800 for the City and it will be customized with the desired City script. 2. Capability for Internet, phone, and fax reporting. For your convenience, claims can be reported several different ways as outlined below: * Call a dedicated 1-800 Number and verbally report the claim to our intake specialists * Email a completed report to ciaimreporting(cr)usis-tpa.com * Report the claim on the web (with secured access) * Fax a fully completed first report to 407-352-5788 Below is a screenshot of claims reported by an individual through the USISiNet web portal. Page 59 Recently Reported Claims (Reported by Me or Others, Last 90 Days) - oar Of Fa7rr6a 1 MOM/ wt< rumple impry Canna/ 10 !T iaar6a bF 1MMO WY C Laan 10 iv alfir u hal N ET 7 L 11,h) 52111 Errlar2d 213311/222 FL 11 16 t NiPM [Amin <42E..Li 11:1fj 1 26PM FL 11,15120PM FinaF; Eli 217211n 11.:5122P2.1 FL 11,16 11 210.1 F111aItl.d Gt74.71 11:15 72 4Gr r4 FL 11 a 16 10 33A1.1 6nnraa 11125N1 I I. Va 10 5311,7 GA 11061011A144 F12214 22 TROPICS 1' 'h "I 3SM1 FL 11;16211hM Enlarge TROPICS 1 7I16 2 I IAM SC 111i153 NW Flna6229 rd1122 11;16 11 %9AM FL 11:1.i 1 14PM F,nalIL1 2543.1 111 Recently Reported Claims (Reported by Me, Last 90 Days) WC22223,1 Mow, Qli•••asri ID Mamma / ST 622•226 aM 012212,2 MAMA 221112r elan 1p MOOD 6rlrrna 3 sT 622•226 ay SDP.3 Deems ODD 22.2(62 3. Ability to utilize tape feed for: a) The City employee information and demographics, via secure FTP in the reporting system using employee ID. USIS has the ability to transfer via secure FTP, the City employee information and demographics, using employee ID. USIS is able to create reports for the City to retrieve this information if desired. b) Receive tape feed via FTP of the City (or related entity) vehicle information with the ability to look up vehicles by VIN, Tag or the City Number. USIS is able to receive and implement a data feed for the vehicle information. Reports, grid, and/or dashboards can be created to look up the vehicles, by VIN, Tag, or the City Number. c) Ability to provide the City immediate contact upon the receipt of claims involving certain criteria to be established by the City. During the implementation phase USIS and the City of Miami will establish Special handling instructions that would allow the City to be contacted immediately for claims involving certain criteria. Pale 6° 4. Ability to electronically send claim data to adjuster and nurse, no later than two hours after entry/receipt of claim, by any of the reporting methods outlined above. Upon receipt of the FROI, the supervisor and adjuster are automatically notified via diary and triggers of receipt of a new claim for review and handling. An email can also be submitted as an alternate method of notification to adjuster, nurse, supervisor, and anyone requiring to be notified. This system includes external system codes and allows for multiple levels of reporting. These location/employer records are an integral part of the FROI and claim creation process. The system will also capture the received date for claims reported to USIS. 5. Ability to provide automatic First Reports of Injury via e-mail, immediately after system entry to the City designated recipients. USIS has the ability to automatically send the First Report of Injury via e-mail to the city's designated recipients based by the injured workers' department or location. The City will receive a notification email with the claim assignment, and NOI attached. Immediately the claim will also be available on the USISiNet. 6. Ability to customize the intake screen to automatically inform the interviewer of the location's physician panel or recommended injury clinic, so the interviewer can inform the caller (Note: The City may wish to contract separately with a Preferred Provider): a) Ability to automatically notify the City regarding reserve updates that breach the Administrator's reserve level. USIS has the ability to create custom dashboards that allow for triggers. Reserve triggers can be setup up where notifications can be sent. b) System that can accommodate the use of form letters composed with input from the City. USIS would be able to add any letters from the City in our Claims Systems. c) Capabilities to provide various scheduled reports along with custom client -defined reports. Reports can be scheduled and delivered via our web portal to each user. d) Client access to create ad -hoc reports and standard reports. The USISiNet Portal provides various interactive grids that allows the client to filter the data and move it around. This would allow the City of Miami to create ad -hoc reports and export it to any format desired. e) Ability to customize data fields as per the City requirements. Via the USISiNet web portal, the City will be able to select which data fields appear on a particular grid or report. 7. Describe your company's technology infrastructure for your company's first report system (claims intake, database management, application language, hardware, telephone, switch, etc.). Risk Manager V6R7 from ERIC Systems in Seattle, Washington -- Risk Manager is an integrated suite of programs designed for the day-to-day administration of workers' compensation, property & casualty, professional liability, and general liability claims. It is an Internet capable, multi -state, client -server application designed to maximize performance in high volume environments. It is supported by a Microsoft SQL database and a .NET platform. Risk Manager is a real-time design, meaning that there are no posting routines required at the end of day or to prepare for end of period reporting. Transactions affect financial totals as soon as the entry is saved. End of period closings can be completed without disrupting daily operations. A web portal is available to clients 24/7 via the USISiNet, which is built on a MS .NET platform and MS -SQL database. There is not a charge for access, and it does not require special software. Access is granted to clients based on authority level and permissions dictated by the client via user idipasscvord. The web portal contains reports that be directly accessed by the client. USISiNet is a highly customizable application that was built to directly meet the needs of our clients and partners. Unlike, the 'out of the shelf" tools, our web portal allows for client flexibility. The USISiNet has customizable dashboards which allows for real- time data that is important to track. The web portal also has an analytics module that will allow for detailed analysis. The USISiNet provides secured access to claims information, claim notes (including imaged documents), medical bills, financial reports, and more, via individual user security level. Our web interface is a true reelection of our claim system wherein clients have access to all claim data. The City will be provided full access to the financial information of all claims including reserve totals by reserve category, total payments by category, outstanding reserves, total incurred. Access is granted to clients based on authority level and permissions dictated by the client via user ID/password. The web portal and our ERIC back -end system are fully integrated in real-time. The claim intake is done on the web portal and once finalized by our processing department, it is then immediately available in ERIC for the adjusters and nurses. Hardware: USIS partners with NEC for its telephony solution. The SV8100 is a comprehensive NEC system which provides the necessary agility for today's ever -changing work environment. It enables USIS to tailor its communication needs to our specific business partners plus have total control over how. when and where you choose to be reached. This is a VOIP system with full redundancy built on the PBX as well as on the Voice Mail systems. In the event of a failure, USIS has the ability to fail over to one of our other redundant systems minimizing any down time. Our telecommunications vendors have a strong partnership which eliminates the need for USIS to deal with multiple vendors in the event of troubleshooting a problem. The SV8100 streamlines communication for the entire organization with its diverse suite of features and applications. It enables individuals, departments and locations to work more efficiently by ensuring seamless internal and external communications. PC Assistant — gives users the ability to manage and operate desktop phones from their PCs; and Softphones — provide convenient, cost- effective mobility for remote employees. Our systems are secured both externally with multiple firewalls and internally with Kaspersky Antivirus and multiple layer security on all software. We operate with tirewalls, routers and server banks at each of our locations that are integrated via MPLS and Metro Ethernet. Our equipment is constantly evaluated and upgraded or replaced as needed and we audit compliance with all software licensing agreements. Our systems operate in Windows platforms with relational databases in MS SQL and Sybase SQL. Wage 62 3. EMPLOYEE/LOCAL OPERATIONS COMMUNICATIONS Excellent employee and customer communications regarding reporting and process requirements, rights under workers' compensation, and recommended primary care providers, are paramount to an effective claims management program for the City. Please demonstrate your company's ability to meet the following criteria, and detail how your company would meet the requirement, and any qualification or stipulation that applies to any response for the following: 1. An effective process and framework for communication supported by state of the art technology. USIS will communicate with the City by phone. email, web portal and in person. During the transition phase, USIS will use a Gantt chart to manage the transition process. USIS uses its RMIS system, ERIC, and Medical Management system, Corrus, to manage the claims process through a diary system. 2. A process to provide and disseminate to the City and its locations, claims reporting media (i.e. posters, telephone stickers, employee cards, etc.,) to best communicate how to report claims under varying circumstances [Would prefer one central number that would accept all types of the City claims]. USIS will provide claims reporting instructions to the City to distribute to all locations. 3. Production and delivery of statutory posters for each location (New locations and changes in preferred providers would require new communications) USIS will produce and deliver statutory posters for each location, 4. Introductory and at least annual continuous improvement meetings with the City coordinated by the designated adjusters USIS agrees to at least an annual continuous improvement meetings with the City coordinated by the designated adjusters 5. Please describe how your company would meet the above requirements, and provide an outline of your company's proposal for communications. The USIS standard is that the adjuster is expected to have continual communication and interaction with the client and injured workers. Information is communicated in a number- of ways, including: system documentation (viewing access available on the USISiNet), phone calls, letters, faxes, diaries and e- mails. USIS will provide weekly and/or monthly standard reports based on client criteria through the USISiNet. Often with large volume accounts, there would be daily communication. Each of our customers has specific preferences for contact. It is our intent and approach to assure that we provide service, and therefore, communication consistent with your organization's needs and preferences. All staff members are trained extensively in our culture, policies and procedures, specific client requirements, utilization of the computer system and various software programs. Our overall philosophy is customer -centric and excellent customer service is trained and re-trained at all levels. The adjusters are educated on client -specific policies and procedures to ensure constant communication with the client on all claims -related matters, as well as the USIS Quality Assurance program and auditing requirements. They are fully familiar with any Return -to -Work policy and procedure emphasizing communication with the customer, and with the medical providers, to assist the injured employees in returning to work as quickly as possible. Page 63 With a reputation borne of commitment to service, our competent team is dedicated to serving our customers. Our focus is on quality, professional. superior service. This service -driven philosophy. conveyed throughout the organization, means dedicated individuals with the client's best interests at heart, constantly reinforcing the corporate mission — Service Beyond The Contract. 6. Outline and provide samples of communication materials your company have that promote and facilitate injury management (i.e. posters, website etc.). All state required literature is mailed to the injured worker upon setting up and throughout the claim. The USISiNet also has a claims portal that provides basic claims information including indemnity payments to the injured worker. USIS can incorporate injury management information into the Claimant Portal upon request. ers' Comp o M4 K A'+xb TT. TIP* 7..atetta Nl6tatNy vises Is 6.2sovo a9)1' s6 owl !a 36.541116 ynvtOct pnveyartaa ty tar PAP....? n' K�aeue wlv.FYrt 6 Artmg TA litr .41.44.4.1.10.14.4.1. at yenna6 oarmaith E/ squalor. from% kietbdlokt otaplowr,* .tW to4-41am .r MI.P..rw.P eS t 41147 Atd FMM 1!J T.. I .wasr/w /am• ro m. a.oar{lmeat wr A IgwePb not A*bNmt u swtl &Nati bar rientriMei.f . R ifa.slytM). A aYrll y+rswl asf6 AftA0N malx. trim! lad lain. 693.4Ma-.F4.0 :' orsra-lsta AT.. Warn 3010 ks 11 you are injured on the job: 1. Notify your employer immediately to get the name of an approved physician. Workers comp insurance may not pay the medical bills if you don't report your injury promptly to your employer. 2. Notify the doctor and medical staff that you were injured on the job so that bills may be properly filed. 3. If you have any problems with your claim or suffer excessive delays in treatment. contact the State of Florida's Division of Workers' Compensation at 1-800-342-1741. mot: �C.E NIA, FER INFORMATION SFiC!`R -ES E Page 64 4. CLAIMS MANAGEMENT The City requires a team approach for quickly establishing and executing an aggressive claims resolution and injury management strategy on each claim. Individual members and The City have roles in reporting and investigating injuries, communicating with employees, claimants, and supervisors, and in returning employees to work. The City expects the Successful Proposer to facilitate a relationship with the City's locations, contacts, and resources and to work with them as a team in the claims management process. The Successful Proposer should understand and subscribe to the City's commitment to best practices and continuous improvement. Please respond to the following requests for information, demonstrate your company's ability to meet the outlined criteria, detail how your company would meet the requirement, and any qualification or stipulation that applies to any response: 1. Provide a flowchart of your company's claims management process, indicating in detail, the flow of information, decision points, supervisor intervention, etc. for all lines of business outlined in Section One. USIS/AmeriSys will develop, in consultation with the City, Claim Handling Requirements for workers' compensation claims assigned by the City to USIS. At a minimum, such requirements will include the Claim Handling Requirements set forth in the RFP. Once developed the requirements will be subject to revision and modification by the parties, provided that no such revisions or modifications are inconsistent with the Contract. Please reference the following Life of a Claim flow chart. Fled Nurse Injury Occurs Report Injury via phone. website, email or fax intake New Claim Maned to Ad{osiers & Supervisor far Handlmg Triage Is Claim Medical Only. Lost Time- Large/Catastrophic? Medical Only urse < t TCM Assessment c sure Of File Mica Only Adjuster fees New Set Ups 24i-lour Contact Inve0t oat,on Compensability Determined File Reviews. Discussion and Drspeerben of Bills Closure Of File Field Nurse T Lost Time Nurse LUR or Precert C losure Of File LT Adi osier 24-Hour Contact tnvestigat.+0n Compensabdity Determined Leioe+Catestrophic Fleet Nurse Evaluation of Reserves - Adjuster & Supervisor Fide Reviews, Ciscussion, and Disposition of BiEls Closure Of File "Field Nurse will be assigned to Medical Only/Lost Time claims based upon City triggers. "Nurse will be assigned to Medical Only claims based upon City triggers. Nurse Achievement of Medical Stability Access needed far Continued FCM Involvement 4 Access Rehabilitation Need Refer to Vocational Rehab Counselor ost Time Adjuster Immediate Contact Inveetigatron Ca crensabay Oetennmed i Evaluation of Reserves - Adjuster & Supervrsar File Reviews. Discussion, and Desposrean of Rift Addressing MMIIPIR, PTO Status. Life Care Plan Coss Projection, Excess Updates and .f applicable. Medicare Set Aside Closure Of Pile Page 65 Our goal is to keep the employee at work (Stay at Work). But if that is not possible, the adjuster and the City of Miami work as a team to facilitate a quick return -to -work in a modified/transitional duty position, taking into account reasonable accommodations, as soon as a release to return to work (RTW) and restrictions are received. We have numerous customers with Stay -at -Work or Return -to -Work (SAW or RTW) programs in place. We can assist the City with designing and implementing a SAW or RTW program but in reality this must be "your' program. It is essential that there is buy -in from the City of Miami at the top. The number of employees and job positions available overall within the City has a great deal to do with the program design and efficacy. USIS/AmeriSys prides itself on customization of programs to maximize utilization management. It begins with ensuring compensability of the injury and the treatments being prescribed are related to the reported injury. Once that has been determined, then all measures are taken to return the injured employee back to gainful employment. Is the disability time in accordance to ODG standards, if not, why? Questions are posed to the Authorized Treating Physician (ATP) regarding functional limitations rather than blanket off work statements. This allows employers to maximize modified duty positions by focusing on what the injured employee can do, rather than what they cannot do. All ATP's treatment requests are compared to evidenced based guidelines. It is our goal to have and maintain an excellent rapport with the provider community. USIS/AmeriSys utilizes peer to peer contact to help resolve any issues regarding medical necessity. It is in this way we ensure a strong relationship with the provider community that understands the intentions and goals of the City to provide an expedited and safe return to work for its employees, thereby lowering costs. While ATP's treatments are compared to evidenced based guidelines, so are ancillary services such as therapies and diagnostics. USIS/AmeriSys has put together a panel of preferred ancillary providers. These organizations have been put through a stringent process that includes providing services in accordance to evidenced based guidelines and performance guarantees to ensure the guidelines are being adhered to. Finally, our bill review process involves high levels of technology to allow for the deepest discounts that are compliance with state statute and rule. USIS prides itself on proactive claims management in a team approach with the injured worker, the employer, and medical case manager if applicable. Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. An efficient claims system allows for effective claims administration. Software from leading vendors within the Workers' Compensation and medical management field, supplemented with programs and components developed by in-house programmers, provides an environrnent tailored to the special needs of the client. • Employers have online access to all claim information through database and document utilities. • Support services include all up-to-date office management tools • Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as interact or VPN Page 66 • In-house prograinners are able to develop customized reports where special client needs exist • Claims data is available via the USIS website for use in client spreadsheets, word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure, state-of-the-art web portal warehouse. All claim data within the system is viewable online and able to be downloaded into an Excel format directly from the website. Features include First Report of Injury reporting: check registers; loss reports; all account and injured worker statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall costs and to provide cost-effective solutions best suited to the client's situation. Our service commitment is to make our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional. superior service: with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the telephonic case -managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case -manager (when assigned) and cost containment. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy. Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. Ongoing Claims Management Supervisors will review claims after the initial review, every 30, 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness of reserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may become litigated. The supervisor will also review the quality of all documentation, paying close attention to the medical documentation to ensure that a treatment plan is in place. that the employee is compliant with appointments and testing and that the adjuster has a current action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 days will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. The adjusters are well trained on when to recognize when a case is deteriorating and are instructed to Page 67 control these claims as quickly as possible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Utilization Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with the injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee, to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to full duty, restricted duty, and the employers' ability to accommodate the injured employee's restrictions. USIS is acutely aware that an employee's status cannot remain at modified duty for an indefinite period of time. The treating physician is routinely asked to identify the injured employee's progress as it is related to the decreasing of functional limitations. Issues such as the decreasing of weight lifting restrictions are tracked, documented and communicated to the employer. When a failure to progress with Iimitations is noted in comparison to the guidelines, the treating physician is asked to address this area in the treatment plan, and a physician advisor may be called upon to opine on the situation. Catastrophic or large losses seldom occur but when they do they have a chilling impact on claims expense. Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and burns. These claims are complex from beginning to end. Rapid response in claims investigation. assignment of Catastrophic Case Management Providers and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. AmeriSys, our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized many times on large and catastrophic claims bringing the City of Miami the experience, when necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to maintain the highest degree of compassion and service to that employee and his/her family. Page ( Liability The claims adjusters are responsible for providing thorough, accurate, timely communication and advice to the City in order to resolve any and all claim related issues. The claims adjuster will handle all cases professionally in order to assure a mutually beneficial resolution in a timely and cost effective manner. The handling of the claims will involve, but not be restricted to: A) Initial investigation to determine liability. B) Investigation to determine the damages. C) Identify and pursue any and all third party (subrogation) possibilities. D) Establish, monitor and assure the accuracy of any reserves. E) Notify the excess carrier of any claim that is catastrophic or has excess potential. F) Adhere to all recommendations provided through the claim review process. G) Prepare and manage all litigation. H) Adhere to the timely filing of any and all legal documents. I) Close all files as deemed appropriate on a timely basis. It is policy that all reported claims will be investigated to fullest extent warranted. The adjuster will perform the investigation to include all available information from the claimant, the account. witnesses, medical providers and experts if warranted. All determinations of liability and the damages owed will be made in accordance with the laws The adjuster will perform all investigation warranted including obtaining information from the claimant, the account, witnesses, medical providers and experts. The adjuster will gather documentation and obtain any estimates needed to properly evaluate the claim. This will include but not be limited to: 1. Recorded statement where warranted by liability and / or damages. A summary of this statement should be included with the tape. 2. Verification of any physical injuries will be made. With any claim involving a physical injury, a medical release form will be obtained. 3. The police and incident reports will be obtained on all claims. 4. The fire department reports will be obtained on all property claims. 5. Photographs will be taken on all property claims. Photographs will be dated and carry a description. 6. Estimates and/or appraisals will be obtained on all automobile physical/property damage claims. Photographs will be obtained on all automobile claims. Page 2. Specifically detail the locations of your company's claim operations that would be handling the City claims, the number of employees in each office, the overall organizational structure of the office, and when the respective offices were established. Home Office USIS, Inc. PO Box 616648 Orlando, FL 32861-6648 Previously operated under L'irlted Self 1nsru•ecd Services # of Employees: 88 Established 1982 US1S management and claim technical teams are composed of high level, dynamic claim and medical professionals. These teams thoroughly understand the challenges related to the unique operational needs of individual clients. Our personnel includes a dynamic and experienced leadership and management team, experienced adjusters in All Lines of claims management, RN medical case -managers and other support professionals to promote efficient, timely and technically -sound claims and medical management. Vice President er tinniness Imegrellan Programmer Anaiyets NC,M9rh Suac:n IS Supervisor Pragrantenoe Analysis Network Supson I CuERVL StL4SA RN VIC. President Amalgam RON WARBLE LeSie �Meanrore EXECUTIVE VICE Executive PRESIDENT A.aislant Admimslrauve Assisl,rm Ranee Ilediul Slanyement urnn Linn Par gars TCMrFCM Suuemesors 1 VLSI/'SCRs IRNsi RTWFICIerical Itallsatean Review Und Manager Serapes UR Speciaksts IRNs) Clerical Support Cott Cdnlainment Supervisor Medical Sill Reviewers MDR Cutter Canlrnller Georgia Magog Idenmgmnsrel tkdl Program Wrsger GA Case Management Rte Supe v or TCMs {RNsj Clerical Support Provider Relations Coordinator Accoumina unit Manage AccaunlinglOC LWhllits 1Jed Claims Supervleor Adjustors Lass Cannel Consultants ware Comp Claim. Unit s1 Marne Menage Clnma llmt Claims Supervisor Adjusters MO Adjuster Claims Clerical Support Team Lead Clerical Suppers HRYAN STR=SMLMI EER Manager guanaco C..®Wpmeal Ware Cora? Clam. uel eg Claim. Manger Claims Lind Claims Supervisors Adjuster. MO Adjuseaes Sulam Llablllly Adjusters NAG FOJRSTER Vlee President OperadaradH m en Resources Work Cramp Ciaimm Linn r3 Vice President Clanrrs Und Claims Supervisors Adjusters MO Ha llen NR Assistant I_ Reccpnnnisls Cledcal Assieland Operations 4dministrauve Assismnt Page 1II 3. Attach a map of your claims offices statewide, and list which offices handle what types of claims (workers' compensation or liability). Confirm if you have any plans to consolidate, reorganize, relocate any of these offices, or any personnel within these offices, to facilitate the administration of the City's claims. If so, please provide details to the extent they are known/available. USIS does not have plans to consolidate, reorganize, relocate any of these offices, or any personnel within these offices, to facilitate the administration of the City's claims. We may engage employees who live within the Miami area to work on this program and telecommute. item Office Workers' Cexppermalsnn and Liabildy Claims 4. Outline normal work hours and workdays, provide a list of your company's holidays, and discuss any optional/flexible work arrangements currently in use in your offices, or contemplated for administering the City's claims. Servicing Office - USIS, Inc. 5728 Major Blvd., Suite 450 — Orlando, Florida 32819 8-5 p.m. Monday to Friday for Customer Service Unit Intake Unit for initial claim report 24/7 Normal business hours are 8-5 p.m. Monday to Friday. The USIS Intake Dept. operates 24/7/365. Upon policy verification, claim information will be entered immediately to the system while the person is on the phone. Claim team contacts will be available for management direction in emergency situations, Direct web claim reporting options are also available. USIS 2017 company holidays are listed below: New Year's Day (observed) Martin Luther King, Jr. Day Memorial Day Independence Day Labor Day Thanksgiving Christmas Day Pate 7I 5. Discuss your proposal for handling emergency issues during and/or after normal working hours, including identifying what personnel, by title, will be involved in those activities. 24/7 staffing -- our claims management team is always available for consultation regarding emergency claim issues after hours. In a case of emergency, a field nurse case -manager would be expedited to the hospital. Account -specific handling requirements are followed. ,fenny Ross will be the Account Executive. She will be the City`s main point of contact for Claims Reviews and Service Issues ensuring a high quality of service and support. Page 72 6. Provide an organizational chart of those persons who would be involved in providing claim services to the City, listing the experience and qualifications of the key individuals who would be involved in the account by title, and identify those specific individuals if they are currently with your organization. All key personnel includes all principals, owners, parties, directors, managers, senior and other professional staff who will perform work and or serves in the specific category of services (Part 1 & II). Proposed Organizational Chart RON WARBLE EXECUTIVE VICE PRESIDENT MICHELLE COTTO Accounting Manager TERRI SNAPP WORK COMP UNIT Claims Manager Supervisor TBD (5) Lost Time Adjusters JENNY ROSS Account Executive (1) Medical Only Adjuste YARIXA ELIASON LIABILITY UNIT Liability Supervisor (2) Liability Adjusters 4rus's w x. F.la ggga I6ajr.u1 VIVIANE RUIZ Vice President of Business Integration IT Department Programmers and Developers Dedicated Designated I',ige 73 Management Experience Ron Warble, Executive Vice President, Ext. 6503 ron.warble a usis-tpa.com Mr. Warble serves as Executive Vice President of USIS and is responsible for oversight of claims. medical management and overall operations within USIS. He has 33 years of experience in the Workers' Compensation arena. He previously owned and managed his own company which was acquired by USIS in April of 2000. That experience has allowed him to develop skills and expertise in many areas and is now being utilized to assist USIS' customers in providing quality and relevant programs on behalf of their injured employees. Additionally, Mr. Warble has had the honor and privilege to serve on the Georgia Chairman's Advisory Council for Workers' Compensation since 2008 and currently serves as the Chairman ofthe Medical Committee in that group. Jenny Ross, Account Executive, Ext. 6302 jenny.ross(ausis-tpa.com Jenny Ross has been in the claims industry for over 20 years. Joining USIS 16 years ago, Jenny has been steadily promoted throughout her career. She started as an adjuster, handling a large volume of workers' compensation claims, conducting client visits and claims reviews; and has become an integral part of our claims management team. Jenny's customer service, dedication and commitment to our clients, along with claims knowledge and analysis, make her a top notch Project Manager. Prior to joining USIS, Jenny was employed at Executive Risk Consultants as a lost time claims adjuster. Jenny was the proud recipient of the 2011 Nationwide Brown & Brown Claims Professional of the Year Award, as well as USIS's Employee ofthe Year in 2007. Terri Snapp, Claims Manager, Ext. 6409 terri.snapp a usis-tpa.com Terri Snapp has over 28 years of experience in the workers' compensation insurance claims industry. Beginning her career as a the clerk with Leatherby Insurance Co., she was steadily promoted within the industry and has been with USIS, a leading Third Party Administrator, since 1988. Terri is currently a Claims Manager with USIS, supervising the work product of over 18 adjusters and supervisors. One key component of her job is dealing directly with clients, a lot of which are public entities, to ensure a high quality of service and support. Her knowledge and experience in the insurance claims industry has been significant in ensuring the continued success of USIS as a TPA. Yarixa Eliason, Liability Supervisor, Yarixa.eliason c?usis-tpa.com Yarixa Eliason has over 20 years of experience in the liability insurance claims industry. Beginning her career in Miami with John's Eastern as a liability adjuster, she was steadily promoted within the industry. She has her all lines adjuster license with experience in handling claims for commercial auto, general liability, employment liability and governmental entities. One key component of her job is dealing directly with public entity clients. Viviane Ruiz, MBA, NIIS/HIS, Vice President of Business Integration, Ext. 3109 viviane.niiz(wusis-tpa.com Viviane Ruiz joined the Brown & Brown team in 2007 and is the Vice President of Business Integration for USIS. She is responsible for an IT staff of web developers, system analysts. database administrators, network administrators, technicians, and computer operators. Viviane has exceptional skills in Project Management and is an excellent liaison between the IS staff and the business staff. She takes pride in meeting deadlines and sets a high priority on quality of work. Viviane is responsible for maintaining current systems, and ensuring the implementation of all state and medical rules guidelines, as well as leading new initiatives and keeping USIS/AmeriSys on the cutting edge of technology. Viviane has a Bachelor's Degree in Computer Information Systems, a Master's Degree in Business Administration, and a Master's Degree in Information Systems with concentration in Health Information Technology. Page 74 Prior to USIS, Viviane had nine years of experience teaching Information Systems as well as business courses for undergraduate and graduate students. She is fluent in Portuguese and Spanish. Michelle Cotto, Accounting; Manager, Ext. 6213 michelle.cotto(ctusis-tpa.com Michelle Cotto obtained a Bachelor of Science degree in Accounting from the University of Central Florida in 2007 and has been with USIS for 7 years. Responsibilities include Sarbanes-Oxley oversight for Accounting and IT environments, oversight of internal controls (SSAE 16), excess reimbursement filing. and interface with excess carrier representatives and auditors. Ms. Cotto's duties at USIS extend beyond accounting; she also leads a team dedicated to quality control and oversees the performance audit of each adjuster. Her department is also charged with the responsibility of maintaining bank accounts for each customer and securing funding from the customers for timely claim payments. TBD Work Comp Supervisor* TBD - Work Comp Adjusters* TBD - Liability Adjusters* Please reference Attachment 7 - Resumes/Licenses, Job Descriptions* Please reference Attachment 1 - Brown and Brown, Inc. Annual Report for a complete list of officers and directors. 7. Describe your structural approach to claim services (i.e. dedicated unit, supervisor and unit manager, whether one adjuster will be assigned for the life of the claim or will the claim transition as the status changes). USIS proposes to provide a dedicated unit with (1) Work Comp Supervisor and (6) Work Comp Adjusters (5 Lost Time 1 Medical Only). The Work Comp Adjusters will be assigned for the life of the contract. The Liability Unit will have (1) working Supervisor and (2) Liability Adjusters. The designated Workers' Compensation Claims Manager will also manage the USIS Florida Independent Unit. 8. Provide the average caseload for your adjusters by line of business. a) Specify the caseload by BI/PD/lndemnity, Medical Only, and Record Only claims;. Lost Time adjusters will handle a maximum case load of 160 claims and the Medical Only adjuster 350 claims. To maintain the caseload below the maximum, USIS would move non litigated Lost Time files not receiving indemnity payments to the Medical Only adjuster. The Liability adjusters will have a maximum caseload of 160 claims. Incidents — Report Only claims are set up in the system as reported, and documents are mailed to the employee and attached in the system; however not assigned to an adjuster unless the employee begins missing time or incurs medical treatment. At that point it is placed on the adjusters/supervisor diary for handling. b) Explain how the caseloads are monitored, noting the frequency with which managers review each level and/or category of claim; Caseloads are monitored via weekly claim count reports — system -generated for claim supervisors and managers. The County can access this report through USISiNet. This report is a tool that allows the supervisor to make case load adjustments as necessary. Page 75 c) State the average number of new claim assignments per adjuster per week/month; and USIS Current Caseload Average Pending Caseload Average New Assignments per Month Lost Time Adjuster 127 10 Medical Only Adjuster 294 152 WC Supervisor WC Supervisors do not handle a caseload d) Provide statistics on your closing ratio and closing lag; USES benchmarks: Lost Time closing ratio - 98% closed at 24 months Liability Closing Ratio — 1:1 9. Provide the average number of cases your supervisors adjust personally. USIS workers' compensation supervisors do not have a caseload and act strictly in a supervisory capacity. managing and directing the claims via supervisory reviews, etc. The Liability Supervisor's caseload will be determined by the number of files the 2 Liability Adjusters are handling at any one time. 10. Provide your current and average adjuster turnover ratio by level of examiner. USIS hires \yell recommended, customer service -orientated individuals looking for long term commitments. We run background checks as part of our oversight to ensure the security of our clients' finances. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards, Our turnover in our claims operation is historically very minimal. Employees like working here! USIS/AmeriSys turnover for the past three years: 2013 17.83% 2014 — 26.36% 2015-21.76% USIS historically averaged turnover in the single digit range. Two factors are driving the increased turnover in the past three years. First, due to the large number of long term employees USIS has had many retirements. Second, USIS/AmeriSys was awarded the State of Florida Medical Management contract and hired approximately hire 70 employees in a short period of time. A large part of our turnover in 2014-2015 has come from turnover on this account - approximately 5% relocation out of state: about 5% personal family issues: some had advancement opportunities that were not available with us in that short period of time, and some were not able to support our high standards and culture of excellent customer service and work ethic. The core group of initial new hires is still with us and exceling. The State of Florida is extremely satisfied with our work and we have maintained at 98% or higher score on the monthly performance standards every single month since January 2014. The Management/Supervisory team (30) has been with US[S an average of 13 years. The Management team (11) has been with USIS an average of 17.6 years. 11. Explain the career path provided for examiners. USIS standard career path. Upon hire, each adjuster will receive our Claims Procedure Manual for review and trainin`r. Experienced adjusters are trained in our culture, policies and procedures, specific cli in procedures, utilization of the computer system and various software programs. Page 76 An entry level claim person would be placed in an assistant adjuster position. He/she will receive training for a Medical Only adjuster position and/or by assisting the adjuster making 3-point contacts, payment of compensation benefits, approving medical bills and tiling State forms. He/she will either already have, or will study for the State exam and apply for the State license once passed. Once the adjuster and supervisor are confident that the trainee has complete knowledge of the job duties, State requirements, office and account procedures, he/she will then move to a Medical Only adjuster position. The time frame varies based upon the individual but does not occur until the supervisor feels confident that the trainee is capable of handling a case load and diary without constant supervision. Promotion to a Lost Time adjuster position will occur after more years of handling litigated Lost Time files with constant active supervision and training. Many of our senior level adjusters (Lost Time) have attained their current positions by internal promotions. Our training is geared to assist the adjusters in making the most prudent and cost effective claims decisions. USIS will hire Lost Time adjusters with 3 -5 years of experience for the City of Miami unit. 12. Provide your current supervisor to adjuster ratio. Outline your protocol for supervisor involvement, including fixed diary requirements. The City of Miami supervisor ratio will be 6 adjusters to I supervisor. Claims are monitored by a diary system by each adjuster and the supervisor. The supervisory reviews include proper reserving. timely form filing, monitoring of compliance with all State regulations and statutes, direction and action plan — all with the goal to successfully return the injured worker to gainful employment and/or settle the claim to bring files to a successful closure. Supervisors will review claims after the initial review, every 30, 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness of reserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may becorne litigated. The supervisor will also review the quality of all documentation, paying close attention to the medical documentation to ensure that a treatment plan is in place, that the employee is compliant with appointments and testing and that the adjuster has a cun-ent action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 days will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. 13. Provide the average years of experience by position. Position Average Years of Experience Account Executive 26 years Claims Managers 29 years Claims Supervisors 27 years LT Adjusters 21 years MO Adjusters 11 years I':rge 77 14. Outline education and experience requirements by position. Position _ _ Experience Requirements by Position Claims Manager7 years of Workers' Compensation claims handling, experience with a consistent high level of performance and achievement. Claims Supervisor 3-5 years of Workers' Compensation claims handling experience with a consistent high level of performance and achievement. LT Adjuster 3-5+ years in a claims environment handling lost time claims including litigated tiles MO Adjuster 1-2 years of MO Claims handling experience in Florida WC law. Please reference Attachment 7 — Resumes/Licenses, Job Descriptions. 15. Outline adjuster diary schedule and requirements. All files/activities must be diaried in the computerized diary system. Diaries must be kept current. These are criteria monitored on supervisory reviews, quarterly scorecards and annual performance evaluations. All incoming mail and new claims (red) are diaried to the adjuster daily. Time - sensitive and any legal material is also monitored by the supervisor. All claim actions are placed on a computerized diary, according to company and client policy and procedure and statutory guidelines. Indemnity payments are placed on a bi-weekly diary. Each indemnity diary indicates the type of benefit (TTD, TPD. PPD), payment period and the dollar amount. The adjuster is responsible for setting PPD diaries to also indicate the number of weeks to which the employee is entitled, with a deduction of weeks each payment is made. This will ensure the correct amount of weeks are paid to avoid under and overpayments. The adjuster also places a note in the system documenting verification of benefits due. 16. Outline ongoing training and development programs. We provide in-house CEU classes on a variety of topics that an examiner/adjuster would handle on a desk. We generally offer 3 to 5 classes per month on law, ethics, fraud, medical terminology, etc. Classes are given by providers, physicians, specialty vendors and attorneys. Some examples of recent training classes include: • Insurance fraud • Knee injuries • Medicare Set Asides • Limiting PTD claims • Shoulder injuries • Case law issues and updates • Brain injuries • Changes to 440 rules • Vocational assessments • Adjuster ethics • Ethical issues of surveillance • MRSA (Methicillin Resistant Staphylococcus Aureus) • Pain management • Dental trauma Page 78 17. The City requests that your company's adjusters participate in periodic meetings with the City, Indicate your company's agreement, Yes, USIS representatives will be available to attend the City of Miami's periodic meetings to perform timely, review of all open cases to establish the status of disabled employees in order to assist in the appropriate action to be taken. 18. The City also requires quarterly loss reviews and periodic claim reviews on categories to be identified by the City. Indicate your company's agreement to these requests and provide any additional charge for these reviews. It is USIS' recommendation to conduct claims meetings no less than once a quarter in person or by phone at no additional cost to the City. 19. The City requires dedicated/designated adjusters with a minimum of three (3) years' experience directed by a supervisor with at least five (5) years' experience. Indicate your company's agreement. USIS agrees to a minimum of three (3) years' experience directed by a supervisor and with at least five (5) years' experience. 20. Provide information and documentation regarding your company's current training program, available to your adjusters to further develop their knowledge base and adjusting skills. Specify what annual requirements your company has for continuing education beyond that required for the maintenance of their licenses. We provide in-house CEU classes on a variety of topics that an examiner/adjuster would handle on a desk. CEUs are available in excess of what is annually required, Training is also provided on industry trends as well as industry issues. We generally offer 3 to 5 classes per month on law, ethics, fraud, medical terminology, etc. Classes, which include webinars are given by providers, physicians, specialty vendors and attorneys. Some examples of recent training classes include: • Insurance fraud • Knee injuries • Medicare Set Asides • Limiting PTD claims • Shoulder injuries • Case law issues and updates • Brain injuries • Changes to 440 rules • Vocational assessments • Adjuster ethics • Ethical issues of surveillance • MRSA (Methicillin Resistant Staphylococcus Aureus) • Pain management • Dental trauma Page 79 21. Confirm your company's agreement to provide the company's claims staff to present and participate at claims workshops, and on -site injury management training throughout the year. USIS agrees to provide claims staff to present and participate at claims workshops, and on -site injury management training throughout the year. 22. The City may request that your company hire specified adjusters who are currently handling their claims. The City will need your company's written agreement that the City and/or any subsequent claims administrator, will also have the option to hire your company's adjusters at the termination of the agreement. Please provide your company's agreement. The City of Miami will have the option to hire the City of Miami Unit adjusters at the termination of the agreement. Regarding the City's request that USIS hire specified adjusters currently handling the City's claims, USIS will interview those adjusters and follow USIS policy. Since USIS will be the employer and USIS/Brown & Brown could potentially be at risk for any perceived liability of wrongdoing in the hiring process, it would not be standard practice to accept an outside entity into our hiring processes. It is our intent to positively ensure that our equal employment opportunity philosophy. in accordance with federal, state, and local law, applies to all aspects of employment with USIS including recruiting, hiring, training, transferfpromotions, compensation and benefits, and termination. At USIS, handled through our own Human Resources Department we must ensure that our employment practices are free of discriminatory practices and that employment decisions are made on the basis of job -related qualifications. experience, including personal competence and potential for advancement. With that stated, we will he open and pleased to strongly consider anv recommendations or referrals of properly qualified staff that the City might provide or request. We will also be willing to share the resumes of the employee(s) hired or transferred internally to handle the City of Miami account. Once into the contract, should there be any staffing changes necessary, USIS would communicate with the City of Miami as soon as known. It should be noted that at USIS we are committed to ensuring equal employment opportunity for all employees and applicants for employment. It is our goal to recruit, hire and develop the best employees using only job -related qualifications. We know that our people are the heart and soul of our enterprise and we recognize that our continued success depends on the full and effective recruitment, hiring and development of the very best employees, taking into consideration only job -related qualifications, regardless of race, color, religion, sex, age, national origin, marital status, disability, veteran status. genetic information and any other category protected by state or federal laws. USIS strives to recognize the talents and job performance of all employees, and values the contributions that come from people with different backgrounds and perspectives. It is USIS` desire to promote an environment that maximizes the potential of all of our employees, and to promote diversity throughout the Company because we believe that diversity is important to our ability to continue to excel in an increasingly diverse and dynamic marketplace. The Company does not permit discrimination or retaliation against qualified individuals with disabilities in regard to application procedures, hiring, advancement, discharge, compensation, training, or other terns, conditions, and privileges of employment. The Company will reasonably accommodate qualified individuals with a temporary or long-term disability so that they can perform the essential functions of a job. A job applicant who can be reasonably accommodated for a job. without undue hardship, is given the same consideration for that position as any other applicant. Page RO 23. Commit that your company's employees, including but not limited to, the adjusters, will return all phone calls within twenty-four (24) hours. USIS Claims Handling Guidelines mandate a return phone call within 24 hours. Emails/written correspondence are to be responded to daily. Supervisor has access to adjuster emails and voice mail to ensure compliance. It would be expected that the adjuster would respond within an hour since he/she would be dedicated to the City of Miami and be in continual communication. USIS has Key Performance Indicators (KPIs) for each adjuster, some of which include the above, and quarterly scorecard reviews are completed to ensure these KPIs are being met. 24. Agree that your cornpany's adjusters will initiate three (3)-point contact within twenty-four (24) hours. Describe how your company currently monitors compliance, and how that monitoring will be done to assure compliance to this standard on an ongoing basis. Provide an example of a management report that measures this requirement. The claims supervisor monitors compliance by running a system report that identities the date of (3) point contact to ensure timely contact. USIS has Key Performance Indicators (KPIs) for each adjuster, some of which include the above, and quarterly scorecard reviews are completed to ensure these KPIs are being met. Upon claim report and set up of claim in the system, the adjuster makes contact within one business day after receipt of the claim. USIS will agree to contact within 24 hours. Contact with the physician and injured worker and defense attorneys, if applicable, are done bi- weekly, or more frequently if the claim/situation demands it. Files are maintained on diary and all contacts are documented thoroughly in the system. The claims supervisor reviews each new Lost Time claim on the day it is received and provides specific written instruction to the assigned adjuster within one work day of receipt. These instructions will assist the adjuster with information to determine compensability, possible "red flags", subrogation (or other offset potential). as well as any jurisdictional or claims management issues. The adjuster is then given a due date to return the claim to the supervisor within 7 days with the initial contacts (3 point contact) completed (within 24 hours) as well as a detailed claim review, thorough investigation, reserve recommendations and if possible the decision on compensability. The supervisor will follow up to verify that all criteria have been completed in a timely manner. Diaries are then set for follow up by the adjuster, the supervisor and the TCM if applicable. If a detailed investigation is needed in order to determine compensability, this is assigned with employer approval without delay. Medical records may also need to be obtained in an expedited manner in order to make a compensability decision within 14 days. Compensability investigations begin by reviewing the facts of each case. i.e.: • Was the employee injured while performing his regular duties within the course and scope of his employment'? • Did the injury occur on the employer premises? • Idiopathic? • Are there any pre-existing conditions? • Is the injured worker a "repeat claimant"? Page 8I The adjuster will obtain most of this information during the initial 3 point contact. If further investigation is needed in order to make a decision, recortaed statements may be taken. If USIS/AmeriSys recommends a denial of the claim based on the investigation results, the adjuster will discuss the claim and request approval of denial from the City. The City will have final authority to determine if the claim should be denied. If the City approves the denial recommendation, USIS/AmeriSys will so notify the injured worker by DWC-12, and inform the City. The following is an excerpt of the 3-Point contact from our Procedure Manual: • PROMPT initial contact — within one business day. Verify SSN and Date of Birth. Each attempt needs to be thoroughly documented in system notes. ■ Employer - Obtain all the details on the accident including subrogation potential and witnesses. Find out what type of employee he/she is. Inquire about light duty availability. • Employee - Details of the accident, any prior workers' compensation claims, auto accidents or other injuries. A detailed medical history is vital to determining major contributing cause and compensability of the claim. Explanation should be given to the employee to notify the employer when released to Tight duty to determine if suitable employment is available within the restrictions. (Contact must be done within 24 hours) • Medical provider -- Contact with the medical provider to obtain a DWC-25 to document the diagnosis, prognosis, work status and future treatment plan. Explain that all authorizations should be approved by USIS/AmeriSys. A file is exported and sent to ISO at the initial indemnity payment; any report received is scanned to the claim file which diaries the adjuster. The adjuster has the ability to request an ISO search at any time. Contact with the physician and the injured worker and defense attorneys, if applicable, is done bi- weekly or more frequently if the claim/situation demands it. 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Provide your company's definition of a BI/Indemnity case and Medical Only case. Detail how, and when, a Medical Only claim would escalate to an Indemnity case, and any fast track claims handling alternatives. Once a claim escalates from a Medical only to an Indemnity claim, advise how the City is able to see, and track the change. Incident Only is any claim wherein the injured worker returned to work with no time missed from work and did not receive medical treatment. This is for Report Only purposes; no adjuster is assigned. Medical Only is any claim wherein the injured worker did not lose more than 7 days from work and is treating for medical. Indemnity is any claim wherein there is lost time from work of 7 days or more, or a Medical Only claim reaches S5,000.00 in medical expense. We may also classify a claim as Lost Time if there is a need for investigation to determine compensability, or the claim is litigated, regardless of lost time. Once a Medical Only claim reaches S5,000 in medical expense it is transferred to an indemnity file. It would also be transferred should the IW start to lose time from work and lost days exceed 7 days. The claim would also be transferred to lost time in the event it becomes litigated. An event is created and the City of Miami would see the claim reclassified on the web portal. A case note is also created documenting the change, which is also available for viewing in the portal. 26. Describe the current subrogation process. Provide sample reports of how your company monitors subrogation/SITF activity and recovery. We carefully evaluate any and all subrogation possibilities and follow the claim to ensure the best recovery possible. Subrogation activities and recoveries are reported in the system. The supervisor monitors subrogation/SITF activity through the RMIS system diary. USIS handles Subrogation claims in-house. The First Report is reviewed by the supervisor to identify any third party involvement on the claim. The supervisor will note this on his/her instructions to the adjuster in the system. The subrogation adjuster places the file on diary for review and initiates the investigation process. The initial review involves a thorough review of all volumes of the claim, including the claimant's recorded statement and other investigative material obtained. The adjuster monitors the file for liability or comparative negligence. Upon determination of these, the adjuster prepares a Subrogation package (all parties placed on written notice by certified mail) to submit to tort for recovery. The employer may agree to hire its own attorney to protect and enforce its lien, or it may hire the employee's attorney to also represent its lien interests, as long as the employee gives his/her consent. The selection of counsel should be decided on a case by case basis. Subrogation recoveries are important at USIS; with a Subrogation Specialist Adjuster on staff pursuing recoveries for the best possible outcomes for its clients. The claims adjuster will identify the potential for subrogation information gathered in the initial investigation of the claim, during which time contacts are made and available documentation such as police and medical reports are obtained. If the initial investigation indicates possible third party liability as a factor in the loss, the claim will be referred to the Subrogation Adjuster for further review, and if subrogation potential exists, lien letters will be sent by certified mail to the appropriate parties. The claim will be placed on a diary so that contact is maintained with all parties in regard to the status of our subrogation and applicable timelines. Success is determined when all Page 84 parties reach a consensus as to the amount of our lien recovery, with the Subrogation Adjuster pursuing a maximum recovery in line with statute and case law, or by settling the Workers' Compensation claim with the incorporation ofa full or partial wavier of the lien. In negotiating the lien recovery, the option of settling the Workers' Compensation claim is often a factor. In some cases, subrogation can be most effectively utilized by agreeing to waive all or part of the lien in return for a reduced settlement amount in the claim. USIS will ask for the City's consensus in pursuing subrogation. Recoveries are reviewed, logged and prepared for entry by the Administrative Assistant and then entered to the system by the Accounting Dept. After entry. an Exception Register is run to verify that the recovery check was entered properly. Recovery checks are then forwarded on to the attention of the designated representative at the client's location for deposit to the client's bank account. Each month, the Exception Register is reviewed by the Accounting Manager to verity all recoveries received have been entered properly. An Exception Register is sent monthly to the designated client representative detailing the recoveries received for that month. In addition, a copy of the recovery check and any supporting documentation is saved in the system claim file. Date: Adjuster: Subro Referral (Please note urgency of referral if settlement is pending) Claimant Name: SSN: Address: File Number: IClaimant Open ❑ Closed ❑ Date of Accident: Fund/Carrier: Employer: Details of Accident/Loss: At Fault Party Name: Address: Insurance Company: Address: Third Party Attorney: (if applicable) Address: Police Report: ❑ Attached ❑ Ordered Other Report / Outside Investigation: Paid to Date: Indemnity: $ Medical: Comments/Remarks: Pale 85 Date: Adjuster: Subro Changes (Please note urgency of change if settlement is pending) Claimant Name: SSN: Claimant Address: File Number: Open: • Closed: ❑ Date of Accident: Fund/Carrier: Employer: **Sabra Changes (please list changes below): New Attorney Additional Ins info Pending status of settlement Police Report: U Attached Other Reports / Outside Investigation: Paid to Date: Indemnity: Medical: Comments/Remarks: 27. Describe your company's current process for identifying claims having fraud potential, including your company's process for referring those claims for investigation. Describe the parameters of that investigatory process. Describe how these claims and their related investigations are monitored, the parameters, and any proposed changes to that process for monitoring this activity and its performance. Provide sample reports. Our adjusters are well trained in recognizing `red flag' indicators. If the adjuster suspects any fraudulent activity, he/she would contact the City to discuss and make reconnnendations for further investigation, such as surveillance or recorded statements. Claims would be assigned to a third party for surveillance documentation and/or further investigation. All suspected fraud would be pursued to the fullest extent available under the law, At the City's request, an attorney (City choice) will review all potential fraud cases. SIU assignments will be made upon approval from the City. The adjuster submits a complete copy of the file to the Fraud Division with the States Attorney's Office for review to determine if the State w ill pursue action. The adjuster continues to have communication with the State Attorneys' Office regarding further action or activity. Page 86 Subject to client approval, all new claims are sent through ISO search to determine if there were any pre-existing accidents and/or injuries. A new ISO search is done on an annual basis to ensure that any intervening accidents are noted as long as the file remains open. 28. Describe your company's quality assurance policy and procedures, Provide copies of your company's current policy. Include: (Sent to Ken) a) Internal Quality Control processes and current reporting designed to monitor Quality b) System prompts requiring supervisor attention c) Criteria for supervisor intervention related to QA deficiencies d) Criteria for measuring adjuster performance e) Discuss reports addressing Quality issues and proposals for improvement USIS is dedicated to ensuring quality control reviews measure timeliness, accuracy and compliance within a cost effective program. Internal audits done on a monthly basis ensure that claims handling processes and procedures are being followed on a day to day basis. II applicable, an action plan for improvement is written by the claims supervisor to address any necessary items. Claims are reviewed by the Supervisor on diary to ensure the quality of the adjusters' work and adherence to the USIS quality control standards and client -specific protocols. File reviews are also done by the USIS Quality Control Department. The Supervisor reviews are to ensure adjusters are working the claims appropriately and to provide direction/guidance to the adjuster as necessary. If an issue is identified the supervisor will address with the adjuster and place on a follow up diary to ensure it has been handled. The adjuster will have continuous contact with Risk Management. If there are any issues they will be resolved immediately. It will be the responsibility of the Account Executive, Jenny Ross, to identify and resolve any issues brought forth during the project duration. The Account Executive has been responsible for multiple large clients and is experienced in dealing with and resolving any issues. She will be accessible to the City by keeping the lines of communication open. USIS strives for an excellent customer service relationship. If there are any concerns, they will be immediately handled. Our goal is to build and ensure excellent rapport between our staff and the City's for a superior working relationship. The Account Executive will remain fully involved in the day to day claims handling process in order to ensure that all critical decisions being made by the staff are in the best interest of the City and its injured employees. Any concerns will be discussed with Risk Management as needed. The following describes USIS' quality assurance and account management processes. QUALITY ASSURANCE of claim files is monitored by the Quality Control Analyst, a licensed adjuster, under the direction of the Accounting Manager, Every quarter, the Accounting Manager gives the QC Analyst a list of adjusters for claims audit, The selection is rotated to ensure all adjusters are audited throughout the year. Claire files are audited for compliance with company procedure and State rules and regulations — monitored by the QC Review Form. The outcome of these audits is reviewed by the Accounting Manager, Claims Managers and Supervisors and submitted to our corporate internal audit staff as an internal control established for Sarbanes- Page 87 Oxley compliance. A Quality Control Survey is initiated to all employees by the Accounting Manager every month to comply with Sarbanes-Oxley protocol ACCOUNT MANAGEMENT PROGRAM: The claims will be handled by a Lost Time adjuster and a Medical Only adjuster under the review of a supervisor and manager, according to USIS Policy and Procedure, State rules and regulations, and client protocol. Claims are monitored by a diary system by each adjuster and the supervisor. The supervisory reviews include proper reserving, timely form filing, monitoring of compliance with all State regulations and statutes, direction and action plan — all with the goal to successfully return the injured worker to gainful employment and/or settle the claim to bring files to a successful closure. Internal quality control audits are performed on a regular basis; internal auditors verify controls placed in operation and test for operating effectiveness and that claims are handled per policy and procedure; audits are performed by the State for compliance with rules; external audits are performed by excess carriers and clients — all to verify proper claims handling. 29. Please provide a copy of your company's claim handling practices (Best Practices). These Best Practices should at a minimum, include your company's standards on: a) Initial Contact (3-point on WC and Auto); b) Recorded statements, including scripts that have been designed for various types of statements to be taken; c) Claim Investigation; d) Scene Investigation; e) Follow-up Contact, including requirements for all parties; f) Diary requirements and requirements for the completion of claim strategy/action/resolution plans; g) SITF/Subrogation; h) Indexing; i) Reserving practices; j) Explain your reserving philosophy, policies, and practice. (i.e. ultimate probable exposure v. worst case); k) Outline the specific deadlines applicable to appropriate reserving; I) Describe any reserving software or modules that are used; m) Describe how you identify and report reserving performance and overall trends; n) Confirm if reserves are set on Medical -only files; o) Outline your company's controls to achieve consistent and appropriate reserving among various adjusters. Describe how your company's monitor reserving performance and overall reserving trends; p) Medical Management; q) Pre-Settlement/Settlement procedures; r) Confirm your company's agreement to obtain settlement authority prior to any settlement; s) Confirm your company's agreement to provide the City with a reserve advisory/consult on all claims that have a reserve set at $25,000 or greater or are changed/increased by $25,000 or greater and category claims with quarterly updates; t) Confirm your company's agreement to submit the proper filings to all required states on the City's behalf; u) Confirm your company's willingness to allow the City to select and/or approve defense counsel; v) Confirm your company's agreement to allow audits by the City or consultants with appropriate notice. Outline your company's audit protocol; Page ES w) Confirm your company's willingness to provide regular stewardship/report cards to the City measuring your company's performance on their services and outcomes of their services. Provide a sample stewardship report; x) Confirm your company's agreement to adhere to the City's Client Service Instructions, and to adhere to your company's claim handling Best Practices with the City's Client Services Instructions, taking a primary position to any of your best practices; Following is an Excerpt from our Procedure Manual: • PROMPT initial contact - within one business day. Verify SSN and DOB. Each attempt needs to be thoroughly documented in system notes. • Employer - Obtain all the details on the accident including subrogation potential and witnesses. • Employee - Details of the accident, any prior workers` compensation claims. auto accidents or other injuries. A detailed medical history is vital to determining major contributing cause and compensability of the claim. Explanation should be given to the employee to notify the employer when released to light duty to determine if suitable employment is available within the restrictions. • Medical provider - Document the diagnosis, prognosis and future treatment plan. Explain that all authorizations should be approved by USIS. Request copies of any medical documentation to substantiate payment of benefits and treatment. If claim is Lost Time, the following should be done: • Initiate payment of indemnity benefits • File First Report of Injury with the State within 21 days. • Send Benefits letter along with appropriate attachments to the claimant • Send wage statement request to the employer • Determine if case has subrogation potential. if so, complete Subro Referral form in system and forward to Subro Specialist (email). Copy to file, copy to Accounting Mgr.) • Set appropriate diaries (future indemnity payments, etc.) • If investigation is needed (and denial is not to be filed immediately) andlor compensability is questionable; send WC-3 to claimant, State Board of Workers' compensation and assigned Field Adjuster for recorded statements and investigation. • Set appropriate reserves for potential exposure, according to client specifications • ALL the above to be documented in the system The supervisor/manager monitors the FROI handling to ensure compliance with the State timeframes. If claim is Medical Only, the following should be done: • Make contact with the employer to verify return -to -work date and whether working/paid at full wage. Please reference Attachment 13 - Claim Handling Practices and Liability Claim Procedure Manual. A copy of USIS, Inc. proprietary Claims' Manual can he provided upon completion ()fan executed contract between USIS and the City of NIunni. Page 8') 5. LITIGATION MANAGEMENT USIS agrees to utilize the City of Miami's selection of counsel. As requested, USIS, Inc. has a relationship with the following South Florida law firms: Miami, Florida West Palm Beach, Florida Kip Lassner Christian Petrie Cole, Scott & Kissane, PA Conroy Simberg/West Palm Beach 954.343.3901 Office 561.478.6034 Lizette Francisco Francisco/Blanco, P.L. Alison Schefer 305.444.8336 Adelson, Testae, Brundo, Novell & Jimenez Stephanie Robinson 561.402.8924 Conroy Simberg Hollywood Office 954.518.1328 1. Confirm your company's agreement to notify the City of all legal dates including hearings, trial dates, settlement conferences, deposition, etc. with enough advance notice to allow attendance if desired. USIS agrees to no notify the City of all legal dates including hearings, trial dates, settlement conferences, deposition, etc. with enough advance notice to allow attendance if desired. 2. Confirm your company's agreement to maintain a litigation calendar to ensure all deadlines are met. USIS agrees maintain a litigation calendar to ensure all deadlines are met. The litigation calendar triggers a creation orlitigation diaries to ensure that actions are scheduled. 3. Identify whether your company's claims handling system can generate alerts to internal and external persons related to specific deadlines. Yes, our claims systems generates alerts in the form of Diaries, creating Action items with deadline for different requirements. Reports for overdue diaries are also auto generated and reviewed by users and supervisors to ensure timely of action items completion. Litigation management occurs within the claims system, following policy and procedure of the company and any client requirements. The Litigation screens within the system are utilized for handling and monitoring all litigation practices, e.g. with receipt of a Notice of Appearance denoting the plaintiff counsel of record, our claims system "Litigation screen" is completed with the name and contact information of plaintiff counsel. Defense counsel, when assigned, is also noted on this screen as well as the date assigned to track lag days from date claim is received until date assigned to defense. All litigation paperwork that is received is attached in the claims system and a color coded diary is set for the adjuster and supervisor. It is the adjuster's responsibility to timely respond to all pleadings, and the supervisor will also set a "legal" diary to ensure that this is being done timely. All legal proceedings are noted on the docket of the litigation screen and the system will alert the adjuster of the upcoming legal proceeding via an alert from the claims system to ensure the adjuster is prepared. There are system triggers and alerts, some pre-set system -wide. There are automated features to assist the adjuster related to litigated claims. If an attorney is entered to a screen, an Alert subsequently pops up every time that claim is opened. There is also a litigation flag that stays red in the default screen. There is also the ability to run reports related to litigated claims based on specific criteria. There are specific procedures in place for legal documents that are scanned to the claim tile with specific note and subject types, diaried to the adjuster and supervisor. r'agi 90 4. Describe and provide examples of the periodic status reports your company will provide to the City online/via a -mail. To establish the proper and most accurate reserve the adjuster completes a reserve worksheet that breaks down into 4 categories — Indemnity, Medical, Other and Legal. At any time the medical or legal changes the adjuster reviews for any necessary changes that will either increase or decrease the reserves. A Claim Summary report is completed on selected files for a claims review. The Claim summary report provides the employees information, employment information including AWW/CR, description of injury, reserves (paid to date and total incurred) and a detailed summary of the claim along with a plan ofaction. Litigation Report Sample RESERVE WORKSHEET Pane I RR Own • I EMerpa dire'+ TOT.LLAV0I"NT OF RESER%T5 Cc( REAMD REAR'ism) S:.0,0'd4 ram,x r .: LNDE.LNTT.- - tP.00a at iaow ITO . ma.CR 1 � ......._ .� r,la•C7t 1to f.nP0 fa . wa i } ° , Ph1. rs sea �r aar. WI I : rr Sew : 0Pr .dot onto rs [wren+ t-9n ar; .-.;.I 0 'Ett Cot (RRLO TOJ.Ii. ON MEDICAL I SMamil aa.. u 3.e. tl'att Meecal +Ad s. y.•1 MV+a lr..I.3I nt ksomell 141SSi9f tit. . C7etk. iNXIW II%Id, OM M0,3715 OF 01'. ICY L...r.... iL..." :Ie..0`A I tawp00 pt dmw. impyprt¢ NES1 TOTAL ENCCIWIL 13 t91690 93 _ .VIwdaY 19wc .r..wr0e«,r.a.• `t tti.'Yl9y 5FE 't1fE 10DnrAPE 45 AVM COST finatcliCer DETAL ATTACHED EXPENSE Pan to damn 'Mt, -a Crrrrau MarradW E' 'T Fans. 5700 Orr OUTSIDE ASS NAM= { S45A i sukws0G.N. f ofktps ClrmaOa ..- __ NEW 101AL WCORREa.I.. rbi'Jf30� LEGAL: Palle dire _.. 00 Corm laraeredl 1.Yi0al . 1Nr00o RAJ — "SE FEES TO DRAW A T31PL1 tom 1005.M %PM Chomp t 93 NEW TOIAl WARRED I REAM/CC roarp.0unen. weMpTe Ion She is rr0aat Tint halnm rare Met 'heapr. A. planar...duad0a ae,branat. Iepan dial tbeceermon S_.p0:)0 memidr. Dunn4 ow preparation arewml Iwamwroded new reared nv coin' lake 5.60.33. IO .tap at aye Our meat*. Far um writ One rwnei clam mei aa. RESERVES EsDf 1LNT(7: 1.DL.LNf/1..41 11011t1 ER THE LNDE.I0TI% COMPF_NSA IC€TtM(' AL RI m etf reared RN. R•reerd NOR 09:140' let it She back and hip d has. math Dr ➢eeekt far Pane mahatma.' belsrrlt-tithr. lea back pant. Ceamen ro ett mearkf, r.+1.1 an. thee. awl pi exra.4io+le allured not Llr attempt. ieante; the clout Ian n.ateuar nab Dr. Doadet damn mt.'' remittent et. we lot .Meth, rw wave a .15.4, at to poo0 cf CMS mrmein and we art net paint hat indemte.' to weer.n that pnmaarot 14 sear+ math el 1r.a.Brt i iS"3.74.eeek 'S ate Derv. Ile npenan and IV -moo ptopo.al will folon ear. n atna men I, ha,.d en the MAMMA+ aormamh Me roman char EV ALT tttON WE REtO.LHLND TO.SILO( TIUEt1RREN1 MOMENT .45 PART OF t PCrsSIBLE 011ICH EQUALS If DION RATE. 11E RECOSEIIIN J JILLCi.ATE% ELLS Rr< trap W7LERE TO PA1 r: UAW F40N, WE OF ONE 41ONT11 OF RENEFTTS THIS ALLOCATION'S FOR FUTITIE .W.DICAL IRE A.110UN T OF S2I2:410.001S FOR THE SIEVAC.1RE SET OFi1EE 115/TS. PRES( PHOTONS, 1 SEE DETAILED PACE ATTACREM AS PART OF OUR. PROCESS SS whereat. We late paid eat 18t as ne Other has had CI dares aal H.akl First Rem dapped romp re DN—Spoarpkh 4t. lwMwracrat .p.0ad.lo.4, wroth* ,R,errlec. Iardyunal radkari, aW !oat n auk aimelea0 Lab week. der an rrealal barn. 1h Denthe o .o.l to mama mot...lrc. ,aup of the ker. ken es.'. radar ha+ not orree led- In fare silo 115 and aar raxdwtp 104 tease in pam Het e.wdlranon np.arn raaga Sow S1401 +Valiud th. po.olbltlnn el a ,rural unlew*. la .t4 YOy tt a Medical 'emplane. The mama ted arm. re lbw awmtar of S.: WPM00 HA NV.; is brrofirx Roam M. far pml»xn or Ikit estuarine anal dt,abdtrr_.f •be n food eltib5e far tech benefit. it the :003 s•lrme.ltea. PTD pa.... re aweam eh 1 AA toles be c0a1014ft kr+ a 1ntkme131 a. .brana tls claatn to Pawl el. %ES.A. of rl. }ESA at II++ aa. 0nr fell etretm, for tbcs mall ter .eadderal for . 0de rti p 1pote.. -1TE A UEOLMI'.I 4.41017T TOWARD MULL IS NOL.M0SERE FOR ENDLWNTTI'. Sir CLEMCLN' WE WILL ESTL.L4 FE Sts9M FOR O'EEks Of BENEFITS ;i SS'336 WTLIC11 IT LS TRR 3.J,540110R PL0DENG PAYMENTS, TF1E5E THE E1.4,LA0CE OF RESERVES IRE NOT ALLOCATED i3.?AI00 FOR Ilht'RE tins Is rNYLI'LNG OITICE VISITS. LOW CO.N'S[DERLNG THAT THE BILK OF THE EXPOSURE. IS FOUND SSTTION 714E .ESA nit A.00LNT PIE01L1➢..0➢L➢ 10 BE ASIDE. IRIS .TLLOCATION IS RLL O.LICL.DLf) ENIEC TTONS.. [HMV"... DIAGNOSTIC FOR ILA.NDLLNG T1T45 FTLI THERE ART S1..000.00 41,000.00 L.YI.NsES L0 THE £'IIOIYI OF %Rut-D. ON THIS (LADE HOWEVER. IF THE MT ATTORNEY TO PREPARE SETTLEMENT NOT HAVE AN.AITORNE.. THE SETTLEMENT TEiE TIT)GE OF COMPENSATION. WE MIRE TOR PAU.A.NT OF OM ➢EIE.NSE ATTORNEI' ARE MITD0CAL LNO'UGH EQETA'.1LINT PRESCRIPTIONS ALLOCATION'S REPORT. .1L.LOC.ATED TO INCLUDE TESTING E1.TENst.i Ll'PCN0T5 1100 st 0ML451O151.900d0 SITIIEELLLNCE OITS➢)E.0Lt1L'STER OTTER MI5CEIL WE REF O.LL.END r , 0 -_ ASSMIATTD WITH 5:300.00 ASSIGNMENTS ONEOL'S MENSES TO LSE REASE TIS WE DO NOT H.111 LITIGATION WE STILL NEED A DEFENSE BECAUSE TIM ITS' DOLS A LIVE HEARING WTCH %LLO( A TING 31.50000 10 ROLES .1 SITTL.Lo. DOCI IE ITS, DUE REQUIRE RECOMMENDING .0I20.00 X Alloww Nors•?5re.. Sara (k.9. 0 :'i$ Sy... S0 5.0.ut1EttS D. 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Van $4 Ka R0 Y410m0.Yai Par au wn.m oama tw4.nawea.dm arm Was* e.anw..w. •ar sass ass lames a 41b4 r Is •.a a a.sdasat ..e.ua ''tc 0a...mt....me,aenmaana OA!. a Y mtna30 nazi. :CROP 103 • e-se3 eC .e r-mmem n. ^C.'.n03t deaf ,nom, b mirwoa0-Tea mat.Mv=.a walddta b+wcn Tat ann. ae...Ya..*43fYes ...WM ..W. task ;.. t+y ad:l Armm.n20te.sab4 23%1 }Yu49 Fe 9QS Use+ mums c •3 ya-Jra*a cmma 0P4 •:1r3rmo nmow an.xwanam.-aa ao.f Immedtdw ce.m apWam axrn.. rnar mummer c.c.s Meimm .sM t4 x.a.l red•r'sB m3..113 MKa No:YMN 0,3432 o, 3a4l04twa4,w Ax a4a24437 NNS ,Elan sal m1 meamaarraf4.. a1eaa'lUS v Am 0.03x44fa4 aata ssa,—MSts,s AS!? 104.4'l [ ton. loam: Mod. ifmnaa law. 3wemaInr ma.MC, 2:12*SC.f3Q .-, Amd•,a t 4a •.[mnelb mnaea.Moe 4x M1...t, 32.C[4 30 Meannaeaaa10vast evman:4 an, W...:sr AG. x-muea 1S 24 43154 a4,wwute two*.. 4 man.. eac4ea'.I.4. a.a_ ova_.pt.T..,.33!.f 5. Describe your company's internal process for the oversight of major claims, identifying by whom such claims will be overseen. USIS/AmeriSys' philosophy is for the adjuster to always be in control of the tile. Defense counsel is assigned when it is apparent that the issues cannot be resolved between the adjuster and opposing counsel. The adjuster, with the approval of the City, will assign defense giving direction as to how to proceed with the defense of the file. The adjuster will maintain communication with defense counsel and the City determining strategy on a go forward basis to bring the file to fair and equitable resolution for all parties. The adjuster maintains control of the file in an effort to control costs. The adjuster gives a synopsis of the claim to the defense attorney. The attorney generally handles the deposition of the claimant and any witnesses. The attorney handles the legal aspects of the case. i.e. work that has to be filed through the court system. The adjuster maintains control and direction of the claim, working as a part of a team with the defense attorney to bring the case to a rapid conclusion. Within the claims system, there are automated features to assist the adjuster related to litigated claims. if an attorney is entered to a screen, an Alert subsequently pops up every time that claim is opened. There is also a litigation flag that stays red in the default screen. There is also the ability to run reports related to litigated claims based on specific criteria. There are specific procedures in place for legal documents that are scanned to the claim file with specific note and subject types, diaried to the adjuster and supervisor. Page 92 6. Provide several Plans of Action (POA) examples, noting specific action -oriented goals. STATUS SUMMARY as of 11-02.2016 65yr old retired R`1 Received SS re remert. We have paid out IBs and no other oarpensatlon INMI 09i10107 214 Pt She has had 12 daims with Health First from chipped tooth to mutt** low back and hip darns She is treating with Dr Da dell for pain management DX--Spondyitlyes. kumbesa£ral spondylosks, Trothantenc bursitis -right, low back pair., sacroiliac disorder, lwr.bosaua1 radacu tbs and ION term drug therapy. Continues to get monthly rx and Injectors Lab woks done on regldar basis. A pharmacy uti]:.atrcn review wa done and Dr D ridel agreed to monitor and reduce some of the medications prrstnbed to the r>)ured worker, however, that has not occurredIn fact the Fitt' repots that she attempted In rig the dosage and was cawing increase in part She continues her treatment with Dr. Dowddl Her medlcatrcn expel -sea range from S 1500- $2.200 00 monthly During our ctarrrs review confetaix,es we discussed the possrarktes c( an overaA settlement_ h preparason'or such, we secure a MSA as Ms, XX is a Medicare recrpien1. The estimated red amount recommended to protect CMS interests arrived 10 the arrourx of $212.696.00 Ms XXX is now retired and we are not paying her rr•a urn ty benefits However. for purposes of this evaluation we would Ike to mention that permanent total disabilityrf she is found eligible la such benefYt, et S266.33246 19 years worth of benefits it 557 3.3 ek 1 the 2003 route atlowes PTD payments to stop at age 75 Our reserves are below the exposure and the amount that we could be cons+derutg for a settement For our settlement proposal will follow once we obtain the quotes to turd the MSA Our reserves evaluations based on the amount of the USA as If it was our full exposure for this drum and not necessarily the amount that vat be considered for settlement exposes. Clam Nee. art% Stasta 1.111rYr1. f:X4 tat 1-4"_1 Y'. 1L#. Riff a$a4. 4IW vete ,Conn X 4tzwR f4 Cal. .44;ore t.porv,sveTtY 1wn51 '! YH'R^ st .t .V� •9 .7°2. +^ 1 .. wt Mrs sot**ors ras..n.ey .1...n ora.l..iva. ryr.w.axbanlrl.•odmid D tw "from and Lztn:an wi. ar^e xr C. ire* ate sew.: Tr ire frt044 ov ai fir. CAC rMa aw ***** Mr TS*ww. f.r .oItk90ER:4 *II t'a9 ws £1$ 1*A.]`+`ffrt1***Aa itt4sfl91* ql 4[?is:'AeRt OF P. i'i!'r• 11Yl+I.A/ IN. r. — e.o.4 f.. gee ,+ x$.aTrr'.'sf talon) won. L'xdY T. p wo To44To •t on 5§cTo-04tpfl sae t j1r. 'y as. ont 1044 sl 5.411.it .o.. Mr.. .ti +�.YI.CtI •. ~MI* inalt ✓ >.1r: ✓o moo& ISN'T, &woo lit a Knit r.An°Jls - ]/U calf atsmb a%p1 9R R'4 14, trot.. M 1.v+t "CV '\I Elul. SO "I.J*V [r *13 * .I 3l1 p.w'.a .1.110 4**,4. WO ;Y` +. :r ... we...b ca. to o* 6it+n. gory `out ill:F :"I.•aor, Nw 411.0arW'17•' .41 AiJC...l rwa I1•4t:4.l. fi Z ;i i.Woon: M w.1..c w 3:r tiro b to xraule N ~a.7 . va c!' otakolOT Ct moved v a T1 *wale IP% sffic.x .t mow '*.414..• 1.1 ittt1 11.. W. *KA331 *Oro) .1 x w >. I.a =AT aOcare.on war. a 1r cAa ,1" w !11r..t tirli009 41 a. kit, 1i E .t/rt3. - .31 *Nop rLY1% 1IS %*. *Mu., of .1.1h 9,21 *-*****1 r. pa tnw, trstoim sae wua.; L ri tA9X WM'sm my xl+.]^;fir I *an MI ..j. 11,1041 .Iwre. •rr ..• .j. 01.1•11..0.. `ft Sr,-i2 .4 Y...an4l#] 1 WIN 138 41q ***AAA tI me* 4.Ir.4* row n •t.stswt./ 15t u1.xs 31. r. vows, txr ez, 4 SaCC pr *.' 1' 33 ** 4r .1.1 $14e, e'-.oc L.xl1 fw !CIE e.w.C.'ik1^ i.1.'r11 M •]. eciew AIM ts4,612-4 VFW, I: tit S R4: Yor1 era. X,6 CILWANI CLAY Q MAW.it Lorat A. TO ft7'weY To" worm ww . tQ,Y :k4 M 41 :t rotkab.1 3 tot, f 01*AP 7.9 10•'e * * ,.. 14r+a **a** 1a sOr.V-ar.,.r*.rS con `111. ., **NM !%C1`MN t•91004! Page 03 6. CLAIMS MANAGEMENT AND MANAGED CARE SERVICES The City believes management of the medical component is key to returning employees back to work and facilitation of WC claim resolution. The City has the following expectations relating to medical: 1) a provider who actively and aggressively manages medical; 2) a network of physicians specializing in Return to Work; and 3) a claims management team approach whereby the tears understands and works as partners in the RTW/Transitional-duty efforts. The City is very interested in the Successful Proposer's philosophy on utilization of TCM & FCM within their claims management model, with the understanding that The City may elect to use a separate managed care vendor. USIS/AmeriSys has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the telephonic ease - managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case -manager (when assigned) and cost containment. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. The adjusters are well trained on when to recognize when a case is deteriorating and are instructed to control these claims as quickly as possible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Utilization Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with the injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee, to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to full duty, restricted duty, and the employers' ability to accommodate the injured employee's restrictions. Catastrophic or large losses seldom occur but when they do they have a chilling impact on claims expense. Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and burns. These claims are complex from beginning to end. Rapid response in claims investigation, assignment of Catastrophic Case Management Providers and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. Page 94 AmeriSys. our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized many times on large and catastrophic claims bringing the City of Miami the experience, when necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to maintain the highest degree of compassion and service to that employee and his/her family. Recommendations for Assignments of Telephonic Nurse Case Management Upon receipt of the First Report of Injury, the claims adjuster reviews the nature and cause of the injury to determine the necessity for further intervention. At the direction of the claims adjuster (per client protocols), a referral for case management is initiated. Serious injuries will be assigned for telephonic case management immediately. The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case -manager within the first 24 hours will make contact with the injured worker and complete an assessment of the initial medical treatment; evaluation of the treatment plan and assess the need for continued medical case management. If specific tasks need to be completed to assist the claims adjuster with the handling of the file, these can also be assigned. Telephonic case management is the systematic evaluation of medical services, procedures, facilities for medical necessity, appropriateness and efficiency. This promotes optimal patient outcomes, reduce period of disability and assure high quality of care while controlling costs. A nurse facilitates the medical activity on a file with the ability to individualize the plan of care and coordinate early return -to -work strategy with the employer and medical provider. The functions included • Coordination and referral to network medical providers • Coordination of the treatment plan with the provider • Working with the provider to establish functional abilities and conditional release to return to work • Discussion with the injured worker to clarify the worker's understanding of the diagnosis and treatment plan • Monitor the treatment compliance of the injured employee • Identify and assist in the resolution of problems with compliance to the treatment plan • Provide regular reports to the claims handler to assist them in the management of the claim • Recommend on -site case management and vocational services when needed • Work with the employer to identify a medically appropriate job Coordination and referral to network medical providers allows for the best network penetration. The channeling of the network providers will allow for the best network discounts. The Telephonic Case -Manager acts as the center point of contact ensuring delivery and communication to all approved providers of PBM and appropriate parties, forwarding appropriate issues to the utilization review department as necessary and reporting outcomes to the AmeriSys Quality Assurance Committee. Page 95 Case Management Employer Adjuster Diagnostics Injured Employee Medical Case -Manager Case Manaoement Plan - Assess Needs - Develop Plan Imo ement Plan Items - Monitor Progress - Evaluate Outcomes - Re -Evaluate Plan Physical Therapy Home Health DME Pharmacy Transportation & Languages i ATP (Attendng Treating Physician) Vocational and Field Case Management CAT Supplier Utilization Review Prospective (PreCerli Concurrent Retrospective We understand that it is imperative for both employee and customer satisfaction; we communicate promptly, which includes facilitating care and appointments properly. Prompt, accurate and complete communications are perfonnance standards and measurements for our case management team. Page 96 Recommendation for Assignments of Field Case Management 1. All catastrophic injuries, such as, but not limited to: • Spinal cord injuries • Head injuries 2. Neck injuries (except for minor strains) • Burns of face, hands or greater than 9% of the body • Amputations • Loss of hearing • Electrical shock • Multiple fractures 3. Any potential serious back injury: • Failed back syndrome • Multiple fractures in the back • Herniated disc with radiculopathy • Positive neurological findings • Any back injury with any degree of paralysis 4. Chronic Pain Cases 5. Claims with high potential for PT rating including, but not limited to: • Fractures in or near major joints or weight -bearing body parts • Crush injuries • Hand injuries, particularly of the dominant hand 6. Injured employees with a previous history of workers' compensation injury or injuries. 7. Difficult pre-existing medical or social problems • Diabetes • Heart disease • Psychiatric problems • Illiteracy • Mental retardation • Alcoholism and/or chemical dependency • Morbid obesity 8. Cases not fitting an expected recovery time frame: • Not responding to provided care • Time delays in getting appointments • Irregular appointment attendance • Disagreement with the course of treatment • Questionable or experimental treatment recommendations 9. Injured employees who are approaching 60 days without returning to work. The need for Re-employment Assessments is decided on a case -by -case basis. 10. Need for extended home care. 11. Hospital discharging requiring planning for home health and/or durable medical equipment.. 12. Location or communications barriers. (Injured employees in small rural areas with limited local facilities, or with language barriers who know limited or no English) 13. All new claims with an initial reserve established of $50,000 or greater. Page 97 Please outline and discuss the following: 1. Organization and work/flow process for the provision of medical management care services including: a) Process of notification from reporting center; Upon receipt of the First Report of Injury, the claims adjuster reviews the nature and cause of the injury to determine the necessity for further intervention. At the direction of the claims adjuster, a referral for case management is initiated and approved by the City. Serious injuries will be assigned for telephonic case management immediately. The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case -manager within the first 24 hours will make contact with the injured worker and complete an assessment of the initial medical treatment; evaluation of the treatment plan and assess the need for continued medical case management. If specific tasks need to be completed to assist the claims adjuster with the handling of the tile, these can also be assigned. b) Decision points for intervention; Early Intervention - The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case manager upon assignment by the adjuster; will within the first 24 hours of a reported injury conduct a 3 or 4-point contact. An assessment of the initial medical treatment; evaluation of the treatment plan and the need for continued medical case management will be evaluated. This is the first step in the aggressive return to work coordination. A Telephonic Nurse Case -Manager will be utilized based on the approval criteria set by the City of Miami and USIS/AmeriSys. The Telephonic Nurse Case -Manager would provide Quality Care in a Cost Effective Manner focusing on early Return -to -Work. During the transitional phase USISfArneriSys will develop protocols with the Risk Management staff that would trigger triage and nurse case management, Early Intervention Criteria: • Severe lacerations, especially tendons and muscles • Server eye injuries • Back injuries with anticipated lost time exceeding statutory waiting period • Knee injuries with anticipated lost time exceeding statutory waiting period • Cumulative trauma (including carpal tunnel syndrome and tendonitis) • Concussion. severe head injuries • Chemical inhalation/poisoning • Severe sprains, strains (major body area such as ankle, shoulder or wrist) • Dislocations (major body area such as ankle, shoulder, wrist) • Rotator cuff injuries • Second/third degree burns not considered catastrophic • Injuries involving immediate inpatient hospitalization • Psychological claims/stress claims • History of protracted recovery from prior Indies or illnesses • Repeater claimants if prior claims involved the same body part and same or similar type of injury Page 98 • Any type of injury with lost time exceeding statutory waiting period • Cases with multiple providers • Crush injuries • Fractures • Amputations Aggressive Return to Work Coordination An early return to work after an illness or injury benefits a patient: physically, psychologically, financially, and socially, preserves a skilled and stable workforce for the employer. c) Frequency and duration of case manager intervention; The frequency and duration of case manager intervention will be based upon the City of Miami and ArneriSys agreed upon criteria. d) Decision points and process reflecting integration of pre -certification and utilization review with the case management process; Utilization Review Utilization review is the evaluation of appropriateness in terms of both the level and the quality of health care and health services provided a patient. UR is based solely on medically accepted standards. Utilization file review is the cornerstone of identifying potential quality assurance issues. Prospective, Concurrent and Retrospective reviews can be conducted. Ongoing utilization review throughout the process of adjusting health care billings is required to identify issues and initiate corrective action as early as possible. ACCREDITED f;e;Liauen ManniterneDI EVI«,O1- GI 207 Prospective Utilization Review This review is conducted prior to the delivery of the services requested. Prospective reviews may be for inpatient or outpatient services. Prospective review facilitates the prompt timely authorization of prescribed services and the documentation of authorized services which must be recorded in a consistent manner. Pre -Certification of Procedures Pre -certification is the timely authorization of medical/surgical services before treatment is rendered based on established third party guidelines, practice parameters and accepted standards in the medical community. An experienced nurse specialist completes all reviews and utilizes peer review physicians when the decision to certify cannot be made. Page 99 Pre -certification services address: • Appropriateness of setting (inpatient versus outpatient) 40 • Appropriateness of surgical procedure, diagnostic study, or treatment prescribed • Appropriate length of stay or treatment pre-certi 'cation services • Pre -certification of hospital admissions • Reduce unnecessary hospitalizations e. uce t e engt o stay especia y w ere per . iem reimbursement is established for hospitals • Foster a shift from inpatient to outpatient care • Provide a mechanism for timely identification of patients1 who require discharge planning and case management J A properly licensed nurse will obtain the demographic data and relevant information to the clinical conditions to be treated and procedures to be performed from the provider. The nurse reviewer will consult acceptable established guidelines — established and accepted Practice Parameters such as McKesson's InterQual, or the Length of Stay by Region. If the data provided meets these criteria the request for service will be determined as medically necessary. If the data does not meet the criteria, the request is referred to our medical director or a physician advisor for a determination. All parties are notified of decisions by telephone, fax or mail and the carrier is kept informed at all steps. Concurrent Review for Continued Stay or Services Concurrent review is a review of the clinical information and coordination, assessment. planning and follow-up procedures during the course of treatment to determine medical necessity. This review is performed while the injured employee is still hospitalized and/or services are being provided. Concurrent review also occurs with the request for additional physical medicine. If the data does not meet the criteria, the request is referred to the USIS/AmeriSys medical director or physician advisor. The medical director will review all available data from the provider and review the established criteria and may contact the attending physician requesting the services. The medical director may consult a peer physician of the same specialty as the requesting provider for further investigation and decision on the service. All parties are notified of decisions by telephone, fax or mail. Page 100 Retrospective Utilization Review This review is performed after the requested service or procedure has already occurred, This includes random and focused reviews, which are quantified and evaluated by senior staff and/or physician advisors. Problems identified from these reviews are addressed through an action plan in-house or with the provider. Utilization review is also conducted on medical billings to identify over -utilization of a particular service as well as review of multiple surgical procedures, questionable CPT coding, review of related to level of service, relatedness, as well as all Hospital billings over a pre -determined dollar amount. All Retrospective reviews are conducted by a Registered Nurse. Medical and hospital bill audit USIS/AmeriSys services are a combination of automation with manual oversight and verifications. Manual reviews are performed on multiple surgical billings and hospital bills over $5000 by a Utilization Review Nurse Specialist prior to entry. Bills are also reviewed against pre -determined criteria, which indicate that a more in-depth review is indicated. These criteria include: • Hospital bills which indicate inpatient stays for procedures normally performed on an outpatient basis • Hospital bills with lengths of stay which exceed the 50th percentile of the normal length of stay • Hospital bills which show multiple diagnostic tests or diagnostic tests not usually related to the injury • Hospital bills which contain unidentified detail charges • Hospital bills which contain duplicate charges, data entry errors, or unidentified charges posted after the discharge date • Hospital bills which note unrelated diagnosis or procedures on the UB-04 • Provider bills which meet the indicators of potential abuse (double billing, common referrals, cross billing, fragmented billing, missing modifiers, over -charging, over - itemization, over -prescribing, overutilization, prolonged follow-up, self -referrals, services not rendered, substandard care, or upcoding) • Provider bills which indicate more than two modalities of therapy per visit • Provider bills which show an excessive number of diagnoses for the same condition/injury • Provider bills accompanied by narratives which do not meet CPT guidelines, or appear to be duplicates or computer -generated • Provider bills which show an excessive amount of surgical or other supplies or medications Unbundling The UR Nurse Specialist identifies procedure codes that are individually billed that are included or should be billed using a single procedure code. The codes are verified if they are included in other CPT codes and should not be billed separately. This procedure is consistent with outpatient, surgical, laboratory and diagnostic procedures. If additional documentation is needed it is requested. Page 301 Peer Review Peer review is a process where a physician evaluates an individual physician's medical treatment of at least one patient in order to assess the quality of care provided by that physician. This will include documentation of care (medical audit), diagnostic steps used, conclusions reached, therapy given, appropriateness of utilization and reasonableness of charges claims. A specialized nurse will conduct a preliminary file review to assess appropriateness/cost-effectiveness of peer review service. Files may be reviewed for: Appropriateness Availability Continuity • relevance to clinical need • issues of under -utilization or over -utilization • most beneficial or necessary timeframes • achievement of expected outcomes • coordination across the care continuum The RN will obtain any missing medical records, prepare questions/issues to be addressed and coordinate referral to an independent, specialty -matched physician. The physician, acting as advisor to the RN, will decide upon the questions and issues arising from the chart review. The Peer physician will review all available medical records and will provide an unbiased, constructive opinion of all medical activity documented on the ease. The Peer physician may contact the provider for further information, clarification or discussion of the case. A detailed written report will be prepared to include specific reasons supporting conclusions reached and suggested approaches to corrective action. e) Processes for bill review, approval and payment detailed in flowchart; Upon receipt of paper billings, the bills, along with any corresponding documentation, are scanned and attached to individual claimant files within the Corrus system. Medical bills may also be submitted electronically via HIPAA compliant X12 5010 standard files. A bill record is then created corresponding to the scanned/imported document/bill. Simultaneously the adjuster is diaried as to the presence of the bill for electronic review and approval. After approval by the adjuster, the bill record, along with scanned document/bill, is transferred to a user bill list for the bill reviewer to examine and prompt the system adjudication to apply fee schedule limitations/rulings and MRA, As the adjudication system validates data, the bill review analyst must respond to any "Review Messages" prior to finalizing the bill. During this process the bill review staff will also be alerted to any reimbursement issues identified from the adjuster review via Corrus notes that are accessible by all parties involved with the claim. The Corrus database maintains a complete history of all medical bill processing including the payment information and EDI results. The data stored within our database includes original Page 102 bill data as entered, plus scanned copies of the documents; vendor information; reduction information and EOBR codes assigned; allowed codes and amounts; payment date, amount and check number; all dates relevant to receipt, processing and external transmission; EOBR comments from the bill reviewers; EDI control numbers and status. Please reference the Medical Bill Review Flow Chart below. We recognize that each client has unique needs, requirements and expectations. The utilization of USIS services will be tailored to the City of Miami's individual needs, expectations and requirements. Medical Bill Review Flow Chart incoming Mail Electron+c Billing from PEM and Ar_ Itartes Receive. review. rode and scan medical pills and attached documents Bills/documents attached as PDF copies to Corrus system file Ailf Review (adtudicaton process is completed) EDB is created automatically and held with attached documents pending authorization by adjus!er Waiting period of 24-48 hours pending bill approval by Adjuster. Aging report is auto generated Medical Bib Review for clean non.comptex bills Bill Review RN reviews Surgical, Hospital. ASC and UR consderations and Adjuster Requests. instal is noel -tad o the need for bat approval through mutually agreed Protocols Review and approve bats on diary within 24-48 hours Duality checking process by second reviewer and series o Coitus reports Transfer Data to Payment System Check 8 EDB sent to provider in 313 days or reel Submit EDI to CPS Correct any rejections widen 3 love Re-suhmii Bill is approved Bit is questioned Bill Review is notified and BR Manager may be dianed tor further review OAutomatic Process ❑ Manual Process ▪ Claims ▪ Cost Containment Page 103 Cost Containment Analyties are also performed by an internal tool that allows USIS to view the historical trends by provider type, claimant demographics, and billing codes or zoom in on a particular claim. It also allows us to review claim outcomes for over/under utilization or possible duplicates and to break out trends or review a particular claim by diagnosis or procedure codes. Ari Caen Cat Anakysis viewer IrL03037) - FAdho1 Cube Que*y ori Cute Analysis Configuration window about Chao tours to ex Perot6nd 32 Dam Of Serw.e Dote Hard Dam 1st seen .. �os Rd `teal .�, :nysrted '!. Mrmc Se+v Months Fran Clam Date -;5 4temork Manx rNf Ceic pie between Wean s ,w, `1-e Me, Area ' 2aterr. area Site DOS 'ea Row Area Z Data Area Conmot tar Clan Cant Total 121 Aeoweo :ot_i Iota 2sfw Layout Letoate 2.425 'rear 2013 29:4 Canmrhedrty Can Count Died Toted - Alnwed -afn- l Avg 9i Cost Cam =an Cot, Seed 'ata3 Atoned -ota 25 325,779.89 207,445..31 1,646.35 29 -16,267.42-24,423.61 359 5,023,961.11 3.562.367.69 3,14..01 335 4,427,51931Z 2,956,733.73 Disease 1 132 3,496, 261.36 1,493,556.65 3,762.69 121 1,26.1,906,67 7/0,954.93 1 1,05'r 32.,392,362..12 6,117,595.02 2,292_06 1,012 10,001,395.95 4,771,371.41 Lover Casten Z1 154,955.33 24,556.74 3,196.53 26 224,437.27 e5,314.98 Mentdl7seMers 13 23,314.20 17.433.96 792.45 46 46,165.35 5,051.05 :4.539 104, _641.23. 50,392,123.72 292.75 13,451 105.535.3.4,61 52,296,603.50 C1Eeraty 229 2,213,312.29 1,033,635-39 2,312,38 231 2,367,596.53 1,591,963.24 Orel j 1to 672,007.29 316,034.23 1,015.96 99 397,4(17.17 355.316.44 Puitunerr tkse... 1 132 1,443,615,42 663,448,74 2,297,40 114 1,291,,936,71 520,379,48 Rmai Dseease SO 2,703,298.97 3,530,145..12 7,464,12 38 335,495.35 1":-: Grand Total 14,633 125,075,979.18 59,532,340.75 333.40 13,528 121,33 ,0.5.50 59.5::.:5,,.. SY Page 104 For the calendar year 2015, USIS/AmeriSys was able to offer its customers savings achieved by a variety of medical management approaches. As an organization we were able to demonstrate in excess of $27,082,651 in case management savings. urac Case management savings is achieved in variety of ways including, but not limited to, fee negotiation, directing treatment into the ancillary provider network to benefit from contracted rates, the recognition of non-compensable body parts or treatments ACCREDITED and reaching the Maximum Medical Improvement goals for the claim prior to the �!;°',Mo nty, benchmarks set by the approved guidelines. In addition to the case management savings we were able to document in excess of $9,534,227 in Utilization Review Savings by the identification of medically unnecessary procedures and/or procedures that are not causally related to the compensable injury. These reviews are done in compliance with the standards set forth by URAC and with the assistance of physician advisors in issuing non -certifications. There was an additional $5,823,500 in documented savings accomplished by returning the injured employee to work prior to the benchmarks set by the Official Disability Guidelines. Days saved are calculated in accordance with the injured employee's average weeklong wage. This also demonstrates the importance of a robust return -to -work program offering modified duty positions. In the processing of over 253,531 bills, the USIS/AmeriSys Bill Review Department in compliance with statute and rule, utilizing PPO networks, the skills of seasoned bill reviewers and utilization review nurses who specialize in retrospective bill review, reviewed total submitted charges of $215,386,620. We saved 55% on those submitted charges. The Fee Schedule Savings were 40% of that number with the remaining $32,529,040 resulting from our professional review and contracted savings. Our contracted savings average was 11.34% below Fee Schedule. All of this totaling more than $117,788,132 in documented savings collectively for our customer partners. US1S/Ameri5ys Actual Results Based On 2015 Bill Volume of 253,531 Total Billed Charges: $215,386,620 Total Savings $117,788,132 ■ Fee Schedule Savings l Other Professional Saving, 81 PPO Savings Below Fee schedule ■ Total Mowed Page 105 f) Unique software and/or other knowledge resources utilized, and the value they add; Corrus is the primary Case Management and Bill Review/Cost Containment Information System at USIS. It is interactive with customer data imports and exports, and the extensive database provides the data for reports requested by a client. The application provides for detailed tracking of case notes, diaries. claim contacts, provider utilization and letters as well as a complete medical bill re -pricing system for efficient and effective adjudication of medical bills. Our computer system allows us to enter claim information based on dates of injury or occurrences and allows for multiple claims per claimant. Additionally, Risk Manager (ERIC) is used as the primary claims system at USIS. Corrus and ERIC are fully integrated systems which provide advanced claims handling capabilities in order to maximize technical efficiency. On a daily basis we exchange many different types of information with claim systems, ancillaries, and our customers, including EOBs, claims, invoices, and eligibility data via secured methods. Corrus and ERIC are synched via live data feeds. Adjusters primarily work out of ERIC for their daily functions. diaries, and case notes. The Cost Containment staff primarily works out of Corrus for the adjudication and review of bills. The authorization and/or denial of bills are done in Corrus by the adjusters and a business work flow is built into the system to move the bill to the next step. Vendors have access to the review the status of bills via our provider portal. The portal currently has the ability to track and display the status of each step of a bill. The portal shows if a bill has been approved. adjudicated, sent for payment, under review, denied, EDI and more. This allows providers, at their convenience, to view the current status of their bills. This feature significantly reduces medical provider phone calls seeking information regarding their bill status. EOB Search Tool 4.3 /, 1111601VS Crean, • e »cr+,.e Eft GT LtCa i¢: otoe r •tolO `Totes . A iIr&I$ _ ace saerO. S AmeriSys Ptovide,EDS Search . xt .cese•C se 73=SOSS M. looms Ns Ow 0S/2:=41. M'r ri ve d • . C . » a . 5Qt r • - o ' +F - 'boo • 'ykt, - 11Awtai Soled. ASV* Deis :dement I Mare tereeee test adoes ef45M r tte.Me.6v 0e1deal Use* Pali Seen Sower Dee End Weft Dole eeraeiRM Toowdes mare awl eaowt al ear -maw Ws. pewee Wing eremeeh Clew Ember at pe et Yee rowed re lee msreet not doe al mortal Ana Mt dhres :7tA.o eeteetr ,PLO,avbie•et.a}ih 4. �tcn.rer.a•ee. weoeeet Pert Page 106 r Cost Containment analytics are also performed by an internal tool that allows USIS to view the historical trends by provider type, claimant demographics, billing codes, or zoom in on a particular claim. It also allows us to review claim outcomes for over/under utilization or possible duplicates and to break out trends or review a particular claim by diagnosis or procedure codes. we clam Cosa Analysis Viewer t ' OA371- [de not Cuac Query! init Cube A4salysb Cosoftgaauen Winslow Abm! Doc Deese+e AvoKra 005 rear - ,3'eOFSaw, - lAli IOF4 ;,1 pate Pant Canor4d1Y Clan Cowl . Med Torte *wee Tow I A0;6110O01 cam Cart 06ee'oa saem,em Iola }? Oate:51 Sum � ..OgReson 24 375,779.49 207,443.31 1.646.15 29 -1a.26242-24.620,61 i :1C%5 gel rear L11 Debella' 369 3,0119961.13 2,562,357.69 3,144-Ot 325 4,477,510.72 7,066,733.72 cax4 Z. *d ee Sen,Ce 13 Fkh n,* Name 906 IkaQ Rik be:lraan arse WOW: I' r-e:e, area ��- cases Ares LSlte ' ` �F306'rteat j_ _ Slew area Cr.,esate awn elali area toss ailed %tie atee.ec "ono Os* unreel' -Max _c reartflYHae t12 3,496,770,16 1,903,556-85 3,762.39 :21 1,754,906.67 770,054.13 4lpeleliO1 1,054 17,392,362.12 6,117,508./32 4.79248 IA12 10,001,395.86 4,771,37141 uur Moor 21 154,035-87 74,556,74 3,106.53 26 224,437.27 86,314.9E Mend 0 Marie 13 21319.26 17,413-96 792-45 10 46,106-35 5,055A5 Were - =W..- 14,539 104,066.641-i3 51110132i12 292.75 13,451 105,505.34441 57,398,563-60 ODente 229 2,213,312-2D I,033,635.39 2,312.38 231 2,367,566.53 L091,968.24 nteEatatry 110 672,03/29 3169934,23 1,01591 90 797.407.17 358.319,44 'Wma:aRY 1321.443.611.42 163,946.7a 2.297.40 :14 1.29i,936-71 628,379.49 Rene' Meese 50 $303.296.07 1,530,145.17 7,464.12 30 835,495,8S 313,240.43 3faxl atel :4423 123,075,929. IA 59.532,84005 338.40 13,328 12 1,392.046,60 59,813,730:4 Listed below are some of the software capabilities (not exhaustive): • Software Availability Access to our system is available through several means: 1. Direct internet connection to our secured web site allows for viewing and entering of Case Notes and Diaries, viewing bills, running reports, and more. 2. TSWeb connection to a specified computer via a VPN allows full access to the system 3. VPN/ODBC connection allows for full usage of the system if our software is installed at the remote site. • SFTP Site (Secure File Transfer Protocol) A FTP site will be hosted and maintained by AmeriSys to allow transfers of data and or/reports required by client. The site will be accessible by client and with proper authorizations. Page 107 g) Decision criteria for assignment and discontinuance of field case management and vocational rehabilitation; Field Case Management The purpose of Field Medical Case Management is to provide services that allow for more specific and detailed information regarding care, home situations, family dynamics and employee job site. This manner of delivery is important for establishing rapport with the injured worker and/or family, particularly with high risk or severe injury situations. Medical Case Management includes, but is not limited to, coordinating physical rehabilitation services such as medical, psychiatric, or therapeutic treatment for the disabled individual. These services have proven to be of assistance in the resolution of workers' compensation cases, auto, general and product liability cases, Long Term Disability and Catastrophic Case Management cases. Recommendation for Assignments of Field Case Management Recommendation for Assignments of Field Case Management 1. All catastrophic injuries, such as, but not limited to: • Spinal cord injuries • Head injuries 2. Neck injuries (except for minor strains) • Burns of face, hands or greater than 9% of the body • Amputations • Loss of hearing • Electrical shock • Multiple fractures 3. Any potential serious back injury: • Failed back syndrome • Multiple fractures in the back • Herniated disc with radiculopathy • Positive neurological findings • Any back injury with any degree of paralysis 4. Chronic Pain Cases 5. Claims with high potential for PT rating including, but not limited to: • Fractures in or near major joints or weight -bearing body parts • Crush injuries • Hand injuries, particularly of the dominant hand 6. Injured employees with a previous history of workers' compensation injury or injuries. 7, Difficult pre-existing medical or social problems • Diabetes • Heart disease • Psychiatric problems • Illiteracy • Mental retardation • Alcoholism and/or chemical dependency • Morbid obesity Page 108 8. Cases not fitting an expected recovery time frame: • Not responding to provided care • Time delays in getting appointments • Irregular appointment attendance • Disagreement with the course of treatment • Questionable or experimental treatment recommendations 9. Injured employees who are approaching 60 days without returning to work. The need for Re-employment Assessments is decided on a case -by -case basis. 10. Need for extended home care. 11. Hospital discharging requiring planning for home health and/or durable medical equipment. 12. Location or communications barriers. (Injured employees in small rural areas with limited local facilities, or with language barriers who know limited or no English) 13. All new claims with an initial reserve established of S50,000 or greater. Activities also include, but are not limited to: • Providing health training to the Injured party and family •Monitoring the disabled individuals recovery •Consulting with treating physicians to develop an appropriate individual written rehabilitation plan * Gathering medical information if needed • Documentation of findings with recommendations on a monthly basis • Coordination of referrals and delivery of services •Home Assessments •Ergonomic Job Analysis Vocational Services Ergonomic Job Analysis & Job Description With the ever-increasing demands of today's occupations and new legislation governing the workplace, the ergonomic job analysis is necessary in the prevention and management of injury and disability. This is accomplished by matching worker capabilities with occupational demands and providing this information in a manner consistent with systems developed by the Federal Government. Our Nationally Certified Consultants visit each worksite to observe and gather data regarding the job being performed. This information can be utilized in the recruitment, promotion, job modification, training, perfonnance evaluation and safety program development, Page 109 Providing these in an Essential Function format demonstrates the employer's understanding of the basics and the desire for compliance with guidelines of the ADA. Activities Include ✓ Essential Function Identification and Analysis • Physical Demands Analysis Environmental Conditions Analysis ✓ Worker Characteristic Components Analysis Benefits ✓ Prevention of workplace injuries ✓ Facilitates early return to work ✓ Identification of transitional work opportunities ✓ Useful in the recruitment, placement and promotion of employees ✓ Identification of training needs ✓ Compliant with The Americans with Disabilities Act h) Management of provider networks, including utilization of credentialing and/or outcomes management; AmeriSys is proposing DimensionComp for hospital and provider access, Coventry PPO as the secondary or "wrap" network, the AmeriSys Preferred Provider network for ancillary providers, and myMatrixx as the Pharmacy Benefit Manager. USIS/AmeriSys employs a Director of Provider Services who will work closely with the City, DimensionComp, the adjuster and the case -manager. The Director of Provider Services will make recommendations as to what outcomes would be monitored as well as work with the City to determine the criteria that are important. DimensionComp is an affiliate of Dimension Health, Inc. DimensionComp provides clients access to the one of the largest Workers' Compensation networks in South Florida. By maintaining strong relationships with the provider community, DimensionComp is able to offer clients superior network savings and greater access. Provider credentialing and monitoring — All providers must have privileges at a participating Dimension Hospital, bold a current license in the state of Florida, Must be Board -Certified or Board -Eligible, hold an unrestricted DEA certificate and comply with the State in maintaining malpractice coverage. The Florida License is verified to ensure it is active and clear of sanctions. DimensionComp also verifies malpractice history. It also ensures the DEA license is current. Board Certification is verified through the American Board of Medical Specialties. Physicians agree to comply with all other provisions of Florida law applicable to a worker's compensation policy, plan, or program. Physicians have agreed to promote high standards of medical care and to control the cost and utilization of medical services, including, but not limited to, policies and procedures regarding quality assurance, utilization review, record keeping, billing, and grievances. Recredentialing is conducted every 3 years. Page 110 Under the 2003 -2011 managed care agreement, AmeriSys provided the City with a certified carve out version of Dimensions Health Care. The carve -out was modified to meet the specific needs of the City while meeting the requirements of the Agency for Healthcare Administration. The AmeriSys Network Manager established a strong rapport with Dimensions Healthcare; thus ensuring the prompt attention to specific provider needs of the City of Miami, including the recruitment of specialty physicians that are qualified to care for those individuals covered under the Heart and Lung Bill. Coventry Health Care Workers' Compensation, Inc. Coventry provides clients access to the largest national provider network offering in the workers' compensation industry. By maintaining strong relationships with the provider community, Coventry is able to offer clients superior network savings and greater access. Ancillary Network Access AmeriSys Preferred Provider network • The AmeriSys Preferred Provider Network is made up of a select group of vendors to perform the services referenced below. • Every three (3) years AmeriSys undergoes a very detailed RFP process for Ancillary Medical providers that include transportation, translation/languages, Physical Therapy, Diagnostics, Home Health and Durable Medical Equipment. These organizations undergo due diligence and are then contracted. Contracting includes indemnification for customers, insurance coverage verification as well significant discounting for services. We believe this provides our customers with the best protection at the best price, creating best value. Utilization of physician review, IME, and other ancillary services; USIS/AmeriSys provides utilization/peer review services in accordance to the standards set forth by URAC. Our accreditation period is current through March of 2017. Utilization Review issues are identified and the file is referred to a Utilization Review Specialist. The UR specialist will conference with members of the case management and claims team to determine the issues to be addressed and the most appropriate utilization review approach. The UR specialists have access to multiple third party guidelines, including, but not limited to, InterQual, Medical Disability Advisor and Official Disability Guidelines. The review can be performed as a Prospective, Concurrent or Retrospective Review. In the Prospective or Concurrent format. the UR specialists can review the issues requested and communicate their findings to both the case - manager and claims team. In the Retrospective format, the file can be reviewed and the UR specialists will formulate questions to be posed to a "peer" physician. Once the "peer review' is returned, the physician's determination is communicated to both the case -manager and claims team. The decisions are defended by confirming the process was in compliance with URAC standards, the peer physicians are also functioning within URAC standards and the guidelines utilized have been approved. As always, it is the claims adjuster's decision to utilize the determination to best serve the claim and the injured worker. In conjunction with our performance standards for our Preferred Physical Therapy providers as it relates to adherence to evidenced -based guidelines, all providers have set up processes for Utilization Management. These processes are routinely utilized in the services provided for USIS/AmeriSys customers. Page 111 See an example below from one of our Preferred Partners: ALIGN ALIGN NETWORKS Goto STANDARD REVIEW ....v..e....,n,..e........,.«,...,..-w«wF« QT. ..»«,m.:or,. o.e..,.;. nv Name r+nvrevwtae rutnew„a. .vae n. rc«. .... »..nt n. ®.....,.. e,wwe.r ,t ssun. ru RSsw NetweAs. eAment Renvnno tlekti TT. µtw«. a«a�ntaro. . txrrvrnS :,.rep,:. ,e.a..*0 HMI Alleys N wnwur xn.yu.1•r u.K [Wm ' ALIGN Mr Nijn& WPM,W.4U �I+�n+Axwyn, wcrxau Mate/ Pi/AlleV/tti etrsrrs.. 'TT .,.paTmele eweamnc,Amlroi«p...scx Acuu PI in>,xa uA LInx.e..nr me x.„ilf M. tiLsztirtni muttfiv4evl rt.p. e.R54/M w «eiuta.. pr w�. .. MO en. Pt Peer was+ *nap, RPM 4 gaqtrunc no, vim,. mni. +r.1.0 to/..a.n Mewx w/, //// Mum/ eV.: en e�eiwv w n3.nx�ims�.eurV orw...alw.y wdx,b bn eA+a,+b,,. emmxe.wr.. a.Trt ITC1.11116fl.tu, [uAa*Mr.ulxcne waxentanerneruy CREa.6si¢tlf2;A*wt, A„wp Gvitm.+.rliw %w .,y,y Pnwmwex Should the nurse reviewer determine that request for care or treatment is in variance to the evidenced -based guidelines or statutory guidelines, that request is forwarded to a peer of a like specialty to review. If resolution cannot be achieved by a non -physician reviewer, the review is escalated to a peer physician of a like specialty. Through our Physician Advisor organizations and as well as our physical therapy partners, non -physician review consultants are available for use for ambulatory care review, such as chiropractic and physical therapy specialists. AmeriSys works with Dane Street for Physician Advisor services. Physician Advisor Services for UR Dane Street, LLC Debbie Hill, MSN, RN, CCM, Director of Account Management 891 Centre Street • Boston, MA • 02130 951.543.1627 561.206.0659 (fax) dhill@?danestreet.com www.daneStreet.com Dane Street provides Workers' Compensation Peer Reviews to Managed Care Organizations, Third Party Administrators, Utilization Review Organizations and Employers. Licensed in all mandatory UR states, with an active Regulatory and Compliance group which interfaces with the appropriate State workers' compensation Boards and Departments of Insurance. Dane Street is a URAC-accredited review organization and the reviews are delivered according to all URAC, jurisdictional and client requirements. They understand the importance of state - specific medical treatment guidelines, turnaround times, match requirements —and track any changes across these categories in their rules -based PeerAccess platform. Paac 112 1) Methodology for tracking lost days (include your company's definition of lost days); measures the savings in comparison to ODG guidelines Third party guidelines and standards of care benchmarks are referred to validate the need for treatment or to confine the disability status. The physician is contacted to verify discrepancies between the care being delivered and the established third party guidelines. The Official Disability Guidelines are referenced for disability management and Pressley Reed's Medical Disability Advisor is referenced for standard medical treatment including but not limited to diagnostics and therapies. McKesson's InterQual is utilized under the URAC guidelines for the pre -certification of invasive/surgical procedures. As stated earlier, the use of these guidelines allows the nurse case -manager to plan and benchmark the claim for appropriate treatment and anticipated return -to -work and MMI. Once the timefraines are set per the evidence -based criteria and variances occur in either treatment or disability, the nurse case -manager can then question the treating physician as to the medical necessity of either. If this does not resolve the discrepancy, the medical director or physician advisors will be consulted to opine and intervene. When the NCM identifies treatment that appears outside of guidelines or there is a delay in release to RTW, AmeriSys can and does utilize our Medical Director to provide a peer to peer telephone conference to discuss any issues of concern. Very often this is able to resolve any questions. If questions remain, we may choose to use IME's or formal Peer Review to address the issue. The followinlg screen shot Duplas o„ the ltTW Reports Date Fart ; :9 ), 5.NV Clam Date. all 2016 shows the NCM current Return -to -Work benchmark tracking. lthDiv ofDisability 800G6000 • pmleeted$enamtneWodt Date - . ':1t • amerce ? roj cted Norabe afloat Dat e l„r.Ad Return To -Weak Lost Tor Om Dare Days Occupation Education Average Weekly WJgt Ccaapn wean Rate Return to -Work Wait Released to oft olds St3¢2 End Day+: Rearm-pont 62 a: xua w Ga Released to nark -+N, Rest:Mi ns: 3 : I :'. [: c.• Reirase to Full Mewl 00 so 0:+:w1 7 .}� return to uork ]Sodded Duty Star ! :U 5 Actual Renure-to-Work Der ' Fug Wage i— N?cd6rd Dray es Lmvaiabie Raem To Work ModiRed Duty Released re Rem End Days Full Dun. :1 :016 [7671252916= 12 1 = I " 1; MO = 85 u6 5016 J 0" 11 ?illy — 112016 T 10a036 Comests 3:nee ;maer. P eat Nuns LT Dasy. 1.17 Even Unto Calendar Days 1 Lost TOM Work Days POR cntrnt za*um-To-Work Sacra peq..NFa LT caletda Coup. Cuomo 1TW LT Days Dry Rate Satin t( 1r - 1 13 1.')• j49'33 • tram 15 Mork Duty rs Coon ?dot Duty Calmly Dayt } 1111 Mod. .Duty Wedt Drays (OSH F 61 RottemalAddewtul-Utdtmeity Swop Rammed Tim Comp • m Uneatable Rate ") • r9733 • The &h air C. Rate mu area m nkalate de Can.>a BTµ Satla;t I'a!_>c 113 Describe and provide an example of documentation of medical management within your company's notes system; Documentation of medical management is inclusive of all pertinent aspect of an injured employee's care, inclusive of functional limitations. The DWC-25 is reviewed, as well as any physician notes. Treatments and procedures are reviewed for medical necessity and causality. Once a determination is rendered, then the care is coordinated. All actions are documented in Corms as well as the guidelines referenced. Office Visit - TCM Case Assessment Note Received by: 09/05/15 Dr. Orthopedist LOV: 08/09/2015 NOV: after MRI DX: M54.41 Lumbago M96.1 Post-laminectomy syndrome, Lumbar Region Acute or chronic lumbar syndrome in previously operated spine with previous history of 1- ThIP L4-5 and stenosis L3-4 Work Status: OOW Anticipated MMI per ODG guidelines: 10/05/2013 Drs. Eval: INSPECTION: No swelling or bruising. No gross deformity. There is a healed lumbar incision. PALPATION: No midline tenderness. Diffuse bilateral paraspinal lumbar tenderness. There is no paraspinal spasm. There is no sciatic notch tenderness. There is no sacroil incjointtenderness. RANGE OF MOTION: Marked restriction of forward flexion, extension, lateral bending and rotation to each side. There is more lower back pain with extension. There is no pain with hip range of motion. STRAIGHT LEG RAISING: Negative on the right. Negative on the left. She has lower back pain with bilateral straight leg raising and pulling into her thighs. MOTOR STRENGTH: 5/5 bilaterally in hip flexion (TI,2,3), hip extension (L5,I), hip abduction (L.5), hip adduction (1.2,3,4), knee extension (L2,3,4), knee flexion (L5,1), ankle dorsiflexion (L4), EHL (L5), plantarflexion (SI). The patient is able to stand on their toes and heels without difficulty. SENSATION: Intact to pin prick and light touch bilaterally. RELLEXES: Patellar (LA) 2+ bilaterally, Achilles (S1) absent bilaterally. There is no clonus or Babinski, GAIT: The patient walks with a slowed gait Imaging Orders: Three views with AP, Lateral and L5-SI spot of the lumbosacral spine were ordered, obtained and interpreted from an orthopedic standpoint Lumbosacral Spine X-rays: Lumbar x-ray shows a transitional L5-SI level, There is disc space narrowing throughout the lumbar spine. Drs. Treatment Plan: I had a long discussion and reviewed treatment options in detail, after reviewing the clinical findings and diagnostic studies with the patient. Due to the severe pain T would recommend an updated lumbar MRT scan with and without contrast. She has an appointment scheduled today with Dr. Epstein for medication management and will keep that appointment. No pain medications were prescribed from this office today. After the MRI scan I will be able to heifer determine whether not require surgery for lumbar spine and whether or not this is related to the pre-existing condition or this new accident on 7/3112013. MRI of the lumbar spine with and without contrast was ordered. The patient is to return when the result of MRI is available. A copy of the patient's note was sent to the adjuster. A copy of the patient's note was sent to the nurse case manager. Improvement noted: no Medications: Wellbutrin, Nabumetone 750mg Tab Oral Are there any medications concerns: no Average monthly medication cost: $63.25 per My Matrixx Treatment in compliance with MD Guidelines: yes Lumbar HNP Paee. 114 Based on clinical suspicion of a disc herniation, conservative treatment, which may range from simple rest to elaborate traction devices is recommended initially, except when signs of severe or progressive nerve compression (radiculopathy) are present. The individual is instructed to avoid aggravating activities such as heavy lifting, bending, twisting, or prolonged sitting. A corset may be worn during the day to provide support. For relief of pain and inflammation, treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs) and, if pain is severe, a narcotic or an anticonvulsant for its analgesic effects. Muscle relaxants are frequently prescribed for their sedative effects. Other treatments such as ice, heat, massage, and ultrasound therapy may help relieve pain and muscle spasm. As symptoms subside, an increase in activity is recommended, including physical therapy and/or a home exercise program to strengthen the lower back and abdominal muscles and improve aerobic capacity (walking), The individual may attend "back school" to learn correct posture and body mechanics. Many individuals recover completely; however, recurrences of back pain and sciatica are common. Therefore, preventive and maintenance measures such as exercise and proper body mechanics may be continued indefinitely. If little or no improvement is seen after 4 to 6 weeks of treatment, and if the pain is severe and debilitating, further evaluation is appropriate. if imaging studies have not yet been performed, MRI or CT/myelogram are indicated. Individuals who have leg pain (radicular pain) as the predominant symptom may gain relief through the administration of epidural corticosteroid injections. If non -operative measures are unsuccessful in relieving the individual's symptoms, surgery consisting of a laminectomy and disc excision or a minimally invasive disc excision, may be considered. Proper patient selection is the key to favorable surgical results, and good outcomes are more highly associated with correlation between clinical findings of radiculopathy and imaging studies. Central disc herniations generally present with low back pain and without radicular complaints; they, rarely benefit from a lumbar laminectomy and discectomy. Individuals who have persistent back pain as the predominant symptom usually do not benefit from surgery intended for disc herniation (discectomy). Individuals with chronic low back pain may benefit from a rehabilitation program, and/or pain management. Emergent disc excision (discectomy) is indicated in the patient with cauda equine syndrome, which presents with bilateral severe leg pain, saddle anesthesia, and bowel and/or bladder incontinence. Surgery is also indicated in the individual with progressive muscle weakness; severe unilateral leg pain with objective signs of nerve root compression (nerve tension signs and/or loss of neurological function) that has not improved during an adequate trial of conservative treatment, with an imaging study that correlates with the clinical findings for nerve root compression; or recurrent episodes of severe leg pain with objective signs of nerve root compression and a matching defect on imaging studies. Microdiscectomy or minimally invasive discectomy are alternative procedures that may be done on an outpatient basis and may have shorter recovery periods. However, the indications for these procedures are the same as the indications for open laminectomy. Adjuster conference: per corrus notes Are there any red flags: pre-existing lumbar surgeries, complicating this claim Nurse Care Plan: coordinate MRI accordingly, results to provider, determination of exacerbation or new injury by Dr XXX. Monitor medicals. Field Case Manager update/report: Possible FCM request after, if surgery is indicated. RN BS Page I15 PCP A PCP B PCP C Ability to profile provider practice patterns and report on both clerical and financial outcomes on a case by case basis, as well as in aggregate; and AmeriSys has the ability to report on a providers practice patterns, both from a compliance with submitting of the correct documents as well as their billing practices. Comparison of Physician Outcomes for Claim Year 2015 at 12 months 20 Claim PT Days l 1.L 0 Avg Bill Cost 5-149. i 11r5S0.28 Bill Count Avg Claim Cost Claim Count 0 11 36 15 $ .1.7,61 187 $1,130 200 400 600 800 1000 1200 • PCP C aPCP 8 ■ PCP A 6 'Claim Count Avg Claim Cost BB Count Avg Bill Cost Claim PT Days 11 $ 205.19 25 $ 90.28 0 15 $ 518.42 52 $ 149.54 11 36 $ 1,130.36 187 $ 217.61 20 Page 196 m) Examples of medical cost containment reports (either ad hoc or standard) that have been generated from your company's system using a real blind client. USIS/AmeriSys has 8 on staff and on -site programmers who are able to build ad hot reports and/or data extracts at your request for no additional charge. ,%mertSys (L'SIS Database) RTW Savings Report Retort To Work Date: 07101/2015 - 09/30/2015 • Indemnity - TC11 Both opeaed and Closed (by date) Claimant lame DOA Claim Status Projected RTW Proj. tam. LT Calendar Days Comp Released Claim 11) Claim lumber Paee1 Lost Time TCM Status LT Days Da',s Sand Rate Saints Full Duty »I':015 Ces.d 17232017 0_ Si 1:6.13•• 164'19` t21NI! 10.1.4ory [366..3 C101100 OL 29 011 Cau04661 109k 011 as 1 st saris • • user'1 lailaraF CV.* C:7393:.D 3 13 :-'4 " C1 ...d 09 I! 311.` 31 13 11 1333" i3 • • 542 1 17 1 ;f ; 1 .4.14.r.r:19 C16.ed Cldra C4a91: :4 O1'!.':Ot1 or* O941011 5111 9 311 1097i$•• 5:3,'t3 Wf1^_011 kewaly DP•M 01i:^. . C:6.41 i0:.261) SS 541:11•• 51,16'23 is-,')i! iO4+393a9 Qpn+ 09.7.' 70V CiasIA 1171312 1: 2 19 t+f`a3 •• SA.191 3 9:s 701 • - Cloned .4rrrge: i' 71 't S7LZ.it 11.00431 Sew 3 W7 1,:31 510 _17 • N AmcroSys t,kmeiSysOataBasc1 Medical Bill Review Activity Report *0 Payers. Date SLitsge: 110114:1113 Though .5'31;2,113 A11 Medhst Sas ±i1k sect ^ grs __,521_ �r - - •..."6-•*6 .- 46:936. MrA4d 7019 393.9ret ' 433,1 11*M4 0909* 9*6..iG4.. ah,xan 14..97 WO.39 41.3771i2.491:sL3S40:4.0100.39 L4.113A1-4.19 43.4% 15-94U1LR2 1311.O06.91 3.7% 1:37.10J9 2S 4. 15. 704,579.43 15.»2.41..51 47.14 .440-117 $ 10-09 410100.911. 1L441.00411Imo % s1.I 0Za7f4s N.1% 1SOt,*MN St70.120A3 103% 10.039.71 1.49 4479.04R0f 1304.402' 11-2% .7.04 7.2- sl 0.e. 231 1090 % 1.324 100.0 % 11.:42.40-22 100.0'4 049.9 00 12-2% 1503,S4*/.12 t'3.411.70 7.4 % 1+1,01S.07 9.7 % f k1.4N.i9 _ 13113.037.111 43.1 % +n*t.twtorr ugw-r Mot 1009% 3t01009'e. SS: "94.34100.7% 6,71.20294.4% 0349,41137 914.007.3 LS% 139.09S4 10.7% 1314.421.73 120.011.17 14,71. M,4r43 ih4.90.- 3,121 1004% 10.4.410.07 S5: .'7100.0 1:'S.379.0 2941 14MA02.02 14,f15.W 0,7% 1104,117.21 24.516 0331..111.11 1327,400.11 4449 .49"..36.9.4 :99 AO* .1.** ?:+MO9 :• .. t '.S s•;t.3rE SU% RW.131.14 $3$,a'.7 3,3\, 1S4,00.97 26.4\ L1S4,41S.:7 $13/.391./0 71.14 ....30.34.3 Si 111.M.77 10:00 OA9 0.00 99'K ill-119r 1:1,260.77 42.9R. 2'21 1C : . SS. 100d n •.. 3:..'3.0 1.1 9 114.11t.94 51.41.-0 S., 9 L.S,41729 41.1 % LS44,fMSS 1.1:.:01.37 45.19 a. :ra 100.: •. :.$41 :00.>. .,..... $4.40010 1.$ . 134/,497.13 1:1,169.97 1,0% 442,1074 124 % $301-649.+, $211.5'1.51 1i.S1. :61x, . . :.74010031i 139Aa14.7 100 •. S66,473.37 51-11 1.'0.5.0.70 $21,091.44 '.39 $3,06_67 1.7 9 i2J` 6,+44.r0 1:143S:.64 40.1 . 16.4E ._ -. , . . 94411 100A 14 115.41* 494 22 1?:.] *. 1'.:94.705.70 4S.S • 1RSO4, 912.52 5.9713.471.43 4.t 1 f441.444-5: 4.: % iE:014.649.70 17,147.77:41 S2.7 Page 117 Cost Containment Report 1.134.670.71 405.504.37 725.772_34 Ambulance Ambdtattry Surgical Center Cert Regis. Nurse!Advanced Nurse Practitioner Doctor Durable Medical Ecuiument HosPrtal Independant Lab Pharmacy Physical Therapy Cert Regis. Nurse!Advanced Nurse Practitioner Dentist Doctor Durable Medical Egar�lxncm Hospital Iedependanl Lab Pharmacy Physical Thf.apy Doctor 1,134,576.71 33 59 3,0 %5.15 3.940.85 171,42025 453 50 217.988.94 4.13921 513 7,921 74 340 84 114 17 31.898 95 5.178 OB 5,5i1 39 505 39 8,359.58 15922.0e 30 00 3000 d5.7°.829 809.954 08 Fee Schedule Reductions 4.955 ME Ambulance Atrbulalwy Surgical Carder Caen Rego IN N;useeaavan d_ ▪ Ooctor Durable Idedi "r Elharsa,ona 1.11 H6st#ai Indeberiden1 Lab ▪ Pharmacy Physcal Therap,. Network Reductions Card Rtrlfr, Mu1a+Aetanre 7. nn,Inl ▪ Ductm MiffD1 uo5t. lMdde,ti eqc npnl Huapa0i (.,,dependant Lab Pm.,bniaCy ▪ P'Y3._84 'Meier Other Reductions 659,954.08 MI Doctor 474,622.63 Page 118 2. Detailed outline of medical management and medical cost containment fees for services proposed to the City to include the following: a) List all of the medical cost containment services included in your company's claim service fee, NA - Refers to Part II All medical cost containment services are priced separately from the claim service fee. b) List all of the medical cost containment services provided by your company or your company's vendor partners, that are not included in the claim service fee with the itemized charges. NA - Refers to Part II c) Outline all medical cost containment services provided to your company by an outside vendor, including PPO, Nurse Triage, Dedicated Nurse Case Manager and any other proposed services. Note: Proposers are requested to address the issue of physician dispensing and the high cost of repackaged drugs. AmeriSys is proposing DimensionComp for hospital and provider access, Coventry PPO as the secondary or "wrap" network, the AmeriSys Preferred Provider network for ancillary providers, and myMatrixx as the Pharmacy Benefit Manager. DimensionComp is an affiliate of Dimension Health, Inc. DimensionComp provides clients access to the one of the largest Workers' Compensation networks in South Florida. By maintaining strong relationships with the provider community, DimensionComp is able to offer clients superior network savings and greater access. Under the 2003 -2011 managed care agreement, AmeriSys provided the City with a certified carve out version of Dimensions Health Care. The carve -out was modified to meet the specific needs of the City while meeting the requirements of the Agency for Healthcare Administration. The AmeriSys Network Manager established a strong rapport with Dimensions Healthcare; thus ensuring the prompt attention to specific provider needs of the City of Miami, including the recruitment of specialty physicians that are qualified to care for those individuals covered under the Heart and Lung Bill. Coventry Health Care Workers' Compensation, Inc. Coventry provides clients access to the largest national provider network offering in the workers' compensation industry. By maintaining strong relationships with the provider community, Coventry is able to offer clients superior network savings and greater access. The AmeriSys Preferred Provider Network is made up of a select group of vendors to perform the services referenced below. Every three (3) years AmeriSys undergoes a very detailed RFP process for Ancillary Medical providers that include transportation, translation/languages, physical therapy, diagnostics, home health and durable medical equipment. These organizations undergo due diligence and are then contracted. Contracting includes indemnification for customers, insurance coverage verification as well significant discounting for services. We believe this provides our customers with the best protection at the best price. creating best value. Page 1 1- Matrix Healthcare Services, Inc., d/b/a myMatrixx, is a full -service pharmacy benefit management (PBM) and ancillary services company focused on workers' compensation. The AmeriSys/myMatrixx partnership has existed 10+ years since the inception of myMatrixx. Together we have provided quality medical management and pharmacy services to customers in the entire south-east region. AmeriSys and myMatrixx through their relationship have joined forces to face multiple challenges in the Workers' Compensation arena such as the escalation of the need for cardiac medications (BADGE Program), and currently we are working together on the AmeriSys Pain Management initiative called SECURE. The Vice President of AmeriSys is currently a member of the myMatrixx pharmacy and therapeutics committee which establishes the general protocols and formularies for this PBM. Physician Dispensing USIS' procedures adhere to Florida Statute and Rule requirements that the dispensing of medicinal drugs is limited to a pharmacist or a licensed dispensing practitioner and must billed under the original NDC (National Drug Code) number. The Florida Fee Schedule reimbursement for the dispensing of prescription medications is: Average Wholesale Price (AWP) + $4.18 = $ Reimbursement [Note: In order to properly reimburse repackaged medications, USIS requires both Original and Repackaged NDC #j Through our PBM, myMatrixx, we are able to offer an extended network discount on repackaged physician -dispensed medications. For physicians who are willing to participate. the pricing is as follows: Average Wholesale Price (AWP) + $5 + $4.18 = $ Reimbursement which is a discount from the Florida Fee Schedule allowance. This is a savings over the Florida Fee Schedule pricing for repackaged physician -dispensed medications which is: Average Wholesale Price (AWP) x 112.5% of the original + $8 = $ Reimbursement Example: For non -repackaged drugs, whether from a pharmacy or a physician, payment is based on Fee Schedule, unless a PBM contract is in place. If the physician has repackaged the drug, but there is no PBM in place, payment would be based on 112.5%, and both the repackaged code and the original code have to show. Dane Street, LLC - Physician Advisor Services for UR Dane Street provides Workers' Compensation Peer Reviews to Managed Care Organizations, Third Party Administrators, Utilization Review Organizations and Employers. Licensed in all mandatory UR states, with an active Regulatory and Compliance group which interfaces with the appropriate State workers' compensation Boards and Departments of Insurance. Dane Street is a URAC-accredited review organization and the reviews are delivered according to all URAC, jurisdictional and client requirements. They understand the importance of state - specific medical treatment guidelines, turnaround times, match requirements —and track any changes across these categories in their rules -based PeerAccess platform. 3. Provide the name, address and contact of the vendor and please also: DIMENSION Dimension Health, Inc. 5881 N.W. 151 Street Suite 201 Miami Lakes, Florida 33014 Contact: Creta Diehs (305) 823-7664 Provider Hospital Network T COV'LNTRY Coventry Health Care Workers' Compensation, Inc. 4141 North Scottsdale Road Scottsdale, AZ 85251 Contact: Jennifer Cummings 615.854.0359 (Wrap) Provider Hospital Network • ®� rinyMatrixx 5706 Benjamin Rd. Tampa, Florida 33634 Contact: Artemis Emslie 877.804.490() Pharmacy Benefit Manager Dane Street, LLC Debbie Hill, MSN, RN, CCM, Director of Account Management 891 Centre Street • Boston, MA • 02130 951.543.1627 561.206.0659 (fax) dhilltcr-danestreet.com ww•w.daneStreet.com Peer Review Provider Page 121 AmeriSys Preferred Provider Network l ADDRESS PHONE NUMBER FAX DIAGNOSTIC'S (inc Call Care Management 841 Prudential Dr.. Suite 900 Jacksonville, FL 32207 800 8722875 866,632.2161 Orchid Medical P.O. Box 560370 Orlando, FL 32856 866.888.6724 407.893.7363 Spreemo 88 Pine Street, 1 1 `h Floor New York, NY 10005 800.595.7173 2(}! .289.5765 TRANSPORTATION/TRANSLATION IU Group Languages & Transportation Services 10650 Treena Street. Suite 308 San Diego. CA 92131 800.726.9891 888.497.191 JNJ Services 170 Camden 11111 Road, Suite G Lawrenceville. GA 30045 800.588.9679 877.308.3805 Speak Easy 1411 N. Westshore Blvd., Suite 320 Tampa, FL 33607 88$.939.7767 866.507.8362 ProCare Eisenhower Technology Park 4710 Eisenhower Blvd, Suite C-4 Tampa, FL 33634 866.941.7878 813.769.3883 DME (inc Call Care Management 841 Prudential Dr., Suite 900 Jacksonville. FL 32207 800.848.1989 866.672.6807 Orchid Medical P.O. Box 560370 Orlando, FL 32856 866.888.6724 407.893.7363 Priority Care Solutions 3802 Corporex Park Drive, Suite 100 I r�11pa. FL 3i619 866.932.5779 877.212.91 37 Page 122 HOME HEALTH One Call Care Management 841 Prudential Dr., Suite 900 Jacksonville, FL 32207 800.848. 1989 866.672.6807 Orchid Medical P.O. Box 560370 Orlando, FL 32856 866..888.6724 407.893.7363 Priority Care Solutions 3802 Corporex Park Drive, Suite 100 Tampa, FL 33619 866.9 32.5779 877.212.9137 PHYSICAL THERAPY Therapy Direct PO Box 915 Ooltewah, TN 37363 888.904.6776 678.298.6271 Alignl�'etworks 7785 Baymeadows Way, Suite 305 Jacksonville, FL 32256 866.389.0211 904.998.0299 SPNet Clinical Solutions 22 Inverness Center Parkway. Suite SOU Birmingham, AL 35242 888.654.0049 205.995.1894 HOME MODIFICATION Home Modification Solutions P.O. Box 10541 Brooksville, FL 34603 8fi6.939,6637 Home Safe 5914 Jet Port Industrial Blvd. `Tampa, FL, 33634 877.854.8897 877.854.8898 Orchid Medical P.U. Box Sf70370 Orlando, FL 32856 866.888.6724 407.893.7363 One Call Care Management 841 Prudential Dr., Suite 900 Jacksonville, FL 32207 800.848.1989 866.672.6807 Dental/Doctor/Hearing/Eye Programs Express Doctors 2004 N. Flamingo Road Pembroke Pines, FL 33028 888-569-0577 888-539-0579 Dental Works USA 1408 N. Westshore Blvd. Suite 704 Tampa. FL 33607 855.443.9872 813.251.3850 Page 123 a) Confirm your company's willingness to allow the City to select and utilize a separate managed care vendor the City would like to utilize on the City's files; If it is the City of Miami's preference to utilize another vendor, USIS would be willing to work with that vendor. However, USIS prefers not to utilize a separate a managed care vendor as the USIS/AmeriSys systems and processes are wholly integrated which provides better economic outcomes for our clients. USIS has an integrated approach to claims management which involves Telephonic Case Management when required as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the TCMs work with the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case -manager (when assigned) and the cost containment bill review team. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Hoene Health, etc.). These providers are contracted not only for significant pricing reduction but also for performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City's overall economic impact. b) Outline your company's philosophy on field medical case management versus telephonic case management; The Telephonic Nurse Case -Manager should provide Quality Care in a Cost Effective Manner focusing on early return -to -work. The purpose of Field Medical Case Management is to provide services that allow for more specific and detailed information regarding care, home situations, family dynamics and employee job site. This manner of delivery is important for establishing rapport with the injured worker and/or family, particularly with high risk or severe injury situations Telephonic Nurse Case Management will be utilized based on criteria set by the City of Miami and AmeriSys. AmeriSys recommends Field Case Management assignments if the triggers listed below occur. We believe that Telephonic Case Management, when feasible, is the most cost effective method of providing case management services. Travel and related expenses are cost drivers for case management and should only be utilized where there is the need for face to face or direct contact such as Horne Assessments, meetings with providers, etc. Page 124 Recommendation for Assignments of Field Case Management I. All catastrophic injuries, such as, but not Iimited to: • Spinal cord injuries • Head injuries 2. Neck injuries (except for minor strains) • Burns of face, hands or greater than 9% of the body • Amputations • Loss of hearing • Electrical shock • Multiple fractures 3. Any potential serious back injury: • Failed back syndrome • Multiple fractures in the back • Herniated disc with radiculopathy • Positive neurological findings • Any back injury with any degree of paralysis 4. Chronic Pain Cases 5. Claims with high potential for PT rating including, but not limited to: • Fractures in or near major joints or weight -bearing body parts • Crush injuries • Hand injuries, particularly of the dominant hand 6. Injured employees with a previous history of workers' compensation injury or injuries. 7. Difficult pre-existing medical or social problems • Diabetes • Heart disease • Psychiatric problems • Illiteracy • Mental retardation • Alcoholism and/or chemical dependency • Morbid obesity 8. Cases not fitting an expected recovery time frame: • Not responding to provided care • Time delays in getting appointments • In-egular appointment attendance • Disagreement with the course of treatment • Questionable or experimental treatment recommendations 9. Injured employees who are approaching 60 days without returning to work. The need for Re-employment Assessments is decided on a case -by -case basis. 10. Need for extended home care. 11. Hospital discharging requiring planning for home health and/or durable medical equipment. 12. Location or communications barriers. (Injured employees in small rural areas with limited local facilities, or with language barriers who know limited or no English) 13. All new claims with an initial reserve established of $50,000 or greater. Page I2S Recommendations for Assignments of Telephonic Nurse Case Management Upon receipt of the First Report of Injury, the claims adjuster reviews the nature and cause of the injury to determine the necessity for further intervention. At the direction of the claims adjuster (per client protocols), a referral for case management is initiated. Serious injuries will be assigned for telephonic ease management immediately. The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case -manager within the first 24 hours will make contact with the injured worker and complete an assessment of the initial medical treatment; evaluation of the treatment plan and assess the need for continued medical case management. If specific tasks need to be completed to assist the claims adjuster with the handling of the tile, these can also be assigned. Telephonic case management is the systematic evaluation of medical services, procedures, facilities for medical necessity, appropriateness and efficiency. This promotes optimal patient outcomes, reduce period of disability and assure high quality of care while controlling costs. A nurse facilitates the medical activity on a file with the ability to individualize the plan of care and coordinate early return -to -work strategy with the employer and medical provider. The functions included • Coordination and referral to network medical providers • Coordination of the treatment plan with the provider • Working with the provider to establish functional abilities and conditional release to return to work • Discussion with the injured worker to clarify the worker's understanding of the diagnosis and treatment plan • Monitor the treatment compliance of the injured employee • Identify and assist in the resolution of problems with compliance to the treatment plan • Provide regular reports to the claims handler to assist them in the management of the claim • Recommend on -site case management and vocational services when needed • Work with the employer to identify a medically appropriate job Coordination and referral to network medical providers allows for the best network penetration. The channeling of the network providers will allow for the best network discounts. Page I26 The Telephonic Case -Manager acts as the center point of contact ensuring delivery and communication to all approved providers of PBM and appropriate parties, forwarding appropriate issues to the utilization review department as necessary and reporting outcomes to the AmeriSys Quality Assurance Committee. Adjuster Diagnostics Physical Therapy Home Meath Case Management Employer Injured Employee Medical Case -Manager Case Manaoement Plan - Assess Needs - Develop Plan - Impiement Plan Items - Monitor Progress - Evaluate Outcomes - Re -Evaluate Plan DME Pharmacy Transportation 8 Larg.ages ATP iAtterding Treating Physiaael Vocational and Feld Case Management CAT Super Utilization Review Prospective iPreCani ConCurrent Retrospective We understand that it is imperative for both employee and customer satisfaction; we communicate promptly, which includes facilitating care and appointments properly. Prompt, accurate and complete communications are performance standards and measurements for our case management team. Page 127 c) Provide a sample of quarterly reports detailing savings realized as a result of your company's cost containment/medical management programs; 10(0‘e Performance Report Report Outcomes for Fiscal 4'1i Quarter April - June 2015 Flscai Year End Jury 2014 - June 2015 .- nzeriaS.1"s * 311.911 3141.1,a rna•se..1*144 ,.. ic1..9191n w clot mos Iti*a+t. 5a1 1.1a -99a19,4l'ti )N9 arb .nd... y.1. w 10444*0014 arul.y 1alan.slol.+. ...ale, 19.9.1.4 ,aowonw **rah !re :nral, Lar919.199r9g .Ila vegotaiteg ..a4 .199n499.4 "war. w orww 1..41n Ins/' 1e cce M4.4 amt., Meg 41r4 xurAues 4.4 » 4ly....3.1..4ewm .e4R,4. 1199/999wt a 1e,1 *41111 y4ae441914.11 wne r.4.r414. Of Iha. 121) r1* uol. re vw i. 11111. 0nemM z uw. 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Soo.," He4** hpr a aaftln r+d stkest n twem ode a re on, Wm My MIMI' kAI Mtata. * .f n,* a* - n.r..srons rot Shoe soon seta - Drow5.11 to the Bray, d pfrysau+a fr.kw comersitsonR rwirasted r•4er8r1 chd moo Rnria,drr owes of no moon 'd Ot :ete ptdWwt Om" LM Mrtraen neataCiOeti CM.," Ise 7K 41C2 AMMO SS - d M etheiw mated be nsa derma listed A yryleaid *Lamed. and Cue .:.w. eeM.i ak,^: He ,Yl.:U+M*» to swam Y0CI es1 1M,* rewar Return on investment sru6wr.fef W CX4 C.*Aas;as 4E419,to Mturels. aa:uss CoMeeted 794 5:1aa357 SYsiesmessk kossm Sfi`..47 auazk, 2.2.2 1 as.7 7: Cafe Maki nme +att,s messes StU.9i: • tnSaE ems %ZS, aLd: 417 12J wene.a he rev** Co1rtexdtVe 41.61567 nrotivonsi Row'•' SIC7,141 4ldfLG;n lewd./ Can AfMt( we 5115.I71 P4e471 So won $oL971 `oeo Ytes PLUM 104r $7.60 ;l•OMITTED 1. Cat earAa(t1S' Mann. P4 49 Ic' OM rameacW PPO 46, te Prainnne.erne. 471. YI llWara teAre a sea+_*+ Ca.e laaagam. Rims % ak 4`,t i.`9 ont Poo 4.'1 •11 RCS Ste 41 Wero•e l'ee ',haw* Caeawore PPO Ptekwomi Ra-.w Set ten 474, 71 eyrm id a Rana 0 Wart ..e.. v:rri St•t •11 RW s•1e es you no tw noso e, n :a.+•!. ( n motets Adam IO rondo nit 'NU tin ON t Ol thee mew oesrAM oohs flat 7 oe Mms n mom foe Art/ a• 9wartw 04 wins Caen L2.4 ones., woos r o ford era tr•A We re Ar`.*ae dl -ho.. sts leaf 7. t you 0t .wnel l Physician Dispensed vs. Pharmacy Dispensed n• .... 7Pit Claims that Received Medications rfr,...•.,r»aer .rw.n s•.s rn. ntS Page 129 TQTAI. SAYINGS BREAXOQWN Fiscal 4' Quartet: April--lurle 2015 al Bits StNe .na.craes ..x•., +emm wmr..a X)X'SSAVINGS 6L1RM7 pJV�)•� TOTAL SAVINGS SREAXAf3WN Fiscal Year End: July 2014 - June 2015 XXX'S $AVINGS T2u24.RMFer Arrpn� TOFa�Aagwpd ArnenSys (AmCru8y3 C ntOBesel Medical Bill Review Activity Report Payer:. Date Rave: U7J0.11.2014 t4SrO.QM1 MOO' 1615 Eer�5..S1`�r'a. 9sr Sc3�dc 2sa 4n� 4!hss. £*, .art Re¢¢¢.4 Arrtmrt ^.wsa* 4&.s.i u.xktct.m Pt cfe# 41 9. Tot d ChkQproulk- S6 warn J® .94 Imo^e DTTF WT 1alU+y 762100,E°a ,:i;SA SCv 1.41.3 F-CC IJ'L 3.327 no a., :dxi 14J. S:',.. )5tR .-. -. .`3A>w j: ,:,b3n-SI Si4O----'--'+ 1..9.13Si :.5 :"G,G Se;.:o..' "e. ., ,- '33 '% i:?i..5i.d7 SkSS..0 Tatads IJ, 453 1 .- .a ALAI" 160.R% FID,y49,..4D.w9,Oa.C.% 53,Y5J,40.,61 33 It 22551.618.0E 2'55.25231 a ^<e.,.. ..._4E5'.5§4.3+ F&.319 24.ss'}..',[]• 1R :3233.4.4.21 S+,: W Page 130 d) Outline any association your company may have with a managed care organization or PPO including the network your company utilize; AmeriSys is the Medical Management division of USES and is contracted with DimensionComp for utilization of the Hospital and Physician components of medical services and Coventry PPO as the secondary or "wrap" network. We are direct -contracted with providers for Ancillary (DME, Physical Therapy, Diagnostics, Transportation, Translations and Home Health) for preferred service, as well as better pricing. Providers from Dimensions as well as our direct -contracted providers are readily accessible in your area. e) Provide references of clients using these associated medical management services indicating detail of services purchased; Client Bay County Board of County Commissioners Type of Entity Public Client contact person Eve Tooley Phone number 850.248.8231 Email address etooley@ baycountytl.gov Description of work WC Claims TPA Medical Bill Review Total dollar value S 15,000+ annually Dates covering the term of the contract Established 1993 and remains active Prirrre contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, Tight duty / return - to -work program, etc. RTW Client Broward County BOCC Type of Entity Public Client contact person Jeff O'Connor Phone number 954.357.7230 Email address JCOCONNOR@broward.org Description of work Network Access/Bill Review/Intake Total dollar value S50.000+ annually Dates covering the term of the contract Established 2007 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Page 131 Client City of Cocoa Type of Entity Public Client contact person John Titkanich Phone number 321.433.8686 Email address jtitkanich(a,cocoafl.org Description of work WC Claims TPA, Medical Bill Review Total dollar value $50,000--annually Dates covering the term of the contract Established 2009 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc.. RTW Client City of Jacksonville Type of Entity Public Client contact person Twane Duckworth Phone number 904.630.2777 Email address twanedcoj.net Description of work Network Access, Medical Bill Review and Medical Only Claims Handling on an as needed basis Total dollar value $275,000+ annually Dates covering the term of the contract Established 2013 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Client Orange County Public Schools Type of Entity Public Client contact person Regina Cochrane Phone number 407.317.3918 Email address regina.eochrane a ocps.net Description of work WC Claims TPA, Bill Review and Medical Management Total dollar value $400,000+ mutually Dates covering the term of the contract Established 1996 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program. Tight duty / return - to -work program, etc. RTW, Light Duty, Loss Control Client Palm Beach County Sheriffs Office Type of Entity Public Client contact person Hilda Gonzalez Phone number 561.688.3550 Email address gonzalezH(pbso.org Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value $750,000+ annually Dates covering the term of the contract Established 2000 and retrains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Client State of Florida (DRNI) Type of Entity Public Client contact person Candy Janes Phone number 850.413.4827 Email address Candy.Janes@,:mytloridaclo.com Description of work Intake/Triage Medical Management Total dollar value $9,000,000+ Annually Dates covering the term of the contract Established 2014 and remains active Prime contractor or subcontractor Ptirne Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Client Volusia Countv Public Schools Type of Entity Public Client contact person Sandra Higginbotham Phone number 386.734.7190 Email address skhiai, in(it volusia.k12.fl.us Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value $250,000+ Annually Dates covering the term of the contract Established 2007 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Page 133 Client Preferred Governmental Insurance Trust Type of Entity Public Client contact person Ann Hansen Phone number 321.832.1510 Email address ahansen@ipublicrisk.cotn Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value Confidential Dates covering the term of the contract Established 1999 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp TPA Indicate whether Proposer assisted in disability, safety program, Eight duty / return -to -work program. etc. Client Brevard County BOCC Type of Entity Public Client contact person Julie Jones Phone number 321.637.5446 Email address Julie. Jones<d;brevardcountv.us Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value $250,0001- annually Dates covering the term of the contract Established 2003 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp TPA Indicate whether Proposer assisted in disability. safety program. light duty / return -to -work program. etc. Client Charlotte County Type of Entity Public Client contact person Raymond Carter Phone number 941.743.1334 Email address Raymond.Carter(ct charlottecountyti.gov Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value $40,000+ annually Dates covering the term of the contract Established 2010 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability, safety program, light duty : return -to -work program, etc. Page 134 Page 135 Client City of Delay Beach Type of Entity Public Client contact person Eddie DeMicco Phone number 561.243.7150 Email address demicco@,:mydelraybeach.com Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value $50,000+ annually Dates covering the tern of the contract Established 2013 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability, safety program. light duty - return - to -work program, etc. Client Leon County BOCC Type of Entity Public Client contact person Karen Melton Phone number 850.606.5120 Email address Meltonk ri'leoncountyf1.gov Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value S50,0O0+ annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability. safety program, light duty / return - to -work program, etc. Client Preferred Governmental Claims Services Type of Entity Private Client contact person Ken Picton Phone number 800.237.6617 Email address kpicton(p pgcs-tpa.com Description of work Medical Management, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 2005 and remains active Prime contractor or subcontractor Prime Contractor for Medical Bill Review and Medical Management Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Client Ferman Motor Car Company Type of Entity _ Private Client contact person Webb Bond Phone number 831.251.2765 Email address webb.bond@ferman.com Description of work WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability. safety program, light duty I return - to -work program, etc. RTW, Light Duty Client Halifax Health Type of Entity Private Client contact person Terry Martin Phone number 386.254.4048 Email address Terrv.martin(fi;halifax.org Description of work WC Claims TPA, Bill Review Total dollar value $75,000+ Annually Dates covering the term of the contract Established 2012 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Client Health First, Inc. Type of Entity Private Client contact person Nancy Johnson Phone number 321.868.7248 Email address Nancy.johnson(u health-first.org Description of work WC Claims TPA, Bill Review Total dollar value $125,000+ Annually Dates covering the term of the contract Established niid 1980's and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability. safety program, light duty / return - to -work program, etc. RTW, Light Duty Page l (, Page 137 Client Orlando Health Type of Entity Private Client contact person Christy Pearson Phone number 321.841.6104 Email address christv.pearson(ci orhs.ors Description of work WC Claims TPA, Bill Review Total dollar value $175,000+ Annually Dates covering the term of the contract Established 1996 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Client Parrish Medical Center Type of Entity Private Client contact person Roberta Chaildin Phone number 321.268.6333 Email address roberta.chaildin(a:parrishmed.com Description of work WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prune contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability. safety program, light duty / return - to -work program, etc. RTW, Light Duty Client Ring Power Corporation Type of Entity Private Client contact person Cindy Acosta Phone number 904.737.7730 Email address Cindy.Acosta(ci.ringpower.com Description of work WC Claims TPA, Bill Review Total dollar value $40,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, Tight duty / return - to -work program, etc. RTW, Light Duty Client FHM Insurance Company Type of Entity Private Client contact person Phone number Email address Description of work Total dollar value Jack l,emine 800.329.4340 jlemine@,,fiunic.com WC Claims TPA. Bill Review, Medical Management Confidential Dates covering the term of the contract Prime contractor or subcontractor Established 2003 and remains active Prime Contractor Indicate whether Proposer assisted in disability. safety program, light duty / return - to -work program, etc. Client Florida Citrus, Business Industries Fund Type of Entity Private Client contact person Phone number Jim Emerson 86 3.660.5943 Email address Description of work Total dollar value iirn.emerson48 a'gmail.com WC Claims TPA. Bill Review, Medical Management Confidential Dates covering the term of the contract Prime contractor or subcontractor Indicate whether Proposer assisted in disability, safety program. light duty / return - to -work program, etc. Established 2002 and remains open Prime Contractor Client Florida Rural Electric Self Insurers Fund Type of Entity Private Client contact person Phone number William Willingham 850.877.6166 Email address Bill(a;FECA.Com Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value Confidential Dates covering the term of the contract Prime contractor or subcontractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Established 2002 and remains active Prime Contractor Pa ze 138 City an to Page 139 tv licnt Florida Workers' Cotnpensation Insurance Guaranty Association Type of Entity Private Client contact person Sandra Robinson Phone number 850.386.9200 Email address sobinson@agfgroup.org Description of work WC Claims TPA, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 1998 and remains active Prune contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Run off claims Client Sugar Cane Growers Cooperative of Florida Type of Entity Private Client contact person Carmen Abercrombi Phone number 561.996.4751 Email address cabercrombi(a:scoc.org Description of work WC Claims TPA, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 2010 and remains active Prime contractor or subcontractor Prirne Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. f) Outline the process for nominating physician/facilities to your company's provider networks; USIS!AmeriSys employs a Director of Provider Services who coordinates provider nominations with DimensionComp. She will work closely with Risk Management, DimensionComp, the adjuster and the Telephonic Case -Manager to meet the needs of the of Miami. DimensionComp has a formal nomination process in place and encourages/welcomes client provider nominations for inclusion into the network. DimensionComp may receive nominations via on-line website, e-mail and/or fax_ When its client services team receives eligible provider nomination, the provider is logged and forwarded to the network development team to begin the contracting process. DimensionComp will make every effort to obtain a contract with the nominated provider. Dimension Health providers understand and respond to patients' concerns about being able receive excellent medical care promptly and efficiently. At Dimension Health quality and access are emphasized. Dimension's local presence means that questions from insurers. employers and covered employees can often be answered on the spot. 9) Describe your company's attributes for physicians within your Outcome Based Network, if applicable; While we measure outcomes of our physicians, we do not have a network based solely on outcomes. The attributes we look for in the physicians that treat our injured employees are as follows. First that they are familiar with the Florida Worker's Comp requirements for physicians treating injured employees within the state. We ensure through our network that they are credentialed and contracted below fee schedule to allow our customers savings. AmeriSys Director of Provider Services monitors the level of quality service and care being provided through multiple quality initiatives, including but not limited to satisfactions surveys. We also provide direct education to providers when there are industry changes to ensure the providers are current with standards of care. h) Provide medical cost savings as a percentage for the State of Florida; Calendar year 2015: AmeriSys total Medical Cost Savings including Fee Schedule savings is 53.5%. AmeriSys total Medical Cost Savings below fee schedule is 13.1%. i) Indicate if savings accomplished by use of outside medical vendor. N 'A 4. Provide the following information regarding your company's medical bill review offerings: a) Provide benchmarking data pertaining to your company's book of business bill review average savings per bill, per claim and return on investment; AmeriSys customizes benchmarking for each client based on the specific network, geographic location and business rules the client sets. b) Outline how duplicate bills will be charged; and No charges for duplicates c) Identify any states in which your company use, a third party vendor for medical bill review services, and provide any unique pricing arrangements. AmeriSys does not use a third party vendor for medical bill review services with the exception of Dane Street for Peer Review services. ��;�, I4() 7. RISK MANAGEMENT INFORMATION SYSTEMS Google Chrome -compatible or Firefox-compatible claims management system platform providing real-time interactive communication and claims management between nurses, adjusters, the City, and its business units. The City will determine the number of accesses by level of use dependent on your company's system capabilities in coordination with your company during this RFP process. USIC NET www,USIS.iNet.com 1. USISiNet Portal Features a. Reports — 40+ standard reports i. Check Registers (Payments) 1. Full Detail (By Individual Check/Transaction) 2. Totals by Year 3. Totals by Unit ii. Employer's Reports (Claim Payment. Reserve, Incurred Totals) 1. Full Detail (By Claim with Claim Details) 2. Totals by Year 3, Totals by Unit b. Interactive Grids (Filter, Sort, Column Customization, Export) i. Claims ii. Reserves iii. Payments iv. Notes v. Claims Totals by department, unit, location c. Complete Loss Control Module d. Claimant Module Security i. Ability to Customize what claims each user can sec ii. Ability to Customize what features each user can use iii. Ability to Exclude specific claims or features on claims where User is also Claimant f. Report Export Types Supported i. Excel ( XLS, XLSX, CSV ) ii. Word ( HTML, MHT, RTF, Text ) Rendered ( PDF, Image, XPS ) c. 2. Screenshots (See Below) 3. Customization a. Customizable Dashboards i. Choose the Dashboard Tiles that are right for you ii. Customize Dashboard Tile Size and Position Customize Settings/Filters to your needs (e.g. New Claim (Days), Recent Note (Days) ) iv. Additional New Custom Dashboard Tiles can also be created on Request b. Customizable Security i. For each Feature and per User ii. For Users who are also Claimants ' Claimants in Litigation (e.g. removing notes from "my claims") Page 14I c. Branding i. Custom " vWelcomeiNC" Login/Landing page with Branding ii. Client Low on Every Page d. Grids r. Add and Remove columns ii. Filter by any column ii. Sort by any column iv. Add field v. Move field e. Reports i. New Custom Reports can be created on Request 4. System Requirements a. All Major Systems Supported: i. Desktop/Laptop (Windows, Apple, Linux, ... ) ii. Tablet (Windows, iOS, Android, ... ) iii. Mobile Phone (Windows, iOS, Android, ... ) * * Some Features may be more convenient on a larger screen, such as a Desktop, Laptop, or Tablet b. All Major Browsers Supported (Latest Recommended) Please reference Attachment 4 - USISiNet & AmeriSysiNet. Please respond in detail to the following: 1. Confirm your company's ability to establish an interface with a RMIS vendor of the City's choice with no fee to implement. USIS has the ability of establishing an interface with a RMIS of the City's choice with no fee to implement. 2. Confirm that your company will provide a daily feed to a RMIS vendor of the City's choice at no cost. USIS is ready to implement a daily feed with the City at no cost. 3. Identify the access your company provides to the database: Internet, 1-800 or local call access. An absence of any one of these could cause the City to incur unreasonable costs for long distance calls for access. Please describe alternatives to direct long distance charges if applicable. USIS will provide a 1-800 number for the City of Miami to contact USIS. The USIS web portal can be accessed from any web browser. 4. State your company's current internal requirements for claim files updates. Discuss how often claims files are updated for: a) Adjuster/nurse notes Adjusters update the claim notes every 2 weeks if the injured worker is missing time, if the injured has returned to work and continues to follow up with medical care the claim notes are updated upon receipt of medical reports. Nurses update the case notes when medical notes are received with medical treatment plan and work status. b) Financial information Financials are reviewed on each diary date for accuracy. They are also reviewed upon any medical/legal changes that occur whether it be an increase or decrease. c) Resolution plans Adjusters input an action plan each diary date. The plan should include indemnity medical and legal updates. The notes also include any recommendations by the adjuster regarding settlement potential and or recommendations regarding the anticipated exposure. Page l42 5. Confirm that your company's system has scanning capability for all mail/correspondence pertaining to the claim file, and if so, whether the images can be accessed real time by the client or if there is a delay. Detail any delay. All mail'correspondence/bills are scanned, on the same day of receipt, to the claim file. The images are scanned into a .pdf format and are accessible to the client via the USISiNet web portal real time. 6. Outline your company's system abilities to report on each specific claim line as opposed to gross reporting on the incident. USISiNet has a reports section where existing reports can be found and new reports can be added to meet the City's needs. Currently, the detail Employer's report would report on each specific claim line. Additionally, the portal offers interactive claim grids that allows for detail on a claim line level that can also be exported to Excel and be used a report. O teAft CIa r s - Last 3,siress Day • 4.1 .. . can, tC.., ;:;< 1 :Ns 00! PP.4.M a• 1.gwOM C YTir:tll }C �t to. 1115e.St1 Y.Y]411 tiln ap 11 ea 41r! 8.U644t! .... _ a__-1+11 a. tiw 4 t WML14:a.:4 i. 1,rkot. 'AS M:s 4trtt 4/14201. &44? .4 f1:5 P: It 17 ..1 „a Dar Pte*te1•P.Wen,.q C a"R!XR+ 4. M[ rott [4:Sef4l 4M.'lSll I:p. I: al [t ::1 Nw le Noe Rs'Ittrry4[µ 4 +-LIM1. _. 1 'at. `l!'!.:Lla %,,;;;y7} ,9:U N 88 U ae':a.l >BtY::1 f[1 hx GP1XIR,tAUMMy 49,41 C Yee40t4 .r (/414 41. 1,1444414 }1212014 tt]0 N :A 57 :11 Pan PFWN M[]PIL: P.AMU C 41::201+ [. 4.4X 1 4V1. I43r411 40:'r811 a:24 ., 11 l3 1Ce14t i:7 .:.,.-a7;4-, e<14- :C 4. i {w IF W4115AYIN:, M'4 C 4e1fir#1H !At AL. 8444 10,Wie L".W:MI /P30 +.1 W MI ✓42*4 L77 tee !WM114.Clewwwed a 112!:2t11 MC .27za t.2x. ':..t*C PI4421:11 ,C4F 1J el .J. Ll1 _ .,.1, 1/*/1 +. YYS:C:P sa t Doe esmattlmq....tm. C Ir:I A,1+ uti CCCs la 1:"Fv11.1 4914.16.14 17,0 11 te b [.9 - ... I, 4..-C:1 [h✓ rat tit,. sari Mat 4, y. C 1'J,.7.1 CM• & ess 1:d^.:4[n 1,W9011 IA 17 MI ea w.suil Lt.4_4 i19 ...11 /14 ..ar, y yoe eurrrer 124141t Ltr C rure-F1+ o .4i+ tra NYY.}ll 1144WA. III .e 17 w I.i, b I.o41,' .. ...en am C a_..M «e c+ ..de WUXXIa emhma ::0 44 a fF LL•l ._..:..._. 1 No .1se.....,.,a,.a....,. C ae°t1'Sa kR 7011 PMP, 718E1C4. YAM* MP '1t 1S W Act., ],42tRa44 7. State your company's policy on the ability of any outside entity to enter notes into your company's system and describe how this is managed. The ability for an outside entity to enter notes in the system is decided during the implementation process and very careful permissions would be applied to each user. A notification process is in place to allow the claim staff of a new note and for review purposes. 8. Outline how notes are categorized in your company's system (i.e. by type or subject] and your company's ability to select, or identify those notes pertaining to a particular category for review). Please explain the difference, if any, between Client access to notes vs. Adjuster access notes. Case Notes are categorized by a Case note type and also a subject. They can be grouped, and reported by any of the groupings available. The web portal grid allows to easy search of a particular set of notes via the advanced search feature. The clients have access via the web portal to the same notes the adjusters do. Page 143 9. Confirm that nurse's notes are included in the same system as the adjuster notes within your company's system. Confirm if client has access to all nurse notes, and if so, whether or not the notes are readable in real time, or if there is a delay. Detail any delay. Nurse notes are included in the same system as the adjuster's notes. Similar to the adjusters notes, they are made available to clients in real-time, however. sensitive notes containing confidential / medical information will not be made available on the web portal. 10. Confirm that your company's system incorporates e-mail for easy communication between users, permitting an email to be launched from the claim pages. USISiNet allows the client to launch an email window from the claims page of the web portal. 11. Explain controls and requirements around version updates of software and any fees associated with them. Our RMIS ERIC system is maintained by ERIC Systems and version updates of software are maintained by the company. Once received we fully test it prior to implementation. Our USISiNet web portal is designed by an internal team of developers and also fully tested and documented by different developers prior to being released to production. Neither system have fees associated with them to the client. 12. Confirm your company's agreement for providing tapes or EDI transfer of data, loss runs, weekly transaction registers, claims updates, and 1099 reports on a timely basis and detail any additional charge. tJSIS confirms and agrees to provide tapes or EDI transfer of data, loss runs, weekly transaction registers, claims updates, and 1099 reports on a timely basis and detail any additional charge. 13. Confirm that your company's system allows for entry, tracking and reporting of: a. Claims data by Client specific coding (locations, departments, divisions, Employee Numbers, etc); Yes, USISiNet does allow for claims data by Client specific Coding. b. Policy Information and whether that information can be attached to the claim; and Yes. and yes, the policy information can be attached to the claim. c. Exposures. Yes 14. Confirm your company's ability for the City to manage location changes within the system (i.e. closing of facilities and/or adding new locations). At the current time, the ability to manage location changes is an internal process, however, we have the ability of automating the process via a data interface as we do with many of our clients. 15. Describe systems standard reporting capabilities. Please describe ad -hoc and custom reporting as well as the Clients ability to create, modify, and run reports in your company's system. Please provide examples of ad -hoc reports and describe the ability to run the following: The web portal contains several reports that be directly accessed by the client. For existing reports, parameters are available to allow the user to customize the end result. These reports cane be exported in various different formats. Reports can also be scheduled for delivery. USIS has 8 on staff and on -site programmers who will be able to build ad hoc reports and/or data extracts that you desire in a reasonable time frame. All custom reports can be made available on the web portal for future use by the City. If you have a standard monthly or quarterly spreadsheet that I'ne 144 monopolizes your time every month -end or quarter -end, there is likely a process that can be built for it to be downloadable to your desktop after any month -end. We host and control source code and all of the data files that make up the workers' compensation application. Reports may be downloaded in Excel and can be customized upon request. The number of data fields available depends on the data download need — there is no limitation to the number of fields. u SISsiNET Schedule Report Parameters 'Enter Account Number (ex: 1991: Enter Policy Number or leave blank for "ALL': 'Enter Asotdate (rrmradryyyy): s.:fwzor� Enter Policy Year Start tyyyy) or leave blank for "ALL": 'Enter Acc+aent Start Date (mrr,/ctdryyyy): Enter Policy Year Eno tyyyy) or leave Drank for 'ALL': 'Enter Accident End Date (rneuddfyyyy): ri'c�;ve!z Q Page 145 The web portal offers powerful dashboards that have a number of ways for the users to customize it based on their needs. Below is an example of the dashboard also displaying how easy it is to customize. a Dashboard Claim Status Trend Fat Rap. C Yu. I mi _ 110 r.' (.me C.l.F L•w•• yr*491.yer..w.F:. Iq M.1... CN.rF .HMM 10 MO.I ISriy0 N WGr. QY1. 44% 583% • ..,.., Da. :A.,14. 0% 2.6 Day; I • Page 146 The web portal also contains powerful, detailed, interactive grids that can be customized, filtered, sorted. and exported at the user's convenience. Preferred searches can also be saved on that particular user's profile for future use. Claim Status Trend • 44 as All Cairns 1 ,, .06 7 sos sJe 3fic SAh 306 306 sob 306 306 X16 306 300 306 Aa9e t.r •1 112OR94$ 11i1d1991 1fi?✓1999 037/19B/ 215332002 Sf17/1946 3 20r19a7 90231967 117;1096 10/1990 3122l1495 5125/1496 61;7000 a i r •.: nnr r -Atm i±.wel -, +nd 1le-.rM ourua..mrmne;al ,05, Snow C633361305lon YAW°. III Custom Grid Pleas provide a Name fur te wen alstOm¢aeans Marne Save P Edit Tile - Claim Status Trend (56) floe 03603 5tl1u3 r1en0 51r111eed n Monthly lwm 4316330y Filters Ersierprese td 11U 0 13 0 t • i L. - ? Ql 3/`/ b.6 :T 1955 rrw 22:11355 O L333333963 t1 133e :the 12/14f1941 O $/3.1999 IT 1919 33335 533/1394 33 2/3090 1T 130: T,44w 011987 01 9/V2015 1t ;0O2 16e. 3333;2OO2 Ct 1/332013 IT 1945 True 3/22/1995 O 7/3531938 LT 135: CywG 205/19E6 0 3/3619116 AT 14a7 T.531* ;631983 O 5r7o✓1955 LT 1?9« ,etee 5✓W1996 O 1/".;414K Lf 1990 Fake 1f13/1990 a 317r195. 1T 1195 rutse 3,23;1994 O 3/24/19911 1T 1499 F:y1e 3/1 /1998 O if11/2041) a ?Oro Fuu tit Column (Wei, Au:a r1 [.u..s 41. r:Uorrlf Unto Page 147 The advanced filtering page is excellent for power users who are researching for specific analytical data. Grid Advanced Filtering Current Filters Policy Year B tween 2.011 - 5015 11 Claim Status Not Equal Claim Type Not Equal v NBO Adci More Enterpri e Id Apply rrter m Gnd 0 + / Finer Various Total Grids are also available for quick management use. Here is an example. Grid Advanced Filtering Current Filters Enar, ;d Australian Pair fes raeilw'!en Fairy Elam OM Leant a ta Clam Status to v ;7 Clan Tyye In ` It nl<y rt,l - 0 Q 0 0 CL A§C) d flaiia,t nlivy EPtvre �n ' WO 11115i2016 Add More ntevpr.rn 1i Apply Flier 10 Gtid 0 a Paye 148 a. Run triangles by policy years; USIS currently provides Triangle reports. Below is an example. Loss Triangle Report - Total Incurred FLORIDA DOI Reyi11nrng 04-01-2006 Sualrnaues as Or 1247.2015 Paned Count 12 MonW 24 Montt 36 Months 48 Maru9x 60 Monte 72 Months 84 Months 96 Montt 108 Months Jan 1, 2006-Dec 31, 2006 901 10.507.326 2,542,464 951,974 1349,004) (7.27,727} (38,0041 743,663 136.939) 217. 065 Jan 1, 2007_ Dec 31. 2007 706 18,752,138 443.023 242,801 (101,628( 164.112) (103,908) (3,113) 33.931 2381 Jan I, 2008 . Dec 31. mars 623 17.101.434 134.455 (96.658) 352.016 134.363 381.294 269.711 (6,6601 Jan 1, 2009 - Dec 31, 2009 606 30 050,181 (747,2351 951,302 285.757 213,004 371,838 134.030 Jan 1, 2010 - Dec 31, 2010 875 20.384923 11,200,912) 652.627 338.569 585,558 251,472 Jan I, 2011 - Oeo 31.. 2011 1,190 113,843406 (2.19,674) 633,076 495,730 (85,5063 Jan 1. 20 12 . Dec 31, 2012 1,852 22.759,320 1,532960 563,328 51307 Jan 1, 2913 - Dec 31. 2013 2.002 36.093.997 1.697.908 701,827 Jan 1, 3314 - Dec 31, 2014 2,066 38,057530 210,773 Jon 1, 2015 - Dec 31. 2015 1.)383 25.033.647 Claims 11,943 Eelelp if<iota1 b. Loss stratification; USIS can provide Loss Stratification reports from its RIVHS system. XYZ Corporation (Sample Report) 1 nc.c Ct7111nrinnn . Rant nn Trial k e rain YVaxars Canpon:ar on 1 ,.108 Menthe Teta1 (40601 14,466.159 7,240,519 18,869,955 10,958,663 21,169.836 19.658.0.3 25, 3118,915 38,493631 38.388.303 25903'_947 ilatieelas 3?7L'pS %e1 xtr Cant( Tar rx411ncIn11<1 oar Urges: Averare if/ 121 to 4: 1t 060 111r[1.1 199 08 wales 7433044 Laws' $1 1,15 317730 751,70303 OD% 3a% zss t� 89,4 iz% 1786, sift 14S% 332% 293% 42-9% r2A% 15A 14" lac 3 9.35 030 1,iim fl ls' 2j00A0 1,63744 0 071 */5 5 am76 73,115.9t 15,42151 43r464 354713E 94,212.a0 54,14544 3X.667 00 13,4.5750 In/19% co 77110007 111 5.114544.011 2Ci,it7.60 1,210 42 8r1(2067 to 713979. 00 0 119 7Xj0 0)0a2,100 25C b80,3 lug*, lS,JW Z.900 ►.A006 16600 w t00,1100 155 es 1G 1c O0'6 110L 39% 39% 74% 112'1 32.93 433% lot% rp1 10D 5 16" 1.845 100" 6148 1 Sq0-00 9,360:30 344192 ui 43.6 0.9 44 315.10 101241X,10 u11rr0011 4b 1.14115149 10,3759F! 6M 43796 1,49437 9,11997 ta,azs5a 31,.1732 14,3/ 00 1,814It Page 149 c. Ability to create graphs within a report; Reports available on the web portal, USISiNet, do and can contain graphs. t'xry ra. 1.. C ii ifT1 Status 1rend a • • 0 • gQtl Fiatr 0 2 a34 100 $0 60 40 20 0 • r • • • • $11 3C12 20t3 2C14 121E X14 ZOMURIKIW1/41...11....A., ww 3. 3aas Edit Tile - Claim Status Trend (56) I fie r a States Tu•nd a,wroamag 3r<CA11rty alarm Aetnr ry Filters &NIixlse kt = - 119 CUNT TWA hithitrt Erµlai • NI11 tv{1a C 11:I4e 150 d. Client's ability to create scorecard and dashboards; The web portal offers powerful dashboards that have a number of ways for the users to customize it based on their needs. Below is an example of the dashboard also displaying how easy it is to customize. !j. Dashboard Claim Status Trend !y YSAM (IOW 1.._____ • t.• C.Y,. (of., Slf+a H t9119 Y t*.l.l-.. -[3 ! Yaw, C.f.s •.9r.1. .M •. .. w PM 0.,s 44% S83% • 4 0 +.Yr. Pe, 99+4 096 2.5 Days II11 II se ma NI 111 am am e. Automated import into Excel, Access, Microsoft Word etc.; As show below. reports can be exported in several formats. XML file with report data Csv (comma delimited) PDF MHTML (web archive) Excel TIFF file Word Page 151 f. Litigation reports including mediation and trial dates; USISiNet currently includes legal reports. If' there is a particular report that the City would like to have, USIS will include build it and it can be discussed during the implementation meeting. g. SOL reports. Reports that are run 90 calendar days prior to the SQL's running for SOX compliance purposes; SQL reports can run at any time and provided to the City to meet compliance. h. Samples of standard available reports, a listing of ail available fields within the system, and your company's ability to customize fields for the City and its locations; and Please reference Attachment 5 — US1S Sample Reports. i. Ability to track and run Toss time reports. Loss run reports are available on the web portal. 16. Describe Bank Reconciliation, Cash Disbursement System, Audit Trails, and overall financial controls. Checks are issued via the computer system on blank stock, printed with client bank account information on a daily basis. The computer room is locked and access is limited to authorized personnel. • Checks are printed in the computer room and taken to the Accounting Coordinator(s) for processing. Check numbers are verified to ensure they are sequential and continuous from prior day. Checks to be mailed are kept in Accounting Manager's office until processed for out -going mail. All Accounting Dept. offices are kept locked when unoccupied. • Checks are not returned to adjusters unless necessary for settlement or special handling by adjuster. Those have back-up sheets signed by management. and checks are given to adjusters with signed acknowledgement. • Company policy dictates that no employee may put checks in the Outgoing Mail bins to sit throughout the day — they must be returned to the Accounting Coordinator(s) for secure handling. W-9 Procedures Handled by Accounting Coordinator, who has no system access to issue checks or make changes in the claims system. For a change of address/name for a provider to be made in the system, a properly completed W-9 form must be received from the provider. Supplemental addresses or billing entities (such as a dba) will be accommodated when verifiable and requested in writing. This is verified for accuracy, where applicable, against available IRS andior Division of Corporations information. Checks are only paid to providers when the 'Billing Information' area of the medical bill form matches the W-9 (or Substitute) information on tile which becomes the Payee on the check. Additional addresses: only Claim Managers and Supervisors have access to create addresses that are not the claimants' or verified providers. e.g. settlement checks payable to attorney and claimant. Page 152 Cheek Signing Protocol: Two signatures are required on all checks; hand -signed original signatures are required on checks $2500 and over, and for any amount on settlements, etc. This allows us to personally verify that no large checks go through the system without being scrutinized. Checks are issued every day and the check signing processing is a detailed, time consuming process as a lot of different data is checked before the check is signed. Internal controls are very stringent. Signers are selected based on authority, tenure and always ensuring complete diversification of duties for security purposes. No employee from the Accounting Dept or Claims Dept is permitted or has access to sign checks since they have claims system access and can issue checks; under Brown & Brown corporate guidelines it is forbidden. Anyone who can enter claims to the system, pay bills or has system access to anything related to claims is not allowed to sign checks. This ensures there is an absolute separation of duties. Our company check signing procedures are set by USIS per corporate guidelines, audited by Brown & Brown corporate audit team (including a SSAE 16), reviewed by Quality Control as part of its audit, governed by Sarbanes Oxley guidelines, audited by clients, the State and reinsurers. The people who are chosen must have nothing whatsoever to do with claims so that there is no crossover of duties. They are long term employees and/or those in whom management has confidence and who take the responsibility very seriously. There are great lengths taken to ensure security on the checks, particularly because it is clients' money -- any check in the amount of $2500 and over is pulled and verified with back-up paperwork and hand signed. The facsimile signature is computer -generated - printed to a check via the system check print onto blank check stock; the MICR coding, check number and client information is printed on the check in the computer room, which is a secured area. There is always back-up to any check. A check is not signed without a bill, EOB or a back-up form signed by the adjuster and the supervisor. As well as signing, the check -signer is verifying that the check was entered/paid correctly with the correct FEIN, claimant name, dates of service, amount, etc. Any item in question is verified with the claims manager and if anything is incorrect. the check is voided. Positive Pay We work with our clients and their preference of bank to set in place a "Positive Pay" process for all checks that are written within our system. Your bank is electronically notified the same day your checks are processed. Your bank will then only accept checks that were verified by our data feed to them. Payee, Check number, and Amount are key elements on all transactions. Bank Reconciliation — Bank reconciliations are completed on a monthly basis. A copy of the reconciliation, bank statement and detailed check register will be emailed to a designated representative at the City of Miami. 17. Confirm the system has been reviewed by impartial outside experts and rated or written about in any publication. If so, please include copies of the publications/articles. The internal quality control system at USIS is built in a working environment that is maintained by checks and balances for all activities. Control activities begin with a code of conduct and behavioral standards that must be signed by each USIS employee at hire confirming his/her responsibility to follow company policies and procedures. USIS implements separation of duties to avoid any acts with detrimental consequences. Separation of duties and all other internal controls are reviewed yearly by a SSAE 16 Audit. The City of Miami would have access to the USIS SSAE 16 results each year. Page 153 A quality control review process is also in place at the claim level. Each claim is reviewed by a supervisor after 30 days. then again after 60 days and then every 90 days thereafter. In addition. the Quality Control Analyst audits every adjuster (on a rotating basis). The Quality Control Analyst reviews a random selection of the adjuster's claims in detail using an internal audit program, which checks to make sure the claim was previously reviewed timely by the supervisor. Upper management is extremely involved in day-to-day processes and procedures making fir an even more secure control environment. Please reference Attachment 8 — SSAE 16 excerpt. 18. Please outline in detail access fees for your company's Claims/RMIS system and alternatives fee arrangements. USIS does not charge access fees. 19. List the technical/system requirements necessary to access your company's Claims/RMIS. The client has access to our web portal USISiNet. The only requirement is a web -browser. 20. Please detail available system training for the City and member employees including the typical time periods that should be dedicated to that training. Training for USISiNet would be conducted by USIS in person at the City's facility if chosen by the City. After implementation, future trainings would be available and web training is always an option during the course of the contract. 21. Please detail that ongoing technical service assistance would be provided to the City and included in your company's fees, Please outline costs for additional services and what those additional services might include. Ongoing technical service assistance for would be provided by USIS to the City and it is included in the company's fees. 22. Please provide the name and phone number of the technical resource(s) that will be responsible for data transfers, upload and system changes. Viviane Ruiz, Vice President Business Integration 407-949-3100/Viviane.ruizicl usis-tpa.com 23. If the City does not renew its contract, outline and itemize in detail, all charges to maintain indefinite access to the system for all prior users. USIS would charge S5,000,00 annually to maintain indefinite access to the system for all prior users. 24. Outline your company's system OSHA Recordkeeping and reporting ability: a. Outline/describe how the OSHA recordkeeping is integrated with the claims management system and your company's ability to provide annual logs in PDF format by plant/location. USIS' has the ability to enter OSHA events into its RMIS system. Annual logs can be provided in PDF format at the claim level. Upon award the system can be modified to the plant/location level. The City of Miami will be responsible for reporting to OSHA. b. Confirm if your company have an OSHA consultant that is able to make a determination regarding recordability [reportability] under OSHA. USIS does not have an OSHA consultant on staff. Page 154 25. Please describe in detail your company's implementation process and provide bio for implementation team. Please reference Attachment 9 — Transition Plan Ron Warble, Executive Vice President, Ext. 6503 ron.warble(a usis-tpa.com Mr. Warble serves as Executive Vice President of USIS and is responsible for oversight of claims, medical management and overall operations within USIS. He has 33 years of experience in the Workers' Compensation arena. He previously owned and managed his own company which was acquired by USIS in April of 2000. That experience has allowed him to develop skills and expertise in many areas and is now being utilized to assist USIS' customers in providing quality and relevant programs on behalf of their injured employees. Additionally, Mr. Warble has had the honor and privilege to serve on the Georgia Chairman's Advisory Council for Workers' Compensation since 2008 and currently serves as the Chairrnan of the Medical Committee in that group. Viviane Ruiz, MBA, 3IIS/HIS,_ Vice President of Business Integration, Ext. 3109 viviaiie.rriiz(ti usis-tpa.com Viviane Ruiz joined the Brown & Brown team in 2007 and is the Vice President of Business Integration for USIS. She is responsible for an IT staff of web developers, system analysts, database administrators, network administrators, technicians, and computer operators. Viviane has exceptional skills in Project Management and is an excellent liaison between the IS staff and the business staff. She takes pride in meeting deadlines and sets a high priority on quality of work. Viviane is responsible for maintaining current systems, and ensuring the implementation of all state and medical rules guidelines, as well as leading new initiatives and keeping USIS/AmeriSys on the cutting edge of technology. Viviane has a Bachelor's Degree in Computer Information Systems, a Master's Degree in Business Administration, and a Master's Degree in Information Systems with concentration in Health Information Technology. Prior to USIS, Viviane had nine years of experience teaching Information Systems as well as business courses for undergraduate and graduate students. She is fluent in Portuguese and Spanish. Jenny Ross, Account Executive, Ext. 6302 iennv.ross{a usis-tpa.eom Jenny Ross has been in the claims industry for over 20 years. Joining USIS 16 years ago, Jenny has been steadily promoted throughout her career. She started as an adjuster, handling a large volume of workers' compensation claims, conducting client visits and claims reviews; and has become an integral part of our claims management team. Jenny's customer service, dedication and commitment to our clients, along with claims knowledge and analysis, make her a top notch Project Manager. Prior to joining USIS, Jenny was employed at Executive Risk Consultants as a lost time claims adjuster. Jenny was the proud recipient of' the 2011 Nationwide Brown & Brown Claims Professional of the Year Award, as well as US1S's Employee of the Year in 2007. Terri Snapp, Claims Manager, Ext. 6409 terri.snapp(dusis-tpa.com Terri Snapp has over 28 years of experience in the workers' compensation insurance claims industry. Beginning her career as a tile clerk with Leatherby Insurance Co., she was steadily promoted within the industry and has been with USIS, a leading Third Party Administrator, since 1988. Terri is currently a Claims Manager with USIS. supervising the work product of over 18 adjusters and supervisors. One key component of her job is dealing directly with clients, a lot of which arc public entities, to ensure a high quality of service and support. Her knowledge and experience in the insurance claims industry has been significant in ensuring the continued success of USES as a TPA. Page 155 Yarixa Eliason, Liability Supervisor, Yarixa.eliasona4usis-tpa.com Yarixa Eliason has over 20 years of experience in the liability insurance claims industry. Beginning her career in Miami with John's Eastern as a liability adjuster, she was steadily promoted within the industry. She has her all lines adjuster license with experience in handling claims for commercial auto, general liability, employment liability and governmental entities. One key component of her job is dealing directly with public entity clients. Eunice Roniich, RN, Director of Provider Services, Ext 3118 eunice.rornich(c1Jamerisys-info.com Eunice is currently the Director of Provider Services at AmeriSys. Primary responsibilities include managing and coordinating issues involving provider networks utilized by AmeriSys, and educating and training case managers and staff regarding utilization, access, and grievances for network providers. Prior to this role, she was the telephonic case manager supervisor at AmeriSys. Eunice is also the Quality Assurance Coordinator and she ensures all medical management services are in compliance with statutory regulations, and the deliverance of quality care to all injured employees. She has 13 years of nursing experience, with the last 6 working in the workers' compensation field. Background nursing experience consists of cardiology, orthopedics, and surgery while working in both hospital setting and outpatient surgical setting institutions. Prior to joining AmeriSys in 2014, Eunice worked for an international all lines insurance company in Alpharetta, Georgia, as a telephonic ease -manager for workers' comp claims in the states of Georgia and Alabama. 26. Detail system support set-up. USIS will provide a Helpdesk email address and 1-800 number. Additionally, an email address could be implemented as a distribution group that would reach key personnel at USIS in event of an urgent matter. 27. Is there an 800# provided for technical support. Yes, our help desk has a 1-800 number. 28. Confirm your company's agreement to provide a designated support/contact and backup for the City. USIS agrees to provide a designated support/contact and backup for the City. 29. Please detail any ongoing technical service assistance that would be provided to the City that is included in your company's fees as well as outlining costs for additional services. USIS would be prepared to provide technical services with our USISiNet web portal, additional training, reports, data interfaces, and with any additional technology used and offered by USIS as part of the contract. 30. Confirm your company's agreement to provide loss information to Beecher Carlson as requested. Please provide the name of the individual who would be responsible for providing this information and working with Beecher Carlson on that information. USIS agrees to provide Beecher Carlson loss information. Additionally, if allowed by the City. Beach Carlson could be granted access to USISiNet to retrieve loss runs at their convenience. Viviane Ruiz is the responsible at USIS for ensuring this data is provided. 8. ACCOUNT MANAGEMENT The City believes coordination of service would best be accomplished with an empowered Account Executive. This individual should have excellent service management skills; analytical skills with strong spreadsheet, graphics, and database experience; a background in claims and risk management; and tenure within your organization. The Page 156 Account Executive would need to have clear authority and lines to operating authority within your company's organization, so that required changes in service could be readily accomplished. We envision the Account Executive would have responsibilities to include: a) b) c) d) e) f) g) h) i) Working cooperatively with the City and its partners and/or vendors; Monitoring and reporting on compliance to agreed Quality standards; Using your company's Claims/RMIS to analyze and report on performance, with a view towards discovering and communicating potential for continuous improvement; Educating Successful Proposer's team members regarding their performance and the City expectations; Developing satisfaction surveys, and survey reports on the City satisfaction with various services; Providing the City with ongoing assistance in using your RMIS/claims management system and analyzing data in a pro -active manner; Troubleshooting all problems related to service delivery/claims management, in coordination with the Successful Proposer's claims office(s), the City, business units and locations; Studying the potential benefits of new or revised services, and making recommendations for such; and Assisting the City and Beecher Carlson with special project requests. USIS agrees to the above Account Executive responsibilities. Please respond to the following: 1. Confirm your company's agreement to ensure that the assigned Account Executive will be available to the City 24/7. USIS agrees that the assigned Account Executive will be available to the City 24/7. 2. Provide a backup for the Account Executive. Provide credentials of the Account Executive who will be primarily responsible for the management and supervision of this account, and a listing of other clients this Account Executive handles. USIS will provide a backup for the Account Executive. Please reference Attachment 7 - Resumes/Licenses, Job Descriptions. - (Terri Snapp) Terri handles the following accounts: Palm Beach County Sheriffs Office Bay County Board of County Commissioners City of Cocoa Ferman Motor Car Company Florida Rural Electric Self Insurers Fund Orange County Public Schools Volusia County School Board HealthFirst Orlando Health Sugar Cane Growers Cooperative of Florida 3. Describe the manner in which the Account Executive will monitor the level and Quality of service provided to the account. The Account Executive will review all QC audits to ensure that internal service guidelines as well as special handling account guidelines are being met. The Claims Manager will perform quarterly claims reviews to ensure that the claims are being handled as aggressively as possible to bring to closure in the most economical way as possible while still providing needed medical care to the injured employees. The Claims Manager will review supervisor reviews to ensure that recommendations for adjuster claims handling are pertinent and relevant to appropriate claims handling. Page 157 4. Explain the account manager's limits of authority. Provide an example of a client mandated change that would require authority beyond that of the Account Executive. The Account Executive reports directly to the Executive Vice President of USIS. The only limits of authority would be that of contractual issues. 5. Provide an organizational chart of your company with special emphasis on operations, sales & marketing and account management. l.s 6.r1.141.11 ur Nu.... �vIlnn ..Mt1 Meng. is Sup.remor r ,,,.. Wuirml ind 14naprn 'cape. at:wr...a.s TCMWCM. flat+. I RTfF:CI10.I praw.r.la APAPAIS Rrpoa.k Support Yk1 nr1.Mlns Rom. Una AtS.+r ua SpvtWge. IKMs) clre.t&, a w«e Cott COafpnrlwlll Sopuwsor MWIUI BIFI Rrw.worr MAR QUOrr ... C.untrcffi.r RON WARBLE EXECUTIVE VICE PRESIDENT AEtnn,l.R.O,, A,+hranl urmoo.l�W MMuprau I.® p .Pmo ilonspor RA iMr WORPIWorel RN Sup.rl.or !CMS IRM. Ca111M Supple lOaRelor w s a.r1r Atircoso atwl.it $! lap--vli Com PruPot onldl ; Extcuslal lA,a,u�r 6. Provide where the Account Executive will be located geographically. The Account Executive's main office is located in Orlando, Florida. lauamwl Cwaesoap .,nlrrRre turf Can. Clara tenR.} Rem ARAMAC I:I.MM WAS Gb-e• a.p.t,n r-. RR A1re'oot MRtMw1 WO Atlyu ixa Recgtarota Cht1vM A,fltan OPROlielrr AWnepwo-M;w i Miusluot 7. Outline the process that would be followed by the Account Executive should an adjuster, supervisor, or other team member fail to meet agreed the City expectations, based on an appropriate and acceptable performance evaluation. Performance would be monitored according to the policy, procedures and expected high standards at USIS. Should an adjuster or other team member fail to perform to USIS or client expectations, the staff member would be placed on a performance improvement plan, including re-training and assessment. If consistent and on -going improvement is not noted within the defined timeframe (e.g. 30-60 days depending on the issues) to the satisfaction of the manager and/or client, then a change in staff would be made. Please be aware that perforniance management and training is ongoing at USIS to ensure client satisfaction and retention, teammates are monitored and guided in the performance of their duties by supervisors and managers in normal daily interactions, along with more formal quarterly 'scorecard' reviews and annual performance evaluations. Page 158 8. Please confirm the availability of the Account Executive to travel and participate in meetings and training throughout the year. Ms. Ross will regularly travel to the City of Miami for client meetings, office/team visits, training as necessary to ensure client satisfaction. 9. Should it become necessary, describe the process for the replacement of the Account Executive and/or claims adjusters. The USIS Executive Vice President will inform the City of Miami if the Account Executive needs to be replaced. Once the new Account Executive is identified. the City would be notified of the new Account Executive and provided with his/her bio. The new Account Executive would meet with the City of Miami in person no later than the following Quarterly Claims Review. If an adjuster needs to be replaced, the Account Executive will notify the City of Miami. The Account Executive, Adjusters and support staff are employees of USES. Alt of our staff is properly licensed as required and attend continuing educational classes on a regular basis. It is our intent to positively ensure that our equal employment opportunity philosophy, in accordance with federal, state, and local law, applies to all aspects of employment with USIS including recruiting, hiring, training, transfer/promotions, compensation and benefits, and termination. At USIS, handled through our Human Resources Dept., we ensure that our employment practices are free of discriminatory practices and that employment decisions are made on the basis of job -related qualifications, experience, including personal competence and potential for advancement. We would be willing to share the resumes of the employee(s) hired or transferred internally to handle the City of Miami account. Once into the contract, should there be any staffing changes necessary, USIS would communicate with the City as soon as known. USIS will ensure that the staff handling the City's account is a good fit with the City's personnel and has the necessary experience for properly managing the claims, along with excellent customer service, communication and rapport -building skills. It should be noted that at USIS we are committed to ensuring equal employment opportunity for all employees and applicants for employment. It is our goal to recruit, hire and develop the best employees using only job -related qualifications. We know that our people are the heart and soul of our enterprise and we recognize that our continued success depends on the full and effective recruitment, hiring and development of the very best employees, taking into consideration only job -related qualifications, regardless of race, color, religion, sex, age, national origin, marital status, disability, veteran status, genetic information and any other category protected by state or federal laws. USIS strives to recognize the talents and job performance of all employees, and values the contributions that come from people with different backgrounds and perspectives. It is USIS' desire to promote an environment that maximizes the potential of all of our employees, and to promote diversity throughout the Company because we believe that diversity is important to our ability to continue to excel in an increasingly diverse and dynamic marketplace. The Company does not permit discrimination or retaliation against qualified individuals with disabilities in regard to application procedures. hiring, advancement, discharge, compensation, training, or other terns, conditions, and privileges of employment. The Company will reasonably accommodate qualified individuals with a temporary or long-term disability so that they can perform the essential functions of a job. A job applicant who can be reasonably accommodated for a job, without undue hardship, is given the same consideration for that position as any other applicant. Page I59 10. Provide the City with the name, contact person and number for (two) 2 current clients and (two) 2 former clients serviced by the proposed Account Executive so we may conduct reference checks. Current Clients Client Florida Citrus, Business Industries Fund Client contact person Jim Emerson Phone number 863.660.5943 Email address jim.emerson48(J!gnail.com Client Brown & Brown, Inc. Client contact person Bob Lloyd Phone number 386.239.5752 Email address rlloyd(u bblegal.com Former Clients Client Normandy Insurance Company Client contact person Sim Feuer Phone number 718.758.2780 Email address sfeuergnoimandyins.com Normandy is the only.fornk;r account in which the proposed Account Executive managed. * Page 160 9. PRICING The City is requesting pricing for: PART I: Third Party Claims Administration (Please also refer to Section 2.18, Compensation Proposal of the solicitation): 1. Please provide your company's pricing options for claim handling such as; annual flat fee/annual retainer, per claim, per hour, etc. All pricing should be based on a life of claim basis within the authority and reporting levels outlined. Please also provide an alternative quote for a dedicated unit for handling claims for the City. Please be specific and detailed in all explanations of claim pricing. Please reference Attachment B1 Claims Administration Price Proposal Schedule. 2. Provide a complete listing of all charges that will appear as an allocated expense in addition to the flat rate/dedicated unit pricing. If the actual fee is known for that allocated expense, please include that fee. Examples of items that would be allocated to the claim file, though not an exhaustive list, would be as follows: 1 Index Bureau Reporting Surveillance Vocational Services • Court Reporters l Medical Records • Legal Services f IMEs 4 Expert Witnesses $ MSAs $ Auto Appraiser The City will be responsible for payment of these additional costs. 4 Transcripts 1. Investigators Translation Services for legal proceedings .$ Life Care Plans 3. Provide a complete listing of all services that are included in the flat rate claim handling charge. identify any services that your company consider outside the flat rate claim handling charge. Administrative services which include, but are not limited to, the following, key elements: • Prepare (with the City's assistance) and tile with the appropriate State agencies all applications required for the City's qualification as a self -insurer. • Prepare, maintain and file statistical information as required by appropriate State agencies, including all data necessary for the promulgation of Experience Modifications and establishment of claim reserve requirements. • Report to the City legislative changes and regulatory standards as well as case law events which relate to your claims programs. • Regulatory or state agency form reporting. • Promulgate any required excess reporting. • Assist in the selection and/or interface with selected service partners of the City as needed or requested. Claims services include, but are not limited to, the following kev elements: • Establishing reporting procedures, which are compatible with the needs and organizational structure of the City. Twenty-four (24) hour claim -reporting services are available. • Receiving and examining on behalf of the City all reports of employee injury claims. • Three point contact (injured employee — physician — employer) within 24 hours after receipt of the First Report of Injury (FRCI). Pave 161 • Accepting or denying all reported claims for employee injuries on behalf of the City in accordance with the applicable law. If it appears that the final value of any claim will exceed an established discretionary limit, the final decision to accept or deny will rest with the City. • Conducting the required investigations as deemed necessary on a case -by -case basis. • Subject to the prior approval of, and established agreements with, the City, employing outside professionals such as private investigators, expert witnesses, field claim investigators, and attorneys, to assist in the investigation and adjustment of claims. • Preparing and maintaining files necessary for legal defense of claims and/or litigation (such as actions for subrogation) or other proceedings. • Paying in a timely fashion all claims and expenses pertaining thereto from the loss fund. The loss fund will be established by the City, and will be maintained at a dollar level sufficient to meet the monthly obligations of the City until such time as all known obligations have been discharged. • Timely investigation and compensability decisions on all reported claims. • Pursuing all possibilities of subrogation and recovery on behalf of the City. SDTF r Subrogation Recovery services and excess insurance reporting / recovery are handled by specialized adjusters on staff • Maintain a lost -time adjuster case Toad of no more than 160 active files. • Management requirement that vendor referrals, such as rehabilitation and surveillance, be approved by both the supervisor and the City. • Management requirement that all reserve increases be reviewed and approved by the supervisor. • Management requirement that all settlements being considered must be reviewed and approved by the supervisor prior to being submitted to the City for approval. • Written explanation to the City and/or conferencing with the City for controverted or potentially controverted claims. • Monthly monitoring of reserves with an emphasis on the rapid closure of claims where activity has ceased, thus minimizing the impact of reserves on the City's loss ratio. • Claim status updates to the City, as requested, outlining the current medical and lost -time status of claims, as well as assessing the adequacy of reserves, summary of compensability issues or other areas of dispute, and recommendation for future handling with a goal toward limiting claim costs of the City. • Periodic seminars for professional stair covering all aspects of claim handling, with emphasis on necessity of employer involvement including importance of the timely reporting of claims; the importance of early return to work through the use of light duty; USIS' role in the claims process including the setting of reserves, evaluation for settlement and reasons for benefit denials. • Claims reviews. In which agreed upon claims will be discussed in detail — reserves, action plans, etc. Examples of items that would be allocated to the claim file, though not an exhaustive list, would be as follows: .4 Index Bureau Reporting 4 Surveillance , Transcripts 4 Vocational Services .f Court Reporters ! Investigators 4 •4 Medical Records 4. Legal Services Translation Services for legal proceedings 4 IMEs 1 Expert Witnesses 4 Life Care Plans 4 MSAs • Auto Appraiser The City will be responsible for payment of these additional costs. Page 162 4. Identify any outside vendors with which your company's contracts, stating their names, locations, and expertise, and identifying under what circumstances they are retained. Liabilitv Claims Administration Preferred Governmental Claims Solutions (PGCS) A Brown & Brown Company Since its founding in 1956, PGCS Claim Services has provided claims administration for public and private entities, carriers, and trusts. Our subsidiary, Preferred Governmental Claim Solutions, is solely dedicated to providing claims administration to over 450 public entities. Our adjusters are uniquely qualified to handle liability, property, and workers' compensation claims. SIU Company Command Investigations, LLC is the preferred provider of Surveillance, SIU & Anti -Fraud Programming to P&C Carriers, Sell -Insured Entities and Third -Party Administrators. Command is not a traditional vendor...but rather a strategic resource and committed investigative partner. Conunand has successfully blended the most sophisticated technology platforms with the finest staff to create a unique combination that leverages man, woman and machine. Their founding principles remain consistent with our 20 years of investigative experience: • Consistently deliver the best service and results • Develop, maintain and nurture rewarding customer relationships • Maintain a healthy, challenging, rewarding and fun work environment • Identify, develop and mentor new Command employees • Utilize and employ the finest technology available • Operate as a profitable and socially conscious business Iklana2ed Care External Providers: Preferred Provider Network USIS/AmeriSys is proposing DimensionComp for hospital and provider access, the AmeriSys Preferred Provider network for ancillary providers, and myMatrixx as the Pharmacy Benefit Manager. In addition to using DimensionComp as the primary network due to its South Florida specific geography; USIS/AmeriSys is prepared to offer the Coventry Preferred Provider network, which is a national provider, as a wraparound network to DimensionComp to capture the claims that do not fall within the primary network. USIS/AmeriSys employs a Director of Provider Services who will work closely with the City, DimensionComp, the adjuster and the case -manager. The Director of Provider Services will make recommendations as to what outcomes would be monitored as well as work with the City to determine the criteria that are important. DimensionComp is an affiliate of Dimension Health, Inc. DimensionComp provides clients access to the one of the largest Workers' Compensation networks in South Florida. By maintaining strong relationships with the provider community, DimensionComp is able to offer clients superior network savings and greater access. Page I63 Coventry Health Care Workers' Compensation, Inc. Coventry provides clients access to the largest national provider network offering in the workers' compensation industry. By maintaining strong relationships with the provider community, Coventry is able to offer clients superior network savings and greater access. Pharmacy Benefit Manager USIS/AmeriSys contracts with myMatrixx for PBM services. Matrix Healthcare Services, Inc., d/b/a myMatrixx, is a hull -service pharinacy benefit management (PBM) and ancillary services company focused on workers' compensation. Please reference Attachment 11 — Overview of myMatrixx PBM Services. The AmeriSys/myMatrixx partnership has existed 10+ years since the inception of myMatrixx. Together we have provided quality medical management and pharmacy services to customers in the entire south-east region. USIS/ArneriSys and myMatrixx through their relationship have joined forces to face multiple challenges in the Workers' Compensation arena such as the escalation of the need for cardiac medications (BADGE Program), and currently we are working together on the AmeriSys Pain Management initiative called SECURE. The Vice President of AmeriSys is currently a member of the myMatrixx pharmacy and therapeutics committee which establishes the general protocols and formularies for this PBM. Ancillary Network Access AmeriSys Prefen-ed Provider network • The AmeriSys. Preferred Provider Network is made up of a select group of vendors to perform the services referenced below. • Every three (3) years AmeriSys undergoes a very detailed RFP process for Ancillary Medical providers that include transportation. translation/languages, Physical Therapy, Diagnostics, Home Health and Durable Medical Equipment. These organizations undergo due diligence and are then contracted. Contracting includes indemnification for customers, insurance coverage verification as well significant discounting for services. We believe this provides our customers with the best protection at the best price, creating best value. Page 164 AmeriSys Preferred Provider Network Spreemo Spreemo provides a diagnostic network through the AmeriSys Preferred Provider Network Orchid Medical Orchid Medical provides a Diagnostic, DME and Home Health network services through the AmeriSys Prefen-ed Provider Network Streamline Streamline provides a diagnostic network through the AmeriSys Preferred Provider Network One Call Care Management / Align Networks One Call / Align provides Diagnostic, DME and Home health network and Physical Therapy services through the AmeriSys Preferred Provider Network Priority Care Solutions Priority Care Solutions provides DME and Home Health network services through the AmeriSys Preferred Provider Network _ Speakeasy Translation & Transportation Speak Easy provides Transportation and Translation network services through the AmeriSys Preferred Provider Network ProCare ProCare provides Transportation and Translation network services through the AmeriSys Preferred Provider Network JNJ Services J&J provides Transportation and Translation network services through the AmeriSys Preferred Provider Network Intrepreters Unlimited Intrepreters Unlimited provides Transportation and Translation network services through the AmeriSys Preferred Provider Network SPNet SPNet provides Physical Therapy services through the AmeriSys Preferred Provider Network Therapy Direct Therapy Direct provides Physical Therapy services through the AmeriSys Preferred Provider Network DentalWorks USA Dental Works provides dental network services through the AmeriSys Preferred Provider Network. NuQuest Bridge Point NuQuest provides Medical Set Aside services (a Brown & Brown. Inc. company) Field Case Management AmeriSys hires independent FCM subcontractors under the direction of AmeriSys' FCM Supervisor. All subcontracted FCM's are contracted to adhere to the standards of quality set forth by AmeriSys. Physician Advisor Services for UR Dane Street, LLC Debbie Hill, MSN, RN, CCM, Director of Account Management 891 Centre Street • Boston, MA • 02130 951.543.1627 561.206.0659 (fax) dhill(a danestreet.com www.daneStreet.com Dane Street provides Workers' Compensation Peer Reviews to Managed Care Organizations, Third Party Administrators, Utilization Review Organizations and Employers. Licensed in all mandatory UR states, with an active Regulatory and Compliance group which interfaces with the appropriate State workers' compensation Boards and Departments of Insurance. Dane Street is a URAC- accredited review organization and the reviews are delivered according to all URAC, jurisdictional and client requirements. They understand the importance of state -specific medical treatment guidelines, turnaround times, match requirements —and track any changes across these categories in their rules -based PeerAccess platform. Page 165 5. Confirm your company's agreement to keep any necessary time and expense charges to a minimum. USIS agrees to keep any necessary time and expense charges to a minimum. 6. Describe, from an accounting standpoint, how your company treats duplicate files and files set- up in error once the error is caught. Describe procedures in place to identify duplicate claims. When the claim is reported the processing department validates the coverage. The system matches same name, same social security and same date of accident and flags it as a potential duplicate. If determined not to be a duplicate based on the information provided the claim will be entered into the system. If after investigation is complete and is determined to be a duplicate the claim will be deleted. 7. Confirm your company's agreement to participate in a Performance Guarantee. USIS is agrees to negotiate a mutually agreeable performance guarantee with the City of Miami, 8. Confirm your company's agreement to assume any contractual responsibility for reporting to excess or re -insurance carriers. USIS agrees to assume contractual responsibility for reporting to excess or re -insurance carriers. 9. Please outline your company's options for banking and loss funding arrangements. A bank account will be set up by the client, using the client's FEIN. The funds in the account are the property of the client. The account can be setup as a regular business account or a zero balance account. For a regular business account, an initial loss fund deposit would be estimated based on prior claim activity. USIS can assist with determining an appropriate initial loss fund deposit. The USIS Accounting Coordinator assigned to the client will review the balance of the account daily to ensure adequate funds are available. When the account balance is low (amount to be discussed and determined by USIS and the client), or at a specified time interval (i.e. weekly), the Accounting Coordinator will request funding for the account. In the event that there is a large medical bill or settlement in the near future, USIS will request intermittent special funding from the client so the account is properly funded, If the client chooses to setup a zero balance account, the funds will be drawn from an operating account of the client's choice as checks are presented to the bank for payment. USIS will send copies of check registers showing payment detail to a designated representative of the client's choice on a weekly basis. PART II: Managed Care/Medical Bill Review Services. Provide quotes for all possible pricing alternatives, including a flat fee inclusive of PPO, and specialty network savings for the following: a) Fee Schedule (Bill Review); b) Medical provider System Networks; Preferred Provider Network (PPO); c) Out of Network (OON), Specialty Networks/Physical Therapy (PT); d) Medical bill review; e) Incident triage; f) Pharmacy Benefits Manager; g) Telephonic Nurse Case Management; h) Field Nurse Case Management; i) Utilization Review; j) Physician Review/Peer Review. N/A Refers to Part II Page 166 ATTACHMENT 1 Brown & Brown, Inc. Annual Report ,.r•.�= _ - ;� - 10-•• a 1 a Brown & Brown, Inc. • "6 _ . - -- r "'%aeir+" ,iCsr - - .� -fir: r1141. 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ROW* = *t. ueme,.., .-m+ - .... :72- my, a to***-*, *T i. -i 7,_.= c ! 1 ; . _. ._., ...: 7:1=47 '11.---. : '747,-1 Wel la RP 'Il =11/1==.-• Jr-7% ,mre; in****•.' ...§... I• ,n,....,. wr-t" .•- r• i:' '''''1!..- r *e. tem-. 8........ .t, 11 aftF, ft or. ,... mem Ate me :COX Jumassu . _ r;; ;,-_.*.i.u* Irma opo * OR w* r "a q * IR PIR ORR ear r"- 1 t .0• . ere.: ert• g • 11. . MIR MO rr I; FUR ME" + . swill IA .1 rz r , 4,,e 2!! I M. Ili FR IIR R or r : p** la HMIS MR tl W' 0 f LRAM let a WI ...? r se. WM .1111 Rig 6 I &WM CR I I EAR= W. 6. 1 ._.. laurels .= m., r whim; mate -....reR. fig' : f. .2, p . _ -- riff' I,.'.' , *.f-ilk. 0, - Brown & Brown. Inc 2 3 Brown & Brown, Inc. 4 a1 iateAVA ern 41 5 Brown & Brown. Inc. 6 We ciil know that things go wrong sometimes, Helping anticipate and lan for r sly is our expertise, e 5 a bi_:siness must have to ana foc'us.1n _k„ _a:e s the agi :y o- Japt tot.._ - _ ,.__.liVehavea =_ability to .=:)6 on j react F.._—nuances an both the loca' and ii :a`ianalevers..:: u _ _ _. ne our focus never waivers. Every is gu',Oec by c principle: Do what's best for each and every :Ustornier. This sing, la" Intention has been central to our s ccess for more than 75 years. 7 LETTER TO SHAREHOLDERS To our shareholders: 2015 was another year of growth and investment for Brown & Brown, even with a slowly improving economy and continued rate pressure, most notice- ably in coastal property. We grew our business to $1.66 billion in revenue, which is an increase of 5.4% and 2.6% organically over 2014. Our earnings per share were $1.70, which represents a 2.5% increase. Our growth would not be possible with- out the continued progress and development of each team member in our group ofjust more than 7,800 teammates. Through all the hard work of those teammates, we generated just over $400 million of cash flow, which was redeployed into our Company and back to our shareholders. Last year, we allocated our capital through a mix of hiring new teammates, acquisitions and returns to shareholders through dividends and share repurchases. We constantly review this strategy with an eye towards the long term and how we can deliver shareholder returns. Last year, we made investments in people, acquired $56 million of annualized revenue, bought back $175 million of our stock and paid dividends of $64 million. Our dividend increase last year rep- resents our 22nd consecutive year of dividend J. Powell Brown. CPCU President anC Chief Executive Officer increases. As we approach our $2 billion intermedi- ate goal, analytics are essential to forecasting and achieving long-term results. It is essential that we tap the deep pool of information that is dispersed in our 241 locations and use this information to the benefit of our customers. Thus, we will be making incremental investments in technology over the next tyro to three years with a total estimated cost of $30-$40 million. This is part of our evolution to the next level and beyond. This will give us the ability to leverage our revenues and gain additional insight into our business. We are an organization that grows organically and through acquisitions. When it comes to the acqui- sition process, cultural fit is the most important dynamic. and then the acquisition must make sense financially. If there is not a cultural fit, we do not move forward. In 2012, 2013 and 2014, we purchased about $150 million annualized revenues. In 2015.we acquired companies with 56 million of annualized revenue. Our goal is to acquire firms of all sizes in each of our four segments that fit culturally and make sense financially. 2015 was a year in which we looked at a number of acquisitions that fit culturally, but the economics did not make sense. We are comfortable that this approach will enhance shareholder value for the long run. For the past 12 to 18 months. we have been dis- cussing rate pressure. especially in coastal property areas and the middle market. This is positive for our customers, but puts pressure on several of our pro- grams' businesses and certain segments of our retail and wholesale businesses. As ycu may know. it has been 11 years since the last hurricane struck Florida. So long as the sur keeps shining and fair winds keep blowing. property rates in coastal areas will continue to be under pressure. One of the changes we experienced in 2015 was the retirement of Linda Downs. Linda was one of our most valued leaders and closest friends. When she started with Brown & Brown 35 years ago. we were $2 million in revenue. Linda has been instrumental in the Company's growth and success. and she helped Brown & Brown, Inc. 8 shape who we are today. The recognition we bestow annually to leaders who are integral to the development of rising team- mates will be named the Linda S. Downs Mentor of the Year Award from now moving forward. Brown & Brown's culture statement is very straightforward — "We are a lean, decentralized, highly competitive, profit oriented sales and service organization comprised of people of the highest integrity and quality, bound together by clearly defined goals and prideful relationships" This is what drives us each and every day as a team to perform at a higher level and links us with our strategic plan. We strive to: • Exceed customer expectations every time • Increase long-term shareholder value • Recruit. develop and reward our teammates • Grow our business organically and make quality acquisitions that fit culturally • Cultivate and enhance relationships with our carrier partners Thank you for your support of Brown & Brown. Our greatest assets are our teammates, our reputation and our capital. We make investments with this in mind for the long term. We are now approaching our $2 billion intermediate goal that we will attain through profitable organic growth and acquired revenue. There is no timeframe, but when we get there, we will set a new intermediate "stretch' goal. In closing, we are a "three yards and a cloud of dust" company that believes the only constant is change. All of us here at Brown & Brown are excited about 2016 and beyond. Regards, J. Powell Brown, CPCU President and Chief Executive Officer This letter ircluees selected references to certain "or-GAAP 5narc;al Teasi.res hat are made to provide additional mearirgf.ii methods of evawatrg certain aspects of our operating performarce from per od to period or a basis that may rot be other vise ap0arert on a GAAP basis, Far recore Iiatior and other information concerning trese nor-GAAP hearcial measures refer to page 88 of the Company s 2015 Ahni,al Report. Total Revenues dollars in millions 1,661 1,576 1,363 1,200 1,014 11 12 13 14 15 Net Income Per Share Diluted in dollars 170 L48 L41 126 L12 11 12 13 14 15 Shareholders' Equity dollars in millions 2,007 2,114 2.150 Hill 9 2015 Annual Report Expertise and education support growth of The Joint Corp.'s business. When Brown & Brown first wrote coverage for The Joint Corp.. a busi- ness specializing in chiropractic care. it was a startup with 12 locations. Now it's a publicly traded company with 335 locations nationwide with ever-increasing business and risk complexity. As a result of Brown & Brown's expertise and educational approach, and ability to manage The Joint's national expansion and breadth, The Joint named the Com- pany as the required Property and Casualty insurance provider for all franchises. Brown & Brown accom- plished this by holding monthly seminars for new franchise owners to explain why it's so important to manage risk and why it is imper- Brown & Brown.:nc. ative to buy proper coverage. This approach empowered the franchisees to feel informed and knowledgeable about how to man- age their risks and how what they're buying will respond in the event of a claim. Brown & Brown originally provided only the Property and Casualty lines of insurance for both the corporate -owned and franchise locations of The Joint. As a result of delivering value-added solutions. Brown & Brown began providing their employee benefits, as well. It is through Brown & Brown's flexibility, expertise. depth and attention to customer service that the Company is able to tailor solutions for The Joint and our many other customers. 10 John Richards Chief Executive Officer The Joint Corp. Scottsdale, Arizona Wayne Hubbard, CIC Senior Vice President Property and Casualty Brown & Brown Insurance of Arizona. Inc. Phoenix, Arizona Chris P. Scherzer Senior Vice President Employee Benefits Team Leader Brown & Brown Insurance of Arizona, Inc. Phoenix, Arizona 11 _ Ic Executive Vice `'x` dent Brown & Brown Insurance of Arizona, Inc. Phoenix, Arizona REVIEW OF OPERATIONS The Retail Segment Success under all conditions. The Retail Segment is the largest of Brown & Brown's four segments and generated approxi- mately 52% of the Company's total revenues in 2015. In September, the Retail Segment was realigned into several regionalized segments. We believe this realignment will enable the Retail Segment to better focus on the specific needs of each particular region and serve our local customers by being able to adapt to changing market conditions even more quickly. One of the most striking testaments to the strength of our unique culture at Brown & Brown is our ability to succeed in both in good times as well as when circumstances are less than ideal. In 2015, the Retail Segment grew in spite of rate reductions and a slowly improving middle market economy. The success of the Retail Segment is solely the result of the efforts of our teammates. While no one enjoys challenging times, they do show what people are made of, and our teammates perform well under pressure by collaborating and innovating. In the Retail Segment. we continued to deliver great solutions for our customers by leveraging the capabilities of our carrier and wholesale brokerage partners that drove new business to a record high in 2015. Again, this is attributable to the culture of cooperation and self-discipline at Brown & Brown. Our offices did a tremendous job of sharing information and working together to find or create the best solutions for our customers. We believe we are well positioned for 2016. Looking to 2016, the Retail Segment will con- tinue to focus not just on hiring the best people, but also on the training and development of our teammates. Additional priorities include enrich- ing our partnerships with carriers and continuing to develop innovative new products that reduce risk for our customers. Brown & Brown, Inc. 12 Segment Total Revenues dollars in millions 870.3 737.3 6521 6141 11 12 13 14 823.7 Our Retail Office Locations Segment Adjusted Operating Profit') dollars in millions 239.4 197S 2113 11 12 13 lkit ArA • Contribution to Total Revenues 52.4% 14 15 Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Illinois Indiana Kansas Kentucky Louisiana Contribution to Total Adjusted Operating Profit{tl 50.0% Segment Adjusted Operating Profit Marginm as a percentage 32.2 32.4 32S 31.3 31.2 11 12 13 14 15 Massachusetts Michigan Minnesota Mississippi Missouri Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Vermont Virginia Washington Wisconsin Outside the U.S. Bermuda Cayman Islands (1) Please see non-GAAP reconciliation on page 88. 13 Crystal Million ViceR Sir I r, `.i1�+ �. and �. Operations, roperty Division Arrowhead General Insurance Agency. Inc. Carlsbad, California Mark Corey President, Personal Property Division Arrowhead General Insurance Agency. Inc. Carlsbad. California L Thum Vice sident - Marketin Per s ; Property Divisio Arr. :d General Ins Age, alifornio Brown & Brown, Inc. 14 Responding to challenges with innovation and determination. The National Programs Segment has always been diversified and innova- tive, and in spite of the challenges. the entire industry faced in 2015.. the National Programs Segment continued to innovate and expand our program offerings that delivered growth in 2015 and will have a pos- itive impact in 2016 and beyond. To exemplify this innovation, our Arrow- head business in San Diego realized there was an opportunity for our cus- tomers to better manage their coastal property risks. This was specifically in response to a need for broader earthquake coverage in California, hurricane coverage in coastal areas, and coverage for tornadoes in the Midwest. By finding niche markets. 15 following the need and offering innovative solutions, we've helped thousands of people manage their risks and provided growth oppor- tunities for our carrier partners. In addition. last year our teammates saw an opportunity to work with our carrier partners and expand coverage for certain commercial customers. In addition to providing coverage for earthquake damage, with our new "all-risk" insurance program, we now have additional capacity to insure customers for a combination of wind damage. fire damage and more. This new "all- risk" program further broadens our capabilities and creates additional solutions for our customers. REVIEW OF OPERATIONS The National Programs Segment Viewing challenges through a lens of finding opportunities, Brown & Brown's National Programs Segment generated approximately 26% of the Company's total revenue in 2015_ The goal of the National Programs Segment is to be the most efficient and innovative program manager in the specialty insurance market. while providing our teammates. carrier partners and distribution partners with opportunities for growth and enrichment. The importance of Brown & Brown's unique culture was never more evident than in 2015. Through collaboration. the National Programs Segment was able to grow in spite of a competitive and dynamic market. The challenging market conditions in 2015 sharpened the focus of the National Programs Segment and served as a launching pad for some truly exciting achievements, including the creation of our new "all-risk" insurance program. The new incubation team we created in 2015 is a team designed to collaborate and vet new ideas, products and programs. Again, without the culture of cooperation that exemplifies Brown & Brown. an effort such as this wouldn't be possible. At Brown & Brown we work together to create innovative. viable solutions for our carrier and distribution partners. The focus has always been, and will continue to be. on our partners and how we can create solutions for our customers. The diversification and specialization of Brown & Brown's National Programs Segment is aimed at allowing it to achieve good results in the industry. For example, while competition in commercial property insurance was fierce last year. our personal lines grew strongly, bolstered by close relationships with our partners and the introduction of new products. This balanced portfolio of businesses enabled the National Programs Segment to grow in 2015 in spite of rate pressures and economic challenges. Innovation was not only focused on revenue growth. but the National Programs Segment worked tirelessly to further increase the scale of our technology platform and enable continued increasing profitable growth by taking advantage of our leadership position in the marketplace. As a result, the National Programs Segment oper- ates more efficiently than ever and will continue to seek opportunities to capitalize on our scale and standardization. This is critical because while no one can anticipate the direction market con- ditions will go, we believe the National Programs Segment is well prepared to face any challenge. In 2016, the the National Programs Segment's top priority is to achieve a solid rate of organic growth. capitalize on our new initiatives, and add more talented, hard-working insurance professionals to our team that will enable us to achieve our goals. Brown & Brown. Inc. 16 Segment Total Revenues dollars in millions 428.7 169.7 901.4 260 4 12 13 14 40 National Programs AFC insurance Allied Protector Plan American Specialty Arrowhead General Insurance Agency Bellingham Underwriters CalSurance Associates Clear Risk Solutions CPA Protector P1an° Downey Public Risk Underwriters Florida Intracoastal Underwriters Ideal insurance Agency Contribution to Total Revenues 25.9% Segment Adjusted Operating Profit'', dollars in millions 97.6 741 I II 11 12 U 14 15 11 12 13 14 15 Segment Adjusted Operating Profit Margin(" 159.3 as a percentage 152.4 :ems• 43.7 104.9 Irving Weber Associates Lawyer's Protector Plane OnPoint Underwriting Optometric Protector Plan* Parcel Insurance Plan Proctor Financial Professional Protector Plan for Dentists Professional Risk Specialty Group Professional Services Plans Public Risk Advisors of New Jersey Contribution to Total Adjusted Operating Profits" 28.8% !7S1 37.7 37.1 11 Public Risk Underwriters Sigma Underwriting Managers Texas Monarch Management Corporation TitlePac° Wright Flood Wright Public Entity Wright Specialty For additional information on National Programs please visit www.natpragrams.com (1) Please see non-GAAP reconciliation on page 88. 17 2015 AnnLa, ;eort WHOLESALE BROKERAGE New opportunities where there once were none. One especially exciting accom- plishment for Brown & Brown's Wholesale Brokerage Segment in 2015 was a new opportunity in professional practice coverage for a large law firm. One of our retail agents approached us about this prospect and indicated they didn't have access to carriers that focus on this type of coverage. We quickly selected one of our top teammates to work on designing a solution for both the agent and the customer. Brown & Brown, I nc. We analyzed the expiring policy. risk profile, and the customer's risk retention appetite. then worked with our vast group of carrier partners to secure coverage that would manage the risks and provide the customer with a cost-effective solution. It was only through our innovation and deep carrier rela- tions that we were able to win the business. Through this creativity. it has opened up other potential leads for more large law firms. 18 19 REVIEW OF OPERATIONS The Wholesale Brokerage Segment The loyalty of our teammates is a testament to our culture. The Wholesale Brokerage Segment of Brown & Brown generated approximately 13% of the Company's revenue in 2015. In spite of enormous rate pressure on coastal properties, the entire team rallied in 2015 and made it possible for the Wholesale Brokerage Segment to deliver 5.9% organic growth. The Wholesale Brokerage Segment. like other areas of the Company, is a highly diverse business, which we believe enables us to be successful even when we face challenges on a number of fronts. In 2015, our property brokerage business was challenged by declining property rates, but our team looked for opportunities and worked tremendously hard to make progress in other areas. Because of our expertise and strong carrier relationships, the Wholesale Brokerage Segment created new opportunities in the area of professional practice liability coverage. It's this type of collaboration and tireless determination that exemplifies both the Wholesale Brokerage Segment and the entire Company. A huge testament to the importance of the culture at Brown & Brown is the loyalty and determination of our teammates. When times are tough, our team doesn't give up. They keep pushing forward to find new opportunities and solve risk management challenges for our customers every day. That leads to our top priority in 2016: hiring, training and mentoring even more new team- mates. It's important to remember that the effort doesn't stop with hiring. Brown & Brown has an excellent training program and is also fortunate we have numerous teammates throughout the Company who make it a point to seek out and mentor new talent. Many of our seasoned brokers have newer brokers with them everyday in order to help develop their skills and become highly successful. It is this type of one-on-one attention and education that makes a real differ- ence in developing tomorrow's leaders. Another top priority for 2016 is expanding our capabilities geographically and serving some of the markets that we do not fully support today. This effort will be led by a number of our top lead- ers, and we are excited about our potential for growth as we expand our geographic footprint. Regardless of what 2016 brings. we believe the Wholesale Brokerage Segment will continue to innovate, endure and thrive. Thanks to the loyalty, creativity and determination of our teammates and our willingness to present our customers with effective solutions, we believe we are positioned for continued growth and success. Brown & Brown. nc. 20 Segment Total Revenues dollars in millions 16L9 Wholesale Brokerage Segment APEX Insurance Services Big Sky Underwriters Braishfield Associates Combined Group Insurance Services Decus Insurance Brokers ECC Insurance Brokers Graham Rogers Contribution to Total Revenues 13.1% Segment Adjusted Operating Profit" dollars in millions 78.3 727 65.2 5L9 54.5 I I 11 12 13 14 Halcyon Underwriters Hull & Company MacDuff Underwriters Mile High Markets National Risk Solutions Peachtree Special Risk Brokers Procor Solutions + Consulting Public Risk Underwriters of Texas Segment Adjusted Operating Profit Margin"} as a percentage hill 3" 3 32.1 32.5 11 12 13 14 15 Summit Risk Services Texas Security General Insurance Agency Contribution to Total Adjusted Operating Profit 14.2% (1) Please see non-GAAP reconciliation on page 88. 21 2015 Artnua'. Reoort Ron Warble Executive Vice President USIS/AmeriSys Orlando, Florida Michael White Director of Brokerage Apex Insurance Services Norcross, Georgia Brown & Brown. Inc. 22 SERVICES Results come from perseverance and cooperation. The Services Segment is particularly proud of the difference it made for Columbus Consolidated Govern- ment in Georgia. Brown & Brown first approached Columbus several years ago, and reconnected with the new risk manager in late 2012 to discuss their Columbus Consolidated Government Contract for Workers' Compensation and Medical Care Organization TPA services. Colum- bus had been in a risk pool for several years and was looking for a more customized solution. Our teammates listened to the issues presented by the risk manager and then began the process to create a better alternative. • Brown& Brown's USIS business assembled a team of subject matter experts from across Brown & Brown, including USIS, AmeriSys and Apex as well as external partners in order to provide a new solution using a Med- ical Care Organization model as the key differentiator for managing risks and costs. With the risk manager's leadership, the council decided that the USIS/AmeriSys option was the best choice for Columbus. It was only through our capabilities and inno- vation that we were able to create a new and creative solution for this customer that has saved Columbus over half a million dollars annually. 23 REVIEW OF OPERATIONS The Services Segment Planting seeds and nurturing them to growth. In 2015, the Services Segment of Brown & Brown was responsible for generating approx- imately 9% of the Company's revenue and delivering 7% organic growth. The Services Segment generates its revenues differently than the Company's other segments. Much of its revenue is derived from fees paid for services, so the Segment generally doesn't feel the direct impact of rate pressures to the same degree as our other segments. In the Services Segment, our customers are municipalities, self -insured companies and insurance carriers, with the latter impacted mostly by premium rates. The Services Segment had an exciting year. For this Segment, 2015 was a year of planting seeds and generating new ideas. It's been tremen- dously exciting to see which of those seeds germinated and grew. In spite of challenges pre- sented by the economy, we were able to write new business and develop new solutions. Many of our offices rose to the challenges presented and had a really good year. Our success in Columbus County, Georgia, is just one example of what can be accomplished by working together,, being resourceful and focus- ing on customers° success. It can't be stressed enough that at Brown & Brown. the culture is everything. Our Company is infused with a 'get it done" attitude that drives success and allows us to overcome almost any obstacle. Further. our decentralized sales and service model enables our offices to respond and make decisions on a local level and is a critical component of our success. Looking ahead to 2016, the adjective"exciting" continues to be an appropriate descriptor for the Services Segment. To be successful in 2016, first the Services Segment will continue making changes and implementing strategies quickly and nimbly as conditions evolve. Given the ingenuity, perseverance and resource- fulness the Services Segment demonstrated in 2015, there's every reason to believe we can achieve this in 2016. Success breeds success. With our unique culture, Brown & Brown attracts and retains individuals who are driven by results and are focused on delivering solutions for our customers. Regardless of what the market does, the Services Segment will maintain its unwavering focus on providing excellent service and solutions for our customers. Brown & Brown. Inc- 24 Segment Total Revenues dollars in millions 117.5 65.8 11 12 131.5 13 Services Segment 136.6 14 145.4 Segment Adjusted Operating Segment Adjusted Operating Profit's Profit Margie) dollars in millions as a percentage 41.2 31.2 20.0III 31.3 30.7 31.7 26.5 II in 22.5 21.8 15 11 12 13 14 15 11 12 13 The Advocator Group American Claims Management Insurance Claims Adjusters Contribution to Total Revenues 8.8% NuQuest Protocols Preferred Government United Self Insured Claims Services Services Contribution to Total Adjusted Operating Profit" 5.7% • 1 r (1) Please see non-GAAP reconciliation on page 88. 25 LEADERSHIP OVERVIEW J. Powell Brown, CPCU President & Chief Executive Officer Charles H. Lydecker, CPCU, CIC, AIM Executive Vice President; Regional President - Retail Segment J. Neal Abernathy Senior Vice President Kathy H. Colangelo CIC, ASLI Senior Vice President Richard A. Knudson, CIC Senior Vice President; Regional President - Retail Segment R. Andrew Watts Executive Vice President, Treasurer & Chief Financial Officer J. Scott Penny, CIC Chief Acquisitions Officer Sam R. Boone, Jr. Senior Vice President Steve Denton Senior Vice President; Regional President - Retail Segment Richard A Freebourn, Sr., CPCU, CIC Executive Vice President - Internal Operations & People Officer Anthony T. Strianese President - Wholesale Brokerage Segment Steve M. Boyd Senior Vice President Anthony M. Grippa Senior Vice President; Regional President - Retail Segment Robert W. Lloyd, Esq., CIC Executive Vice President, Secretary & General Counsel Chris L. Walker President - National Programs Segment P. Barrett Brown Senior Vice President; Regional President - Retail Segment Thomas K. Huval, CIC Senior Vice President; Regional President - Retail Segment n.- Brown. nc. 26 BOARD OF DIRECTORS Leff to right: Samuel P. Bell, III, Esq. Of Counsel to the law firm of Buchanan Ingersoll & Rooney PC Acquisition Committee: Compensation Committee James S. Hunt Former Executive Vice President and Chief Financial Officer, Walt Disney Parks and Resorts Worldwide Acquisition Committee: Audit Committee, Chair: Compensation Committee Theodore J. Hoepner Former Vice Chairman, SunTrust Bank Holding Company AuditCommit-tee: Compensation Committee Bradley Currey, Jr. Former Chairman & Chief Executive Officer, Rock Tenn Company Nominating 'Corporate Governance Committee Chilton D. Varner, Esq. Partner, King & Spalding LLP Nominating/Corporate Governonce Committee Wendel] S. Reilly Managing Partner, Grapevine Partners, LLC Lead Director: Nominating/Corporate Governance Committee, Chair J. Hyatt Brown, CPCU, CLU Chairman, Brown & Brown, Inc. J. Powell Brown, CPCU President & Chief Executive Officer. Brown & Brown, Inc. Tani Jennings Chairman, Jack Jennings & Sons Former Lieutenant Governor, State of Florida Audit Committee: Compensation Committee. Choir H. PaImer Proctor, Jr. President/Director, Fidelity Bank Acquisition Committee, Chair: Compensation Committee Hugh M. Brown Founder and former President & Chief Executive Officer, BAMSI, Inc Acquisition Committee: Audit Committee: Nominating/Corporate Governance Committee Timothy R. M. Main Managing Director, Evercore Group LLC Acquisition Committee 27 15 Annual Report COMMUNITY INVOLVEMENT The honor to serve our communities We value the communities we serve and find every opportunity to give back. Each year we contribute millions of dollars to non-profit organizations in our communities. Below is a sample of some of the organizations we supported in 2015: AccessCNY Achieve Aliie's Friends American Cancer Society American Diabetes Association American Heart Association American Lebanese Syrian Associated Charities American Red Cross Aspire - Massachusetts General Hospital Barbara Bush Foundation - Annual Celebration of Reading Basis Schools Better Housing Coalition Bighorn Golf Club Charities Bivona Child Advocacy Center BJ's Wholesale Club Charitable Foundation The Bottom Line Boys & Girls Club Boy Scouts of America Broward County Outreach Center Cai State Fullerton Philanthropic Foundation Camp Boggy Creek Catskill Area Hospice and Palliative Care Central City Concern Center for Family Services Children's Cancer Association Christel House Crouse Health Foundation Cumberland County Guidance Center Development at Schechter Westchester Doug Flutie, Jr. Foundation for Autism Education Foundation of Lake County Elwyn Foundation Embassy of Hope Embry Riddle Father Lopez Catholic High School FCCA First Call Far Help of Broward - 2-1-1 Broward The First Tee Florida Hospital Foundation Florida Lions Conklin Centers Florida Southwest State College Florida Southwestern University Footlocker Foundation Florida State University Gamma Iota Sigma Glens Falls Hospital Greater New York Councils Halifax Health Foundation Holy Redeemer Health System Hospice by the Bay Horizon House Humane Society I Have A Dream Foundation international Rhett Syndrome The Jason Ritchie Hockey Foundation Jesuit High School Foundation Joliet Catholic Academy Junior Achievement Juvenile Diabetes Research Foundation Larc's Acadian Village Lee Memorial Health Foundation Lifepath Foundation Lighthouse Louisiana Make -A -Wish Mary McLeod Bethune MEHTA Milagros para Ninos Miss Tampa Crown Scholarship Mount Sinai Medical Center Museum of Arts and Sciences The NASCAR Foundation Nathan Adelson Hospice National Black McDonald's Franchisee Foundation National Multiple Sclerosis Society New York Police and Fire Widows' and Children's Benefit Fund Niagara Falls Memorial Medical NY Schools Insurance Foundation Oakland Zoo PBA Piscataway Township Education Foundation Pooch & Poodle Rescue Portland State University R'Club Child Care RFK Children's Action Corps Rochester General Hospital Foundation Rome Memorial Hospital Foundation Ronald McDonald House Rotary Club Saint Francis Hospice and Cancer Research Schwager Memorial Scholarship Fund Southeastern Guide Dog Association Special Olympics St. Mary's Academy St. Matthews House Step Up For Students Temple University University of Central Florida University of Florida University of Georgia Union for Reform Judaism United Way UR Medicine Valley Health Services Vincent DePaul Foundation Voices For Children Foundation Volunteer New York Walker Home and School WeSN I P Whirlpool Collective Impact WSCFF Benevolent Fund YCS Foundation YMCA Youth About Business Brown & Brown. !nc. 28 2015 Financial Review 30 Management's Discussion and Analysis of Financial Condition and Results of Operations 51 Consolidated Statements of Income 52 Consolidated Balance Sheets 53 Consolidated Statements of Shareholders' Equity 54 Consolidated Statements of Cash Flows 55 Notes To Consolidated Financial Statements 88 GAAP Reconciliation —Income Before Income Taxes to Operating Profit and Adjusted Operating Profit 89 Reports of Independent Registered Public Accounting Firm 91 Management's Report on Internal Control Over Financial Reporting 92 Performance Graph 29 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS Or OPERATIONS General The following discussion should be read in conjunction with our Consolidated Financial Statements and the related Notes to those Financial Statements and"Information Regarding Non-GAPP Measures" with regard to important information on non-GAAP financial measures, all contained in our discussion and analysis included elsewhere in this Annual Report. We are a diversified insurance agency, wholesale brokerage, insurance programs and services organization headquar- tered in Daytona Beach, Florida. As an insurance intermediary, our principal sources of revenue are commissions paid by insurance companies and. to a lesser extent, fees paid directly by customers. Commission revenues generally represent a percentage of the premium paid by an insured and are affected by fluctuations in both premium rate levels charged by insurance companies and the insureds' underlying "insurable exposure units," which are units that insurance companies use to measure or express insurance exposed to risk (such as property values, or sales and payroll levels) to determine what premium to charge the insured. Insurance companies establish these premium rates based upon many factors, including loss experience, risk profile, and reinsurance rates paid by such insurance companies, none of which we control. We have increased revenues every year from 1993 to 2015, with the exception of 2009, when our revenues dropped 1.0%. Our revenues grew from $95.6 million in 1993 to $1.7 billion in 2015, reflecting a compound annual growth rate of 13.9%. In the same 22-year period, we increased net income from $8.1 million to $243.3 million in 2015, a compound annual growth rate of 16,7%. The volume of business from new and existing customers, fluctuations in insurable exposure units, changes in premium rate levels, and changes in general economic and competitive conditions all affect our revenues. For example, level rates of inflation or a general decline in economic activity could limit increases in the values of insurable exposure units. Conversely, the increasing costs of litigation settlements and awards have caused some customers to seek higher levels of insurance coverage. Historically, our revenues have typically grown as a result of our focus on net new business growth and acquisi- tions. We foster a strong, decentralized sales and service culture with the goal of consistent, sustained growth over the long term. The term "core commissions and fees" excludes profit-sharing contingent commissions and guaranteed supplemental commissions, and therefore represents the revenues earned directly from specific insurance policies sold, and specific fee -based services rendered. The term 'core organic commissions and fees" is our core commissions and fees less (i) the core commissions and fees earned for the first twelve months by newly -acquired operations and (ii) divested business (core commissions and fees generated from offices, books of business or niches sold or terminated during the comparable period). "Core organic commissions and fees', a non-GAAP measure, are reported in this manner in order to express the current year's core commissions and fees on a comparable basis with the prior year's core commissions and fees. The resulting net change reflects the aggregate changes attributable to (i) net new and lost accounts, (ii) net changes in our clients' exposure units, and (iii) net changes in insurance premium rates or the commission rate paid to us by our carrier partners. We also earn "profit-sharing contingent commissions,' which are profit-sharing commissions based primarily on underwriting results, but which may also reflect considerations for volume, growth and/or retention. These commissions are primarily received in the first and second quarters of each year, based on the aforementioned considerations for the prior year's). Over the last three years, profit-sharing contingent commissions have averaged approximately 4.0% of the previous year's total commissions and fees revenue. Profit-sharing contingent commissions are included in our total commissions and fees in the Consolidated Statement of Income in the year received. Certain insurance companies offer guaranteed fixed -base agreements, referred to as "Guaranteed Supplemental Commissions" ("GSCs") in lieu of profit-sharing contingent commissions. Since GSCs are not subject to the uncertainty of loss ratios, they are accrued throughout the year based on actual premiums written. For the twelve-month period ending December 31, 2015, we had earned $10.0 million of GSCs, of which $7.6 million remained accrued at December 31, 2015 as most of this will be collected in the first quarter of 2016. For the twelve-month periods ended December 31, 2015, 2014, and 2013, we earned $10.0 million, $9,9 million and $8.3 million, respectively, from GSCs. Brown & Brown, Inc. 30 Fee revenues relate to fees negotiated in lieu of commissions, which are recognized as services are rendered. Fee revenues have historically been generated primarily by: (1) our Services Segment, which provides insurance -related services, including third -party claims administration and comprehensive medical utilization management services in both the workers' compensation and all -lines liability arenas, as well as Medicare Set -aside services, Social Security disability and Medicare benefits advocacy services, and claims adjusting services, (2) our National Programs and Wholesale Brokerage Segments, which earn fees primarily for the issuance of insurance policies on behalf of insurance companies, and to a lesser extent (3) our Retail Segment in our large -account customer base. These services are provided over a period of time, typically one year. Fee revenues, on a consolidated basis, as a percentage of our total commissions and fees, represented 30.6% in 2015, 30.6% in 2014 and 26.6% in 2013. Additionally, our profit-sharing contingent commissions and GSCs for the year ended December 31, 2015 decreased by $5.8 million over 2014 primarily as a result of increased loss ratios in our National Programs and Wholesale Brokerage Segment. Other income decreased by $5.0 million primarily as a result of a reduction in the gains on the sale of books of business when compared to 2014 and the change in where this activity is presented in the financial statements as described in the results of operations section as described later in this document. For the years ended December 31, 2015 and 2014, our consolidated internal revenue growth rate was 2.6% and 2.0% respectively. Additionally, each of our four segments recorded positive internal revenue growth for the year ended December 31, 2015. In the event that the gradual increases in insurable exposure units that occurred in the past few years continues through 2016 and premium rate changes are similar with 2015. we believe we will continue to see positive quarterly internal revenue growth rates in 2016. Historically, investment income has consisted primarily of interest earnings on premiums and advance premiums collected and held in a fiduciary capacity before being remitted to insurance companies. Our policy is to invest available funds in high -quality, short-term fixed income investment securities. Investment income also includes gains and losses realized from the sale of investments. Other income primarily reflects legal settlements and other miscellaneous income. Income before income taxes for the year ended December 31, 2015 increased over 2014 by $62.8 million, primarily as a result of acquisitions completed in the past twelve months and net new business, partially offset by the incremental interest expense associated with our inaugural public debt offering completed in 2014 along with incremental investments in revenue producing teammates. Information Regarding Non-GAAP Measures In the discussion and analysis of our results of operations, in addition to reporting financial results in accordance with GAAP, we provide information regarding core commissions and fees, core organic commissions and fees, and our internal growth rate, which is the growth rate of our core organic commissions and fees, and adjusted calculations of core commissions and fees, core organic commissions and fees and our internal growth rate after adjusting for the significant revenue recorded at our Colonial Claims operation in the first half of 2013 attributable to 5uperstorm Sandy. These measures are not in accor- dance with, or an alternative to (including any adjusted internal growth rate) the GAAP information provided in this Annual Report on Form 10-K. Tabular reconciliations of this supplemental non-GAAP financial information to our most comparable GAAP information are contained in this Annual Report on Form 10-K. We present such non-GAAP supplemental financial information, as we believe such information provides additional meaningful methods of evaluating certain aspects of our operating performance from period to period on a basis that may not be otherwise apparent on a GAAP basis. This supple- mental financial information should be considered in addition to, not in lieu of, our Consolidated Financial Statements. Acquisitions Part of our continuing business strategy is to attract high -quality insurance intermediaries to join our operations. From 1993 through the fourth quarter of 2015, we acquired 472 insurance intermediary operations, excluding acquired books of business (customer accounts). 31 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS Critical Accounting Policies Our Consolidated Financial Statements are prepared in accordance with U.S. GAAP. The preparation of these financial statements requires us to make estimates and judgments that affect the reported amounts of assets, liabilities, revenues and expenses. We continually evaluate our estimates, which are based on historical experience and on assumptions that we believe to be reasonable under the circumstances. These estimates form the basis for our judgments about the carrying values of our assets and liabilities, of which values are not readily apparent from other sources. Actual results may differ from these estimates. We believe that of our significant accounting and reporting policies, the more critical policies include our accounting for revenue recognition, business combinations and purchase price allocations, intangible asset impairments and reserves for litigation. In particular, the accounting for these areas requires significant use of judgment to be made by management. Different assumptions in the application of these policies could result in material changes in our consolidated financial position or consolidated results of operations. Refer to Note 1 in the "Notes to Consolidated Financial Statements". Revenue Recognition Commission revenues are recognized as of the effective date of the insurance policy or the date on which the policy premium is processed into our systems, whichever is later. Commission revenues related to installment billings are recog- nized on the later of the date effective or invoiced, with the exception of our Arrowhead business which follows a policy of recognizing on the later of the date effective or processed into our systems regardless of the billing arrangement. Management determines the policy cancellation reserve based upon historical cancellation experience adjusted in accor- dance with known circumstances. Subsequent commission adjustments are recognized upon our receipt of notification from insurance companies concerning matters necessitating such adjustments. Profit-sharing contingent commissions are recognized when determinable, which is generally when such commissions are received from insurance companies, or periodically when we receive formal notification of the amount of such payments. Fee revenues, and commissions for employee benefits coverages and workers' compensation programs, are recognized as services are rendered, Business Combinations and Purchase Price Allocations We have acquired significant intangible assets through business acquisitions.These assets consist of purchased customer accounts, non -compete agreements, and the excess of purchase prices over the fair value of identifiable net assets acquired (goodwill). The determination of estimated useful lives and the allocation of purchase price to intangible assets requires significant judgment and affects the amount of future amortization and possible impairment charges. All of our business combinations initiated after June 30, 2001 have been accounted for using the purchase method. In connection with these acquisitions, we record the estimated value of the net tangible assets purchased and the value of the identifiable intangible assets purchased, which typically consist of purchased customer accounts and non -compete agree- ments. Purchased customer accounts include the physical records and files obtained from acquired businesses that contain information about insurance policies, customers and other matters essential to policy renewals. However, they primarily represent the present value of the underlying cash flows expected to be received over the estimated future renewal periods of the insurance policies comprising those purchased customer accounts. The valuation of purchased customer accounts involves significant estimates and assumptions concerning matters such as cancellation frequency, expenses and discount rates. Any change in these assumptions could affect the carrying value of purchased customer accounts. Non -compete agreements are valued based on their duration and any unique features of the particular agreements. Purchased customer accounts and non -compete agreements are amortized on a straight-line basis over the related estimated lives and contract periods, which range from 5 to 15 years. The excess of the purchase price of an acquisition over the fair value of the identifiable tangible and intangible assets is assigned to goodwill and is not amortized. Acquisition purchase prices are typically based on a multiple of average annual operating profit earned over a one- to three-year period within a minimum and maximum price range. The recorded purchase prices for all acquisitions consum- mated after January 1, 2009 include an estimation of the fair value of liabilities associated with any potential earn -out provisions. Subsequent changes in the fair value of earn -out obligations are recorded in the Consolidated Statement of Income when incurred. Brown & Brown, 'rc 32 The fair value of earn -out obligations is based on the present value of the expected future payments to be made to the sellers of the acquired businesses in accordance with the provisions contained in the respective purchase agreements. In determining fair value, the acquired businesses future performance is estimated using financial projections developed by management for the acquired business and this estimate reflects market participant assumptions regarding revenue growth and/or profitability, The expected future payments are estimated on the basis of the earn -out formula and performance targets specified in each purchase agreement compared to the associated financial projections. These estimates are then discounted to a present value using a risk -adjusted rate that takes into consideration the likelihood that the forecasted earn -out payments will be made. Intangible Assets Impairment Goodwill is subject to at least an annual assessment for impairment measured by a fair -value -based test. Amortizable intangible assets are amortized over their useful lives and are subject to an impairment review based on an estimate of the undiscounted future cash flows resulting from the use of the assets. To determine if there is potential impairment of goodwill, we compare the fair value of each reporting unit with its carrying value. If the fair value of the reporting unit is less than its carrying value, an impairment loss would be recorded to the extent that the fair value of the goodwill within the reporting unit is less than its carrying value. Fair value is estimated based on multiples of earnings before interest, income taxes, depreciation, amortization and change in estimated acquisition earn -out payables ("EBITDAC"), or on a discounted cash flow basis. Management assesses the recoverability of our goodwill and our amortizable intangibles and other long-lived assets annually and whenever events or changes in circumstances indicate that the carrying value of such assets may not be recoverable. Any of the following factors, if present, may trigger an impairment review: (i) a significant underperformance relative to historical or projected future operating results; (ii) a significant negative industry or economic trends; and (iii) a significant decline in our market capitalization. If the recoverability of these assets is unlikely because of the existence of one or more of the above -referenced factors, an impairment analysis is performed. Management must make assumptions regarding estimated future cash flows and other factors to determine the fair value of these assets. If these estimates or related assumptions change in the future, we may be required to revise the assessment and, if appropriate, record an impairment charge. We completed our most recent evaluation of impairment for goodwill as of November 30, 2015 and determined that the fair value of goodwill exceeded the carrying value of such assets, Additionally, there have been no impairments recorded for amortizable intangible assets for the years ended December 31, 2015, 2014 and 2013. Non -Cash Stock -Based Compensation We grant stock options and non -vested stock awards to our employees, and the related compensation expense is required to be recognized in the financial statements over the associated service period based upon the grant -date fair value of those awards. During the first quarter of 2016, the performance conditions for approximately 1.4 million shares of the Company's common stock granted under the Company's Stock Incentive Plan are expected to be determined by the Compensation Committee to have been satisfied relative to performance -based grants issued in 2011. These grants had a performance measurement period that concluded on December 31, 2015. The vesting condition for these grants requires continuous employment for a period of up to ten years from the January 2011 grant date in order for the awarded shares to become fully vested and non -forfeitable. The shares are expected to be awarded during the first quarter of 2016, pursuant to review and certification of the performance measurements against the stated grant targets by the Compensation Committee in accordance with the Stock Incentive Plan. As a result of the awarding of these shares, the grantees will be eligible to receive payments of dividends and exercise voting privileges after the awarding date, and the awarded shares will be included as issued and outstanding common stock shares and included in the calculation of basic and diluted EPS. 33 MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS Litigation Claims We are subject to numerous litigation claims that arise in the ordinary course of business. If it is probable that a liability has been incurred at the date of the financial statements and the amount of the loss is estimable, an accrual for the costs to resolve these claims is recorded in accrued expenses in the accompanying Consolidated Balance Sheets. Professional fees related to these claims are included in other operating expenses in the accompanyingConsolidatedStatement of Income as incurred. Management, with the assistance of in-house and outside counsel, determines whether it is probable that a liability has been incurred and estimates the amount of loss based upon analysis of individual issues. New developments or changes in settlement strategy in dealing with these matters may significantly affect the required reserves and affect our net income. Results of Operations for the Years Ended December 31, 2015, 2014 and 2013 The following discussion and analysis regarding results of operations and liquidity and capital resources should be consid- ered in conjunction with the accompanying Consolidated Financial Statements and related Notes. Financial information relating to our Consolidated Financial Results is as follows: (in thousands, except percentages) Percent Percent 2015 change 2014 change 2013 REVENUES Core commissions and fees $ 1,595,218 6.4 % $ 1,499,903 15.7% $ 1,295,977 Profit-sharing contingent commissions 51,707 (10.4)% 57,706 12.6% 51,251 Guaranteed supplemental commissions 10,026 1.8 % 9,851 19.0% 8,275 Investment income 1,004 34.4 % 747 17.1% 638 Other income, net 2,554 (66.3)% 7,589 6.3% 7,138 Total revenues 1,660,509 5.4 % 1,575,796 15,6 % 1,363,279 EXPENSES Employee compensation and benefits 841,439 6.3 % 791,749 15.9% 683,000 Non -cash stock -based compensation 15,513 (19.9)% 19,363 (14.3)% 22,603 Other operating expenses 251,055 6.7 % 235,328 20.3% 195,677 Lass/(gain) on disposal (619) (101.3)% 47,425 -% - Amortization 87,421 5.5 % 82,941 22.1% 67,932 Depreciation 20,890 - % 20,895 19.5% 17,485 Interest 39,248 38.2 % 28,408 72.8% 16,440 Change in estimated acquisition earn -out payables 3,003 (69.8)% 9,938 NMF"I 2,533 Total expenses 1,257,950 1.8 % 1,236,047 22.9% 1,005,670 Income before income taxes 402,559 18.5 % 339,749 (5.0)% 357,609 Income taxes 159,241 19.9 % 132,853 (5.4)% 140,497 NET INCOME $ 243,318 17.6 % $ 206,896 (4.7)% $ 217,112 Net internal growth rate -core organic commissions and fees Employee compensation and benefits ratio Other operating expenses ratio Capital expenditures Total assets at December 31 2.6 % 2.0 % 6.7% 50.7 % 50.2 % 50.1% 15.1 % 14.9 % 14.4% $ 18,375 $ 24,923 $ 16,366 $ 5,012,739 $ 4,956,458 $ 3,649,508 (1) NMF = Not a meaningful figure Brown & Brown, Inc. 34 Commissions and Fees Commissions and fees, including profit-sharing contingent commissions and GSCs for 2015, increased $89.5 million to $1,657.0 million, or 5.7%over 2014. Core commissions and fees revenue for 2015 increased $95.3 million, of which approximately $76.6 million represented core commissions and fees from agencies acquired since 2014 that had no comparable revenues. After accounting for divested business of $19.3 million, the remaining net increase of $38.0 million represented net new business, which reflects a growth rate of 2.6% for core organic commissions and fees. Profit-sharing contingent commissions and GSCs for 2015 decreased by $5.8 million, or 8.6%, compared to the same period in 2014. The net decrease of $5.8 million was mainly driven by a decrease in profit-sharing contingent commissions in the National Programs Segment as a result of increased loss ratios. Commissions and fees, including profit-sharing contingent commissions and GSCs for 2014, increased $212.0 million to $1,567.5 million, or 15.6% over the same period in 2013. Core commissions and fees revenue in 2014 increased $203.9 million, of which approximately $186.8 million represented core commissions and fees from acquisitions that had no comparable revenues in 2013. After accounting for divested business of $8.5 million, the remaining net increase of $25.6 million represented net new business, which reflects an internal growth rate of 2.0% for core organic commissions and fees. Profit- sharing contingent commissions and GSCs for 2014 increased by $8.0 million, or 13.5%, compared to the same period in 2013. The net increase was due primarily to $4.9 million, $1.3 million, and $1.8 million increases in profit-sharing contingent commissions and GSCs in our Retail, National Programs and Wholesale Brokerage Segments, respectively. Investment Income Investment income increased to $1.0 million in 2015, compared with $0.7 million in 2014 due to additional interest income driven by cash management activities to earn a higher yield. Investment income increased to $0.7 million in 2014, compared with $0.6 million in 2013 mainly due to higher average daily invested balances in 2014 than in 2013. Other Income, Net Other income for 2015 reflected income of $2.6 million, compared with $7.6 million in 2014 and $7.1 million in 2013. Other income in 2015 consisted primarily of legal settlements and also gains and loss on the sale and disposition of fixed assets. In 2014 and 2013, other income included legal settlements and gains and loss on the sale and disposition of fixed assets as well as gains and losses from the sale on books of business (customer accounts). Prior to the adoption of ASU No. 2014-08, "Reporting Discontinued Operations and Disclosures of Disposals of Components of an Entity" ("ASU 2014-08') in the fourth quarter of 2014, net gains and losses on the sale of businesses or customer accounts were reflected in other income. Any such gains or losses are now reflected on a net basis in the expense section since the adoption of ASU 2014-08. The $5.0 million change in 2015 other income from the comparable period in 2014 was primarily due to prior year book of business sales and to a lesser extent, the change to the presentation of this activity in the financial statements. We recog- nized gains of $0.6 million, $5.3 million and $3.1 million from sales on books of business (customer accounts) in 2015, 2014 and 2013, respectively. Employee Compensation and Benefits Employee compensation and benefits expense increased 6.3%, or $49.7 million, in 2015 over 2014. This increase included $25.8 million of compensation costs related to stand-alone acquisitions that had no comparable costs in the same period of 2014. Therefore. employee compensation and benefits expense attributable to those offices that existed in the same time periods of 2015 and 2014 increased by $23.9 million or 3.2%. This underlying employee compensation and benefits expense increase was primarily related to (i) an increase in producer and staff salaries as we made targeted investments in our business; (ii) increased profit center bonuses and commissions due to increased revenue and operating profit; and (iii) the increased cost of health insurance. Employee compensation and benefits expense as a percentage of total revenues was 50.7% for 2015 as compared to 50.2% for the year ended December 31, 2014. 35 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS Employee compensation and benefits expense increased, approximately 15.9% or $108.7 million in 2014 over 2013. However, that net increase included $81.0 million of compensation costs related to new acquisitions that were stand-alone offices. Therefore, employee compensation and benefits from those offices that existed in the same time periods of 2014 and 2013 increased by $27.7 million. The employee compensation and benefit increases from these offices were primarily related to increases in staff and management salaries of $13.8 million, new salaried producers of $4.8 million, profit center and other related bonuses of $6.7 million, compensation to our commissioned producers of $0.9 million and health insur- ance costs of $4.8 million. These increases were partially offset by net reductions in temporary employees, employer 401(k) plan matching contributions and accrued vacation expense. Employee compensation and benefits expense as a percentage of total revenues was 50.2% as compared to 50.1% for the year ended December 31, 2013. This slight increase was driven by continued investment in new teammates. Non -Cash Stock -Based Compensation The Company has an employee stock purchase plan, grants non -vested stock awards, and to a lesser extent grants stock options under other equity -based plans to its employees. Compensation expense for all share -based awards is recognized in the financial statements based upon the grant -date fair value of those awards. For 2015, 2014 and 2013, the non -cash stock -based compensation expense incorporated the costs related to each of the Company's four stock -based plans as explained in Note 11 of the Notes to the Consolidated Financial Statements. Non -cash stock -based compensation expense decreased $3.9 million, or 19.9% in 2015 over 2014. The decrease was the result of: ('s) older grants attaining the vesting requirements and therefore being fully expensed in prior periods: (ii) some forfeitures driven by certain grants not achieving all vesting requirements; and (iii) underlying participation levels; all of which were partially offset by the additional expense attributable to the new grants issued in 2015. Non -cash stock -based compensation expense decreased $3.2 million, or 14.3% in 2014 over 2013, primarily as a result of forfeitures due to the non -achievement of certain performance criteria, partially offset by an increase associated with new, non -vested stock awards granted on July 1, 2013 under our Stock Incentive Plan ("SIP"). Other Operating Expenses As a percentage of total revenues, other operating expenses represented 15.1% in 2015, 14.9% in 2014, and 14.4% in 2013. Other operating expenses in 2015 increased $15.7 million, or 6.7%, over 2014, of which $12.6 million was related to acquisitions that had no comparable costs in the same period of 2014. The other operating expenses for those offices that existed in the same periods in both 2015 and 2014, increased by $3.1 million or 1.3%, which was primarily attributable to increased sales meetings, legal and consulting expenses, partially offset by decreases in expenses associated with office rent, telecommunications and bank fees. Other operating expenses in 2014 increased $39.7 million, or 20.3%, over 2013, of which $39.0 million was related to acquisitions. Therefore, other operating expenses attributable to offices that existed in the same periods in both 2014 and 2013 (including the new acquisitions that "folded in" to those offices) increased by $0.7 million. The $0.7 million net increase includes increases of $2.0 million related to increased data processing and software licensing expense, $1.2 million related to increased inspection and consulting fees, $0.8 million related to office rent, and $0.9 million related to increased employee sales meeting costs, offset by decreases of $3.0 million for legal claims and litigation expenses, $1-0 million for insurance expenses, and $0.2 million in other various expense decreases. Gain or Loss on Disposal The Company recognized a gain on disposal of $0,6 million in 2015 and a loss on disposal of $47.4 million in 2014. The pretax loss for 2014 is the result of the disposal of the Axiom Re business as part of the Company's strategy to exit the reinsurance brokerage business. Prior to the adoption of ASU 2014-08 in the fourth quarter of 2014 as previously men- tioned, net gains and losses on the sale of businesses or customer accounts were reflected in other income. Although we are not in the business of selling customer accounts, we periodically sell an office or a book of business (one or more customer accounts) that we believe does not produce reasonable margins or demonstrate a potential for growth, or because doing so is in the Company's best interest. We recognized gains of $0.6 million, $5.3 million and $3.1 million from sales on books of business (customer accounts) in 2015, 2014 and 2013, respectively. Brown & Brown. nc. 36 Amortization Amortization expense increased $4.5 million, or 5.5%, in 2015, and increased $15.0 million, or 22.1%, in 2014. The increases were due primarily to the amortization of additional intangible assets as the result of acquisitions completed in those years. Depredation Depredation expense remained flat in 2015, and increased $3.4 million, or 19.5%, in 2014. The increase in 2014 was due primarily to the addition of fixed assets resulting from acquisitions completed since 2013, while the stable level of expense in 2015 versus 2014 reflected capital additions approximately equal to the value of prior additions that became fully depreciated. Interest Expense Interest expense increased $10.8 million, or 38.2%, in 2015, and $12.0 million, or 72.8% in 2014. These increases were primarily due to the increased debt borrowings and an increase in our effective rate of interest for the years ended 2015 and 2014. The increased debt borrowings from the prior year include: the Credit Facility term loan entered into in May 2014 in the initial amount of $550.0 million at LIBOR plus 137.5 basis points, and the $500.0 million Senior Notes due 2024 issued during September 2014 at a fixed rate of interest of 4.2%. The Credit Facility term loan proceeds replaced pre-exist- ing debt of $230,0 million with similar rates of interest. The proceeds from the Senior Notes due 2024 were used to settle the Credit Facility revolver debt of $375.0 million, which had a lower, but variable rate of interest based on an adjusted LIBOR. This transitioned the debt to a favorable long-term fixed rate of interest and extended the date of maturity of those funds. These changes were the result of an evolution and maturation of our previous debt structure and provide increased debt capacity and flexibility. Change in Estimated Acquisition Earn -Out Payables Accounting Standards Codification ("ASC") Topic 805 Business Combinations is the authoritative guidance requiring an acquirer to recognize 100% of the fair value of acquired assets, including goodwill, and assumed liabilities (with only limited exceptions) upon initially obtaining control of an acquired entity. Additionally, the fair value of contingent consideration arrangements (such as earn -out purchase price arrangements) at the acquisition date must be included in the purchase price consideration. As a result, the recorded purchase prices for all acquisitions consummated after January 1, 2009 include an estimation of the fair value of liabilities associated with any potential earn -out provisions. Subsequent changes in these earn -out obligations are required to be recorded in the Consolidated Statement of Income when incurred or reasonably estimated. Estimations of potential earn -out obligations are typically based upon future earnings of the acquired operations or entities, usually for periods ranging from one to three years. The net charge or credit to the Consolidated Statement of Income for the period is the combination of the net change in the estimated acquisition earn -out payables balance, and the interest expense imputed on the outstanding balance of the estimated acquisition earn -out payables. As of December 31, 2015, the fair values of the estimated acquisition earn -out payables were re-evaluated and meas- ured at fair value on a recurring basis using unobservable inputs (Level 3) as defined in ASC 820 — Fair Value Measurement. The resulting net changes, as well as the interest expense accretion on the estimated acquisition earn -out payables, for the years ended December 31, 2015, 2014, and 2013 were as follows: (in thousands) 2015 2014 2013 Change in fair value of estimated acquisition earn -out payables $ 2,990 $ 7,375 $ 570 Interest expense accretion 13 2,563 1.963 Net change in earnings from estimated acquisition earn -out payables $ 3,003 $ 9,938 $ 2,533 37 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS For the years ended December 31, 2015, 2014 and 2013, the fair value of estimated earn -out payables was re-evalu- ated and increased by $3.0 million, $7.4 million and $0.6 million, respectively, which resulted in charges to the Consolidated Statement of Income, As of December 31, 2015, the estimated acquisition earn -out payables equaled $78.4 million, of which $25.3 million was recorded as accounts payable and $53.1 million was recorded as other non -current liability. As of December 31, 2014, the estimated acquisition earn -out payables equaled $75.3 million, of which $26.0 million was recorded as accounts payable and $49.3 million was recorded as other non -current liability. Income Taxes The effective tax rate on income from operations was 39.6% in 2015, 39.1% in 2014, and 39.3% in 2013. The increased effective tax rate was largely the result of more income in states with a higher average effective state income tax rate, which was primarily New York State. Results of Operations — Segment Information As discussed in Note 15 of the Notes to Consolidated Financial Statements, we operate four reportable segments: Retail, National Programs, Wholesale Brokerage, and Services. On a segmented basis, increases in amortization, depreciation and interest expenses generally result from completed acquisitions within a given segment in a particular year. Likewise, other income in each segment reflects net gains primarily from legal settlements and miscellaneous income. As such, in evaluating the operational efficiency of a segment, management emphasizes the net internal growth rate of core commissions and fees revenue, the ratio of total employee compensation and benefits to total revenues, and the ratio of other operating expenses to total revenues. Segment results for prior periods have been recast to reflect the current year segmental structure. Certain reclassifica- tions have been made to the prior -year amounts reported in this Annual Report on Form 10-K in order to conform to the current year presentation. The internal growth rates for our core organic commissions and fees for the years ended December 31, 2015, 2014 and 2013 by Segment, areas follows: (in thousands, except percentages) For the Year Ended December 31, Less Internal Internal Total Net Total Net Acquisition Net Net 2015 2014 Change Growth % Revenues Growth $ Growth % Retail $ 836,123 $ 789,503 $ 46,620 5.9% $ 35,644 $ 10,976 1.4% National Programs 412,885 367,672 45,213 12.3% 38,519 6,694 1.8% Wholesale Brokerage 200,835 187,257 13,578 7.3% 2,469 11,109 5.9% Services 145,375 136,135 9,240 6.8% — 9.240 6.8% Total core commissions and fees $1,595,218 $1,480,567 $ 114,651 7.7 % $ 76,632 $ 38,019 2.6% 38 The reconciliation of the above internal growth schedule to the total commissions and fees included in the Consolidated Statement of Income for the years ended December 31, 2015, and 2014, is as follows: (in thousands) For the Year Ended December 31, 2015 2014 Total core commissions and fees Profit-sharing contingent commissions Guaranteed supplemental commissions Divested business $ 1,595,218 51,707 10,026 $ 1,480,567 57,706 9,851 19,336 Total commissions and fees $ 1,656,951 $ 1,567,460 (in thousands, except percentages) For the Year Ended December 31, Less Internal Internal Total Net Total Net Acquisition Net Net 2014 2013 change Growth % Revenues Growth $ Growth % Retail `1} $ 792,794 $ 701,211 $ 91,583 13.1% $ 77,315 $ 14,268 2.0% National Programs 376,483 277,082 99,401 35.9% 93,803 5,598 2,0% Wholesale Brokerage 194,144 177,725 16,419 9.2% 68 16,351 9.2% Services 136,482 131,502 4,980 3.8% 15,599 (10,619) (8.1) % Total core commissions and fees $ 1,499,903 $ 1,287,520 $ 212,383 16.5% $ 186,785 $ 25,598 2.0% Less Superstorm Sandy $ - $ (18,275) $ 18,275 100,0% $ - $ 18,275 100.0% Total core commissions and fees less Superstorm Sandy $ 1,499,903 $ 1,269,245 $ 230,658 18.2 % $ 186,785 $ 43,873 3.5% There would be a 3.5% Internal Net Growth rate when excluding the $18.3 million of revenues recorded at our Colonial Claims operation in the first half of 2013 related to Superstorm Sandy. The reconciliation of the above internal growth schedule to the total commissions and fees included in the Consolidated Statement of Income for the years ended December 31, 2014 and 2013, is as follows: (in thousands) For the Year Ended December 31, 2014 2013 Total core commissions and fees $ 1,499,903 $ 1,287,520 Profit-sharing contingent commissions 57,706 51,251 Guaranteed supplemental commissions 9,851 8,275 Divested business - 8,457 Total commissions and fees $ 1,567,460 $ 1,355,503 39 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS On thousands. except percentages) For the Year Ended December 31, Less Internal Internal Total Net Total Net Acquisition Net Net 2013 2012 Change Growth % Revenues Growth $ Growth % Retail'" $ 706,525 $ 619,057 $ 87,468 14.1% $ 79,455 $ 8,013 1.3% National Programs 280,695 240,550 40,145 16.7% 7,099 33,046 13.7% Wholesale Brokerage 177,725 152,961 24,764 16.2% 4,332 20.432 13.4% Services 131,032 116,247 14,785 12.7% 657 14.128 12.2% Total core commissions and fees $ 1,295,977 $ 1,128,815 $ 167,162 14.8% $ 91,543 $ 75,619 6.7% The reconciliation of the above internal growth schedule to the total commissions and fees included in the Consolidated Statement of Income for the years ended December 31, 2013 and 2012, is as follows: (in thousands) For the Year Ended December 31. 2013 2012 Total core commissions and fees $ 1.295,977 $ 1,128,815 Profit-sharing contingent commissions 51,251 43,683 Guaranteed supplemental commissions 8,275 9,146 Divested business — 7,437 Total commissions and fees $ 1,355,503 $ 1,189,081 (1)The Retail Segment includes commissions and fees reported in the "Other" column of the Segment information in Note 15 of the Notes to the Consolidated Financial Statements, which includes corporate and consolidation items. Brown & Brown. Inc. 40 Retail Segment The Retail Segment provides a broad range of insurance products and services to commercial, public and quasi -public, professional and individual insured customers. Approximately 87.0% of the Retail Segment's commissions and fees revenue is commission -based. Because most of our other operating expenses are not correlated to changes in commissions on insurance premiums, a significant portion of any fluctuation in the commissions we receive, net of related producer compen- sation, will result in a similar fluctuation in our income before income taxes, unless we make incremental investments in the organization. Financial information relating to our Retail Segment is as follows: (In thousands, except percentages} Percent Percent 2015 Change 2014 Change 2013 Revenues Core commissions and fees $ 837,420 5.5 % $ 793,865 12.2% $ 707,721 Profit-sharing contingent commissions 22,051 2.0 % 21,616 23.2% 17,544 Guaranteed supplemental commissions 8,291 7.3 % 7,730 12.9% 6,849 Investment income 87 29.9 % 67 (18.3)% 82 Other income, net 2,497 NMFm 408 (92.1)% 5,153 Total revenues 870,346 5.7 % 823,686 11.7% 737,349 Expenses Employee compensation and benefits 445,242 7.1 % 415,876 13.0% 368,164 Non -cash stock -based compensation 12,109 (25.7)% 16,293 58.5% 10,281 Other operating expenses 137,519 2.9 % 133,682 11.9% 119,489 Loss/(gain) on disposal (1,207) - % - -% - Amortization 45,145 5.1 % 42,935 11.5% 38,523 Depreciation 6,558 1.7 % 6,449 9.8% 5,874 Interest 41,036 (5.7)% 43,502 25.5% 34,658 Change in estimated acquisition earn -out payables 2,006 (73.1)% 7,458 NMFII} (1,427) Total expenses 688,408 3.3 % 666,195 15.7% 575,562 Income before income taxes $ 181,938 15.5 % $ 157,491 (2.7)% $ 161,787 Net internal growth rate -core organic commissions and fees Employee compensation and benefits ratio Other operating expenses ratio Capital expenditures Total assets at December 31 1.4% 51.2 % 15.8 % $ 6,797 $ 3,507,476 2.0 % 50.5 % 16.2 % $ 6,873 $ 3,229,484 1.3 % 49,9 % 16.2 % $ 6,886 $ 3,012,688 (1) NMF = Nat a meaningful figure 41 2015 ATIL.n Reuor: MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS The Retail Segment's total revenues in 2015 increased 5.7%, or $46.7 million, over the same period in 2014, to $870.3 million. The $43.6 million increase in core commissions and fees revenue was driven by the following: (i) approxi- mately $35.6 million related to the core commissions and fees revenue from acquisitions that had no comparable revenues in the same period of 2014; (ii) $11.0 million related to net new business; and (iii) an offsetting decrease of $3.0 million related to commissions and fees revenue from business divested in 2014 and 2015. Profit-sharing contingent commissions and GSCs in 2015 increased 3.4%, or $1.0 million, over 2014, to $30.3 million. The Retail Segment's internal growth rate for core organic commissions and fees revenue was 1.4% for 2015 and was driven by revenue from net new business written during the preceding twelve months along with modest increases in commercial auto rates, and partially offset by: (i) termi- nated association health plans in the State of Washington; (ii) continued pressure on the small employee benefits business as some accounts adopt alternative plan designs and move to a per employee/per month payment model due to the imple- mentation of the Affordable Care Act; and (iii) reductions in property insurance premium rates specifically in catastrophe -prone areas. Income before income taxes for 2015, increased 15,5%, or $24.4 million, over the same period in 2014, to $181.9 million. The primary factors affecting this increase were: (i) the net increase in revenue as described above; (ii) a 7.1%, or $29.4 million increase in employee compensation and benefits due primarily to the year -on -year impact of new teammates related to acquisitions completed in the past twelve months in addition to incremental investments in revenue producing teammates; (iii) operating expenses which increased by $3.8 million or 2.9%, due to increased travel and value added consulting services; offset by (iv) a reduction in the change in estimated acquisition earn -out payables of $5.5 million, or 73.1% to $2.0 million; and (v) a $4.2 million, or 25.7% reduction in non -cash stock -based compensation to $12.1 million due to the forfeiture of certain grants where performance conditions were not fully achieved. The Retail Segment's total revenues in 2014, increased 11.7%, or $86.3 million, over the same period in 2013, to $823.7 million. Profit-sharing contingent commissions and GSCs in 2014 increased 20.3%, or $5.0 million, over 2013, to $29.3 million, primarily due to improved loss ratios resulting in increased profitability for insurance companies in 2013.The $86.1 million increase in core commissions and fees revenue was driven by the following: (i) approximately $77.3 million related to the core commissions and fees revenue from acquisitions that had no comparable revenues in the same period of 2013; (ii) $14.3 million related to net new business; and (iii) an offsetting decrease of $5.5 million related to commissions and fees revenue recorded from business divested in the last year. The Retail Segment's internal growth rate for core organic commissions and fees revenue was 2.0% for 2014, and was driven by net new customers, increasing insurable exposure units in certain areas of the United States, and was partially offset by continued pressure on property and casualty rates, especially in coastal areas. Income before income taxes for 2014, decreased 2.7%, or $4.3 million, over the same period in 2013, to $157.5 million. This decrease was primarily due to a higher interest charge of $8.8 million corresponding to capital utilized for acquisitions in 2014 and $8.9 million related to the year -on -year changes in the estimated earn -out payable. The underlying increase was driven by net new business, acquired business and increased profit-sharing contingent commissions and GSCs. Non - cash stock -based compensation increased $6.0 million, or 58.5%, for 2014 over the same period in 2013, as the cost of grants to employees for the purpose of driving performance were realized. Brown cc, Brown, Inc. 42 National Programs Segment The National Programs Segment manages over 50 programs with approximately 40 well -capitalized carrier partners. In most cases, the insurance carriers that support the programs have delegated underwriting and, in many instances, claims - handling authority to our programs operations. These programs are generally distributed through a nationwide network of independent agents and Brown & Brown retail agents, and offer targeted products and services designed for specific industries, trade groups, professions, public entities and market niches. The National Programs Segment operations can be grouped into five broad categories: Professional Programs, Arrowhead Insurance Programs, Commercial Programs, Public Entity -Related Programs and the National Flood Program. The National Programs Segment's revenue is primarily commis- sion -based. Financial information relating to our National Programs Segment is as follows: (in thousands, except percentages) Percent Percent 2015 Change 2014 Change 2013 Revenues Core commissions and fees $ 412,885 9.7 % $ 376,483 34.1% $ 280,695 Profit-sharing contingent commissions 15,558 (25.3)% 20,822 6.3% 19,590 Guaranteed supplemental commissions 30 42.9 % 21 NMF'1 (23) Investment income 210 28.0 % 164 NMFt1' 19 Other income, net 51 (99,2)% 6,749 NMF0) 1,091 Total revenues 428,734 6.1 % 404,239 34.1% 301,372 Expenses Employee compensation and benefits 178,185 6.1 % 168,018 22.9% 136,748 Non -cash stock -based compensation 4,669 NMF01 1,387 (72,6)% 5,060 Other operating expenses 86,157 9.4 % 78,744 44.0% 54,690 Loss/(gain) on disposal 458 - % - -% Amortization 28,479 13.3 % 25,129 68.1% 14,953 Depreciation 7,250 (7.1)% 7,805 42.1% 5,492 Interest 55,705 12.2 % 49,663 106.8% 24,014 Change in estimated acquisition earn -out payables 158 {49.8)% 315 (139.0)% (808) Total expenses 361,061 9.1 % 331,061 37.9% 240,149 Income before income taxes $ 67,673 (7.5)% $ 73,178 19.5% $ 61,223 Net internal growth rate -core organic commissions and fees Employee compensation and benefits ratio Other operating expenses ratio Capital expenditures Total assets at December 31 1.8 % 41.6 % 20.1% $ 6,001 $ 2,505,752 2.0 % 41.6 % 19.5 % $ 14,133 $ 2,455,749 13.7 % 45.4 % 18.1 % $ 4,810 $ 1,377,404 (1) NMF = Not a meaningful figure 43 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL. CONDITION AND RESULTS OF OPERATIONS National Programs total revenues in 2015, increased 6.1%, or $24.5 million, over 2014, to a total $428.7 million. The $36.4 million increase in core commissions and fees revenue was driven by the following: (i) an increase of approximately $38.5 million related to core commissions and fees revenue from acquisitions that had no comparable revenues in 2014; (ii) $6.7 million related to net new business offset by (iii) a decrease of $8,8 million related to commissions and fees revenue recorded in 2014 from businesses since divested. Profit-sharing contingent commissions and GSCs were $15.6 million in 2015 which was a decrease of $5.3 million over 2014, which was primarily driven by the loss experience of our carrier partners. The National Programs Segment's internal growth rate for core commissions and fees revenue was 1.8% for 2015. This internal growth rate was mainly due to the Arrowhead Personal Property program, which continued to produce more written premium, the Arrowhead Automotive Aftermarket program which received a commission rate increase from their carrier partner, growth in our Wright Specialty education program and the on -boarding of new clients by Proctor Financial. Growth in these businesses was partially offset by certain programs that have been affected by lower rates. Income before income taxes for 2015, decreased 7.5%, or $5.5 million, from the same period in 2014, to $67.7 million. The decrease is the result of the $6.0 million gain on the sale of Industry Consulting Group ("ICG"), along with the $3.7 million SIP grant forfeiture benefit associated with Arrowhead, which were both credits recorded in 2014. After adjusting for these one-time items in 2014, underlying income before income taxes increased and was driven by the net revenue growth noted above and expense management initiatives as we grow and scale our programs. The National Programs Segment's total revenues in 2014, increased 34.1%, or $102.9 million, over 2013, to a total of $404.2 million, The $95.8 million increase in core commissions and fees revenue was driven by the following: (i) approxi- mately $93.8 million related to the core commissions and fees revenue from the Wright and Beecher Carlson acquisitions that had no comparable revenues in 2013; (ii) $5.6 million related to net new business; and (iii) an offsetting decrease of $3.6 million in books of business that were disposed or transferred to other segments. Profit-sharing contingent commis- sions and GSCs were $20.8 million in 2014 which was an increase of $1,3 million from the same period of 2013. This increase was due primarily to a $0.5 million increase in profit-sharing contingent commissions received by Florida Intracoastal Underwriters, Limited Company, and a $0.8 million increase in profit-sharing contingent commissions received by Proctor Financial, inc. Other income increased by approximately $5.7 million primarily due to the gain recognized on the sale of Industry Consulting Group, Inc. ("ICG") of $6.0 million. Income before income taxes for 2014, increased 19.5%, or $12.0 million, from the same period in 2013, to $73.2 million. The increase in income before taxes was due to net new business growth noted above, revenues and operating profits derived from Wright, the gain on the sale of ICG, and a non -cash stock -based compensation decrease of $3.7 million primarily related to partial SIP grant forfeitures associated with Arrowhead. The $12.0 million increase was partially offset by an increase in the inter -company interest expense charge related to Wright. Brown & Brown, Inc. 44 Wholesale Brokerage Segment The Wholesale Brokerage Segment markets and sells excess and surplus commercial and personal lines insurance, primarily through independent agents and brokers. Like the Retail and National Programs Segments, the Wholesale Brokerage Segment's revenues are primarily commission -based. Financial information relating to our Wholesale Brokerage Segment is as follows: (in thousands, except percentages) Percent Percent 2015 Change 2014 Change 2013 Revenues Core commissions and fees $ 200,835 3.4 % $ 194,144 9.2% $ 177,725 Profit-sharing contingent commissions 14,098 (7.7)% 15,268 8.2% 14,117 Guaranteed supplemental commissions 1,705 (18.8)% 2,100 44.9% 1,449 Investment income 150 NMF"" 26 18.2% 22 Other income, net 208 (44.2)% 373 (6.0)% 397 Total revenues 216,996 2.4% 211,911 9.4% 193,710 Expenses Employee compensation and benefits 101,590 1.7 % 99,918 9.3% 91,449 Non -cash stock -based compensation 3,102 2.0 % 3.041 32.5 % 2,295 Other operating expenses 34,379 (5.1)% 36,234 4.2 % 34,770 Loss/(gain) on disposal (385) NMP'' 47,425 -% - Amortization 9,739 (9.0)% 10,703 (0.1)% 10,719 Depreciation 2,142 (13.3)% 2,470 (7.6)% 2,674 Interest 891 (31.1)% 1,294 (44.1)% 2,316 Change in estimated acquisition earn -out payables 830 (67.5)% 2,550 28.4% 1,986 Total expenses 152,288 (25.2)% 203,635 39.3% 146,209 Income before income taxes $ 64,708 NMFm $ 8,276 (82.6)% $ 47,501 Net internal growth rate -core organic commissions and fees Employee compensation and benefits ratio Other operating expenses ratio Capital expenditures Total assets at December 31 5.9 % 46.8 % 15.8 % $ 3,084 $ 895,782 9.2 % 47.2 % 17.1 % $ 1,526 $ 857,804 13.4 % 47,2 % 17.9 % $ 1,825 $ 865,731 (1) NMF = Not a meaningful figure 45 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS The Wholesale Brokerage Segment's total revenues for 2015, increased 2.4%, or $5.1 million, over 2014, to $217.0 mil- lion. The $6.7 million net increase in core commissions and fees revenue was driven by the following: (i) $11.1 million related to net new business; (ii) $2.5 million related to the core commissions and fees revenue from acquisitions that had no compara- ble revenues in 2014; and (iii) an offsetting decrease of $6.9 million related to commissions and fees revenue recorded in 2014 from businesses divested in the past year. Contingent commissions and GSCs for 2015 decreased $1.6 million over 2014, to $15.8 million. This decrease was driven by an increase in loss ratios. The Wholesale Brokerage Segment's internal growth rate for core organic commissions and fees revenue was 5.9% for 2015, and was driven by net new business and modest increases in exposure units, partially offset by significant contraction in insurance premium rates for catastrophe - prone properties. Income before income taxes for 2015 increased $56.4 million over 2014, to $64.7 million, primarily due to the follow- ing; (i) the $47.4 million net pretax loss on disposal of the Axiom Re business in 2014; (ii) the net increase in revenue as described above and (iii) the impact of the Axiom Re business divested in 2014 that reported lower margins than the Wholesale Brokerage Segment's average. The Wholesale Brokerage Segment's total revenues for 2014, increased 9.4%, or $18.2 million, over 2013, to $211.9 mil- lion. Profit-sharing contingent commissions and GSCs for 2014 increased $1.8 million over 2013, to $17.4 million. The $16.4 million net increase in core commissions and fees revenue was driven by the following; (i) $16.4 million related to net new business; (ii) $0.1 million related to the core commissions and fees revenue from acquisitions that had no comparable revenues in 2013; and (iii) an offsetting decrease of $0.1 million related to commissions and fees revenue recorded in 2013 from businesses divested in the past year. As such, the Wholesale Brokerage Segment's internal growth rate for core organic commissions and fees revenue was 9.2% for 2014. Income before income taxes for 2014, decreased 82.6%, or $39.2 million, over 2013, to $8.3 million. This decrease included a $47.4 million net loss on the disposal of the Axiom Re business. Effective December 31, 2014, the Company sold certain assets of the Axiom Re business as part of the strategic plan to exit the reinsurance brokerage market. Axiom Re had annual revenues of approximately $6.9 million in 2014. The underlying performance of this segment was driven by new business growth and to a lesser extent an increase in profit-sharing contingent commissions. Brown & Brown, Inc. 46 Services Segment The Services Segment provides insurance -related services, including third -party claims administration and comprehensive medical utilization management services in both the workers' compensation and all -lines liability arenas. The Services Segment also provides Medicare Set -aside account services, Social Security disability and Medicare benefits advocacy services, and claims adjusting services. Unlike the other segments, nearly all of the Services Segment's revenue is generated from fees, which are not signifi- cantly affected by fluctuations in general insurance premiums. Financial information relating to our Services Segment is as follows: Percent Percent (in thousands, except percentages) 2015 Change 2014 Change 2013 Revenues Core commissions and fees $ 145,375 6.5 % $ 136,482 4.2% $ 131,032 Profit-sharing contingent commissions - - % - -% - Guaranteed supplemental commissions - % - -% - Investment income 42 NMF" 3 200.0% 1 Other income, net (52) NMF" 73 (84.0)% 456 Total revenues 145,365 6.4 % 136,558 3.9% 131,489 Expenses Employee compensation and benefits 76,249 5.1 % 72,583 18.6% 61,193 Non -cash stock -based compensation 845 185.5 % 296 (71.2)% 1,027 Other operating expenses 36,057 12.1 % 32,168 14.7% 28,053 Loss/(gain) on disposal 515 % - -% Amortization 4,019 (2.8)% 4,135 11.8% 3,698 Depreciation 1,988 (10.2)% 2,213 36.4% 1,623 Interest 5,970 (22.2)% 7,678 4.9% 7,322 Change in estimated acquisition earn -out payables 9 (102.3)% (385) (113.8)% 2,782 Total expenses 125,652 5.9 % 118,688 12.3% 105,698 Income before income taxes $ 19,713 10.3 % $ 17,870 (30.7)% $ 25,791 Net internal growth rate -core organic commissions and fees Employee compensation and benefits ratio Other operating expenses ratio Capital expenditures Total assets at December 31 6.8 % 52.5 % 24.8 % $ 1,088 $ 285,459 (8.1)% 53.2 % 23.6 % $ 1,210 $ 296,034 12.2 % 46.5 % 21.3 % $ 1,811 $ 277,652 (1) NMF = Not a meaningful figure The Services Segment's total revenues for 2015 increased 6.4%, or $8.8 million, over 2014, to $145.4 million. The $8,9 million increase in core commissions and fees revenue primarily resulted from growth in our advocacy businesses driven by new clients and growth in several of our claims processing units related to new client relationships. The Services Segment's internal growth rate for core commissions and fees revenue was 6.8% for 2015. 47 2015 Annual Report MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS Income before income taxes for 2015 increased 10.3%. or $1.8 million, over 2014, to $19.7 million due to a combina- tion of: (i) internal revenue growth noted above; (ii) the continued efficient operation of our businesses; and (ill) a decrease in the intercompany interest expense charge. The impact from the sale of the Colonial Claims business on 2015 revenues and income before income taxes was immaterial, The Services Segment's total revenues for 2014 increased 3.9%, or $5.1 million, over 2013, to $136.6 million. The $5.5 million increase in core commissions and fees revenue consisted of the following: (i) an increase of approximately $15.6 million related to the core commissions and fees revenue from the acquisition of ICA, that had no comparable revenues in the same period of 2013; (ii) net new business of $7.7 million; (iii) offset by a reduction of $18.3 million due to the significant flood claims processed in 2013 resulting from Superstorm Sandy in 2012 with no comparable storm in 2013 and (iv) $0.4 million of net sold books of business. As such, the Services Segment's internal growth rate for core commis- sions and fees revenue was (8.1)% for 2014 and excluding the impact of Superstorm Sandy internal growth would have been 6.8% in 2014. Income before income taxes for 2014 decreased 30.7%, or $7.9 million, over the same period in 2013, to $17.9 million due to the reduction in Superstorm Sandy related revenues and corresponding operating profit partially offset by the increase associated with net new and acquired business. Other As discussed in Note 15 of the Notes to Consolidated Financial Statements, the "Other" column in the Segment Information table includes any income and expenses not allocated to reportable segments, and corporate -related items, including the inter -company interest expense charges to reporting segments. Liquidity and Capital Resources The Company strives to maintain a conservative balance sheet and liquidity profile. Our capital requirements to operate as an insurance intermediary are low and we have been able to grow and invest in our business principally through cash that has been generated from operations. We have the ability to access the use of our revolving credit facilities, which provide up to $825.0 million in available cash, and we believe that we have access to additional funds, if needed, through the capital markets to obtain further debt financing under the current market conditions. The Company believes that its existing cash, cash equivalents, short-term investment portfolio and funds generated from operations, together with the funds available under the credit facilities, will be sufficient to satisfy our normal liquidity needs. including principal payments on our long-term debt, for at least the next twelve months. Our cash and cash equivalents of $443.4 million at December 31, 2015 reflected a decrease of $26.6 million from the $470.0 million balance at December 31, 2014. During 2015, $411.8 million of cash was generated from operating activities. During this period, $136.0 million of cash was used for acquisitions, $25.4 million was used for acquisition earn -out payments, $18.4 million was used for additions to fixed assets, $64.1 million was used for payment of dividends, $175.0 million was used as part of accelerated share repurchase programs, and $45.6 million was used to pay outstanding principal balances owed on long-term debt. We hold approximately $17.2 million in cash outside of the U.S. for which we have no plans to repatriate in the near future. Our cash and cash equivalents of $470.0 million at December 31, 2014 reflected an increase of $267.1 million from the $203.0 million balance at December 31, 2013. During 2014. $385.0 million of cash was generated from operating activities. During this period, $696.5 million of cash was used for acquisitions, $9.5 million was used for acquisition earn -out payments, $24.9 million was used for additions to fixed assets, $59.3 million was used for payment of dividends, and $718,0 million was provided from proceeds received on net new long-term debt. Brown & Brown, Inc. 48 On May 1, 2014, we completed the acquisition of Wright for a total cash purchase price of $609.2 million, subject to certain adjustments. We financed the acquisition through various modified and new credit facilities. Our cash and cash equivalents of $203.0 million at December 31, 2013 reflected a decrease of $16.9 million from the $219.8 million balance at December 31, 2012. During 2013, $389.4 million of cash was generated from operating activities. During this period, $367.7 million of cash was used for acquisitions, $15.5 million was used for acquisition earn -out payments, $16.4 million was used for additions to fixed assets, $53.5 million was used for payment of dividends, and $30.0 million was provided from proceeds received on new long-term debt. On July 1, 2013, we completed the acquisition of Beecher Carlson for a total cash purchase price of $364.2 million, subject to certain adjustments. We financed the acquisition through various modified and new credit facilities. Our ratio of current assets to current liabilities (the "current ratio") was 1.16 and 1.24 at December 31, 2015 and 2014, respectively. Contractual Cash Obligations As of December 31, 2015, our contractual cash obligations were as follows: Payments Due by Period Less Than (in thousands) Total 1 Year 1-3 Years 4-5 Years After 5 Years Long-term debt $ 1,154,375 $ 73,125 $ 210,000 $ 371,250 $ 500,000 Other liabilities'=60,516 20,065 15,794 1,098 23,559 Operating leases 195,272 40,900 68,721 47,245 38,406 Interest obligations 227,332 37,182 67,343 44,932 77,875 Unrecognized tax benefits 584 — 584 — — Maximum future acquisition contingency payments'' 137,365 34,467 85,815 17,083 Total contractual cash obligations $1,775,444 $ 205,739 $ 448,257 $ 481,608 $ 639,840 (1 )lncludes the current portion of other long-term liabilities. (2) Includes $78.4 million of current and non -current estimated earn -out payables resulting from acquisitions consummated after January 1.2009. Debt Total debt at December 31, 2015 was $1,153.0 million, which was a decrease of $45.5 million compared to December 31, 2014. This decrease was primarily due to the repayments of $45.6 million in principal payments, and the amortization of discounted debt related to our 4.20% Notes due 2024, of $0.1 million. On January 15, 2015, the Company retired the Series D senior notes of $25.0 million that matured and were issued under the original private placement note agreement from December 2006. As of December 31, 2015, the Company satisfied the third installment of scheduled quarterly principal payments on the Credit Facility term loan- Each installment equaled $6.9 million. The Company has satisfied $20.6 million in total principal payments through December 31, 2015. Scheduled quarterly principal payments are expected to be made until maturity. The balance of the Credit Facility term loan is $529.4 million as of December 31, 2015.Of the total amount, $48.1 million is classified as short-term debt and current portion of long-term debt in the Consolidated Balance Sheet as the date of maturity is less than one year representing the quarterly debt payments due in 2016. During 2015, the $25.0 million of 5.66% Notes due December 2016 were classified as short-term debt and current portion of long-term debt in the Consolidated Balance Sheet as the date of maturity is less than one year. 49 11'0 0 Ann,..1 e cr; MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS Off -Balance Sheet Arrangements Neither we nor our subsidiaries have ever incurred off -balance sheet obligations through the use of, or investment in, off -balance sheet derivative financial instruments or structured finance or special purpose entities organized as corpora- tions, partnerships or limited liability companies or trusts. For further discussion of our cash management and risk management policies, see "Quantitative and Qualitative Disclosures About Market Risk." Quantitative and Qualitative Disclosures About Market Risk Market risk is the potential loss arising from adverse changes in market rates and prices, such as interest rates, foreign exchange rates and equity prices. We are exposed to market risk through our investments, revolving credit line, term loan agreements and international operations. Our invested assets are held primarily as cash and cash equivalents, restricted cash, available -for -sale marketable debt securities, non -marketable debt securities, certificates of deposit, U.S. treasury securities, and professionally managed short duration fixed income funds. These investments are subject to interest rate risk. The fair values of our invested assets at December 31, 2015 and December 31, 2014, approximated their respective carrying values due to their short-term duration and therefore, such market risk is not considered to be material. We do not actively invest or trade in equity securities. In addition, we generally dispose of any significant equity securities received in conjunction with an acquisition shortly after the acquisition date. As of December 31, 2015 we had $529.4 million of borrowings outstanding under our term loan which bears interest on a floating basis tied to the London Interbank Offered Rate (LIBOR) and therefore subject to changes in the associated interest expense. The effect of an immediate hypothetical 10% change in interest rates would not have a material effect on our Consolidated Financial Statements. We are subject to exchange rate risk primarily in our U.K based wholesale brokerage business that has a cost base principally denominated in British pounds and a revenue base in several other currencies, but principally in U.S. dollars. Based on our foreign currency rate exposure as of December 31, 2015, an immediate 10% hypothetical changes of foreign currency exchange rates would not have a material effect on our Consolidated Financial Statements. Brown & Brown, Inc. 50 CONSOLIDATED STATEMENTS OF INCOME (in thousands, except per share data) Year Ended December 31, 2015 2014 2013 Revenues Commissions and fees Investment income Other income, net $ 1,656,951 $ 1,567,460 $ 1,355,503 1,004 747 638 2,554 7,589 7,138 Tatalrevenues 1,660,509 1,5 75,796 1,363,279 Expenses Employee compensation and benefits 841,439 791,749 Non -cash stock -based compensation 15,513 19,363 Other operating expenses 251,055 235,328 Loss/(gain) on disposal (619) 47,425 Amortization 87,421 82,941 Depreciation 20,890 20,895 Interest 39,248 28,408 Change in estimated acquisition earn -out payables 3,003 9,938 683,000 22,603 195,677 67,932 17,485 16,440 2,533 Total expenses 1,257,950 1,236,047 1,005,670 Income before income taxes Income taxes 402,559 339,749 357,609 159,241 132,853 140,497 Net income $ 243,318 $ 206,896 $ 217,112 Net income per share, Basic $ 1.72 $ 1.43 $ 1.50 Diluted $ 1.70 $ 1.41 $ 1.48 Dividends declared per share $ 0.45 $ 0.41 $ 0.37 See accompanying notes to Consolidated Financial Statements. 51 2015 Annual Report CONSOLIDATED BALANCE SHEETS (In thousands, except per share datal December 31. De cember 31. 2015 2014 Assets Current Assets: Cash and cash equivalents Restricted cash and investments Short-term investments Premiums, commissions and fees receivable Reinsurance recoverable Prepaid reinsurance premiums Deferred income taxes Other current assets $ 443,420 $ 470,048 229,753 259,769 13,734 11.157 433,885 424,547 31,968 13,028 309,643 320,586 24,635 25,431 50,351 45,542 Total current assets 1,537,389 1,570,108 Fixed assets, net 81,753 84,668 Goodwill 2,586,683 2,460,611 Amortizable intangible assets, net 744,680 784,642 Investments 18,092 19,862 Other assets 44,142 36,567 Total assets $ 5,012,739 $ 4,956,458 Liabilities And Shareholders' Equity Current Liabilities: Premiums payable to insurance companies $ 574,736 $ 568,184 Losses and loss adjustment reserve 31,968 13,028 Unearned premiums 309,643 320,586 Premium deposits and credits due customers 83,098 83,313 Accounts payable 63,910 57,261 Accrued expenses and other liabilities 192,067 181,156 Current portion of long-term debt 73,125 45,625 Total current liabilities 1,328,547 1,269,153 Long-term debt 1,079,878 1,152,846 Deferred income taxes, net 360,949 341,497 Other liabilities 93,589 79,217 Commitments and contingencies (Note 13) Shareholders' Equity: Common stock, par value $0.10 per share; authorized 280,000 shares: issued 146,415 shares and outstanding 138,985 shares at 2015, issued 145,871 shares and outstanding 143,486 shares at 2014 14,642 14,587 Additional paid -in capital 426,498 405,982 Treasury stock, at cost 7,430 and 2,385 shares at 2015 and 2014, respectively (238,775) (75,025) Retained earnings 1,947,411 1,768,201 Total shareholders' equity 2,149,776 2,113,745 Total liabilities and shareholders' equity $ 5,012,739 $ 4,956,458 See accompanying notes to Consolidated Financial Statements. Brown & Brown, Inc. 52 CONSOLIDATED STATEMENTS OF SHAREHOLDERS' EQUITY Common Stock Additional Par Paid -In Treasurg Retained (in thousands, except per share data) Shares Value Capital Stock Earnings Total Balance at January 1, 2013 143,878 $ 14,388 $ 335,872 $ - $ 1,457,073 $ 1,807,333 Net income 217,112 217,112 Common stock issued for employee stock benefit plans 1,541 154 33,730 33,884 Income tax benefit from exercise of stock benefit plans 2,358 2,358 Cash dividends paid ($0.37 per share) (53,546) (53,546) Balance at December 31, 2013 145,419 14,542 371,960 - 1,620,639 2,007,141 Net income Common stock issued for employee stock benefit plans 442 44 30,405 30,449 Purchase of treasury stock (75,025) (75,025) Income tax benefit from exercise of stock benefit plans 3,298 3,298 Common stock issued to directors 10 1 319 320 Cash dividends paid ($0.41 per share) (59,334) (59,334) Balance at December 31, 2014 145,871 14,587 405,982 (75,025) 1,768,201 2,113,745 206,896 206,896 Net income 243,318 243,318 Common stock issued for employee stock benefit plans 528 53 27,992 28,045 Purchase of treasury stock (11,250) (163,750) (175,000) Income tax benefit from exercise of stock benefit plans 3,276 3,276 Common stock issued to directors 16 2 498 500 Cash dividends paid ($0.45 per share) (64,108) (64,108) Balance at December 31, 2015 146,415 $ 14,642 $ 426,498 $ (238,775) $ 1,947,411 $ 2,149,776 See accompanying notes to Consolidated Financial Statements. 53 2015 Annual Report CONSOLIDATED STATEMENTS OF CASH FLOWS (in thousands) Year Ended December 31, 201S 2014 2013 Cash flows from operating activities: Net income Adjustments to reconcile net income to net cash provided by operating activities: Amortization Depreciation Non -cash stock -based compensation Change in estimated acquisition earn -out payables Deferred income taxes Amortization of debt discount Income tax benefit from exercise of shares from the stock benefit plans (Gain)/loss on sales of investments. fixed assets and customer accounts Payments on acquisition earn -outs in excess of original estimated payables Changes in operating assets and liabilities. net of effect from acquisitions and divestitures: Restricted cash and investments decrease (increase) Premiums, commissions and fees receivable (increase) Reinsurance recoverables (increase) decrease Prepaid reinsurance premiums decrease (increase) Other assets (increase) Premiums payable to insurance companies decrease Premium deposits and credits due customers (decrease) increase Losses and loss adjustment reserve increase (decrease) Unearned premiums (decrease) increase Accounts payable increase Accrued expenses and other liabilities increase Other liabilities (decrease) $ 243,318 87,421 20,890 15,513 3,003 22,696 157 (3.276) (107) (11,383) 30.016 (7,163) (18,940) 10,943 (5,318) 542 (2,973) 18,940 (10,943) 34,206 8.204 (23,898) $ 206.896 $ 217,112 82.941 67.932 20,895 17,485 19,363 22,603 9,938 2,533 7,369 32,247 46 - (3.298) (2,358) 42.465 (2,806) (2,539) (2,788) (9,760) (11,160) 12,210 (31,573) (12,564) 8,164 2,323 (12.210) 31,573 36,949 11,718 (24,727) (85,445) (40.729) {2,583) 61,624 41,049 5,180 70,872 (12,554) Net cash provided by operating activities 411,848 385,019 389,374 Cash flows from investing activities: Additions to fixed assets Payments for businesses acquired, net of cash acquired Proceeds from sales of fixed assets and customer accounts Purchases of investments Proceeds from sales of investments (18,375) (136,000) 10,576 (22,766) 21,928 (24,923) (696.486) 13.631 (17,813) 18,278 (16,366) (367712) 5,886 (18,102) 15,662 Net cash used in investing activities (144,637) (707,313) (380,632) Cash flows from financing activities: Payments on acquisition earn -outs Proceeds from long-term debt Payments on long-term debt Borrowings on revolving credit facilities Payments on revolving credit facilities Income tax benefit from exercise of shares from the stock benefit plans Issuances of common stock for employee stock benefit plans Repurchase of stock benefit plan shares for employees to fund tax withholdings Purchase of treasury stock Prepayment of accelerated share repurchase program Cash dividends paid (25,415) (45,625) 3,276 15,890 (2,857) (163.750) (11,250) (64,108) (9,530) 1,048,425 (330,000) 475.000 (475.000) 3.298 14.808 (3.252) (75,025) (59.334) (15,491) 30,000 (93) 31,863 (31,863) 2,358 12,445 (1,284) (53,546) Net cash (used in) provided by financing activities (293,839) 589,390 (25,611) Net (decrease) increase in cash and cash equivalents Cash and cash equivalents at beginning of period (26,628) 470,048 267,096 202,952 (16,869) 219,821 Cash and cash equivalents at end of period $ 443,420 470,048 $ 202,952 See accompanying notes to Consolidated Financial Statements. Brown & Brown. Inc. 54 NOTES TO CONSOLIDATED FINANCIAL STATEMENTS NOTE 1 Summary of Significant Accounting Policies Nature of Operations Brown & Brown, Inc., a Florida corporation, and its subsidiaries (collectively, "Brown & Brown' or the "Company") is a diversified insurance agency, wholesale brokerage, insurance programs and services organization that markets and sells to its customers, insurance products and services, primarily in the property and casualty area. Brown & Brown's business is divided into four reportable segments: the Retail Segment provides a broad range of insurance products and services to commercial, public entity, professional and individual customers; the National Programs Segment, acting as a managing general agent (°'MGA"), provides professional liability and related package products for certain professionals, a range of insurance products for individuals, flood coverage, and targeted products and services designated for specific industries, trade groups, governmental entities and market niches, all of which are delivered through nationwide networks of indepen- dent agents, and Brown & Brown retail agents; the Wholesale Brokerage Segment markets and sells excess and surplus commercial insurance, primarily through independent agents and brokers, as well as Brown & Brown Retail offices; and the Services Segment provides insurance -related services, including third -party claims administration and comprehensive medical utilization management services in both the workers' compensation and all -lines liability arenas, as well as Medicare Set -aside services, Social Security disability and Medicare benefits advocacy services, and claims adjusting services. In addition, as the result of our acquisition of The Wright Insurance Group, LLC ("Wright") in May 2014, we own a flood insurance carrier, Wright National Flood Insurance Company ("Wright Flood"), that is a Wright subsidiary. Wright Flood's business consists of policies written pursuant to the National Flood Insurance Program, the program administered by the Federal Emergency Management Agency ("FEMA'), and several excess flood insurance policies, all of which are fully reinsured. Recently Issued Accounting Pronouncements In February 2016, the Financial Accounting Standards Board ("FASB") issued Accounting Standards Update ("ASU") 2016-02, "Leases (Topic 842)" (°`ASU 2016-02"), which provides guidance for accounting for leases. Under ASU 2016-02, the Company will be required to recognize the assets and liabilities for the rights and obligations created by leased assets. ASU 2016-02 will take effect for public companies for fiscal years, and interim periods within those fiscal years, beginning after December 15, 2018. The Company is currently evaluating its leases against the requirements of this pronouncement. In November 2015, FASB issued ASU No. 2015-17,"Income Taxes (Topic 740)—Balance Sheet Classification of Deferred Taxes" ("ASU 2015-17"), which simplifies the presentation of deferred income taxes by requiring deferred tax assets and liabilities be classified as a single non -current item on the balance sheet. ASU 2015-17 is effective for fiscal years beginning after December 15, 2016 with early adoption permitted as of the beginning of any interim or annual reporting period. The Company plans to adopt ASU 2015-17 in the first quarter of 2017. This is not expected to have a material impact on our Consolidated Financial Statements other than reclassifying current deferred tax assets and liabilities to non -current in the balance sheet. In September 2015, FASB issued ASU No. 2015-16, "Business Combinations (Topic 805): Simplifying the Accounting for Measurement -Period Adjustments" ("ASU 2015-16"), which requires that an acquirer recognize adjustments to provi- sional amounts that are identified during the measurement period in the reporting period in which the adjustment amounts are determined. ASU 2015-16 is effective for fiscal years, and interim reporting periods within those fiscal years, beginning after December 15, 2015. The Company has determined that the impact of the adoption of this guidance on the Consolidated Financial Statements would not be material. In August 2015, FASB issued ASU No. 2015-15, "Interest -Imputation of Interest (Subtopic 835-30): Presentation and Subsequent Measurement of Debt Issuance Costs Associated with Line -of -Credit Arrangements" This standard is in addition to ASU No. 2015-03 and adds SEC paragraphs pursuant to an SEC Staff Announcement that the SEC staff would not object to an entity deferring and presenting debt issuance costs associated with a line -of -credit arrangement as an asset and subsequently amortizing the costs ratably over the term of the arrangement. The Company plans to adopt ASU 2015-03 in the first quarter of 2016. As the Company's debt issuance costs are not material, implementation of this update is not expected to have a material impact on the Company's Consolidated Financial Statements. 55 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS In April 2015, FASB issued ASU No. 2015-05, "Intangibles -Goodwill and Other -Internal -Use Software (Subtopic 350-40): Customer's Accounting for Fees Paid in a Cloud Computing Arrangement" ("ASU 2015-05"), which issues guidance on determining whether a cloud computing arrangement contains a software license that should be accounted for as internal -use software. If a cloud computing arrangement does not contain a software license, it should be accounted for as a service contract.This guidance is effective for fiscal years beginning after December 15, 2015 and for interim periods within those fiscal years, with early adoption permitted. The Company has to this point not been a party to any material cloud computing arrangements and as such has determined the impact of the adoption of this guidance on the Consolidated Financial Statements to be immaterial. In April 2015, FASB issued ASU No. 2015-03, "Simplifying the Presentation of Debt Issuance Costs" ("ASU 2015-03"), which requires that debt issuance costs related to a recognized debt liability be presented in the balance sheet as a direct deduction from the carrying amount of that debt liability, consistent with debt discounts, and not recorded as separate assets. This update is effective for reporting periods beginning after December 15, 2015, and is to be applied on a retro- spective basis. The Company plans to adopt ASU 2015-03 in the first quarter of 2016. As the Company's debt issuance costs are not material, implementation of this update is not expected to have a material impact on the Company's Consolidated Financial Statements. In August 2014, FASB issued ASU No. 2014-15, "Disclosure of Uncertainties About an Entity's Ability to Continue as a Going Concern" ("ASU 2014-15"), which addresses management's responsibility in evaluating whether there is substantial doubt about a company's ability to continue as a going concern and to provide related footnote disclosures. ASU 2014-15 is effective for fiscal years beginning after December 15, 2016 and for interim periods within those fiscal years, with early adoption permitted. The Company does not expect to early adopt this guidance, and it believes the adoption of this guid- ance will not have an impact on the Consolidated Financial Statements. In May 2014, FASB issued ASU No. 2014-09, "Revenue from Contracts with Customers" ("ASU 2014-09"), which provides guidance for revenue recognition, ASU 2014-09 affects any entity that either enters into contracts with customers to transfer goods or services or enters into contracts for the transfer of non -financial assets, and supersedes the revenue recognition requirements in Topic 605, "Revenue Recognition," and most industry -specific guidance. The standard's core principle is that a company will recognize revenue when it transfers promised goods or services to customers in an amount that reflects the consideration to which a company expects to be entitled in exchange for those goods or services. In doing so, companies will need to use more judgment and make more estimates than under the current guidance. These may include identifying performance obligations in the contract. estimating the amount of variable consideration to include in the transaction price and allocating the transaction price to each separate performance obligation. ASU 2014-09 is effec- tive for the Company beginning January 1, 2018, after FASB voted to delay the effective date by one year. At that time, the Company may adopt the new standard under the full retrospective approach or the modified retrospective approach. The Company is currently evaluating its revenue streams against the requirements of this pronouncement. Principles of Consolidation The accompanying Consolidated Financial Statements include the accounts of Brown & Brown, Inc. and its subsidiaries. All significant inter -company account balances and transactions have been eliminated in the Consolidated Financial Statements. Segment results for prior periods have been recast to reflect the current year segmental structure. Certain reclassifica- tions have been made to the prior -year amounts reported in this Annual Report on Form 10-K in order to conform to the current year presentation, Revenue Recognition Commission revenues are recognized as of the effective date of the insurance policy or the date on which the policy premium is processed into our systems, whichever is later. Commission revenues related to installment billings are recog- nized on the latter of effective or invoiced date, with the exception of our Arrowhead business which follows a policy of Brown & Brown. Inc. 56 recognizing on the latter of effective or processed date into our systems regardless of the billing arrangement. Management determines the policy cancellation reserve based upon historical cancellation experience adjusted for any known circum- stances. Subsequent commission adjustments are recognized upon our receipt of notification from insurance companies concerning matters necessitating such adjustments. Profit-sharing contingent commissions are recognized when determin- able, which is generally when such commissions are received from insurance companies, or when we receive formal notification of the amount of such payments. Fee revenues and commissions for workers' compensation programs are recognized as services are rendered. Use of Estimates The preparation of the Consolidated Financial Statements in conformity with accounting principles generally accepted in the United States of America ("U.S. GAAP") requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities, as well as disclosures of contingent assets and liabilities, at the date of the Consolidated Financial Statements, and the reported amounts of revenues and expenses during the reporting period. Actual results may differ from those estimates. Cash and Cash Equivalents Cash and cash equivalents principally consist of demand deposits with financial institutions and highly liquid investments with quoted market prices having maturities of three months or less when purchased. Restricted Cash and Investments, and Premiums, Commissions and Fees Receivable In our capacity as an insurance agent or broker, the Company typically collects premiums from insureds and, after deducting its authorized commissions, remits the net premiums to the appropriate insurance company or companies, Accordingly, as reported in the Consolidated Balance Sheets, "premiums" are receivable from insureds. Unremitted net insurance premi- ums are held in a fiduciary capacity until Brown & Brown disburses them. Where allowed by law, Brown & Brown invests these unremitted funds only in cash, money market accounts, tax-free variable -rate demand bonds and commercial paper held for a short term. In certain states in which Brown & Brown operates, the use and investment alternatives for these funds are regulated and restricted by various state laws and agencies. These restricted funds are reported as restricted cash and investments on the Consolidated Balance Sheets. The interest income earned on these unremitted funds, where allowed by state law, is reported as investment income in the Consolidated Statement of Income. In other circumstances, the insurance companies collect the premiums directly from the insureds and remit the applicable commissions to Brown & Brown. Accordingly, as reported in the Consolidated Balance Sheets, "commissions" are receivables from insurance companies. "Fees" are primarily receivables due from customers. Investments Certificates of deposit, and other securities, having maturities of more than three months when purchased are reported at cost and are adjusted for other -than -temporary market value declines. As part of the acquisition of Wright in 2014, we acquired additional investments, which include U.S. Government, Municipal, domestic corporate and foreign corporate bonds as well as short -duration fixed income funds. Investments within the portfolio or funds are held as available for sale and are carried at their fair value. Any gain/loss applicable from the fair value change is recorded, net of tax, as other comprehensive income under the equity section of the Consolidated Balance Sheet. Realized gains and losses are reported on the Consolidated Statement of Income, with the cost of securities sold determined on a specific identification basis. Fixed Assets Fixed assets, including leasehold improvements, are carried at cost, less accumulated depreciation and amortization, Expenditures for improvements are capitalized, and expenditures for maintenance and repairs are expensed to operations as incurred. Upon sale or retirement, the cost and related accumulated depreciation and amortization are removed from the accounts and the resulting gain or loss, if any, is reflected in other income. Depreciation has been determined using the straight-line method over the estimated useful lives of the related assets, which range from three to 15 years. Leasehold improvements are amortized on the straight-line method over the shorter of the useful life of the improvement or the term of the related lease. 57 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS Goodwill and Amortizable Intangible Assets All of our business combinations initiated after June 30, 2001 are accounted for using the purchase method. Acquisition purchase prices are typically based on a multiple of average annual operating profit earned over a one to three year period within a minimum and maximum price range. The recorded purchase prices for all acquisitions consummated after January 1, 2009 include an estimation of the fair value of liabilities associated with any potential earn -out provisions, Subsequent changes in the fair value of earn -out obligations are recorded in the Consolidated Statement of Income when incurred. The fair value of earn -out obligations is based on the present value of the expected future payments to be made to the sellers of the acquired businesses in accordance with the provisions contained in the respective purchase agreements. In determining fair value, the acquired business' future performance is estimated using financial projections developed by management for the acquired business and this estimate reflects market participant assumptions regarding revenue growth and/or profitability. The expected future payments are estimated on the basis of the earn -out formula and performance targets specified in each purchase agreement compared to the associated financial projections. These estimates are then discounted to present value using a risk -adjusted rate that takes into consideration the likelihood that the forecasted earn -out payments will be made. Amortizable intangible assets are stated at cost, Tess accumulated amortization, and consist of purchased customer accounts and non -compete agreements. Purchased customer accounts and non -compete agreements are amortized on a straight-line basis over the related estimated lives and contract periods, which range from five to 15 years. Purchased customer accounts primarily consist of records and files that contain information about insurance policies and the related insured parties that are essential to policy renewals. The excess of the purchase price of an acquisition over the fair value of the identifiable tangible and amortizable intangible assets is assigned to goodwill. While goodwill is not amortizable, it is subject to assessment at least annually, and more frequently in the presence of certain circumstances, for impairment by application of a fair value -based test. The Company compares the fair value of each reporting unit with its carrying amount to determine if there is potential impair- ment of goodwill. If the fair value of the reporting unit is less than its carrying value, an impairment loss is recorded to the extent that the fair value of the goodwill within the reporting unit is less than its carrying value. Fair value is estimated based on multiples of earnings before interest, income taxes, depreciation, amortization and change in estimated acquisi- tion earn -out payables (" EBITDAC"), or on a discounted cash flow basis. Brown & Brown completed its most recent annual assessment as of November 30, 2015 and determined that the fair value of goodwill exceeded the carrying value of such assets. In addition, as of December 31. 2015, there are no accumulated impairment losses. The carrying value of amortizable intangible assets attributable to each business or asset group comprising Brown & Brown is periodically reviewed by management to determine if there are events or changes in circumstances that would indicate that its carrying amount may not be recoverable. Accordingly, if there are any such changes in circumstances during the year, Brown & Brown assesses the carrying value of its amortizable intangible assets by considering the estimated future undiscounted cash flows generated by the corresponding business or asset group. Any impairment identified through this assessment may require that the carrying value of related amortizable intangible assets be adjusted. There were no impairments recorded for the years ended December 31.2015, 2014 and 2013. Income Taxes Brown & Brown records income tax expense using the asset -and -liability method of accounting for deferred income taxes. Under this method, deferred tax assets and liabilities are recognized for the expected future tax consequences of tempo- rary differences between the financial statement carrying values and the income tax bases of Brown & Brown's assets and liabilities. Brown & Brown files a consolidated federal income tax return and has elected to file consolidated returns in certain states. Deferred income taxes are provided for in the Consolidated Financial Statements and relate principally to expenses charged to income for financial reporting purposes in one period and deducted for income tax purposes in other periods. Brown Sc Brown, Irc, 58 Net Income Per Share Basic EPS is computed based on the weighted average number of common shares (including participating securities) issued and outstanding during the period. Diluted EPS is computed based on the weighted average number of common shares issued and outstanding plus equivalent shares, assuming the exercise of stock options. The dilutive effect of stock options is computed by application of the treasury -stock method. The following is a reconciliation between basic and diluted weighted average shares outstanding for the years ended December 31: (in thousands„ except per share data) 2015 2014 2013 Net income $ 243,318 $ 206,896 $ 217,112 Net income attributable to unvested awarded performance stock (5,695) (5,186) (5,446) Net income attributable to common shares $ 237,623 $ 201,710 $ 211,666 Weighted average number of common shares outstanding —basic Less unvested awarded performance stock included in weighted average number of common shares outstanding —basic Weighted average number of common shares outstanding for basic earnings per common share Dilutive effect of stock options Weighted average number of shares outstanding —diluted 141,113 144,568 144,662 (3,303) {3.624) (3,629} 137,810 2,302 140,112 140,944 1,947 142,891 141,033 1,591 142,624 Net income per share: Basic $ 1.72 $ 1.43 $ 1.50 Diluted $ 1.70 $ 1.41 $ 1.48 Fair Value of Financial Instruments The carrying amounts of Brown & Brown's financial assets and liabilities, including cash and cash equivalents; restricted cash and short-term investments; investments; premiums, commissions and fees receivable; reinsurance recoverable; prepaid reinsurance premiums; premiums payable to insurance companies; losses and loss adjustment reserve; unearned premium; premium deposits and credits due customers and accounts payable, at December 31, 2015 and 2014, approxi- mate fair value because of the short-term maturity of these instruments. The carrying amount of Brown & Brown's long-term debt approximates fair value at December 31, 2015 and 2014 as our fixed-rate borrowings of $623.6 million approximate their values using market quotes of notes with the similar terms as ours, which we deem a close approximation of current market rates. Of the $623.6 million, $25.0 million is related to short-term notes which approximates its carrying value due to its proximity to maturity. The estimated fair value of the $529.4 million remaining on the term loan under our J.P. Morgan Credit Facility approximates the carrying value due to the variable interest rate based on adjusted LI BOR. See Note 2 to our Consolidated Financial Statements for the fair values related to the establishment of intangible assets and the establishment and adjustment of earn -out payables. See Note 5 for information on the fair value of investments and Note 8 for information on the fair value of long-term debt. Stock -Based Compensation The Company granted stock options and grants non -vested stock awards to its employees, officers and directors. The Company uses the modified -prospective method to account for share -based payments. Under the modified -prospective method, compensation cost is recognized for all share -based payments granted on or after January 1, 2006 and for all awards granted to employees prior to January 1, 2006 that remained unvested on that date. The Company uses the alternative -transi- tion method to account for the income tax effects of payments made related to stock -based compensation. The Company uses the Black-Scholes valuation model for valuing all stock options and shares purchased under the Employee Stock Purchase Plan (the "ESPP"). Compensation for non -vested stock awards is measured at fair value on the grant date based upon the number of shares expected to vest. Compensation cost for all awards is recognized in earnings, net of estimated forfeitures, on a straight-line basis over the requisite service period. 59 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS Reinsurance The Company protects itself from claims related losses by reinsuring all claims risk exposure. The only line of insurance the Company underwrites is flood insurance associated with Wright. However, all exposure is reinsured with FEMA for basic admitted policies conforming to the National Flood Insurance Program. For excess flood insurance policies, all exposure is reinsured with a reinsurance carrier with an AM Best Company rating of "A" or better. Reinsurance does not legally discharge the ceding insurer from the primary liability for the full amount due under the reinsured policies. Reinsurance premiums, commissions, expense reimbursement and related reserves related to ceded business are accounted for on a basis consistent with the accounting for the original policies issued and the terms of reinsurance contracts. Premiums earned and losses and loss adjustment expenses incurred are reported net of reinsurance amounts. Other underwriting expenses are shown net of earned ceding commission income. The liabilities for unpaid losses and loss adjustment expenses and unearned premiums are reported gross of ceded reinsurance recoverable. Balances due from reinsurers on unpaid losses and loss adjustment expenses, including an estimate of such recoverables related to reserves for incurred but not reported ("IBNR") losses, are reported as assets and are included in reinsurance recoverable even though amounts due on unpaid loss and loss adjustment expense are not recoverable from the reinsurer until such losses are paid. The Company does not believe it is exposed to any material credit risk through its reinsurance as the reinsurer is FEMA for basic admitted flood policies and a national reinsurance carrier for excess flood policies, which has an AM Best Company rating of "A" or better. Historically, no amounts due from reinsurance carriers have been written off as uncollectible. Unpaid Losses and Loss Adjustment Reserve Unpaid losses and loss adjustment reserve include amounts determined on individual claims and other estimates based on the past experience of WNFIC and the policyholders for IBNR claims, less anticipated salvage and subrogation recoverable. The methods of making such estimates and for establishing the resulting reserves are continually reviewed and updated, and any adjustments resulting therefrom are reflected in operations currently. WNFIC engages the services of outside actuarial consulting firms (the "Actuaries") to assist on an annual basis to render an opinion on the sufficiency of the Company's estimates for unpaid losses and related loss adjustment reserve. The Actuaries utilize both industry experience and the Company's own experience to develop estimates of those amounts as of year-end. These estimated liabilities are subject to the impact of future changes in claim severity, frequency and other factors. In spite of the variability inherent in such estimates, management believes that the liabilities for unpaid losses and related loss adjustment reserve is adequate. Premiums Premiums are recognized as income over the coverage period of the related policies. Unearned premiums represent the portion of premiums written that relate to the unexpired terms of the policies in force and are determined on a daily pro rata basis. The income is recorded to the commissions and fees line of the income statement. NOTE 2 Business Combinations During the year ended December 31, 2015, the Company acquired the assets and assumed certain liabilities of thirteen insurance intermediaries and four books of business (customer accounts). Additionally, miscellaneous adjustments were recorded to the purchase price allocation of certain prior acquisitions completed within the last twelve months as permitted by Accounting Standards Codification Topic 805 — Business Combinations ("ASC 805"). Such adjustments are presented in the "Other" category within the following two tables. All of these businesses were acquired primarily to expand Brown & Brown's core business and to attract and hire high -quality individuals. The recorded purchase price for all acquisitions consummated after January 1, 2009 included an estimation of the fair value of liabilities associated with any potential earn -out provisions. Subsequent changes in the fair value of earn -out obligations will be recorded in the Consolidated Statement of Income when incurred. Brown & Brown, Inc. 60 The fair value of earn -out obligations is based on the present value of the expected future payments to be made to the sellers of the acquired businesses in accordance with the provisions outlined in the respective purchase agreements. In determining fair value, the acquired business's future performance is estimated using financial projections developed by management for the acquired business and reflects market participant assumptions regarding revenue growth andfor profitability. The expected future payments are estimated on the basis of the earn -out formula and performance targets specified in each purchase agreement compared to the associated financial projections. These payments are then discounted to present value using a risk -adjusted rate that takes into consideration the likelihood that the forecasted earn -out pay- ments will be made. Based on the acquisition date and the complexity of the underlying valuation work, certain amounts included in the Company's Consolidated Financial Statements may be provisional and thus subject to further adjustments within the permitted measurement period, as defined in ASC 805. For the year ended December 31, 2015, several adjustments were made within the permitted measurement period that resulted in a decrease in the aggregate purchase price of the affected acquisitions of $503,442 relating to the assumption of certain liabilities. Cash paid for acquisitions was $136.0 million and $721.9 million in the twelve-month periods ended December 31, 2015 and 2014, respectively. We completed thirteen acquisitions (excluding book of business purchases) in the twelve- month period ended December 31, 2015. We completed ten acquisitions (excluding book of business purchases) in the twelve-month period ended December 31, 2014. The following table summarizes the purchase price allocation made as of the date of each acquisition for current year acquisitions and significant adjustments made during the measurement period for prior year acquisitions: (In thousands) Name Maximum Effective Recorded Net Potential Business Date of Cash other Earn -Out Assets Earn -out Segment Acquisition Paid Payable Payable Acquired Payable Liberty Insurance Brokers, Inc. and Affiliates (Liberty) Retail February 1, 2015 $ 12,000 $ - $ 2,981 $ 14,981 $ 3,750 Spain Agency, Inc. (Spain) Retail March 1, 2015 20,706 - 2,617 23,323 9,162 Bellingham Underwriters, Inc. National (Bellingham) Programs May 1, 2015 9,007 500 3,322 12,829 4,400 Fitness Insurance, LLC (Fitness) Retail June 1, 2015 9,455 - 2,379 11,834 3,500 Strategic Benefit Advisors„ Inc. (SBA) Retail June 1, 2015 49,600 400 13,587 63,587 26,000 Bentrust Financial, Inc. (Bentrust) Retail December 1, 2015 10,142 391 319 10,852 2,200 MBA Insurance Agency of Arizona, Inc. (MBA) Retail December 1,2015 68 8,442 6,063 14,573 9,500 Smith Insurance, Inc. (Smith) Retail December 1, 2015 12.096 200 1,047 13,343 6,350 Other Various Various 12,926 95 4,584 17,605 8,212 Total $ 136,000 $ 10,028 $ 36,899 $ 182,927 $ 73,074 61 70:7 Ann 'ecyr NOTES TO CONSOLIDATED FINANCIAL STATEMENTS The following table summarizes the estimated fair values of the aggregate assets and liabilities acquired as of the date of each acquisition. The data included in the 'Other' column shows a negative adjustment for purchased customer accounts. This is driven mainly by the final valuation adjustment for the acquisition of Wright. (in thousands) Belling - Liberty Spain ham Fitness SBA Bentrust MBA Smith other Total Other current assets $ 2,486 $ 324 $ - $ 9 $ 652 $ - $ - $ - $ 169 $ 3,640 Fixed assets 40 50 25 17 41 36 33 73 59 374 Goodwill 10,010 15.748 9,608 8.105 39,859 8,166 13,471 10,374 21,040 136,381 Purchased customer accounts 4,506 7,430 3,223 3,715 23.000 2,789 7,338 3,526 (2,135) 53.392 Non -compete agreements 24 21 21 - 21 43 11 31 156 328 Other assets - - - - 14 - - - - 14 Total assets acquired 17,066 23,573 12,877 11,846 63,587 11,034 20,853 14,004 19,289 194,129 Other current liabilities (42) (250) (48) (12) - 1182) (6,280) (504) (4,895) (12.213) Deferred income tax, net - - - - - - - - 2,576 2,576 Other liabilities (2.043) - - - - - - (157) 635 (1.565) Total liabilities assumed (2,085) (250) (48) (12) - (182) (6,280) (661) (1,684) (11,202) Net assets acquired $ 14,981 $ 23,323 $ 12,829 $ 11,834 $ 63,587 $ 10,852 $ 14,573 $ 13,343 $ 17,605 $ 182,927 The weighted average useful lives for the acquired amortizable intangible assets are as follows purchased customer accounts, 15 years; and non -compete agreements, 5 years. Goodwill of $136.4 million was allocated to the Retail, National Programs and Wholesale Brokerage Segments in the amounts of $113.8 million, $18.0 million and $4.6 million, respectively. Of the total goodwill of $136.4 million, $91.1 million is currently deductible for income tax purposes and $8.4 million is non -deductible. The remaining $36.9 million relates to the recorded earn -out payables and will not be deductible until it is earned and paid. For the acquisitions completed during 2015, the results of operations since the acquisition dates have been combined with those of the Company. The total revenues from the acquisitions completed through December 31, 2015, included in the Consolidated Statement of Income for the year ended December 31, 2015, were $28.2 million. The income before income taxes, including the inter -company cost of capital charge, from the acquisitions completed through December 31, 2015, included in the Consolidated Statement of Income for the year ended December 31, 2015, was $1.5 million. If the Brown & Browr, Inc. 62 acquisitions had occurred as of the beginning of the respective periods, the Company's results of operations would be as shown in the following table. These unaudited pro forma results are not necessarily indicative of the actual results of operations that would have occurred had the acquisitions actually been made at the beginning of the respective periods. (UNAUDITED) For the Year Ended December 31, (In thousands, except per share data) 2015 2014 Total revenues $ 1,688,297 $ 1,630,992 Income before income taxes $ 411,497 $ 356,426 Net income $ 248.720 $ 217,053 Net income per share: Basic $ 1.76 $ 1.50 Diluted $ 1.73 $ 1.48 Weighted average number of shares outstanding: Basic 137,810 140,944 Diluted 140,112 142,891 Acquisitions in 2014 During the year ended December 31, 2014, Brown & Brown acquired the assets and assumed certain liabilities of nine insurance intermediaries, all of the stock of one insurance intermediary that owns an insurance carrier and five books of business (customer accounts). The cash paid for these acquisitions was $721.9 million. Additionally, miscellaneous adjust- ments were recorded to the purchase price allocation of certain prior acquisitions completed within the last twelve months as permitted by Accounting Standards Codification Topic 805 — Business Combinations ("ASC 805"). Such adjustments are presented in the "Other" category within the following two tables. All of these acquisitions were acquired primarily to expand Brown & Brown's core business and to attract and hire high -quality individuals. For the year ended December 31, 2014, several adjustments were made within the permitted measurement period that resulted in a decrease in the aggregate purchase price of the affected acquisitions of $25,941 relating to the assump- tion of certain liabilities. The following table summarizes the purchase price allocation made as of the date of each acquisition for current year acquisitions and significant adjustment made during the measurement period for prior year acquisitions: (in thousands) Name Maximum Effective Recorded Net Potential Business Date of Cash other Earn -Out Assets Earn -Out Segment Acquisition Paid Payable Payable Acquired Payable The Wright Insurance National Group, LLC Programs May 1, 2014 $ 609,183 $ 1.471 $ — $ 610,654 $ Pacific Resources Benefits Advisors, LLC ("PacRes") Retail May 1, 2014 90,000 — 27,452 117,452 35,000 Axia Strategies. Inc Wholesale ("Axia") Brokerage May 1, 2014 9,870 — 1,824 11,694 5,200 Other Various Various 12,798 433 3,953 17,184 9,262 Total $ 721,851 $ 1,904 $ 33,229 $ 756,984 $ 49,462 63 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS The following table summarizes the estimated fair values of the aggregate assets and liabilities acquired as of the date of each acquisition. (in thousands) Wright PacRes Axia Other Total Cash $ 25,365 $ — $ — $ — $ 25.365 Other current assets 16,474 3,647 101 742 20,964 Fixed assets 7,172 53 24 1.724 8,973 Reinsurance recoverable 25,238 — — — 25.238 Prepaid reinsurance premiums 289,013 — — — 289,013 Goodwill 420,209 76,023 7,276 10.417 513.925 Purchased customer accounts 213,677 38,111 4,252 4,384 260,424 Non -compete agreements 966 21 41 166 1.194 Other assets 20,045 — — — 20,045 Total assets acquired 1,018,159 117,855 11,694 17,433 1,165,141 Other current liabilities (14,322) (403) — (249) (14,974) Losses and loss adjustment reserve (25,238) — — — (25,238) Unearned premiums (289,013) — — — (289,013) Deferred income tax, net (46,566) — — — (46,566) Other liabilities (32,366) — — {32,366) Total liabilities assumed (407,505) (403) — (249) (408,157) Net assets acquired $ 610,654 $ 117,452 $ 11,694 $ 17,184 $ 756,984 The weighted average useful lives for the acquired amortizable intangible assets are as follows: purchased customer accounts, 15 years; and non -compete agreements, 3.4 years. Goodwill of $513.9 million was allocated to the Retail, National Programs, Wholesale Brokerage and Services Segments in the amounts of $86.4 million, $420.0 million, $7.7 million and $(0.2) million, respectively. Of the total goodwill of $513.9 million, $141.9 million is currently deductible for income tax purposes and $338.8 million is non -deductible. The remaining $33.2 million relates to the recorded earn -out payables and will not be deductible until it is earned and paid. For the acquisitions completed during 2014, the results of operations since the acquisition dates have been combined with those of the Company. The total revenues and income before income taxes, including the inter -company cost of capital, from the acquisitions completed through December 31. 2014, included in the Consolidated Statement of Income for the year ended December 31, 2014, were $112.2 million and $(1.3) million, respectively. If the acquisitions had occurred as of the beginning of the respective periods, the Company's results of operations would be as shown in the following table. These unaudited pro forma results are not necessarily indicative of the actual results of operations that would have occurred had the acquisitions actually been made at the beginning of the respective periods. Brown & Brown, Inc. 64 (UNAUDITED) For the Year Ended December 31, (in thousands. except per share data) 2014 2013 Total revenues $ 1,630,162 $ 1,520,858 Income before income taxes $ 358,229 $ 409,522 Net income $ 218,150 $ 248,628 Net income per share: Bask $ 1.51 $ 1.72 Diluted $ 1.49 $ 1.70 Weighted average number of shares outstanding: Basic 140,944 141,033 Diluted 142,891 142,624 Acquisitions in 2013 During the year ended December 31, 2013, Brown & Brown acquired the assets and assumed certain liabilities of eight insurance intermediaries, all of the stock of one insurance intermediary and one book of business (customer accounts), The cash paid for these acquisitions was $408.1 million. Additionally, miscellaneous adjustments were recorded to the purchase price allocation of certain prior acquisitions completed within the last twelve months as permitted by Accounting Standards Codification Topic 805 — Business Combinations ("ASC 805"). Such adjustments are presented in the "Other" category within the following two tables. All of these acquisitions were acquired primarily to expand Brown & Brown's core business and to attract and hire high -quality individuals. For the year ended December 31, 2013, several adjustments were made within the permitted measurement period that resulted in a decrease in the aggregate purchase price of the affected acquisitions of $504,300 relating to the assump- tion of certain liabilities. The following table summarizes the aggregate purchase price allocation made as of the date of each acquisition for current year acquisitions and adjustment made during the measurement period for prior year acquisitions: (in thousands( Name Maximum Effective Recorded Net Potential Business Date of Cash Other Earn -Out Assets Earn -put Segment Acquisition paid Payable Payable Acquired Payable The Rollins Agency, Inc. Retail June 1, 2013 $ 13,792 $ 50 $ 2,321 $ 16,163 $ 4,300 Beecher Carlson Retail; Holdings, Inc. National Programs July 1, 2013 364,256 — — 364,256 — ICA, Inc. Services December 31, 2013 19,770 — 727 20,497 5.000 Other Various Various 10,254 502 2,043 12,799 7,468 Total $ 408,072 $ 552 $ 5,091 $ 413,715 $ 16,768 65 20=3 A:n...1- �c�� NOTES TO CONSOLIDATED FINANCIAL STATEMENTS The following table summarizes the estimated fair values of the aggregate assets and liabilities acquired as of the date of each acquisition. (in thousands) Rollins Beecher ICA Other Total Cash $ - $ 40,360 $ - $ - $ 40.360 Other current assets 393 57,632 - 1,573 59,598 Fixed assets 30 1,786 75 24 1,915 Goodwill 12,697 265,174 12,377 5.696 295,944 Purchased customer accounts 3,878 101,565 7,917 5,623 118,983 Non -compete agreements 31 2,758 21 76 2,886 Other assets - - 107 1 108 Total assets acquired 17,029 469,275 20,497 12,993 519,794 Other current liabilities (866) (80,090) - (194) (81,150) Deferred income tax, net - (22,764) - - {22,764) Other liabilities - (2,165) - - (2,165} Total Liabilities assumed Net assets acquired {866) {105,019) - (194) (106,079) $ 16,163 $ 364,256 $ 20,497 $ 12,799 $ 413,715 The weighted average useful lives for the acquired amortizable intangible assets are as follows: purchased customer accounts, 15 years; and non -compete agreements, 5 years. Goodwill of $295.9 million was allocated to the Retail, National Programs, Wholesale Brokerage and Services Segments in the amounts of $257.2 million, $27.1 million, $(0.8) million and $12.4 million, respectively. Of the total goodwill of $295.9 million, $41.6 million is currently deductible for income tax purposes and $249.2 million is non -deductible. The remaining $5.1 million relates to the recorded earn -out payables and will not be deductible until it is earned and paid. For the acquisitions completed during 2013, the results of operations since the acquisition dates have been combined with those of the Company. The total revenues and income before income taxes, including the inter -company cost of capital, from the acquisitions completed through December 31, 2013, included in the Consolidated Statement of Income for the year ended December 31, 2013, were $63.8 million and $0.9 million, respectively. If the acquisitions had occurred as of the beginning of the respective periods, the Company's results of operations would be as shown in the following table, These unaudited pro forma results are not necessarily indicative of the actual results of operations that would have occurred had the acquisitions actually been made at the beginning of the respective periods. (UNAUDITED) For the Year Ended December 31, (in thousands, except per share data) 2013 2012 Total revenues $ 1,439,918 $ 1,329,262 Income before income taxes $ 373,175 $ 329,291 Net income $ 226,562 $ 198,826 Net income per share: Basic $ 1.57 $ 1.39 Diluted $ 1.55 $ 1,36 Weighted average number of shares outstanding: Basic 141,033 139,634 Diluted 142,624 142,010 Brown & Brown, Inc, 66 For acquisitions consummated prior to January 1, 2009, additional consideration paid to sellers as a result of the purchase price earn -out provisions are recorded as adjustments to intangible assets when the contingencies are settled. The net additional consideration paid by the Company in 2015 as a result of those adjustments totaled $0. The net addi- tional consideration paid by the Company in 2014 as a result of these adjustments totaled $26,000, all of which was allocated to goodwill. Of the $26,000 net additional consideration paid, $26,000 was recorded in other payables. As of December 31, 2015, the maximum future contingency payments related to all acquisitions totaled $137.4 million, all of which relates to acquisitions consummated subsequent to January 1, 2009. ASC Topic 805-Business Combinations is the authoritative guidance requiring an acquirer to recognize 100% of the fair values of acquired assets, including goodwill, and assumed liabilities (with only limited exceptions) upon initially obtaining control of an acquired entity. Additionally, the fair value of contingent consideration arrangements (such as earn -out purchase arrangements) at the acquisition date must be included in the purchase price consideration. As a result, the recorded purchase prices for all acquisitions consummated after January 1, 2009 include an estimation of the fair value of liabilities associated with any potential earn -out provisions. Subsequent changes in these earn -out obligations will be recorded in the Consolidated Statement of Income when incurred. Potential earn -out obligations are typically based upon future earnings of the acquired entities, usually between one and three years. As of December 31, 2015, the fair values of the estimated acquisition earn -out payables were re-evaluated and measured at fair value on a recurring basis using unobservable inputs (Level 3) as defined in ASC 820-Fair Value Measurement. The resulting additions, payments, and net changes, as well as the interest expense accretion on the estimated acquisition earn -out payables, for the years ended December 31, 2015, 2014 and 2013 were as follows: (in thousands) For the Year Ended December 31, 2015 2014 2013 Balance as of the beginning of the period $ 75,283 $ 43,058 $ 52,987 Additions to estimated acquisition earn -out payables 36,899 34,356 5,816 Payments for estimated acquisition earn -out payables {36,798) (12,069) (18,278) Subtotal 75,384 65,345 40,525 Net change in earnings from estimated acquisition earn -out payables: Change in fair value on estimated acquisition earn -out payables 2,990 7,375 570 Interest expense accretion 13 2,563 1,963 Net change in earnings from estimated acquisition earn -out payables 3,003 9,938 2,533 Balance as of December 31, $ 78,387 $ 75,283 $ 43,058 Of the $78.4 million estimated acquisition earn -out payables as of December 31, 2015, $25.3 million was recorded as accounts payable and $53.1 million was recorded as other non -current liabilities. Included within additions to estimated acquisition earn -out payables are any adjustments to opening balance sheet items prior to the one-year anniversary date and may therefore differ from previously reported amounts. Of the $75.3 million estimated acquisition earn -out payables as of December 31, 2014, $26.0 million was recorded as accounts payable and $49.3 million was recorded as an other non -current liability. Of the $43.1 million estimated acquisition earn -out payables as of December 31, 2013, $6.3 million was recorded as accounts payable and $36.8 million was recorded as an other non -current liability. 67 2015 Anna Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS NOTE 3 Goodwill The changes in the carrying value of goodwill by reportable segment for the years ended December 31. are as follows: (In thousands) National Wholesale Retail Programs Brokerage Services Total Balance as of January 1, 2014 $ 1.141,485 $ 475,596 $ 268,562 $ 120.530 $ 2,006.173 Goodwill of acquired businesses 94,080 420,063 47 (239) 513,951 Goodwill disposed of relating to sales of businesses (3,696) (9,564) (46,253) — (59,513) Balance as of December 31, 2014 $ 1.231,869 $ 886,095 $ 222,356 $ 120,291 $ 2,460.611 Goodwill of acquired businesses 113,767 18,009 4,605 — 136,381 Goodwill disposed of relating to sales of businesses — (2,238) — (8,071) (10,309) Balance as of December 31, 2015 $1,345,636 $ 901,866 $ 226,961 $ 112,220 $2,586,683 NOTE 4 Amortizable Intangible Assets Amortizable intangible assets at December 31, 2015 and 2014 consisted of the following: December 31, 2.01S (in thousands) December 31, 2014 Weighted- Weighted - Gross Net Average Gross Net Average Carrying Accumulated Carrying Life Carrying Accumulated Carrying Life Value Amortization Value (years)", Value Amortization Value (years)"' Purchased customer accounts $1,398,986 $ (656,799) $ 742,187 15.0 $1,355,550 $ (574,285) $ 781,265 14.9 Non -compete agreements 29,440 (26,947) 2,493 6.8 29.139 (25,762) 3,377 6.8 Total $1,428,426 $ (683,746) $ 744,680 $1,384,689 $ (600,047) $ 784,642 (1) Weighted average fife calculated as of the date of acquisition. Amortization expense for amortizable intangible assets for the years ending December 31, 2016, 2017, 2018, 2019 and 2020 is estimated to be $84.5 million, $81.6 million, $76.3 million, $71.8 million, and $64.5 million, respectively. NOTE 5 Investments At December 31, 2015, the Company's amortized cost and fair values of fixed maturity securities are summarized as follows: Gross Gross Unrealized Unrealized (in thousands) Cost Gains Losses Fair Value U.S. Treasury securities, obligations of U.S. Government agencies and Municipals $ 11.876 $ 6 $ (26) $ 11,856 Foreign government 50 — — 50 Corporate debt 4,505 7 (16) 4,496 Short duration fixed income fund 1.663 27 — 1.690 Total $ 18,094 $ 40 $ (42) $ 18,092 Brown & Brown, Inc. 68 For securities in a loss position, the following table shows the investments' gross unrealized loss and fair value, aggre- gated by investment category and length of time that individual securities have been in a continuous unrealized loss position as of December 31, 2015: Less than 12 Months 12 Months or More Total Unrealized Unrealized Unrealized (in thousands} Fair Value Losses Fair Value Losses Fair Value Losses U.S. Treasury securities, obligations of U.S. Government agencies and Municipals $ 8,998 $ 26 $ — $ — $ 8,998 $ 26 Foreign Government 50 — — — 50 — Corporate debt 2,731 14 284 2 3,015 16 Total $ 11,779 $ 40 $ 284 $ 2 $ 12,063 $ 42 The unrealized losses from corporate issuers were caused by interest rate increases, At December 31, 2015, the Company had 35 securities in an unrealized Toss position. The corporate securities are highly rated securities with no indicators of potential impairment. Based on the ability and intent of the Company to hold these investments until recovery of fair value, which may be maturity, the bonds were not considered to be other -than -temporarily impaired at December 31, 2015. At December 31, 2014, the Company's amortized cost and fair values of fixed maturity securities are summarized as follows: Gross Gross Unrealized Unrealized (in thousands) Cost Gains Losses Fair Value U.S. Treasury securities, obligations of U.S. Government agencies and Municipals $ 10,774 $ 7 $ (1) $ 10,780 Foreign government 50 — — 50 Corporate debt 5,854 9 (11) 5,852 Short duration fixed income fund 3.143 37 — 3,180 Total $ 19,821 $ 53 $ (12) $ 19,862 The following table shows the investments' gross unrealized loss and fair value, aggregated by investment category and length of time that individual securities have been in a continuous unrealized loss position as of December 31, 2014: Less than 12 Months 12 Months or More Total Unrealized Unrealized (in thousands} Fair Value Losses Fair Value Losses Fair Value Unrealized Losses U.S. Treasury securities, obligations of U.S. Government agencies and Municipals $ 3,994 $ 1 $ — $ — $ 3,994 $ 1 Foreign Government 50 — — — 50 — Corporate debt 4,439 11 — — 4,439 11 Total $ 8,483 $ 12 $ — $ — $ 8,483 $ 12 69 2015 Annual Report. NOTES TO CONSOLIDATED FINANCIAL STATEMENTS The unrealized losses in the Company's investments in U.S. Treasury Securities and obligations of U.S. Government Agencies and bonds from corporate issuers were caused by interest rate increases. At December 31, 2014, the Company had 38 securities in an unrealized loss position. The contractual cash flows of the U.S. Treasury Securities and obligations of the U.S. Government agencies investments are either guaranteed by the U.S. Government or an agency of the U.S. Government. Accordingly, it is expected that the securities would not be settled at a price less than the amortized cost of the Company's investment. The corporate securities are highly rated securities with no indicators of potential impairment. Based on the ability and intent of the Company to hold these investments until recovery of fair value, which may be matu- rity, the bonds were not considered to be other -than -temporarily impaired at December 31, 2014. The amortized cost and estimated fair value of the fixed maturity securities at December 31, 2015 by contractual maturity are set forth below: lin thousands) Amortized Cost Fair Value Years to maturity: Due in one year or less $ 5,726 $ 5,722 Due after one year through five years 12,038 12,041 Due after five years through ten years 330 329 Total $ 18,094 $ 18,092 The amortized cost and estimated fair value of the fixed maturity securities at December 31, 2014 by contractual maturity are set forth below: (in thousands) Amortized Cost Fair Value Years to maturity: Due in one year or less $ 5,628 $ 5,628 Due after one year through five years 13,863 13,897 Due after five years through ten years 330 337 Total $ 19,821 $ 19,862 The expected maturities in the foregoing table may differ from the contractual maturities because certain borrowers have the right to call or prepay obligations with or without penalty. Proceeds from sales of the Company's investment in fixed maturity securities were $5.6 million including maturities for the year ended December 31, 2015. The gains and losses realized on those sales for the year ended December 31, 2015 were insignificant. Proceeds from sales of the Company's investment in fixed maturity securities were $0.2 million including maturities for the year ended December 31, 2014. There were no gains and losses realized on those sales for the year ended to December 31, 2014. Realized gains and losses are reported on the Consolidated Statement of Income, with the cost of securities sold determined on a specific identification basis. At December 31, 2015, investments with a fair value of approximately $4.0 million were on deposit with state insur- ance departments to satisfy regulatory requirements. B•-own & Brown. Inc. 70 NOTE 6 Fixed Assets Fixed assets at December 31 consisted of the following: (in thousands) 2015 2014 Furniture, fixtures and equipment Leasehold improvements Land, buildings and improvements $ 169,682 $ 161,539 32,132 30,030 3,370 3,739 Total cost Less accumulated depreciation and amortization Total 205,184 195,308 (123,431) (110,640) $ 81,753 $ 84,668 Depreciation and amortization expense for fixed assets amounted to $20.9 million in 2015, $20.9 million in 2014, and $17.5 million in 2013. NOTE 7 Accrued Expenses and Other Liabilities Accrued expenses and other liabilities at December 31 consisted of the following: (in thousands) 2015 2014 Accrued bonuses $ 76,210 $ 76,891 Accrued compensation and benefits 39,366 36,241 Accrued rent and vendor expenses 29,225 29,039 Reserve for policy cancellations 9,617 9,074 Accrued interest 6,375 6,527 Other 31,274 23,384 Total $ 192,067 $ 181,156 71 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS NOTE 8 Long -Term Debt Long-term debt at December 31, 2015 and 2014 consisted of the following: (In thousands) December 31, December 31, 2015 2014 Current portion of long-term debt: Current portion of 5-year term loan facility expires 2019 $ 48,125 $ 20,625 5.370% senior notes, Series D, quarterly interest payments, balloon due 2015 — 25,000 5.660% senior notes. Series C, semi-annual interest payments, balloon due 2016 25,000 — Total current portion of tong -term debt 73,125 45.625 Long-term debt: Note agreements: 5.660% senior notes. Series C, semi-annual interest payments. balloon due 2016 — 25.000 4.500% senior notes, Series E. quarterly interest payments, balloon due 2018 100,000 100,000 4.200% senior notes, semi-annual interest payments, balloon due 2024 498,628 498.471 Total notes 598,628 623.471 Credit agreements: 5-year term -loan facility, periodic interest and principal payments, currently LIBOR plus up to 1.75%, expires May 20, 2019 481,250 529,375 5-year revolving -loan facility. periodic interest payments, currently LIBOR plus up to 1.50%, plus commitment fees up to 0.25%, expires May 20, 2019 — — Revolving credit loan, quarterly interest payments, LIBOR plus up to 1.40% and availability fee up to 0.25%, expires December 31, 2016 — — Total credit agreements 481,250 529.375 Total long-term debt 1,079,878 1,152.846 Current portion of long-term debt 73,125 45.625 Total debt $ 1,153,003 $ 1,198,471 On December 22. 2006. the Company entered into a Master Shelf and Note Purchase Agreement (the "Master Agreement") with a national insurance company (the "Purchaser"), The initial issuance of notes under the Master Agreement occurred on December 22, 2006, through the issuance of $25.0 million in Series C Senior Notes due December 22, 2016, with a fixed interest rate of 5.66% per year. On February 1, 2008, $25.0 million in Series D Senior Notes due January 15, 2015, with a fixed interest rate of 5.37% per year, were issued, On September 15, 2011, and pursuant to a Confirmation of Acceptance (the "Confirmation"), dated January 21, 2011, in connection with the Master Agreement, $100.0 million in Series E Senior Notes were issued and are due September 15, 2018, with a fixed interest rate of 4.50% per year. The Series E Senior Notes were issued for the sole purpose of retiring existing senior notes. On January 15, 2015, the Series D Notes were redeemed at maturity using cash proceeds to pay off the principal of $25.0 million plus any remaining accrued interest. As of December 31, 2015, there was an outstanding debt balance issued under the provisions of the Master Agreement of $125.0 million. On July 1, 2013, in conjunction with the acquisition of Beecher Carlson Holdings, Inc., the Company entered into a revolving loan agreement {the "Wells Fargo Agreement") with Wells Fargo Bank. N.A. that provided for a $50.0 million revolving line of credit (the "Wells Fargo Revolver"). The maturity date for the Wells Fargo Revolver is December 31, 2016, at which time all outstanding principal and unpaid interest will be due. On April 16, 2014, in connection with the signing of Brown & Brown, Irc, 72 the Credit Facility (as defined below) an amendment to the agreement was established to reduce the total revolving loan commitment from $50.0 million to $25.0 million. The Wells Fargo Revolver may be increased by up to $50.0 million (bring- ing the total amount available to $75.0 million). The calculation of interest and fees for the Wells Fargo Agreement is generally based on the Company's funded debt-to-EBITDA ratio. Interest is charged at a rate equal to 1.00% to 1.40% above LIBOR or 1.00% below the Base Rate, each as more fully described in the Wells Fargo Agreement. Fees include an up -front fee, an availability fee of 0.175% to 0,25%, and a letter of credit margin fee of 1.00% to 1.40%. The obligations under the Wells Fargo Revolver are unsecured and the Wells Fargo Agreement includes various covenants, limitations and events of default that are customary for similar facilities for similar borrowers. There were no borrowings against the Wells Fargo Revolver as of December 31, 2015 and 2014. On April 17, 2014, the Company entered into a credit agreement with 1PMorgan Chase Bank, N.A. as administrative agent and certain other banks as co -syndication agents and co -documentation agents (the "Credit Agreement"). The Credit Agreement in the amount of $1,350.0 million provides for an unsecured revolving credit facility (the "Credit Facility") in the initial amount of $800.0 million and unsecured term loans in the initial amount of $550.0 million, either or both of which may, subject to lenders' discretion, potentially be increased by up to $500.0 million. The Credit Facility was funded on May 20, 2014 in conjunction with the closing of the Wright acquisition, with the $550.0 million term loan being funded as well as a drawdown of $375.0 million on the revolving loan facility. Use of these proceeds was to retire existing term loan debt and to facilitate the closing of the Wright acquisition as well as other acquisitions. The Credit Facility terminates on May 20. 2019, but either or both of the revolving credit facility and the term loans may be extended for two additional one-year periods at the Company's request and at the discretion of the respective lenders. Interest and facility fees in respect to the Credit Facility are based on the better of the Company's net debt leverage ratio or a non-credit enhanced senior unsecured long-term debt rating. Based on the Company's net debt leverage ratio, the rates of interest charged on the term loan are 1.00% to 1.75%, and the revolving loan is 0.85% to 1.50% above the adjusted LIBOR rate for outstanding amounts drawn. There are fees included in the facility which include a facility fee based on the revolving credit commit- ments of the lenders (whether used or unused) at a rate of 0.15% to 0.25% and letter of credit fees based on the amounts of outstanding secured or unsecured letters of credit. The Credit Facility includes various covenants, limitations and events of default customary for similar facilities for similarly rated borrowers. As of December 31, 2015 and 2014, there was an outstanding debt balance issued under the provisions of the Credit Facility in total of $529.4 million and $550.0 million respectively, with no borrowings outstanding relative to the revolving loan. Per the terms of the agreement, scheduled principal payments of $48.1 million are due in 2016. On September 18, 2014, the Company issued $500.0 million of 4,20% unsecured senior notes due in 2024. The senior notes were given investment grade ratings of BBB-/Baa3 with a stable outlook. The notes are subject to certain covenant restrictions and regulations which are customary for credit rated obligations. At the time of funding, the proceeds were offered at a discount of the original note amount which also excluded an underwriting fee discount. The net proceeds received from the issuance were used to repay the outstanding balance of $475.0 million on the revolving Credit Facility and for other general corporate purposes. As of December 31, 2015 and 2014, there was an outstanding debt balance of $500.0 million exclusive of the associated discount balance. The Master Agreement. Wells Fargo Agreement and the Credit Agreement all require the Company to maintain certain financial ratios and comply with certain other covenants. The Company was in compliance with all such covenants as of December 31, 2015 and 2014. The 30-day Adjusted LIBOR Rate as of December 31, 2015 was 0.44%. Interest paid in 2015, 2014 and 2013 was $37.5 million, $25.1 million, and $16.5 million, respectively. At December 31, 2015, maturities of long-term debt were $73.1 million in 2016, $55.0 million in 2017, $155.0 million in 2018, $371.3 million in 2019 and $500.0 million in 2024. 73 2015 Annua; Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS NOTE 9 Income Taxes Significant components of the provision for income taxes for the years ended December 31 are as follows: (in thousands) 201S 2014 2013 Current: Federal State Foreign $ 118,440 $ 109,893 $ 94,007 17,625 15,482 13,438 430 109 805 Total current provision 136,545 125,484 108,250 Deferred: Federal State Foreign 18,416 5,987 28.469 4,280 1,440 3,723 — (58) 55 Total deferred provision 22,696 7,369 32,247 Total tax provision $ 159,241 $ 132,853 $ 140,497 A reconciliation of the differences between the effective tax rate and the federal statutory tax rate for the years ended December 31 is as follows: 2015 2014 2013 Federal statutory tax rate 35,0% 35.0% 35.0% State income taxes, net of federal income tax benefit 3.9 3.3 3.5 Non -deductible employee stock purchase plan expense 0.3 0.3 0.3 Non -deductible meals and entertainment 0.3 0.4 0.3 Other, net 0.1 0.1 0.2 Effective tax rate 39.6% 39.1% 39,3% Deferred income taxes reflect the net tax effects of temporary differences between the carrying amounts of assets and liabilities for financial reporting purposes and the corresponding amounts used for income tax reporting purposes. Significant components of Brown & Brown's current deferred tax assets as of December 31 are as follows: (in thousands) 2015 2014 Current deferred tax assets: Deferred profit-sharing contingent commissions $ 9,767 $ 10,335 Net operating loss carryforwards 10 951 Accruals and reserves 14,858 14,145 Total current deferred tax assets $ 24,635 $ 25,431 Brown & Brown, Inc. 74 Significant components of Brown & Brown's non -current deferred tax liabilities and assets as of December 31 are as follows: (in thousands) 2015 2014 Non -current deferred tax liabilities: Fixed assets $ 8,585 $ 10,368 Net unrealized holding {loss)/gain on available -for -sale securities (9) 56 Intangible assets 393,251 364,938 Total non -current deferred tax liabilities 401,827 375,362 Non -current deferred tax assets: Deferred compensation 38,966 31,580 Net operating loss carryforwards 2,518 2,796 Valuation allowance for deferred tax assets (606) (511) Total non -current deferred tax assets 40,878 33,865 Net non -current deferred tax liability $ 360,949 $ 341,497 Income taxes paid in 2015, 2014 and 2013 were $132.9 million, $118.3 million, and $110.2 million respectively. At December 31, 2015, Brown & Brown had net operating loss carryforwards of $184,218 and $61,217,003 for federal and state income tax reporting purposes, respectively, portions of which expire in the years 2016 through 2034. The federal carryforward is derived from insurance operations acquired by Brown & Brown in 2001. The state carryforward amount is derived from the operating results of certain subsidiaries and from the 2013 stock acquisition Beecher Carlson Holdings, Inc. A reconciliation of the beginning and ending amount of unrecognized tax benefits is as follows: (in thousands) 2015 2014 2013 Unrecognized tax benefits balance at January 1 $ 113 $ 391 $ 294 Gross increases for tax positions of prior years 773 — 232 Gross decreases for tax positions of prior years — (21) — Settlements (302) (257) (135) Unrecognized tax benefits balance at December 31 $ 584 $ 113 $ 391 The Company recognizes interest and penalties related to uncertain tax positions in income tax expense. As of December 31, 2015 and 2014, the Company had $102,171 and $65,772 of accrued interest and penalties related to uncertain tax positions, respectively. The total amount of unrecognized tax benefits that would affect the Company's effective tax rate if recognized was $583.977 as of December 31, 2015 and $113,032 as of December 31, 2014. The Company does not expect its unrecog- nized tax benefits to change significantly over the next 12 months. As a result of a 2006 Internal Revenue Service ("IRS") audit, the Company agreed to accrue at each December 31, for tax purposes only, a known amount of profit-sharing contingent commissions represented by the actual amount of profit- sharing contingent commissions received in the first quarter of the related year, with a true -up adjustment to the actual amount received by the end of the following March. Since this method for tax purposes differs from the method used for book purposes, it will result in a current deferred tax asset as of December 31 each year which will reverse by the following March 31 when the related profit-sharing contingent commissions are recognized for financial accounting purposes. 75 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS The Company is subject to taxation in the United States and various state jurisdictions. The Company is also subject to taxation in the United Kingdom. In the United States, federal returns for fiscal years 2012 through 2015 remain open and subject to examination by the IRS. The Company files and remits state income taxes in various states where the Company has determined it is required to file state income taxes. The Company's filings with those states remain open for audit for the fiscal years 2010through 2015. In the United Kingdom, the Company's filings remain open for audit for the fiscal years 2014 and 2015. The federal income tax returns of The Wright Insurance Group are currently under IRS audit for the year ended December 31, 2013 and the short period ended May 1, 2014. Also during 2015, the previously disclosed 2013 IRS audit of Beecher Carlson Holding, Inc. was closed with no adjustments. The Company's 2009 through 2012 State of Oregon tax returns were under audit in 2014. The audit was settled in early 2015 with the State of Oregon for an insignificant amount. The Company is currently under audit in the State of Kansas for fiscal years 2012 through 2014. There are no other federal or state income tax audits as of December 31, 2015. NOTE 10 Employee Savings Plan The Company has an Employee Savings Plan (401(k)) in which substantially all employees with more than 30 days of service are eligible to participate. Under this plan, Brown & Brown makes matching contributions of up to 4.0% of each participant's annual compensation. Prior to 2014, the Company's matching contribution was up to 2.5% of each participant's annual compensation with a discretionary profit-sharing contribution each year, which equaled 1.5% of each eligible employee's compensation. The Company's contributions to the plan totaled $17.8 million in 2015, $15.8 million in 2014, and $14.8 mil- lion in 2013. NOTE 11 Stock -Based Compensation Performance Stock Plan In 1996, Brown & Brown adopted and the shareholders approved a performance stock plan, under which until the suspen- sion of the plan in 2010, up to 14,400,000 Performance Stock Plan ("PSP") shares could be granted to key employees contingent on the employees' future years of service with Brown & Brown and other performance -based criteria estab- lished by the Compensation Committee of the Company's Board of Directors. Before participants may take full title to Performance Stock, two vesting conditions must be met. Of the grants currently outstanding, specified portions will satisfy the first condition for vesting based on 20% incremental increases in the 20-trading-day average stock price of Brown & Brown's common stock from the price on the business day prior to date of grant. Performance Stock that has satisfied the first vesting condition is considered "awarded shares." Awarded shares are included as issued and outstanding common stock shares and are included in the calculation of basic and diluted EPS. Dividends are paid on awarded shares and participants may exercise voting privileges on such shares. Awarded shares satisfy the second condition for vesting on the earlier of a participant's: (i) 15 years of continuous employment with Brown & Brown from the date shares are granted to the participants (or, in the case of the July 2009 grant to Powell Brown, 20 years); (II) attainment of age 64 (on a prorated basis corresponding to the number of years since the date of grant); or (iii) death or disability. On April 28, 2010, the PSP was suspended and any remaining authorized, but unissued shares, as well as any shares forfeited in the future, will be reserved for issuance under the 2010 Stock Incentive Plan (the "SIP"). At December 31, 2015, 5,266,707 shares had been granted under the PSP. As of December 31, 2015, 8,000 shares had not met the first condition for vesting, 1,594,214 shares had met the first condition of vesting and had been awarded, and 3,664,493 shares had satisfied both conditions of vesting and had been distributed to participants. Of the shares that have not vested as of December 31, 2015, the initial stock prices ranged from $8.75 to $25.68. The Company uses a path -dependent lattice model to estimate the fair value of PSP grants on the grant date. Brown & Brown, I nc. 76 A summary of PSP activity for the years ended December 31, 2015, 2014 and 2013 is as follows: Weighted -Average Shares Grant Date Fair Granted Awarded Not Yet Value Shares Shares Awarded Outstanding at January 1, 2013 $ 8.72 3,691,022 2,394,505 1,296,517 Granted $ - - - - Awarded $ 10.25 - 122.021 (122,021) Vested $ 4.01 (119,364) (119,364) - Forfeited $ 8.73 (1,200,371) (101,310) (1,099,061) Outstanding at December 31, 2013 $ 8.62 2,371,287 2,295,852 75,435 Granted $ - - - - Awarded $ - - - - Vested $ 16.76 (277,009) (277,009) Forfeited $ 9.75 (165,647) (115,630) (50,017) Outstanding at December 31, 2014 $ 8.71 1,928,631 1,903,213 25,418 Granted $ - - - - Awarded $ - - - - Vested $ 5.55 (208,889) (208.889) - Forfeited $ 9,78 (117,528) (100,110) (17,418) Outstanding at December 31, 2015 $ 9.03 1,602,214 1,594,214 8,000 The total fair value of PSP grants that vested during each of the years ended December 31, 2015, 2014 and 2013 was $6.8 million, $8.4 million and $3.7 million, respectively. Stock Incentive Plan On April 28, 2010, the shareholders of Brown & Brown, Inc. approved the Stock Incentive Plan ("SIP") that provides for the granting of stock options, stock and/or stock appreciation rights to employees and directors contingent on criteria estab- lished by the Compensation Committee of the Company's Board of Directors. The principal purpose of the SIP is to attract, incentivize and retain key employees by offering those persons an opportunity to acquire or increase a direct proprietary interest in the Company's operations and future success. The Si P includes a sub -plan applicable to Decus Insurance Brokers Limited ("Decus") which, is a subsidiary of Decus Holdings (U.K.) Limited. The shares of stock reserved for issuance under the SIP are any shares that are authorized for issuance under the PSP and not already subject to grants under the PSP, and that were outstanding as of April 28, 2010, the date of suspension of the PSP, together with PSP shares and SIP shares forfeited after that date. As of April 28, 2010, 6,046,768 shares were available for issuance under the PSP, which were then transferred to the SIP. To date, a substantial majority of stock grants to employees under the SIP vest in four -to -ten years, subject to the achievement of certain performance criteria by grantees, and the achievement of consolidated EPS growth at certain levels by the Company, over three -to -five-year measurement periods. In 2010, 187,040 shares were granted under the SIP. This grant was conditioned upon the surrender of 187,040 shares previously granted under the PSP in 2009, which were accordingly treated as forfeited PSP shares. The vesting conditions of this grant were identical to those provided for in connection with the 2009 PSP grant; thus the target stock prices and the periods associated with satisfaction of the first and second conditions of vesting were unchanged. Additionally, grants totaling 5,205 shares were made in 2010 to Decus employees under the SIP sub -plan applicable to Decus. In 2011, 2,375,892 shares were granted under the SIP. Of this total, 24,670 shares were granted to Decus employees under the SIP sub -plan applicable to Decus. In 2012, 814,545 shares were granted under the SIP, primarily related to the Arrowhead acquisition. 77 NOTES TO CONSOLIDATED FINANCIAL STATEMENTS In 2013, 3,719,974 shares were granted under the SIP. Of the shares granted in 2013, 891,399 shares will vest upon the grantees' completion of between three and seven years of service with the Company, and because grantees have the right to vote the shares and receive dividends immediately after the date of grant these shares are considered awarded and outstanding under the two -class method. In 2014, 422,572 shares were granted under the SIP Of the shares granted in 2014, 113,088 shares will vest upon the grantees' completion of between three and six years of service with the Company, and because grantees have the right to vote the shares and receive dividends immediately after the date of grant these shares are considered awarded and outstanding under the two -class method. As of December 31, 2014, no shares had met the first condition for vesting. In 2015, 481,166 shares were granted under the SIP. Of the shares granted in 2015,158,958 shares will vest upon the grantees' completion of between five and seven years of service with the Company, and because grantees have the right to vote the shares and receive dividends immediately after the date of grant these shares are considered awarded and outstanding under the two -class method. As of December 31, 2015, no shares had met the first condition for vesting. Additionally, non -employee members of the Board of Directors received shares annually issued pursuant to the SIP as part of their annual compensation. A total of 36,919 SIP shares were issued to these directors in 2011 and 2012, of which 11,682 were issued in January 2011,12,627 in January 2012, and 12,610 in December 2012. The shares issued in December 2012 were issued at that earlier time rather than in January 2013 pursuant to action of the Board of Directors. No additional shares were granted or issued to the non -employee members of the Board of Directors in 2013. A total of 9,870 shares were issued to these directors in January 2014 and 15,700 shares were issued in January 2015. At December 31, 2015, 2,793,832 shares were available for future grants. The Company uses the closing stock price on the day prior to the grant date to determine the fair value of SIP grants and then applies an estimated forfeiture factor to estimate the annual expense. Additionally, the Company uses the path - dependent lattice model to estimate the fair value of grants with PSP-type vesting conditions as of the grant date. SIP shares that satisfied the first vesting condition for PSP-like grants or the established performance criteria are considered awarded shares. Awarded shares are included as issued and outstanding common stock shares and are included in the calculation of basic and diluted EPS. A summary of 51 P activity for the years ended December 31, 2015, 2014 and 2013 is as follows: Weighted -Average Shores Grant Date Fair Granted Awarded Nat Yet Value Shares Shares Awarded Outstanding at January 1.2013 $ 22.91 3.157,311 37,408 3,119,903 Granted $ 31.95 3,719,974 — 3,719,974 Awarded $ 30.71 — 966,215 (966,215) Vested $ — — Forfeited $ 23.88 {271,184) (7,906) (263,278) Outstanding at December 31, 2013 $ 27.96 6.606,101 995,717 5,610,384 Granted $ 31.02 422,572 113,088 309,484 Awarded $ — — Vested $ — — — — Forfeited $ 27.41 (369,626) (47,915) (321,711) Outstanding at December 31, 2014 $ 28.19 6.659,047 1,060,890 5,598.157 Granted $ 31.74 481,166 164,646 316,520 Awarded $ — — — — Vested $ — — — — Forfeited $ 26.32 (863,241) (95,542) (767,699) Outstanding at December 31, 2015 $ 28.74 6,276,972 1,129,994 5,146,978 Brown & Brown, Inc. 78 Employee Stock Purchase Plan The Company has a shareholder -approved Employee Stock Purchase Plan ("ESPP") with a total of 17,000,000 authorized shares of which 5,194,928 were available for future subscriptions as of December 31, 2015. Employees of the Company who regularly work more than 20 hours per week are eligible to participate in the ESPP. Participants, through payroll deductions, may allot up to 10% of their compensation, up to a maximum of $25,000, to purchase Company stock between August 1st of each year and the following July 31st (the "Subscription Period") at a cost of 85% of the lower of the stock price as of the beginning or end of the Subscription Period. The Company estimates the fair value of an ESPP share option as of the beginning of the Subscription Period as the sum of: (1) 15% of the quoted market price of the Company's stock on the day prior to the beginning of the Subscription Period, and (2) 85% of the value of a one-year stock option on the Company stock using the Black-Scholes option -pricing model. The estimated fair value of an ESPP share option as of the Subscription Period beginning in August 2015 was $6.43. The fair values of an ESPP share Option as of the Subscription Periods beginning in August 2014 and 2013, were $6,39 and $8.36, respectively. For the ESPP plan years ended July 31, 2015, 2014 and 2013. the Company issued 539,389, 512,521, and 487,672 shares of common stock, respectively. These shares were issued at an aggregate purchase price of $14.4 million, or $26.62 per share, in 2015, $13.4 million, or $26.16 per share, in 2014, and $10.5 million, or $21.44 per share, in 2013. For the five months ended December 31, 2015, 2014 and 2013 (portions of the 2015-2016, 2014-2015 and 2013- 2014 plan years), 231,803; 235,794; and 222,526 shares of common stock (from authorized but unissued shares), respectively, were subscribed to by ESPP participants for proceeds of approximately $6.8 million, $6.3 million and $5.9 million, respectively. Incentive Stock Option Plan On April 21, 2000, Brown & Brown adopted, and the shareholders approved, a qualified incentive stock option plan (the "ISOP") that provides for the granting of stock options to certain key employees for up to 4,800,000 shares of common stock. On December 31, 2008, the ISOP expired. The objective of the ISOP was to provide additional performance incen- tives to grow Brown & Brown's pre-tax income in excess of 15% annually. The options were granted at the most recent trading day's closing market price and vest over a one -to -ten-year period, with a potential acceleration of the vesting period to three -to -six years based upon achievement of certain performance goals. All of the options expire 10 years after the grant date. The Company uses the Black-Scholes option -pricing model to estimate the fair value of stock options on the grant date. The risk -free interest rate is based upon the U.S. Treasury yield curve on the date of grant with a remaining term approxi- mating the expected term of the option granted.The expected term of the options granted is derived from historical data; grantees are divided into two groups based upon expected exercise behavior and are considered separately for valuation purposes. The expected volatility is based upon the historical volatility of the Company's common stock over the period of time equivalent to the expected term of the options granted. The dividend yield is based upon the Company's best estimate of future dividend yield. 79 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS A summary of stock option activity for the years ended December 31, 2015, 2014 and 2013 is as follows: Stock options Weighted- Weighted- Average Aggregate Shares Average Remaining Intrinsic Under Exercise Contractual Value Option Price Term (in years) (in thousands) Outstanding at January 1,2013 738,792 $ 18.39 4.9 $ 8.891 Granted Exercised Forfeited Expired — $ (115,847) $ 17.56 — $ — $ Outstanding at December 31.2013 622,945 $ 18.55 4.1 $ 7,289 Granted — $ — Exercised (106,589) $ 18.48 Forfeited (46,000) $ 18.48 Expired Outstanding at December 31, 2014 470,356 $ 18.57 3,1 $ 5.087 Granted — $ — Exercised (151,767) $ 18.48 Forfeited (49,000) $ 19.36 Expired Outstanding at December 31, 2015 269,589 $ 18.48 2.2 $ 2.395 Ending vested and expected to vest at December 31, 2015 Exercisable at December 31, 2015 Exercisable at December 31, 2014 Exercisable at December 31, 2013 269,589 $ 18.48 2.2 $ 2,395 164,589 $ 18.48 2.2 $ 2,241 316,356 $ 18.48 3.2 $ 4,565 422,945 $ 18.48 4.2 $ 5,460 The following table summarizes information about stock options outstanding at December 31, 2015: Exercise Price Options Outstanding Options Exercisable Weighted - Average Weighted- Weighted - Remaining Average Average Number Contractual Exercise Number Exercise Outstanding Life (years) Price Exercisable Price $18.48 269,589 2.2 $ 18.48 164,589 $ 18.48 Totals 269,589 2.2 $ 18.48 164,589 $ 18.48 The total intrinsic value of options exercised, determined as of the date of exercise. during the years ended December 31, 2015, 2014 and 2013 was $2.2 million. $1.3 million and $1.6 million, respectively. The total intrinsic value is calculated as the difference between the exercise price of all underlying awards and the quoted market price of the Company's stock for all in -the -money stock options at December 31, 2015, 2014 and 2013, respectively. There are no option shares available for future grant under the ISOP since this plan expired as of December 31, 2008. Brown & Brown, Inc. 80 Summary of Non -Cash Stock -Based Compensation Expense The non -cash stock -based compensation expense for the years ended December 31 is as follows: (in thousands) 2015 2014 2013 Stock Incentive Plan $ 11,111 $ 14,447 $ 15,934 Employee Stock Purchase Plan 3,430 2,425 3,538 Performance Stock Plan 972 2,354 2,310 Incentive Stock Option Plan 137 821 Total $ 15,513 $ 19,363 $ 22,603 Summary of Unrecognized Compensation Expense As of December 31, 2015, there was approximately $115.0 million of unrecognized compensation expense related to all non -vested share -based compensation arrangements granted under the Company's stock -based compensation plans. That expense is expected to be recognized over a weighted -average period of 5.1 years. NOTE 12 Supplemental Disclosures of Cash Flow Information and Non -Cash Financing and Investing Activities Our Restricted Cash balance is comprised of funds held in separate premium trust accounts as required by state law or, in some cases, per agreement with our carrier partners. In the second quarter of 2015, certain balances that had previously been reported as held in restricted premium trust accounts were reclassified as non -restricted as they were not restricted by state law or by contractual agreement with a carrier. The resulting impact of this change was a reduction in the balance reported on our Consolidated Balance Sheet as Restricted Cash and investments and a corresponding increase in the balance reported as Cash and Cash Equivalents of approximately $33.0 million as of December 31, 2015 as compared to the corresponding account balances as of December 31, 2014 of $32.2 million which was reflected as Restricted Cash. While these referenced funds are not restricted, they do represent premium payments from customers to be paid to insurance carriers and this change in classification should not be viewed as a source of operating cash. (in thousands) For the Year Ended December 31, 201S 2014 2013 Cash paid during the period for: Interest Income taxes $ 37,542 $ 25,115 $ 16,501 $ 132,874 $ 118,290 $ 110,190 Brown & Brown's significant non -cash investing and financing activities are summarized as follows: (in thousands) For the Year Ended December 31, 2015 2014 2013 Other payables issued for purchased customer accounts Estimated acquisition earn -out payables and related charges Notes received on the sale of fixed assets and customer accounts $ 10,029 $ 1,930 $ 1,425 $ 36.899 $ 33,229 $ 5,091 $ 7,755 $ 6,340 $ 1,108 81 NOTES TO CONSOLIDATED FINANCIAL STATEMENTS NOTE 13 Commitments and Contingencies Operating Leases Brown & Brown leases facilities and certain items of office equipment under non -cancelable operating lease arrangements expiring on various dates through 2042. The facility leases generally contain renewal options and escalation clauses based upon increases in the lessors' operating expenses and other charges. Brown & Brown anticipates that most of these leases will be renewed or replaced upon expiration. At December 31, 2015, the aggregate future minimum lease payments under all non -cancel able lease agreements were as follows: (in thousands) 2016 $ 40,900 2017 37,109 2018 31.612 2019 25,962 2020 21,283 Thereafter 38.406 Total minimum future lease payments $ 195,272. Rental expense in 2015, 2014 and 2013 for operating leases totaled $46.0 million, $49.0 million, and $43.0 million. respectively. Legal Proceedings The Company records losses for claims in excess of the limits of, or outside the coverage of, applicable insurance at the time and to the extent they are probable and estimable. In accordance with ASC Topic 450-Contingencies, the Company accrues anticipated costs of settlement, damages, losses for liability claims and, under certain conditions, costs of defense, based on historical experience or to the extent specific losses are probable and estimable. Otherwise, the Company expenses these costs as incurred. If the best estimate of a probable Toss is a range rather than a specific amount, the Company accrues the amount at the lower end of the range. The Company's accruals for legal matters that were probable and estimable were not material at December 31, 2015 and 2014. We continue to assess certain litigation and claims to determine the amounts, if any, that management believes will be paid as a result of such claims and litigation and, therefore, additional losses may be accrued and paid in the future, which could adversely impact the Company's operating results, cash flows and overall liquidity. The Company maintains third -party insurance policies to provide coverage for certain legal claims, in an effort to mitigate its overall exposure to unanticipated claims or adverse decisions. However, as (i) one or more of the Company's insurance carriers could take the position that portions of these claims are not covered by the Company's insurance, l{ii) to the extent that payments are made to resolve claims and lawsuits, applicable insurance policy limits are eroded and (Hi) the claims and lawsuits relating to these matters are continuing to develop, it is possible that future results of operations or cash flows for any particular quarterly or annual period could be materially affected by unfavorable resolutions of these matters. Based on the AM Best Company ratings of these third -party insurers, management does not believe there is a substantial risk of an insurer's material nonperformance related to any current insured claims. On the basis of current information, the availability of insurance and legal advice, in management's opinion, the Company is not currently involved in any legal proceedings which, individually or in the aggregate, would have a material adverse effect on its financial condition, operations and/or cash flows. Brown & Brown. Inc. 82 NOTE 14 Quarterlg Operating Results (Unaudited) Quarterly operating results for 2015 and 2014 were as follows: (in thousands, except per share data) First Second Third Fourth Quarter Quarter Quarter Quarter 2015 Total revenues $ 404,298 $ 419,447 $ 432,167 $ 404,597 Total expenses $ 310,520 $ 318,533 $ 319,337 $ 309,560 Income before income taxes $ 93,778 $ 100,914 $ 112,830 $ 95,037 Net income $ 56,951 $ 61,005 $ 67,427 $ 57,935 Net income per share: Basic $ 0.40 $ 0.43 $ 0.48 $ 0,41 Diluted $ 0.39 $ 0.43 $ 0.47 $ 0.41 2014 Total revenues $ 363,594 $ 397,764 $ 421,418 $ 393,020 Total expenses $ 276,757 $ 295,983 $ 308,733 $ 354,574Y11 Income before income taxes $ 86,837 $ 101,781 $ 112,685 $ 38,44611' Net income $ 52,415 $ 61,755 $ 68,331 $ 24,395,11 Net income per share: Basic $ 0.36 $ 0.43 $ 0.47 $ 0.17 Diluted $ 0.36 $ 0.42 $ 0.47 $ 0.17 (1)The Company recognized a pre-tax Joss on disposal of $47.4 million as a result of the safe of Axiom effective December 31.2014. The sale was part of the Company's strategy to exit the reinsurance brokerage business. Quarterly financial results are affected by seasonal variations. The timing of the Company's receipt of profit-sharing contingent commissions, policy renewals and acquisitions may cause revenues, expenses and net income to vary signifi- cantly between quarters. NOTE 15 Segment Information Brown & Brown's business is divided into four reportable segments: (1) the Retail Segment, which provides a broad range of insurance products and services to commercial, public and quasi -public entities. and to professional and individual custom- ers; (2) the National Programs Segment, which acts as a MGA, provides professional liability and related package products for certain professionals, a range of insurance products for individuals, flood coverage, and targeted products and services designated for specific industries. trade groups, governmental entities and market niches, all of which are delivered through nationwide networks of independent agents, and Brown & Brown retail agents; (3) the Wholesale Brokerage Segment, which markets and sells excess and surplus commercial and personal lines insurance, primarily through independent agents and brokers, as well as Brown & Brown retail agents; and (4) the Services Segment, which provides insurance -related services, including third -party claims administration and comprehensive medical utilization management services in bath the workers' compensation and all -lines liability arenas, as well as Medicare Set -aside services, Social Security disability and Medicare benefits advocacy services and claims adjusting services. 83 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL STATEMENTS Brown & Brown conducts all of its operations within the United States of America, except for a wholesale brokerage operation based in London, England, and retail operations in Bermuda and the Cayman Islands. These operations earned $13.4 million, $13.3 million and $12.2 million of total revenues for the years ended December 31, 2015, 2014 and 2013, respectively. Long-lived assets held outside of the United States during each of these three years were not material. The accounting policies of the reportable segments are the same as those described in Note 1. The Company evaluates the performance of its segments based upon revenues and income before income taxes. Inter -segment revenues are eliminated. Summarized financial information concerning the Company's reportable segments is shown in the following table. The "Other" column includes any income and expenses not allocated to reportable segments and corporate -related items, including the inter -company interest expense charge to the reporting segment. Segment results for prior periods have been recast to reflect the current year segmental structure. Certain reclassifica- tions have been made to the prior -year amounts reported in this Annual Report on Form 10-K in order to conform to the current year presentation. {in thousands) For the year ended December 31.2015 National Wholesale Retail Programs Brokerage Services Other Total Total revenues $ 870,346 $ 428,734 $ 216,996 $ 145,365 $ (932) $1,660,509 Investment income $ 87 $ 210 $ 150 $ 42 $ 515 $ 1,004 Amortization $ 45,145 $ 28,479 $ 9,739 $ 4,019 $ 39 $ 87,421 Depreciation $ 6,558 $ 7,250 $ 2,142 $ 1,988 $ 2,952 $ 20,890 Interest expense $ 41,036 $ 55,705 $ 891 $ 5,970 $ (64,354) $ 39,248 Income before income taxes $ 181,938 $ 67,673 $ 64,708 $ 19,713 $ 68,527 $ 402,559 Total assets $ 3,507,476 $2,505,752 $ 895,782 $ 285,459 $ (2,181,730) $5,012,739 Capital expenditures $ 6,797 $ 6,001 $ 3,084 $ 1,088 $ 1,405 $ 18,375 (in thousands) For the year ended December 31.2014 National Wholesale Retail Programs Brokerage Services Other Total Total revenues $ 823,686 $ 404,239 $ 211,911 $ 136,558 $ (598) $ 1,575,796 Investment income $ 67 $ 164 $ 26 $ 3 $ 487 $ 747 Amortization $ 42,935 $ 25,129 $ 10,703 $ 4,135 $ 39 $ 82.941 Depreciation $ 6,449 $ 7,805 $ 2,470 $ 2,213 $ 1,958 $ 20,895 Interest expense $ 43,502 $ 49,663 $ 1,294 $ 7,678 $ (73,729) $ 28,408 Income before income taxes $ 157,491 $ 73,178 $ 8,276 $ 17,870 $ 82,934 $ 339,749 Total assets $ 3,229,484 $ 2,455,749 $ 857,804 $ 296,034 $ {1,882,613) $ 4,956,458 Capital expenditures $ 6,873 $ 14,133 $ 1,526 $ 1,210 $ 1.181 $ 24,923 Brown & Brown. Inc. 84 (in thousands) For the year ended December 31.2013 National Wholesale Retail Programs Brokerage Services other Total Total revenues $ 737,349 $ 301,372 $ 193,710 $ 131,489 $ (641) $1,363,279 Investment income $ 82 $ 19 $ 22 $ 1 $ 514 $ 638 Amortization $ 38,523 $ 14,953 $ 10,719 $ 3,698 $ 39 $ 67,932 Depreciation $ 5,874 $ 5,492 $ 2,674 $ 1,623 $ 1,822 $ 17,485 Interest expense $ 34,658 $ 24,014 $ 2,316 $ 7,322 $ (51,870) $ 16,440 Income before income taxes $ 161,787 $ 61,223 $ 47,501 $ 25,791 $ 61,307 $ 357,609 Total assets $ 3,012,688 $1,377,404 $ 865,731 $ 277,652 $ (1,883,967) $3,649,508 Capital expenditures $ 6,886 $ 4,810 $ 1.825 $ 1.811 $ 1,034 $ 16,366 NOTE 16 Losses and Loss Adjustment Reserve Although the reinsurers are liable to the Company for amounts reinsured, our subsidiary, Wright Flood remains primarily liable to its policyholders for the full amount of the policies written whether or not the reinsurers meet their obligations to the Company when they become due. The effects of reinsurance on premiums written and earned at December 31, are as follows: (in thousands) 2015 2014 Written Earned Written Earned Direct premiums $ 599,828 $ 610,753 $ 439,828 $ 408,056 Assumed premiums - 18 (1) 199 Ceded premiums 599.807 610,750 439,819 408,246 Net premiums $ 21 $ 21 $ 8 $ 8 Ali premiums written by Wright Flood under the National Flood Insurance Program are 100% ceded to FEMA, for which Wright Flood received a 30.8% expense allowance from January 1, 2015 through September 30, 2015 and 30.9% from October 1, 2015 through December 31, 2015. As of December 31, 2015 and 2014, the Company ceded $598.4 million and $439.1 million of written premiums, respectively. Effective April 1. 2014, Wright Flood is also a party to a quota share agreement whereby it cedes 100% of its gross excess flood premiums, which excludes fees, to Arch Reinsurance Company and receives a 30.5% commission. Wright Flood ceded $1.4 million and $0,8 million for the years ended December 31, 2015 and 2014. No loss data exists on this agreement. Wright Flood also ceded 100%, to Arch Reinsurance Company, of the Homeowners, Private Passenger Auto Liability, and Other Liability Occurrence to Stillwater Insurance Company, formerly known as Fidelity National Insurance Company. This business is in runoff. Therefore, only loss data still exists on this business. As of December 31, 2015, ceded unpaid losses and loss adjustment expenses for Homeowners, Private Passenger Auto Liability and Other Liability Occurrence was $8,698, $16,132 and $4,179, respectively. The incurred but not reported balance was $10,335 for Homeowners, $14,383 for Private Passenger Auto Liability and $8,456 for Other Liability Occurrence. 85 2015 Annual Report NOTES TO CONSOLIDATED FINANCIAL. STATEMENTS The reinsurance recoverable balance as of December 31, 2015 was $341.6 million and was comprised of recoverables on unpaid losses and loss expenses of $32.0 million and prepaid reinsurance premiums of $309.6 million. The reinsurance recoverable balance as of December 31, 2014 was $333.6 million that is comprised of recoverables on unpaid losses and loss expenses of $13.0 million and prepaid reinsurance premiums of $320.6 million There was no net activity in the reserve for losses and loss adjustment expense for the years ended December 31, 2015 and 2014, as Wright Flood's direct premi- ums written were 100% ceded to three reinsurers. The balance of the reserve for losses and loss adjustment expense, excluding related reinsurance recoverable was $32.0 million as of December 31, 2015 and $13.0 million as of December 31, 2014. NOTE 17 Statutory Financial Information Wright Flood maintains minimum amounts of statutory capital and surplus of $7.5 million as required by regulatory authorities. Wright Flood's statutory capital and surplus exceeded their respective minimum statutory requirements. The statutory capital and surplus of Wright Flood was $15.1 million as of December 31. 2015 and $10.9 million as of December 31, 2014, As of December 31, 2015 and 2014, Wright Flood generated statutory net income of $4.1 million and $2.3 million, respectively. NOTE 18 Subsidiary Dividend Restrictions Under the insurance regulations of Texas, the maximum amount of ordinary dividends that Wright Flood can pay to share- holders in a rolling twelve month period is limited to the greater of 10% of statutory adjusted capital and surplus as shown on Wright Floods last annual statement on file with the superintendent of the Texas Department of Insurance or 100% of adjusted net income. As an extraordinary dividend of $7.0 million was paid on May 20, 2014, no ordinary dividend could be paid until May 21, 2015. There was no dividend payout in 2015 and the maximum dividend payout that may be made in 2016 without prior approval is $4.1 million. NOTE 19 Shareholders' Equity On July 18, 2014, the Company's Board of Directors authorized the repurchase of up to $200.0 million of its shares of common stock. This was in addition to the $25.0 million that was authorized in the first quarter and executed in the second quarter of 2014. On September 2, 2014, the Company entered into an accelerated share repurchase agreement ("ASR") with an investment bank to purchase an aggregate $50.0 million of the Company's common stock. The total number of shares purchased under the ASR of 1.539,760 was determined upon settlement of the final delivery and was based on the Company's volume weighted average price per its common share over the ASR period less a discount. On March 5, 2015, the Company entered into an ASR with an investment bank to purchase an aggregate $100.0 million of the Company's common stock. As part of the ASR, the Company received an initial delivery of 2,667,992 shares of the Company's common stock with a fair market value of approximately $85.0 million. On August 6, 2015, the Company was notified by its investment bank that the March 5, 2015 ASR agreement between the Company and the investment bank had been completed in accordance with the terms of the agreement. The investment bank delivered to the Company an addi- tional 391,637 shares of the Company's common stock for a total of 3,059,629 shares repurchased under the agreement. The delivery of the remaining 391,637 shares occurred on August 11, 2015. At the conclusion of this contract the Company had authorization for $50.0 million of share repurchases under the original Board authorization. On July 20, 2015, the Company's Board of Directors authorized the repurchase of up to an additional $400.0 million of the Company's outstanding common stock. With this authorization, the Company had total available approval to repur- chase up to $450 million, in the aggregate, of the Company's outstanding common stock, Brown & Brown, Inc. 86 On November 11, 2015, the Company entered into a third ASR with an investment bank to purchase an aggregate $75 million of the Company's common stock. The Company received an initial delivery of 1,985,981 shares of the Company's common stock with a fair market value of approximately $63.75 million. On January 6, 2016 this agreement was completed by the investment bank with the delivery of 363,209 shares of the Company's common stock. After completion of this third ASR, the Company has approval to repurchase up to $375.0 million, in the aggregate, of the Company's outstanding common stock. Under the authorization frorn the Company's Board of Directors, shares may be purchased from time to time, at the Company's discretion and subject to the availability of stock, market conditions, the trading price of the stock, alternative uses for capital, the Company's financial performance and other potential factors. These purchases may be carried out through open market purchases, block trades, accelerated share repurchase plans of up to $100.0 million each (unless otherwise approved by the Board of Directors), negotiated private transactions or pursuant to any trading plan that may be adopted in accordance with Rule 10b5-1 of the Securities Exchange Act of 1934. 87 2015 AflnL. �c cr. GAAP RECONCILIATION GAAP Reconciliation -Income Before Income Taxes to Operating Profit and Adjusted Operating Profit (in thousands, except per share data) 2015 2014 2013 2012 2011 Retail Total revenues $ 870,346 $ 823.686 $ 737,349 $ 652,064 $ 614,093 Income before income taxes 181.938 157,491 161,787 141,918 135,856 Amortization 45,145 42.935 38.523 35,117 33.806 Depreciation 6.558 6,449 5.874 5.209 5,064 Interest 41.036 43,502 34,658 27,021 28,197 Change in estimated acquisition earn -out payables 2.006 7,458 (1,427) 1,988 (5,415) Operating Profit $ 276.683 $ 257,835 $ 239.415 $ 211,253 $ 197,508 Operating Prafit Margin 31.8% 31.3% 32.5% 32.4% 32.2% Less non -cash stock -based compensation adjustment (5.524) - - - - Adjusted Operating Prafit Adjusted Operating Profit Margin $ 271.159 31.2% $ 257,835 31.3% $ 239,415 32.5% $ 211,253 32.4 % S 197.508 32.2% National Programs Total revenues $ 428,734 $ 404,239 $ 301,372 $ 260,368 $ 169,666 Income before income taxes 67.673 73,178 61,223 53.986 61,980 Amortization 28,479 25,129 14,953 14,296 8,130 Depreciation 7,250 7,805 5,492 4,671 2,983 Interest 55.705 49.663 24,014 25,697 1,548 Change in estimated acquisition earn -out payables 158 315 (808) (1,075) (508) Operating Profit $ 159,265 $ 156,090 $ 104,874 $ 97,575 $ 74,133 Operating Profit Margin 37.1 % 38.6% 34.8 % 37.5% 43.7% Less non -cash stock -based compensation adjustment - (3,700) - --- - Adjusted Operating Profit Adjusted Operating Profit Margin $ 159.265 $ 152.390 $ 104,874 $ 97,575 $ 74,133 37.1 % 37.7% 34.8 % 37.5 % 43.7% Wholesale Total revenues $ 216,996 $ 211,911 $ 193,710 $ 168,239 $ 161,948 Income before income taxes 64.708 8.276 47,501 37,834 31,666 Amortization 9,739 10,703 10,719 10,441 10,239 Depreciation 2,142 2.470 2.674 2.619 2,529 Interest 891 1,294 2,316 3,594 6,819 Change in estimated acquisition earn -out payables 830 2,550 1,986 110 691 Operating Profit $ 78.310 $ 25.293 $ 65,196 $ 54.598 $ 51,944 Operating Profit Margin 36.1% 11.9% 33.7% 32.5% 32.1% Less loss on disposai - 47,425 - - -- Adjusted Operating Profit Adjusted Operating Profit Margin $ 78,310 36.1% $ 72,718 34.3 % $ 65.196 33.7% $ 54,598 32.5% $ 51,944 32.1% Services Total revenues $ 145,365 $ 136,558 $ 131,489 $ 117,486 $ 65,822 income before income taxes 19,713 17,870 25,791 17,233 8,099 Amortization 4.019 4.135 3,698 3,680 2,541 Depreciation 1,988 2,213 1.623 1,278 591 Interest 5,970 7,678 7,322 8.602 5,746 Change in estimated acquisition earn -out payables 9 {385) 2,782 395 3,026 Operating Profit $ 31,699 $ 31,511 $ 41,216 $ 31.188 $ 20,003 Operating Profit Margin 21.8% 23.1% 31,3% 26.5% 30.4% Less non -cash stock -based compensation adjustment - (821) - - - Adjusted Operating Profit Adjusted Operating Profit Margin $ 31,699 21.8 % $ 30,690 22.5 % GAAP Earnings Per Share Reconciliation to Earnings Per Share -Adjusted $ 41.216 31.3% $ 31.188 26.5% 2015h" 2014 S Change %Change GAAP earnings per share -as reported $ 1.70 $ 1.41 S 0.29 Loss on disposal - 0.21 (0.21) Non -cash stock based compensation adjustment (0.03) (0.03) - Change in estimated acquisition earn -out payables 0.01 0.04 (0.03) Earnings per share -adjusted $ 1.67 $ 1,63 $ 0.04 (1) Column does not add. due to the cumulative effect of rounding on individual items 20.6% 2.5% $ 20.003 30.4 % Brown & Brown, Inc. 88 REPORT OF INDEPENDENT REGISTERED PUBLIC ACCOUNTING FIRM To the Board of Directors and Shareholders of Brown & Brown, Inc. Daytona Beach, Florida We have audited the accompanying consolidated balance sheets of Brown & Brown, Inc. and subsidiaries (the "Company") as of December 31, 2015 and 2014, and the related consolidated statements of income, shareholders' equity, and cash flows for each of the three years in the period ended December 31, 2015, These financial statements are the responsibility of the Company's management. Our responsibility is to express an opinion on the financial statements based on our audits. We conducted our audits in accordance with the standards of the Public Company Accounting Oversight Board (United States). Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. An audit also includes assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. We believe that our audits provide a reasonable basis for our opinion. In our opinion, such consolidated financial statements present fairly, in all material respects, the financial position of Brown & Brown, Inc. and subsidiaries as of December 31, 2015 and 2014, and the results of their operations and their cash Flaws for each of the three years in the period ended December 31, 2015, in conformity with accounting principles generally accepted in the United States of America. We have also audited, in accordance with the standards of the Public Company Accounting Oversight Board (United States), the Company's internal control over financial reporting as of December 31, 2015, based on the criteria established in internal Control - Integrated Framework (2013) issued by the Committee of Sponsoring Organizations of the Treadway Commission and our report dated February 25, 2016 expressed an unqualified opinion on the Company's internal control over financial reporting. Certified Public Accountants Miami, Florida February 25, 2016 89 REPORT OF INDEPENDENT REGISTERED PUBLIC ACCOUNTING FIRM To the Board of Directors and Shareholders of Brown & Brown, Inc. Daytona Beach, Florida We have audited the internal control over financial reporting of Brown & Brown, Inc. and subsidiaries (the "Company") as of December 31, 2015, based on criteria established in fnterna! Control - integrated Framework (2013) issued by the Committee of Sponsoring Organizations of the Treadway Commission. As described in Management's Report on Internal Control Over Financial Reporting, management excluded from its assessment the internal control over financial reporting at Spain Agency, Inc, Strategic Benefit Advisors, LLC, Bellingham Underwriters, Inc., MBA Insurance Agency of Arizona, Inc. and Smith Insurance, Inc. (collectively the '2015 Excluded Acquisitions"), which were acquired during 2015 and whose financial statements constitute 2.91% of total assets, 1.03% of revenues, and (0.03%) of net income of the consolidated financial statement amounts as of and for the year ended December 31, 2015. Accordingly, our audit did not include the internal control over financial reporting of the 2015 Excluded Acquisitions. The Company's management is responsible for maintaining effective internal control over financial reporting and for its assessment of the effectiveness of internal control over financial reporting, included in the accompanying Management's Report on Internal Control Over Financial Reporting. Our responsibility is to express an opinion on the Company's internal control over financial reporting based on our audit. We conducted our audit in accordance with the standards of the Public Company Accounting Oversight Board (United States). Those standards require that we plan and perform the audit to obtain reasonable assurance about whether effective internal control over financial reporting was maintained in all material respects. Our audit included obtaining an under- standing of internal control over financial reporting, assessing the risk that a material weakness exists, testing and evaluating the design and operating effectiveness of internal control based on the assessed risk, and performing such other procedures as we considered necessary in the circumstances. We believe that our audit provides a reasonable basis for our opinion. A company's internal control over financial reporting is a process designed by, or under the supervision of, the com- pany's principal executive and principal financial officers, or persons performing similar functions, and effected by the company's board of directors, management, and other personnel to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles. A company's internal control over financial reporting includes those policies and proce- dures that (1) pertain to the maintenance of records that, in reasonable detail, accurately and fairly reflect the transactions and dispositions of the assets of the company; (2) provide reasonable assurance that transactions are recorded as necessary to permit preparation of financial statements in accordance with generally accepted accounting principles, and that receipts and expenditures of the company are being made only in accordance with authorizations of management and directors of the company; and (3) provide reasonable assurance regarding prevention or timely detection of unauthorized acquisition, use, or disposition of the company's assets that could have a material effect on the financial statements. Because of the inherent limitations of internal control over financial reporting, including the possibility of collusion or improper management override of controls, material misstatements due to error or fraud may not be prevented or detected on a timely basis. Also, projections of any evaluation of the effectiveness of the internal control over financial reporting to future periods are subject to the risk that the controls may become inadequate because of changes in conditions, or that the degree of compliance with the policies or procedures may deteriorate. In our opinion, the Company maintained, in all material respects, effective internal control over financial reporting as of December 31, 2015, based on the criteria established in Internal Control - Integrated Framework (2013) issued by the Committee of Sponsoring Organizations of the Treadway Commission. We have also audited, in accordance with the standards of the Public Company Accounting Oversight Board (United States), the consolidated financial statements as of and for the year ended December 31. 2015 of the Company and our report dated February 25, 2016 expressed an unqualified opinion on those financial statements. Certified Public Accountants Miami, Florida February 25, 2016 Brown & Brown, inc. 90 MANAGEMENT'S REPORT ON INTERNAL CONTROL OVER FINANCIAL REPORTING The management of Brown & Brown, Inc. and its subsidiaries ("Brown & Brown") is responsible for establishing and maintaining adequate internal control over financial reporting, as such term is defined in Securities Exchange Act Rule 13a-15(f), Under the supervision and with the participation of management, including Brown & Brown's principal executive officer and principal financial officer, Brown & Brown conducted an evaluation of the effectiveness of internal control over financial reporting based on the framework in Internal Control - Integrated Framework (2013) issued by the Committee of Sponsoring Organizations of the Treadway Commission ("COSO"). In conducting Brown & Brown's evaluation of the effectiveness of its internal control over financial reporting, Brown & Brown has excluded the following acquisitions completed during 2015: Spain Agency, Inc, Strategic Benefit Advisors, LLC, Bellingham Underwriters, Inc., MBA Insurance Agency of Arizona, Inc. and Smith Insurance, Inc. (collectively the "2015 Excluded Acquisitions"), which were acquired during 2015 and whose financial statements constitute 2.91% of total assets, 1.03% of revenues, and (0.03%) of net income of the Consolidated Financial Statement amounts as of and for the year ended December 31, 2015. Refer to Note 2 to the Consolidated Financial Statements for further discussion of these acquisitions and their impact on Brown & Brown's Consolidated Financial Statements. Based on Brown & Brown's evaluation under the framework in Internal Control - Integrated Framework (2013) issued by the Committee of Sponsoring Organizations of the Treadway Commission, management concluded that internal control over financial reporting was effective as of December 31, 2015. Management's internal control over financial reporting as of December 31, 2015 has been audited by Deloitte & Touche LLP, an independent registered public accounting firm, as stated in their report which is included herein. Brown & Brown, Inc. Daytona Beach, Florida February 25, 2016 417.1„ J. Powell Brown Chief Executive Officer R. Andrew Watts Executive Vice President, Chief Financial Officer and Treasurer 91 2,0' 5 ,^. } t. a ? P .9tD PERFORMANCE GRAPH The following graph is a comparison of five-year cumulative total stockholder returns for our common stock as compared with the cumulative total stockholder return for the NYSE Composite Index, and a group of peer insurance broker and agency companies (Aon plc, Arthur J. Gallagher & Co, Marsh & McLennan Companies, and Willis Towers Watson Public Limited Company). The returns of each company have been weighted according to such companies' respective stock market capitalizations as of December 31, 2010 for the purposes of arriving at a peer group average. The total return calculations are based upon an assumed $100 investment on December 31, 2010, with all dividends reinvested. 12/10 12/11 12/12 12/13 12/14 12/15 Brown & Brown, Inc. 100.00 95.89 109.34 136.39 144.78 143.21 NYSE Composite 100.00 96.52 112.00 141.19 150.78 144.91 Peer Group 100.00 114.10 122.00 174.63 193.51 191.50 Comparison of 5 Year Cumulative Total Return* Among Brown & Brown, Inc., the NYSE Composite Index, and a Peer Group $250 $225 $200 $175 1 $150 $125 $100 $75 $50 $25 $0 1 12/10 12/11 12/12 12/13 12/14 12/15 II Brown & Brown, Inc. NYSE Composite • Peer Group -$100 invested on 12/31/10 in stock or index, including reinvesting of dividends. Fiscal year ending December 31. P, 92 SHAREHOLDER INFORMATION Corporate Offices 220 South Ridgewood Avenue Daytona Beach, Florida 32114 (386) 252-9601 Outside Counsel Holland & Knight LLP 200 South Orange Avenue Suite 2600 Orlando, Florida 32801 Corporate Information and Shareholder Services The Company has included, as Exhibits 31.1 and 31.2, and 32.1 and 32.2 to its Annual Report on Form 10-K for the fiscal year 2015 filed with the Securities and Exchange Commission, certificates of the Chief Executive Officer and Chief Financial Officer of the Company certifying the quality of the Company's pub- lic disclosure. The Company has also submitted to the New York Stock Exchange a certificate from its Chief ExecutiveOfficer certifying that he is not aware of any violation by the Company of New York Stock Exchange corporate governance listing standards. A copy of the Company's 2015 Annual Report on Form 10-Kwill be furnished without charge to any shareholder who directs a request in writing to: Corporate Secretary Brown & Brown, inc. 220 South Ridgewood Avenue Daytona Beach, Florida 32114 A reasonable charge will be made for copies of the exhibits to the Form 10-K. Annual Meeting The Annual Meeting of Shareholders of Brown & Brown. Inc. will be held: May 4, 2016 9:00 a.m. (EDT) The Shores Resort 2637 South Atlantic Avenue Daytona Beach, Florida 32118 desved and produced by see see eye At area 5, San Anton o Transfer Agent and Registrar American Stock Transfer & Trust Company, LLC 6201 15th Ave. Brooklyn, New York 11219 (800) 937-5449 email: info@amstock.com www.amstock,com Independent Registered Public Accounting Firm Deloitte & Touche LLP 333 SE 2nd Avenue Suite 3600 Miami, Florida 33131 Stock Listing The New York Stock Exchange Symbol: BRO On February 22. 2016, there were 138,616,818 shares of our common stock outstanding, held by approximately 1,119 shareholders of record. Market Price of Common Stock Stock Price Range 2015 High Cash Dividends per Low Common Share First Quarter $ 33.34 $ 30.47 $ 0.11 Second Quarter $ 33.81 $ 31.50 $ 0.11 Third Quarter $ 34.59 $ 29.67 $ 0.11 Fourth Quarter $ 33.09 $ 30.39 $ 0.12 2014 Firs; Quarter $ 32.88 $ 27.77 Second Quarter $ 31.29 $ 28.27 $ 0.10 $ 0.10 Third Quarter 5 33.46 $ 30.02 5 0.10 Fourth Quarter $ 33.40 $ 30.96 5 0.11 Additional Information information concerning the services of Brown & Brown, Inc., as well as access to current financial releases, is available at www.bbi ns u ra nce,c om. TEN-YEAR STATISTICAL SUMMARY (in thousands, except per share data and other information) 2015 2014 2013 Revenues Commissions & fees Investment income Other income, net $ 1,656,951 1,004 2,554 $ 1,567,460 747 7,589 $ 1,355,503 638 7,138 Total revenues 1,660,509 1,575,796 1,363,279 Expenses Employee compensation and benefits Non -cash stock -based compensation Other operating expenses (Gain) Loss on disposal Amortization Depreciation Interest Change in estimated acquisition earn -out payables 841,439 15,513 251,055 {619) 87,421 20,890 39,248 3,003 791,749 19,363 235,328 47,425 8 2, 941 20,895 28,408 9,938 683.000 22,603 195,677 67,932 17,485 16,440 2,533 Total expenses 1,257,950 1,236,047 1,005,670 Income before income taxes Income taxes 402,559 159,241 339,749 357,609 132,853 140,497 Net income $ 243,318 $ 206,896 $ 217,112 Employee compensation and benefits as % of total revenue 50.7% Other operating expenses as % of total revenue 15.1% Earnings per Share Information Net income per share -diluted Weighted average number of shares outstanding -diluted Dividends paid per share Year -End Financial Position Total assets Long-term debt Total shareholders' equity Total shares outstanding Other Information Number of full-time equivalent employees at year-end Total revenues per average number of employees 131 Stock price at year-end Stock price earnings multiple at year-end's' Return on beginning shareholders' equity's' $ 1.70 140,112 $ 0.45 $ 5.012,739 $ 1,079,878 $ 2,149,776 138,985 50.2% 50.1% 14.9% 14.4% $ 1.41 $ 1.48 142,891 142,624 0.41 $ 0.37 $ 4.956,458 $ 3,649,508 $ 1.152,846'2' $ 380,000 $ 2,113,745 $ 2,007,141 143,486 145,419 7,807 7,591 6.992 $ 215,679 $ 216,114 $ 203,020 $ 32.10 $ 32.91 $ 31.39 18.9 23.3 21.2 12% 10% 12% (1) Includes an $18.664 gain on the sale of our investment in Rock -Tenn Company. (2) Represents the incremental new debt associated with the acquisition of Wright and evolution of our capital structure. Please refer to Part L item 7 'Management's Discussion and 4noiysis of Financial Condition and Results of Operations' and Vote 8 -Long-Term Debt' for more details. (3! Represents total revenues divided by the average of the number of full-time equivalent employees at the beginning of the year and the number of full-time equivalent employees at the end of the year. (4) Of the 881 increase in the number of full-time equivalent employees from 2011 to 2012. 523 employees related ro Me Jaguar/ R. 2012 acquisition of 4rrowhead. and therefore are considered ro be full-tirne equivalent as of January 1, 2012. Thus. the average number of full-time equivalent employees for 2012 !s considered to be 6,259. Year Ended December 31. 2012 2011 2010 2009 2008 2007 2006 $ 1,189,081 $ 1,005,962 $ 966,917 $ 964,863 $ 965,983 $ 914,650 $ 864,663 797 1,267 1,326 1,161 6,079 30,494111 11,479 10,154 6,313 5,249 1,853 5,492 14,523 1,862 1,200,032 1,013,542 973,492 967,877 977,554 959,667 878,004 608,506 508,675 487,820 484,680 485,783 444,101 404,891 15,865 11,194 6,845 7,358 7,314 5,667 5,416 174,389 144,079 135,851 143.389 137,352 131,371 126,492 63,573 54,755 51,442 49,857 46,631 40,436 36,498 15,373 12,392 12,639 13,240 13,286 12,763 11,309 16,097 14,132 14,471 14,599 14,690 13,802 13,357 1,418 (2,206) (1,674) - - - - 895,221 743,021 707,394 713,123 705,056 648,140 597,963 304,811 270,521 266,098 254,754 272,498 311,527 280,041 120,766 106,526 104,346 101,460 106,374 120,568 107,691 $ 184,045 $ 163,995 $ 161,752 $ 153,294 $ 166,124 $ 190,959 $ 172,350 50.7% 50.2% 50.1% 50.1% 49.7% 46.3% 46.1% 14.5% 14.2% 14.0% 14.8% 14.1% 13.7% 14.4% 1.26 $ 1.13 $ 1.12 $ 1.08 $ 1.17 $ 1.35 $ 1.22 142,010 140,264 139,318 137,507 136,884 136,357 135,886 $ 0.35 $ 0,33 $ 0.31 $ 0.30 $ 0.29 $ 0.25 $ 0.21 $ 3,128,058 $ 2,607,011 $ 2,400,814 $ 2,224,226 $ 2,119,580 $ 1,960,659 $ 1,807,952 $ 450,000 $ 250,033 $ 250,067 $ 250,209 $ 253,616 $ 227,707 $ 226,252 $ 1.807,333 $ 1,643,963 $ 1,506,344 $ 1,369,874 $ 1,241,741 $ 1,097,458 $ 929,345 143,878 143,352 142,795 142,076 141,544 140,673 140,016 6,438 5,557 5,286 5,206 5,398 5,047 4,733 $ 191,72914' $ 186,949 $ 185,568 $ 182,549 $ 187,181 $ 196,251 $ 189,368 $ 25.46 $ 22.63 $ 23.94 $ 17.97 $ 20.90 $ 23.50 $ 28.21 20.2 20.0 21.4 16.6 17.9 17.4 23.1 11% 11% 12% 12% 15% 21% 23% 51 Stock price at yearend divided by net income per share -diluted. '61 Represents net income divided by total shareholders' equity as of the beginning of the year. Neighted average number of shares outstanding -diluted has been adjusted to give effect for the two -class method of calculating earnings per share as described in jte 1 to the Consolidated Financial Statements. 220 South Ridgewood Avenu Dautona Beach, Florida 32 (386) 252-9601 bbinsurance.com • • :11 , 4.4 ; lAt :‘ 4 '4 11 7.• p e,' ,r, ;RI .• 14T r ,f. 44 • ATTACHMENT 2 Cardiac -Exposure Protocol AmeriSys* Handbook for the BADGE Program ` 2" °� (Cardiac & Exposure Claims) Experts in the Presumption Law Claims Administration and Medical Management Specializing in Florida's Heart and Lung Bill and Exposure and Infectious Disease Claims For more information please call 1-800-752-0886 TABLE OF CONTENTS Section Page Presumption Law 1 First Responder Program 2 Heart and Lung Program 3-4 Cardiac Stages 5-7 Exposure Program and Protocol 8-12 AmeriSys Commitment 13 Flow Chart 14 Cardiac Specialized Network 15 AmeriSys is one beat ahead. FLORIDA HEART AND LUNG BILL Cardiac Disease State Management as it relates to the Florida Heart and Lung Bill of 2003 1) Anv condition or impairment of health of any Florida state, municipal, county, port authority, special tax district, or .fire control district firefighter or any law enforcement officer or correctional officer as defined in s. 943.10(1), (2), or (3) caused by tuberculosis, heart disease, or hypertension resulting in total or partial disability or death shall he presumed to have been accidental and to have been suffered in the line of duty unless the contrary be shown by competent evidence. However, any such firefighter or law enforcement officer shall have saaccessfailly passed a physical examination upon entering into any such service as a firefighter or law enforcement officer, which examination failed to reveal any evidence of any such condition. Such presumption shall not apply to benefits payable under or granted in a policy of life insurance or disability insurance, unless the insurer and insured have negotiated for such additional benefits to be included in the policy contract. (?) This section shall he construed to authorize the above governmental entities to negotiate policy contracts for life and disability insurance to include accidental death benefits or double indemnity coverage which shall include the presumption that any condition or impairment of health of any firefighter, law enforcement officer, or correctional officer caused by tuberculosis, heart disease, or hypertension resulting in total or partial disability or death was accidental and suffered in the line of duty, unless the contrary he shown by competent evidence. Page 1 B.A.D.G.E (Better Administration Dedication Guaranteeing Excellence) Specialty Medical Director/Physician Advisor AmeriSys utilizes a Medical Director and/or Physician Advisor with Board Certification in Cardiology to assist and direct the medical management team. It is extremely important that the treating physician has experience in dealing with Workers' Compensation and knowledge of the components of the Heart and Lung Bill. We are pleased to have a Cardiac Medical Director/Physician Advisor to assist with the following: Reviewed and approved the BADGE program. Treating Physician for employees in this cachement area. Physician Advisor for IMEs, Peer Reviews and other Utilization Review Issues. Medical Director for general technical advice, Liaison activity with other Cardiology or other specialty related providers. Assist with grievances associated with heart and lung claims. Assist in identifying and facilitating recruitment or providers of excellence for these services. Cardiac Case -Manager In addition to the Cardiac Medical Director/Physician Advisor, we utilize Registered Nurses with cardiac patient experience to implement, monitor and assess all presumption claims. Specialty Facilities and/or Specialty Providers contracted for Workers' Compensation We believe to best impact the ultimate outcomes you must recruit and train providers of excellence who demonstrate their willingness to customize and/or modify their program to meet the unique needs of the claimants covered by the Florida Heart and Lung Bill. We recruit and train physician specialists in Workers' Compensation requirements and the components of the Heart and Lung Bill. These specialists include the following to name a few: • Cardiology • Cardiovascular Surgeons • Pulmonologists • Nephrologists We must also identify facilities that are able to provide quick and reliable services related to: • • • Cardiac Diagnostics Services Cardiac Rehab Facilities Thoracic Surgery Transplant Programs Page 2 THE HEART AND LUNG PROTOCOLS Newly Diagnosed The purpose of this protocol is to provide the county/district with a direct means for emergent care if needed, To provide both employee and the county/district with proactive case management regarding assisting with the Emergent discharge needs, arrangement of cardiac diagnostics and treatment. If the following occur: • • • Employee begins to feel ill at work or off duty, and is transported to Physician's Office. Physician, on exam, discovers Employee is in danger and determines it is Emergent. Employee is transported to Emergency Room, After Occurrence • • Page 3 Notice of Injury is completed by supervisor. Cardiac Case Management is notified. Authorization is called to treating facility. Adjusters for claim are notified, A Field Case -Manager is assigned a task assignment of retrieving information, if necessary (approval from adjuster or Government entity required). Request pre -employment records and preliminary information from hospital. Pre-deterronination will be made at this time as to Causality and Major Contributing Cause, notify the adjuster on file. Upon discharge, the treating physicians' orders are reviewed by the Cardiac Case - Manager, assess work status at this time and notify adjuster, Field Case -Manager will be used to arrange care as needed. Once the IW is stable, the Cardiac Case -Manager will attempt to transfer the claimant's care into the Network for treatment with a cardiologist if the situation allows. Further investigation into Causality and Major Contributing Cause, as needed. Once the claim has been deemed compensable by the adjuster, proceed with cardiac case management for intermediate care status. ROUTINE EXAM Employee finds out on a routine exam, either fit for duty or their own personal physician that there is subjective/objective information requiring a further cardiac evaluation, if it is determined by the physician that this is not of an emergent nature proceed with the following protocol: 1. Notice of Injuiy is completed by the supervisor. 2. Cardiac Case -Manager and adjuster notified. 3. Arrange for Employee to be seen by a Network Provider. 4. Request the pre -employment physical. 5. Have the Network Provider review initial testing and determine if a cardiology referral is necessary at this time. Have the Network Provider make a determination of work status at this time. 6. If the Network Provider feels he/she is capable of monitoring the employee for the time being, have the physician address Causality and Major Contributing Cause. 7. The Cardiac Case -Manager will arrange and authorize appropriate diagnostics and treatment as needed. AmeriSys is one beat ahead Page 4 ACUTE CARDIAC STAGE The purpose of this protocol is to provide management to those claims which remain in an Acute Cardiac condition. They require significant medical intervention and/or diagnostics. Acute Cardiac Case Management may include, but not be limited to ensuring hospital discharge planning, scheduling and coordination of additional proper diagnostic testing, arrangement of second opinions and secondary providers, treatment, treatment compliance and recognition of a deteriorating condition. Acute Cardiac Case Management will also include conferencing with the treating physician regarding appropriate referrals, additional diagnostics as well as work status, and identifying projections for permanent restrictions, MMI and PIR. Once the above has been determined the employee will be processed to Intermediate Cardiac Care. These types of claims are: • Identified as being compensable and/or under review based upon the "Presumption Law", • Determined by the physician that the employee is in an Acute Cardiac state at this time. • The employee has been or is being processed through the Emergent Protocol. Treatment 1. Establish a personalized care plan for the employee. 2. Arrange and monitor any further diagnostics by the treating physician. 3. Assist in the coordination for any second opinions and/or secondary provider evaluations or treatments. 4. Assist in Discharge Planning if applicable. 5. Monitor treatment and medications as ordered by the treating physician. 6. Provide for and/or arrange transportation if required for follow-up diagnostics and/or treatment. 7. Identify the projected MMI/PIR and projected future work related information. 8. Consult with the Cardiac Medical Director as required (and approved) to facilitate proper treatment. evaluating treating physician's MMI, PIR and RTW projections, identifying additional needs to promote best medical outcomes. 9. Move file toward Intermediate Cardiac Case Status. Page 5 INTERMEDIATE CARDIAC CASE MANAGEMENT The purpose of this protocol is to provide management to those claims which are no longer emergent. but require further medical intervention. Intermediate Cardiac Case Management will include, but will not be limited to ensuring proper diagnosis, treatment, treatment compliance and recognition of a deteriorating condition. Intermediate Cardiac Case Management will also include conferencing with the treating physician regarding appropriate work status, permanent restrictions, MMI and PIR. Once the above has been determined the employee will be processed to Cardiac Maintenance Care. Types of Claims Include: • Have been accepted by the county/district prior to the establishment of a specialty cardiac division. • It is determined the employee is not in an acute cardiac state at this time and has not reached MMI. • The claim has been processed through Newly Diagnosed/Emergent Protocol, and it has been determined that the file will be accepted by the Employer/Carrier. • The employee is no longer in a state of acute cardiac illness. Treatment 1. Establish a personalized care plan for the employee. 2. Establish goals for the employee. If claim is not litigated, include and discuss goals with the employee. 3. Arrange and monitor any further diagnostics by the treating physician. 4. Ensure a work status is obtained for the employee. 5. Monitor treatment and medications as ordered by the treating physician. 6. Arrange any other specialty referrals as ordered. 7. Monitor compliance with treatment, medications, diet and exercise. Educate on those topics as necessary. 8. Notify the physician and adjuster/employer with concerns of non-compliance. 9. Once the employee as reached MMI/PIR and a permanent work status has been determined, and the cardiac condition is controlled and stable, move file to Cardiac Maintenance Status. Page 6 CARDIAC MAINTENANCE CARE The purpose of this protocol is to establish management guidelines for those employees with I- NL claims that have reached MMI/PIR and there permanent work status has been established. The employee that would be placed in this category is one who we are currently managing that has reached the above criteria or the employee who is processed through Newly Diagnosed, Intermediate Care and now has stabilized to proceed to Cardiac Maintenance Care. The Cardiac Case -Manager will establish and maintain a care plan for each employee. The goals of this plan will be monitored by the Cardiac Case -Manager. 2. Physician appointments will be monitored. 3. The Physicians assessment will be reviewed for compliance with medication, treatment and diet. If the employee maintains stability, their file will remain in this category. If not, their file will be moved to the appropriate category. Page 7 EXPOSURE PROGRAM These exposures usually occur in the course of performing their normal job duties as First Responders. Some of the exposures are readily evident and demonstrable, such as exposure to chemicals, while others may not be as readily evident, such as Tuberculosis and Hepatitus. These claims have the potential of representing significant expense both in Human Resources as well as economic impact. This type of claim is similar to the Heart/Lung Claims, are handled as a "presumption claim". The exposure program allows for: • Claims research and analysis for newly reported claims to identify whether they are related to pre-existing medical conditions. Management of those claims to assure proper diagnosis, treatment, treatment compliance and early intervention and recognition of deterioration or complication. We have developed the enclosed protocols for the county/district. • Blood Borne Pathogens Tuberculosis MRSA (Methicillin Resistant Staphylococcus Aureus) Page MEDICAL DIRECTOR/PHYSICIAN ADVISOR We believe that it is imperative, to address these claims aggressively, to utilize a Medical Director and/or Physician Advisors with experience dealing with issues related to Cardiology, Epidemiology and/or Toxicology. Very often this type of physician lacks significant experience in dealing with Workers' Compensation, therefore it is critical that the program, the Case - Managers and adjusters are coordinated and clear in their support and dealing with these Medical Providers. Our medical directors and physician advisors are readily available to assist in the decision making on these difficult claims. Role of the Cardiac Nurse We utilize Registered Nurses with cardiac experience and workers' compensation experience. These nurses participate in the ongoing recruitment and education of medical providers. The Cardiac Case -Managers participates in the Workers' Compensation education of the physicians recruited. Specialty Facilities and/or Specialty Providers contracted for Workers' Compensation These services are unique and may not be a part of general workers compensation provider networks or systems. We believe to best impact the ultimate outcomes you identify and train providers of excellence who demonstrate their willingness to customize and/or flex their program to meet the unique needs of a workers' compensation claim that involves exposure issues. The provider network offers physician specialties such as toxicology and infectious disease. We have also established relationships with ancillary providers to facilitate the specialty diagnostics needed to diagnose and threat these unique conditions. Page 9 TUBERCULOSIS EXPOSURE PROTOCOL Purpose: The purpose of this protocol is to provide the injured worker who has been exposed to tuberculosis in the workplace consistent guidelines for treatment and follow up. Policy: An effective TB infection control program requires early identification and isolation of persons who have active TB. This includes the monitoring and evaluation of employee compliance with PPD testing, radiological examination and follow up with infectious disease physicians as needed. Procedure: 1) All employees with newly recognized PPD tests will be evaluated promptly for TB. 2) Any employee who reports a persistent cough lasting greater than three weeks in combination with weight loss, night sweats, bloody sputum, anorexia or fever should be evaluated promptly for TB. 3) All employees should be encouraged to have a PPD test done on an annual basis. It is noted that under the Presumptive Illness Legislation, employees diagnosed with TB will be presumed to have become infected while performing duties unless proven by baseline testing at the pre -employment stages. 4) While the results of a tuberculin skin test alone cannot confirm an active TB infection. Other tests, such as a chest X-ray and sputum culture, should be done to confirm an active TB infection when a skin test is positive. If active TB is confirmed, the injured worker should be immediately referred to the designated physician that has been assigned to handle TB exposures for treatment and follow up. 5) An employee, who has a positive skin test or chest X-ray, but no TB symptoms, is usually thought to have a TB infection that cannot be passed to others (latent TB). Once a physician has confirmed the injured worker has latent TB, it is recommended that the injured worker is evaluated and has a chest x-ray annually. 6) It is the responsibility of the Case -Manager to communicate all medical findings to the employer and cagier. 7) It is the responsibility of the Case -Manager to monitor for treatment compliance and report any incidents of non-compliance with TB protocol immediately to the employer and carrier. Page 10 MRSA (Methicillin Resistant Staphylococcus Aureas) Protocol Purposg: The purpose of this policy is to provide the injured worker who has been exposed to MRSA in the workplace the appropriate and current treatment. It is also the purpose of this policy to assist in the prevention of the spread of MRSA in the workplace. Policy: Once the diagnosis of MRSA has been identified in an employee, aggressive measures will be taken stabilize the injured worker's infection, assist the employer in preventing the spread of the infection and assist the carrier in addressing the compensability of the infection. Procedure: Prevention of MRSA Infections: Keep hands clean by washing thoroughly with soap and water or using an alcohol based sanitizes. Keep cuts and scrapes covered with a bandage until healed. Avoid contact with open wounds and bandages. Avoid sharing personal items such as towels or razors. Guidelines for treating and Case Management of MRSA or potential MRSA 1) Once MRSA has been identified in the workplace, refer all injured workers who present with an infection that may appear as a pimple, boil or abscess to a designated worker's compensation physician for evaluation. 2) Obtain and review culture and sensitivity results when available, notify the employer and carrier of the results. 3) Until the culture reports are available, assist the physician in determining work status, and inform the employer and carrier of the work status. 4) Educate the injured worker on ways to prevent the spread of infection. For example, frequent hand washing, keeping wounds covered, and avoid the sharing of personal items. 5) Monitor the tolerance and compliance with all prescribed antibiotics. Educate the injured worker on the importance of the completion antibiotic therapy. 6) Ensure the injured worker complies with all physician follow up appointments. 7) Collaborate with all treating physicians regarding the arrangement of possible IV antibiotic therapy and wound care needing home health services. 8) Confirm with all treating physicians that the injured worker is safe to return to work. Page II BLOOD BORNE PATHOGEN EXPOSURE Purpose: The purpose of this policy is to provide the employee who is exposed to blood and body fluids in the work place the established measures to confirm a diagnosis and provide the appropriate treatment. A significant exposure is defined as an injury during which one person's blood or other high -risk body fluid comes in contact with someone else's body cavity. Injuries of concern include but are not limited to needle sticks, other sharps, splashes and bites. Policy: Employees who report exposure to blood and body fluids in the workplace will be promptly sent to the designated physician to have the appropriate testing and treatment. The Case -Manager will notify the employer and carrier of medical updates, compensability issues and the current work status. The Case - Manager will monitor for compliance with all testing and treatment protocols. Procedure: I 1 If the exposure is emergent in nature, immediately direct the injured worker to emergency treatment and/or initiate the EMS system. 2) If there is no serious injury involved with the exposure, the injured worker should be directed to the designated physician or facility for testing and treatment. 3) Ensure that both the injured worker and the source are tested as soon as possible. If the source is not available, the treating physician will determine the appropriate plan of treatment. If chemoprophylaxis is to be implemented in order to prevent the transmission of HIV, it should ideally be started between 2-4 hours post exposure, however it can be initiated up to 72 hours post exposure. Once the determination has been made that the source is HIV negative, the chemoprophylaxis can be discontinued. Follow up labs and or chemoprophylaxis may be indicated if there is concern that the source may be in the window period sera -conversion phase or if the source is unavailable. HIV testing should be done at baseline, 3 months, and 6 months. Counseling should be provided as to the prevention of a possible secondary infection. 4) The lab work performed should include an anti-HB level in relation to Hepatitis B exposure protection. The physician will determine if the injured worker is sufficiently protected. If it is determined the injured worker is not protected, the HBIG and/or HBV vaccine can be administered. Testing should occur at least one month after the receipt of the last dose of the vaccination, or four months after the receipt of HBIG, whichever is longer. If the injured worker's lab work continues to show insufficient protection, a second dose may be offered. 5) Although there is not a vaccination available to offer protection from Hepatitis C, a lab value should be obtained. 6) Follow up counseling and medical evaluation should be provided for all injured workers who are given chemoprophylaxis. 7) The Case -Manager will aggressively monitor compliance with all treatment and testing, notifying the employer and carrier of all non-compliance issues. Page 12 AmeriSys recognizes the importance of "quality of life" and therefore will exert every effort to educate every employee with a potential for heart disease regarding healthy diet, weight loss and proper medication usage. They will be monitored for compliance in all areas of their care. Serving those who protect Page 13 EXAMPLE OF CARDIAC DISEASE STATE MANAGEMENT FLOW CHART FCh;I Cardiac Claim Field Case Management Cardiac Occurance Report to Intake Coordinator Evaluation of claim status Cardiac; Yes/No Claims Adjuster 2 Pont Contact Same Day (EE'MD) 3 Point Contact Within 24 hrs. (ER) Large Catastrophic Claims Achievement of Madinat Stability Access needed for Continued FCM Involvement Addressing MMI/PIR. PTA Status. Life Care Plan. Cost Projection, Excess Updates and if applicable. Medicare Set Aside Closure of File Page 14 CARDIAC SPECIALIZED NETWORK We currently work with a network that can help create and develop a network_ for your needs. Page 15 AmeriSys* 1-800-752-0886 ATTACHMENT 3 Innovative Programs APRIL 2014 First Edition Newsletter Program Administered b} AmeriSys SECURE Services for the Effective Control and Utilization of Rxthrough Evidence -based Criteria TEAM BASED APPROACH AmeriSys-SECUIE^ is leading the way with quality - centered cast effective management of pain treatment programs. By joining forces with some of the industry's leaders in pain treatment guidelines, pharmacy controls and alerts, functional restoration initiatives and specialized case -managers. AtneriSys has developed unique protocols and criteria for managing these complex and cost -driving claims. This program will maximize the injured employees' comfort level by working closely with physicians who practice according to nationally -approved standards. In utilizing these best practices, the risk of addiction is minimized and costs associated with the addiction are decreased. In doing this, not only do we benefit our industry but our community as well.. FEATURES • Uniquely contracted medical provider network a Strict protocnt adherence • Interdi.sciplinary,tdiisot Board (physicians. physical therapist, pharmacists, nurses, utilization review specialists. psychologists, claim professionals) • Custom computer system to identifi• pain management candidates • Specialized Case -Managers • Pharmacy STEP program BENEFITS • Cost Containment • Reduce the costs associated with addiction • Return injured employees back to work • Minimize the risk of addiction • Maximise the injured employers' comfort level • Reasonable expectations related to pain relief and functionality • Benefit the injured employees' family life • Reduce overall claim costs both medical and indemnity 140 Alexandria Blvd. Suite II, Oviedo, Florida 32765 • 800.752.O886 April 2014 VOL. # ONE ISSUE #1 .,t Michael Coupland CPsych, CRC Expert Physician Panel Locations ADVISORY BOARD • Cheryl Gulasa, VP AmeriSys • Dr. Matthew Imfcld, AmeriSys Medical Director • Dr. Sanford Silverman, Board Certified Pain Medicine and Anesthesiology • Dr. Michael Creamer Board Certified Pain Medicine and PMR • Dr. Michael Coupland, CPsych, CRC. • Kendra Karagozian Pharrn.D. myMatrixx • Brian Imler, Physical Therapist • Kathy Heiting Garcia, Peer Review Consultant ADVISORY BOARD SPOTLIGHT • Certified Psychologist specializing for 30 years in Workers' Compensation and Personal Injury • Developer of 3 National Networks that have performed over 150,000 evaluations • Author AMA Guides Companion Text • Key speaker at over 100 Work Comp and medicolegal conferences • Expert to the Federal Government Social Security Disability Determination projects SPRING INTO ACTION Here are three quick -and -easy tips to help you clean up your act this spring: Freshen up your diet: With new found space in your refrigerator, start eating more fresh fruits and vegetables. Studies show that Americans aren't consuming enough fruits and vegetables. A recent "Life...supplemented" consumer study2 found that only 32 percent of American adults claim, "I love vegetables and easily eat two cups each day," and ,just 27 percent say, "I eat at least two pieces (or cups) of fruit each day." Ms. Forberg suggests aiming for a minimum of four cups of fruits and vegetables daily, and favoring non -dried fruits and non -starchy vegetables. Take inventory of your kitchen cabinets: Be proactive and check expiration dates on your multivitamins and other dietary supplements. While supplements are not required by law to list expiration dates,. most companies do so to ensure that consumers take them before the ingredients lose their full potency. Say "hello again" to Mother Nature: As temperatures warm up across the country, take the time to enjoy the scenery. Jogging, power -walking and exercise -it could be as simple as biking to the neighborhood store for a few small items or taking a jog through the nearby park while your children are at sports practice. • a myiViatr xx CIick Pi 6r'l? ,a cy pharmacy and ancillary "benefit t company focused on workers' compensation, E3y combiningadvanced tech tology and proactive ctirccal rr nagemenl throughout the claims process, rhyMatrix,x delivers a Fast, Simple, Effective solution vrtti proven Results. NEW DRUG SPOTLIGHT: . )"' ) ZohydroTM ER (hydrocodone bitartrate extended -release) Background' ; Zohydro ER was approved by the U.S. Food and Drug Administration (FDA) on October 25, 2013. Zohydro ER is a Schedule 11 controlled substance and is the First and only extended -release dosage Form or hydrocodone that is not combined with acetaminophen. Zohydro ER does not possess any abuse -deterrent properties. The new drug will be par oldie ER -LA opioid Analgesics Risk Evaluation and \litigation Strategy (REMS). According to she manufacturer, an abuse -deterrent lortnulafion is currently being developed and will likely become available within the next three years pending FDA approval. Zohydro ER is available in pharmacies this month (March 2014). FI)A Approved lndications: Zohydro ER is indicated to manage pain severe enough to require daily. around -the -clock. long -tern opioid treatment and for which alternative treatment options are inadequate. Zohydro ER is not approved For as -needed (PRN) pain relief Why is this relevant for workers' comp? As with all opioids, there are concerns for the potential risks of misuse, abuse, increased sensitivity to pain. addiction and overdose. Zohydro ER is not expected to be superior to existiniz therapies that are available in safer formulations, and will likely result in increased use and increased cost For chronic pain patients. Formulary consideration: Due to the risks of addiction. abuse, and misuse with opioids, even at recommended doses. and because of the greater risks of overdose and death with extended -release opioid formulations. Zohydro ER should be reserved for use in patients for whom alternative treatment options are ineffective. not tolerated. or would be otherwise inadequate to provide sufficient pain management, Therefore, it is recommended that Zohydro ER be excluded from IEmnularies and or require prior SECUPK,E) AmeriSys' SECURE* is leading the way with quality -centered cost-effective management of pain treatment programs. y joining forces with some of the industsy's leaders in pain treatment guidelines, pharmacy controls and alerts, functional restoration initiatives and specialized case -managers, AmeriSys has developed unique protocols and criteria for managing these complex and cost -driving claims. This program will maximize the injured employees' comfort level by working closely with physicians who practice according to nationally -approved standards. In utilizing these best practices, the risk of addiction is minimized and costs associated with the addiction are decreased. In doing this, not only do we benefit our industry but our community as well. Background: Today it is reported that approximately 19% of medical spend in Workers' Compensation claims goes to pharmacy. Of that, 38% goes toward opioid medications. The utilization and the resultant impact of opioid analgesics has created a crisis within the Workers' Compensation community. Some states have enacted legislation to curtail the rampant "mis-utilization" of these medications. The resounding cry in the industry by its leading consultants is to develop programs, procedures, protocols and methodologies to address the misuse of these drugs for the treatment of work -related conditions. The misuse of these drugs is responsible for significant challenges both in functional and economic outcomes. Improper utilization of these drugs can and does lead to: • Addiction • Family Dysfunction • Increased Disability Duration • Physical health consequences associated with long term narcotic utilization and addiction such as: o Depression o Loss of libido o Lower testosterone levels o Weaken the immune system o Pulmonary function (secondary to decreased respirations) o Liver functions o Hyperalgesia o Constipation AmeriSys* www.AmeriSys-Secure.com 800,752.0886 SECU!E* The SECUIE*) program s goals are to improve/enhance return -to -work outcomes, reduce disability duration; prevent unnecessary, dangerous and costly consequences of inappropriate or prolonged utilization of opioid medications while reducing the costs of handling pain management claims. Features: • Uniquely contracted medical provider network ✓ Strict protocol adherence • Interdisciplinary Advisory Board (physicians, physical therapist, pharmacists, nurses, utilization review specialists, psychologists, claim professionals) • Custom computer system to identify pain management candidates • Specialized Case -Managers • Pharmacy STEP program Benefits: • Cost Containment • Reduce the costs associated with addiction • Return injured employees back to work • Minimize the risk of addiction • Maximize the injured employees' comfort level • Reasonable expectations related to pain relief and functionality • Benefit the injured employees' family life • Reduce overall claim costs both medical and indemnity Services for the Effective Control and Utilization of Rx through Evidence -based Criteria ArneriSys* www.AmeriSys-Secure.com 800.752.0886 RXMDOS 13 AineriSys 4C*% The ,4nieriSf:s4C goal is to provide a comprehensive multi -disciplinary approach in the management o "ATASTROPHIC COMPLEX claims. This approach will provide exceptional CARE in a cost efficient manner to injured employees, while easing the burden of coordination and handling these challenging claims for employers and carriers. The 4C program will provide exceptional care in a cost-effective manner to severely injured or critically ill employees. AmeriSys will ease the burden of cost and management in dealing with these very challenging claims on behalf of employers and carriers. These claims may arise out of truly catastrophic injury events (accounting for only 1% of claims) or they may be the "Creeping Catastrophic Claim". In either case, the AmeriSys team can help. Features: Benefit: • Prioritize the needs of the injured employee • Provide all aspects of care to the injured employee • Ensure high quality and quantity of care required in a cost effective manner • Cost analysis for the employer and carrier - current and projected • Coordination from centralized point • Industry leaders in one network • Competitive pricing • Streamlined payment system from a central point • Employee Advocate as coordinator providing multidisciplinary specialized services • Vocational rehabilitation assessment • Community Safety evaluation • Specially trained professionals, knowledgeable of the local resources and outstanding case management techniques • Reduce the claim cost by proactively facilitating the injured worker to the most appropriate and cost efficient care of services. Controlling Costs for Complex Claims AmeriSys* www.AmeriSys-Secure.com 800.752.0886 BADGE PROGRAM In 2003, Florida Legislature expanded the fire fighters' "Heart and Lung Bill" to include police, deputies and correction officers. This change in law presented the Worker's Compensation claims and medical management community with increased challenges. ▪ AmeriSys developed a specialized legal and medical program approach in addressing the uniqueness and special needs of handling claims. This was appropriately named BADGE (Better Administration Dedication Guaranteeing Excellence). This team recognizes the importance of "quality of life" and therefore will exert every effort to educate every employee with a potential for heart disease regarding healthy diet, weight loss and proper medication usage. The program consists of an interdisciplinary approach to manage and provide quality services to our employees and clients. The combination of disease state management and worker's compensation case management, allows the employee to benefit from the latest in quality cardiac healthcare providing a constant source of support and education. It improves/enhances return to work outcomes, reduces disability duration, prevents unnecessary, dangerous and costly consequences of inappropriate use of cardiac medications while reducing the cost of handling presumption claims. The BADGE Program Features include: • Medical Director and/or Physician Advisor with Board Certification in Cardiology to assist and direct the medical management team • Registered Nurses with cardiac patient experience to implement, monitor and assess all presumption claims • Specialty Facilities and/or Specialty Providers contracted for Workers' Compensation to best impact the ultimate outcomes you must recruit and train providers of excellence within their specialty and/or modify their program to meet the unique needs of the claimants covered by the Florida Heart and Lung Bill • Most current quality of Cardiac Care while maintaining compliance with the Heart and Lung Bill 112.18 and WC Statute 440 The cardiac registered nurse works directly with the adjuster, employer and employee assisting in the following: • Gathering medical data required to properly determine the compensability by the adjuster • Manage the initial diagnostics and treatment to most effectively diagnose condition • Works with the employee through diagnostics and moving them toward a stable position • Provide education and establish goals with the employee in making lifestyle changes in order to reduce or eliminate future costly events associated with their work -related illness • Conference with the treating physician regarding the job description, and assist in the determination of when the claimant can safely return to work • During the maintenance phase of the program, the cardiac nurse case manager monitors physician's findings, diagnostics, lab values and medications • Coordinates care and provides education. The goal is to maintain the claimant at this stable state, acting proactively when necessary • Facilitates communication with employees, physicians, employers and adjusters, keeping them apprised of any changes ATTACHMENT 4 USISiNet and AmeriSysiNet USISiNet & AmeriSysiNet Programs That Work For You Portal Features Reports • Check Registers (Payments) • Employer's Reports (Claim Payment, Reserve, Incurred Totals) Interactive Grids (Filter, Sort, Column Customization, Export) • Claims • Reserves • Payments • Notes • Analytics (Interactive Data in Addition to Dashboards and Reports) Security • Ability to Customize what claims each user can see • Ability to Customize what features each user can use • Ability to Exclude specific claims or features on claims where User is also Claimant Report Export Types Supported • Excel (XLS, XLSX, CSV ) • Word ( HTML, MHT, RTF, Text ) • Rendered ( PDF, Image, XPS ) Customization Customizable Dashboards • Choose the Dashboard Tiles that are right for you • Customize Dashboard Tile Size and Position • Customize Settings/Filters to your needs (e.g. New Claim (Days), Recent Note (Days) ) • Additional New Custom Dashboard Tiles can also be created on Request • Customizable Security • For each Feature and per User • For Users who are also Claimants / Claimants in Litigation (e.g. removing notes from "my claims") • Branding • Custom "/Welcome/NC" Login/Landing page with Branding • Client Logo on Every Page • Grids • Add and Remove columns • Filter by any column • Sort by any column •- Reports • New Custom Reports can be created on Request 3 System Requirements All Major Systems Supported: • Desktop/Laptop (Windows, Apple, Linux, ... ) • Tablet (Windows, iOS, Android, ... ) • Mobile Phone (Windows, iOS, Android, ... ) * * Some Features may be more convenient on a larger screen, such as a Desktop, Laptop, or Tablet .- All Major Browsers Supported (Latest Recommended): • Internet Explorer • Chrome • Safari • Fire Fox • Opera 4 .d LS'S Homo 'wrw cwita.t SaoFF,llorr, 800-444-9098 Programs That Work For You Our flexibility allows us to custom tailor all or part of our services to meet your unique needs. Loam More •0O000 Workers' Comp Medical Management LISTS has Uun in wIsU d.N] sepolatrae as a dawns admesstial/a idr USIS through ds Omar., ttanayyr n of dnosaser amenSye pruodes iWNMna Compeoo. Io4+ poylanl, Our cbents appcuale star zoom,. *Ncetal nea agemenl paglann lhal alclµde both cY.Nrred rt *oo phy of personal sarysce dleaCalt l commM1em and leant 6V:Ipaudnal maalaQe1 co. pica). aim WA well as lwn. RINf N apw'oach 0 I04teed nll10o1 0 Venn detaers View Mails Complete Claims Administration Programs, Flexible and Tailored to your Unique Need,. Our vast client base includes commercial carriers. self insurance funds, risk pools and trusts. as :Nell as self insured employers in both private and public sectors. But the one thing all of our clients have in common, is that no two are alike. Liability LLSIS has the abaty to prowW& dam manage/mil lot aN lama b gcrawal and f¢oI pa Ey ihpperty eapONNMe £nooadng In+catgatme and rlaans ow/lawmen] .A Aletypary al lanpKly and eanrally U.rm,a View draiar`is a 5 N ET 0 I Dashboard Report Date Aging 5.8 Days Litigated Claims 3Oc. 21% • 0.3 • 4-7 • 8-30 • n. 1 1,111 ".'312 2019 2014 NOn-Ltd Wiled —INIINEMour 45% 400 300 ZOO 100 0 3 Claim Status Trend • • ;-!;,•• • CI cuo a Dashboard News Feed You have 0 New Claims Repnit Date Aging 228 Days 3.0 days Claim StatusTrend Incurred By Policy Year • N iIkr,s.41 Drill -through from Dashboard Tile already filtered Claims Dashboard in Customization Mode (Edit) (NET IN Claims FAIon tO Late 7 gal ZIMMOIS jerl 1115,25,15rn 12:92,.W14 il6IPLOVEA WA5 'ANT A Ffr.A1 AN VTO:Ao.hE, OPPti, AT A /RAPriC Lto7.617 1.4111.1.1 -!E WAS RE.ASpzzo AkCITHE1 FfIrc.f rflirEKUURJES CL.1J511..11 or sroirnn., SAC, WO NEI: no- .iirrosav al, doom atliko., rintdenro. Ff twisiva I • ca.wilp. on Mil 96..4. FE s kur.sx.eole.rl .4,1wat ;meld la :newt. ru Absplal 3nt 10 4,SW tent fn. 7.5 cf.43, [I. 4,11jt /57TAci.FGo • 7 7 2314 4 O.312.1;.:015 a014 Th4 OL ::.,74r2415 NI6 MS Tour n3;20.1.! ,.1.4 3;10.7055 47 '4-14 leur 3,AMS 5.t1.5t27:t 2,13.00.15 7 SOAC. -4.73 7C+D f.* OKA 3.1 222I.SG 37820 SO Or S19 Sal IOW 8 USi SiNET Claim Payments Reserves Notes Treatment Claim Information Claim Stars Closed Accident Cate Wed, May 28, 2333 Report Date Wed, May 28, 23J3 llligaled' Iio Accident Lacatcr Accident Description Cut n!HJdle iirlaer when sli,iry lemons Adjuster Mariar Bye Case Manage: Linda Hamilton There It- 0 recentretes Claim Totals Lathy:icy Paid ,eseree Rrcovr} lowed Salresed t t. Su 00 SO CO S7 00 SCE 00 SCE OC ME S14137 SOLO Slllrl SIN137 SC.00 LE = 30 00 93 CO S) 00 Sr 00 SC OC IX SOOG alto S701 sr Orr Sr Or lord S191-77 Saco S5.0D 819137 SOX ;NET 3701020005433 Wed, May 28, 2003 WorkersCompensation Marian Blye I SawaSof inkareation Linda Hamilton Nave trnda 1"141T143n Phone K0440056 nial tincla hJamlice4tinis 4-64 con, Rtiv.rd Seale Fcavn 111.77GG‘I) FALL - Fall, Shp, Trip, NOC .f ruIy Strain Pi ,140.• 13111116tly Gong to pts.roormslipped and felt on wet floor,landedon left side, strained back :41 4 Status Information ori Return To Work The% &tome curer* ' ") tika Available Lauf ',pais 'AIM' al Oltly Employer Information 4CUS is 'Thursday AM' 23, 2015 NET � C C u;.., ••y.;R 1 s :ens •;.1 7 MISCELLANEOUS lSU 1;25/2715 43100 3(25/2715 US1S P-IC 3/I7;2015 3;19/2015 58.00 C EXPENSEExpense Ciono1n4lch Fee 3/25/2015 43101 3/75,2015 AMERLSY 3/16/21315 3/1511015 55,75 C _5,2615 43101 3125/2615 AMERSSY5 3/7012015 3/60/2615 55.75 C 3,75/2015 63101 3/25/2015 AMLATSYS 3/20/1C15 3/20/2015 S1.92 C BILL REV FEYIr BO Rooms Expense f1SC039P FEES fees BILL REVIEW E se I15CD3CkR 6111 Re nonFEES sP�' fees ell REVIEW b,t1 Rl rnwt NETWOstI( FEES Etpanse L15CO3WV Netwoh Feiss BILL REVIEW Btn R4Yie.Y 3/25/7015 43101 3125/2015 AMERISYS 3/1612015 3/12,2015 $2.15 C kETtSmRX FEES Eryense 115C0311f Netwult Fees MATRIX L15C0670 1/25/2015 43115 3/25/2015 PHARMACY 3/13/2015 3/13/2015 524.60 C DRUGS Mediae L15C06TD CGrrus LLC E013R MATRIX L15C08NY 3/25/2015 43118. 3/25,2615 PHARMACY 3/21/2015 3/21/2015 510.65 C DRUGS Med6tal L15CGANY Carus LLC 60BR 3/25/7015 43134 3(25/2015 4LfFE[SO i ORREA 3/25/2014 43115 3;25/7015 At FRft9C1 CORREA 5716.65 C 5366.43 C TEMPORARY TOTAL TEMPORARY 1UTAL TT Camp 3/21J2015 413;701.S TT Comp 3/712015 3/13r2615 MATR.TX 115006f6 3/1812015 42852 3/18/2015 PHARMACY 3/33L22015 3/13/2015 516..15 C DRUGS Medical L35C06E5 Carrus LLC E06R -MET VV. it 7dFs,1 P.-v, d•rl, Ni INVII! Ill.'.1101111 A:do Balance Carrectr¢n in 4/27/2012 $146 70 Medical Reserve Reserve For Close] CFai n Rebalance INCREASE RESERVE 9/26/2002 S108.73 Med cal Irnponed Relieve FOR PAYMFNFT TO CLOSED CLAIM INCREASE RESERVE 9/2a+2007 S21.40 AEeal imported Aeser.2 FOR PAYMENT TO CLOSED CLAIM INCREASE RESERVE 12/29R003 SLa8.37 Medical Imported Reserve FOR PAYMENT TO CLOSED CLAIM 11/20T2003 S5000) Medical Imported Reserve artstanding hiC 11/70/2003 11/20/2003 10/1S/2003 8/26,2003 6/9/2003 6/9/2003 1S261.86) Medical Imported Reserve CtA1M CLOSET) (5250.O01 EYPetne Imported Reserve CLAIM CL0 ED $500.00 Medical Gra,Ftnled Reserve rrgcang rem 590O00 Medea' Imported Resere a goa 9 urns 560000 Medical Imported Reserve ORI17NA: RESERVES S25000 Expense Imported Reset,.e ORIGINAL RESERVES r..,.n„ .0 Log ON 37O1O2OO43O e 1 IIIl Reserve Summary C+lesacrr Pa6 Racer» *Wave, o-.i o Snap ... SO00 1401.1 1000 SO DO 100O LIF 5764034 S2 ea0M SI100 17f4034 Stag 46 SO00 5000 SO07 SO DO VI MI EN SO DO IOW SO 110 S000 1000 total 5264014 1244034 1000 12 640 34 11467 9 . 1 Status Information Return To Work Employer Information no clam is ctaen0y " N rl Avallahle iNET YMn0IlSr1 a© Log 00 669F1.2O 14OCJO2238 •ore tort Anachmant Spoke »tth the elarmanl He da see the dodo.• on a136/l5, Fib laps remoras s* 4 fl i'a0cw.up an 3/22/1 S. 3, :'4/2015 EEC taIMANT CONTACT' employee Lcntart On 3/?l/Ei he forums an no work shards t 3/2//15 rie is curfenits titan mrd:ahcn to bong the sweNug down Good Mcxnnq Thy TA -Ft error has Won cloud. -Monks. 2171/7015 cF Ct Apt FOkuSIDWc13 EMU era l horn EO1 3/23/20IS CS CLAIM SCAN •ISOSearch ohm 3114✓2015 MED Met cal Records DWC-2S Rea 3117/2013 311612015 my MED Me4rsal Records, DWC-23 Req nM WS WAge 1lhloment Req/Resp. AWW Of ISO Report ISC Search atenesod Onarii3 ISO Sear dh tndruted Wage StlMmenl MAID) ISO Search Inn1Al0d {CLAID) I00 Silo ch 1014led Per Wage Stalemern Efleclne 316/2015 the ANW,/CR n based on a statement tar a woad from 1112012014 to 3/5/2015 Tot 3Day3 :122 T0IY1Werks • 14 GrossPoy - 7716-6e I Grahams ° 01 irvvjo Borman • 0 AWW"33762 Carnp6J1a • i532.62 • 66671 a 6366 a3 Vaa rya 13 i•I'�.iNET (1v1.aYnt[-rd-, f;r:.e•, it -, 61r x l'rt DAN! ... rra •'�C '•,• d +� S/2S/2003 TY Sy30/2003 ST 11(20/2003 ST E �.vr; C•e nl.t ,.r Type- Medical Only Con...en ct Claim Type S[atas Open CLiim Ongtnal open of claim 'Status' Closed Claim closed 1, 11 0-,.1 to•,;•I :a0 Logc* 3701020005433 Claim Event Information I`1aYm 3/010X01..e..0d 4 caat e t as sit I I;:1r100) Ir.. ("awii gat Oven Iv 176 slaws axe g* dal* legated V413(2003 TI,rs L W1 Meal repaled 2 nap ahe it* nala a1 at: Whin N'lidratsarr, May lei 200) 5/6 JE Status Information Return To Work Mee I maramiff NotArrtlnble Lass type es.;1.,,1 •r .„ : ,.., , 0 2015 USIS Inc 1 Employer Information (ACUSIS Thursday April 23, 2015 14 Reporting a Claim — Location Search ,NET L(KJ Ott Ail L111115-tt�.:i`S hnttlrcfL5 Ci Location Search Account 370 04/23/2015i - Employer Number UT.l.lnn Number L ocafran Name Loreban City lucalmr MAIN Lacatwn Zsp us's Thwsday Apfli Li, Reporting a Claim - Location Search iNET Location List Select 000906000001 ADMITTING 121 009999000001 01214C 002500000001 ON SURGERY Select 11:11111 009703000001 Select 003706000001 11E1002505000001 SSEM ACCOUNTING SSEM ADMINISTRATION SOLK SURGiCAL ci Irmo Ice 1414 KUHL AVENUE Pa9e 1 of 86 /43 !WM) 12./1.k tZ Back To Search ORLANDO !:•:tart FL 32806 16 Reporting a Claim - Coverage Type Selection iNET Ilk Coverage Type Worker's Coropention 111 General Lrabiltty A USIS nutsday April 23, 2015 02015 USIS, Inc Po,-ig 1 -7.0+r kfivm,44,110.4-Wre 1 7 • O 1 fkim Z .t rr al WC L eye I .11.31L Insured Reporter Nerw Claimant I-Int Name IArtalfsalm Type lose 1111 LnMNnr ie F441.4110 Poky to Woo keit. Repot! State 41CM-110,1[4wn Phan. N.an- L.t fRC,l rmud SHIN Kendal flitthdif. " PION sw Nwpun'T Comm Ike }implaynsttl rNe r_1Anppudhy annWatN, !ikons 1 Adaieas folly Slnu Hha One (k:uWl}wi Ph Rase Gay i ype $ Par Markel Status Liey.+ttdsms • Sabel Siam hy NunmFet Fmptord 10 Ares Cede Minn&eke. Ilpeya Md,nr WallMvIW PP roll fuse. SupxriAct y OetuWk kooky,* Nlaiitet Nosiness Location MAKS Cad Nal, M MWAefe Location M�nartes� 1 tt.nlnut Aet cant lose. M 14..ty ANAPPAH OL+e,M+PPP was Mon.,.! I:.n,nry tanm*lM4M Ike, t int Ngwn.n Natter Ik.t Pe•• faux Aye.. _l' Up YO PPIPPoron PM 11,a1.d IPPP NIP nYk.tr, r P,,.ry.ry V. N Wnnnny 4iulun.nn lae lia Dam I`e,n w.. trq Opp Ik. ihYnvan " „,ud !hot* I Fvf.,IMy Il,ie P., Way, ,see Np ta•k,ntrn .reli,y "'ow 18 Initial Treatment Physician I Hospital Name Address 1 Address 2 Care type Phypciant)Hospital Initial Treatment Type Autho.i ed Yes No Unknown Area Code Munn Number City Smile Zip Phone Number t Health Care Heine State Specific Fields (NC) Years of Service Average weekly wago with overlinw $ If board, lodging fuel or other advantages wore furnished in addition m wages, estimate value per day weak 01 month der Work Begin Time OSHA Log Number Return Time Return Occupation Return Wage r Save - Need Inlonnatron .JAM PM l} 0 AM PM �riweuy��er,�Yixt Claim Entry - Review State Form, Save / Print for own records and Save / Submit to complete entry rNET rCIaim Review 1121 1001 KeH 1,¢1 ys' 640416 latex 4104 thin ee.e rqt yet Wit rst e•rW hY L SIS IMMO North Carolina lnduslrlal COmmIsslon EMPLOYER'S REPORT OF EMPLOYEE'S INJURY OR OCCUPATIONAL !DISEASE TO TIIE INDUSTRIAL COMMISSION To the Employer: A copy of this Fonn 19 accompanied by a blank Form t8 must be given to the employee. It does not satisfy the employee's obligation to file a claim. The filing of this report is required by law. This form MUST be transmitted to the Industhal Commission through your Insurance Carrier To the Employee: This Form 19 is not your claim for workers compensation benefits To make a claim you must complete and sign the enclosed Form 18 and mad it to Ciarms Administral on, N C. Industrial Commission, 4335 Marl Servico Center, Reloigh. NC 27699-1335 wtthvt two years of the dato of your injury or last payment of medical componsalion For occupational diseases, the claim most be hied within two years of the date of d sebrl;Iy or the date your doctor IOW you that you have a work -related disease. whichever is later The use of this form is required under the provisions of the Workers' Compensation Act ICFoea Emp. FEIN Carrier FEIN Cerner Foe a Clt7 togOe rn., C fib s e Me e+¢. dream b t.. rt., e ea d p,nreiA by milt, SAW one s as ee rebsebbbilw ea»+woavt+ Jets, T Doe r„y.a 9.1.. h.e re A.itlrsae Back rA ,Ar,ai . rr.r.W E M.plomeg M re6e reffibb0.11 Niernbee C.:_.. State Zip 20 (4u.sIs Check Registers Parameters Ar+fnnnr' .••. �.� St.LLur Y00 Parker. =J ..:, Unit Rangn: AE Dates; Totals Payments %4y Reewre Celpery -1321 a �' :1 r � ,E2r% -.� l2:% 1916% 007X lu.:Luurtl Itet:uick. i CoMp Fitter Amount 7141 4984,076.28 0.120.362.34 6123,1115.81 62,779,059.43 Vats Pays Noma click 8 � Comp Amount Claimant type Purpose rf Nman 11011 Nurnl,e1 03/06/2014 Eagle Medral P,, .m E.n+m,pn,es 03106/2014 Eagle 6lodlcal RMv41w Ent-49396*i 03/24/2014 US Legal Suppert OTC 03/05/2014 Seven languages Trarola0ng Sere 03/05(7014 Seven languages T.anssati9g Sere 03/26/2914 US 4ealthosau Med,cal Group Of Fl 1596739 90.00 40.00 16.. 00 46 00 Mane FMmia /596739 40.00 60.00 612 00 917.09 Smog Wier 1590130 40.00 6.0.00 4637 30 1637.30 smith PNOr 159E409 40.00 60.00 6105 00 4105.00 5n9'1411 Petit 1596609 50.00 60.00 4105. 00 5105 00 53.934 Penn 1590209 60.00 505.45 40 00 105.95 Saint Peen Payment Payment Payment Payment Payment Payment 114807PP 114007PQ 013/3/2014 / 3/3/2014 TO 1/6/2914 / 1/6/2014 Tx. 1/7/2014 //12/7014 U4C0442 11707097 11707107 11735053 11713145 11713170 11730904 21 oF2' ► ►I 4 1 ...' 4usis Recent Return to Work Parameters Dates: 12/09/2014 thru 01/08/2015 Totals 3/0 669 Taal Account Account Full Duty tight Duty Count 'Count Claim Id 669 669FL20140002000 669 669FL20140001625 John 370 170gt 201400015A1 John 669 669FLc20140002093 John 370 370FL2014001473 John 370 370FL.20140001574 John 669 669FL20140002070 John 370 370FL20140001573 John 669 669FL201400020131 John Recent Rettig to Work by Type FLA Didy Lgint Duty 94 87 % Claimant First Claimant Last Name Name John Doe Doe Doe 0- 513. Claimant Return To Work Status Injury Date Work Date 11/17/2014 1/6/2015 Full Duty 12:00:00 AM 07/07/2014 1/5/2015 Full Duty 12:00:00 AM 12/24/2014 12/31/2014 Full Duty 12:00:00 AM Doe 32/29/2014 12/30/2014 Full Duty 12:00:00 AM Doe 10/04/2014 12/30/2014 Full Duty 12:00:00 AM Doe 12/21/2014 12/30/2014 Full Duty 12:00:00 AM Doe 12/13/2014 12/29/2014 Full Duty 12:00:00 AM Doe 12/10/2014 12/29/2014 Full Duty 12:00:00 AM Doe 12/19/2014 12/29/2014 Full Duty 22 z$, USIS New Claim List Palramet ers tl.v,rn Ipp:.• Totals IT Ui71nw %ad INK) :II41FrrrYp IG1aimP ParO RMewr-a 3 $2,507.51 5332.06 24 516,777.11 5284,102 59 27 $19,304.82 $204,435.45 39 54,605.31 529,174.75 51 $1,827 42 850.672.58 90 $6.492.73 $115,947.33 76 92 Maw Claims by (Palm Type 23 06 % LT —t10 Account Claim Id Claimant First Name Claimant t:iaim ' Claimant Claim Last Name Rt'csired !Injury Date Type Date NCCI Body Part NCCI Cause Of Injury NCCI Nature (31 Injury ' Total Paid To Date 370 370F17817n0111,706 370 320FL24134401:4Z 370 179F1201340Q37961 370 970F120110001283 669 46961L70130001449 7nhn 7ohn ;oho 7ohn John Doe Doe Due One 04/1$17014 04/18/20I4 04/16/2014 04/15/7014 MI) 04/16/2014 MO 04/17r2014 MO 04118/2034 04/T4/2014 MO 04/1712034 04/17/2014 LT 40 - TRUNK - Mo0iple Trunk 53 • LE • Knee 50 • LE - Multiple LI.:er Erttemiries i0 - TRUNK - MuitopS, Trunk 33 - LIE - Lower Arm 56 - INI - l lrtm j 31 - FALL- Fad, Sip, Tap, NOC 75 - STRUCK - FaWnp or Flying oe7ect 57 - 1rU - PUS1u,uJ 6r P011g 29 FALL - On Same Level 17 - Straus 52 - Strain 10 - Contusion 52 - Strain 10 - Contusion 50.111 50.01 50.0* $0 0, 5679.6, 23 NatureGroup Incurred & Claim Counts By Nature, Cause, and Body Part Groups ClaimCount (Sum) E0 Incurred 2M u 1.5M j 1M 0.5M OM Occupauanal Muth* Injuries: CauseGroup BodyPartGroup ClaimCount (Sum) Fail, Shp or Tnp In1ury.11.— CiW . Plultturr. Sirap,,. Caught in Linder a... Struck or Injured By ,. ClairnCount (Sum) MMip1e Body P Trunk:9.61 % 711p4 [nt+s Fruemgia: 2O- • Upper Earremrties:2- ■ incurred oklemnily (Sum) A IruurrrdMrrlical (Sum) •Inkurredletgal )Sum) Ire ualoci( cpenu (Sum) 2014 2©15 1900 1905 1910 1915 19:0 :9:S 103'' 1935 1'i5: .J50 19%5 1760 19E5 1970 9'rr 1950 1955 1990 1995 ,1lX10 :005 2010 2015 • Depression Diabetes 90.4 73.3 Ip Heart Disease 1rrAr%cs :c Hypertension 61.7 51.9 Obesity 44.7 Pulmonary Disease Renal Disease 38.3 35 < 1K 100K to 4 500K 10K to < 50K $6.58M $20.3M $40.1M ...,••• • 1K to < SK SOOK to 1M 50K to 100K 5K to < 10K $14.8M $5.58M $13M $10AM • • g. 26 aim 41111' Odr < 1K $6.58M 100K to < 500K $20.3M 10K to < 50K $40.1M Claim Anatytics 1K to 5K • in 500K to < 1M M1 50K to < 100K Lt. HAM CM, 5K to < 10K $14.8M $5.58M $13M $10.4M 27 Dashboard $1.924.1. PoLovnlfr Anarytrcs 2; P. 28 DME Hospin HospOther HospOut Other Phys $2.84M $12.3M $8.91M $19.4M $7.71M $34.1M $644M $9.O7M Y'aw'r �iPf �kUM z 7 .ti.' B,'� fi-� } t ,•y� taI ,�.vMG,a. H�:F 41P W si,fi:� W.,y!�v,i�,{�� �-. h -, M1a 4.u:w.:Jllli �7rir, `LfLF�,a�.,.ek1 �i�Ilt'yu 1"� .. 29 Medical Management System APPROVAL OF BILLS WAITING AUTHORIZATION ►` 2168 Open Clam,. Date Priority Claim a 113 P...r.larea. Claimant Assigned a 113 Bills Waiting Approval Action Code Status Presciber Medium : 3 ".! ( ! KIGHT, MARY "MD Pending Edit Approve Medium STAFFORD, BRENDA 'MCIPending @R. HOWAP,D 1 GREEN D.O. Edit Appro. e Medium - . STAFFORD, BRENDA 'MD Pending JORGE A AGUILAR MD drt Aoorg , e Medium BEARD, MARSHA 'MD Pending Flit ?pprr,.e Medium STAFFORD, BRENDA 'MD Pending D1ETRICH f¢it LEn, r Medium STAFFORD, BRENDA 'MD Pendin DR. HOWARD 1 GREEN g D.O. E+!I Aoprc-,s Medium BEARD, MARSHA 'MD Pending Ott Aoorovt Medium BEARD, MARSHA 'MD Pending Eck Aenrove Medium BEARD, MARSHA 'MD Pending Edit APE+rgvg Medium KIGHT, MARY `MD Pending Olt Approve Medium KIGHT, MARY ‘MD Pending F rr AprIrthA Medium KiGHT, MARY 'MD Pending t Ed I .A_Rail,s Medium - . " BEARD. MARSHA 'MD Pending KAMBACH Edit Anurove Medium K1GHT, MARY 'MD Pending MURPHY Pagel of 31 2 3 4 5 6 7 30 31 (i j 31 DIARIES - BY PRIORITY r 2168 Open Claims Date RI 113 Claims (0) CI 113 $ills Waitzn9 Approval Priority Claim `lrJ:ilrn .1 Medium - SFL O1W 10 Claimant ssioned Action Code Description Status Vasconcelos, Viviane 'PM PRIORITY MAIL Pending Vasconcelos, viviane Pending Vasconcelos, Vrviane TPLMR Schedule review Pending Vasconcelos, Viviano TPLPR Call to follow•up on Dig Visit Pending Pending vasconcelos,Viviane TPL©R review diag appt Vasconcelos, Viviano TPLTPR Call to see how transportation services were pending delivered 141 Meou Rouyn To Wart 1n4orrnatian: ae. 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E,.7 14.29 ) f ' 3( ilf 0 4, !Lie 6 33 SECURE PROGRAM Claim Claimant Diaries 8dis Prescriptions Entered 815/2013 815 r2013 Total Score Risk Score Authorized 112 Moderate USISTRANSFER 112 Moderate USISTRANSFER Pain Screening Questionnaire These questions and statements apply if you have aches or pains such as bask, shoulder or neck paee. Please read and answer each question ran -fully. Do not take too long to answer each question. However, d is important that you answer every question, Each question should always have an answer. Head Fex Henels) vnee(s) Nero Trunk le(s) 9nauILer(s1 Chest erm(s) abdomen LON Back Kips rani. r. New many days al work have you missed because al pain us the past la a oaths? 4 0 drys 1.2 days 3-7 days 8.14 days 15-30 days 1 month 2 months 16 months 6-12 months over one year . How fang have yw hod your current pawn arabkmr 0 tiers 1.2 days 3.7 days 6-1a days 1S-30 days 1 month ' 2 months 3-6 months 6.42 months over one rear . Is your work heavy or monotonous? 2 3 not al all heavy and/or monotonous a 5 6 3 9 v 10 extremely heavy and/or monotonous . How would you rate the pain you have had during the pas! week? 3 No Dahl 4 5 3 rain as bad as it can be 34 Clain C1>in,,rn1 849 TMI1A OL HCL TRAMADCt! NLL TRAM4001 HCL TRAMAQOI HCL NAPROXEN TRAMA 4l HCL NAPROXEN 5OOAJM TRAML35 L HC! TRA3.1M)OL HCL NAPROXFN SODIUM Page 1 012;11 ,temsi T 0 21 OAR: 50.0 15 60 11/8'2013 500 12 50 10r/12013 50.0 11 45 8'27'2013 SO 11 15 8/12i2013 325.0 10 60 7 :23,2013 00 0 11 45 7. 03/2013 550 0 10 20 7,14 %2013 SO0 5 30 7116,2013 500 3 24 7'b2013 5100 3 20 7/711013 0npense 0 Cos: S3518 1.82 17713 127.13 533.70 577.13 523 79 5;909 S35 73 514.56 57015 1\1edical Paid by Type 35 Summary Ff , Date of Injury: 6/27/2012 Date of Birth: 05/22/1962 (Age: 51) Recent DTPHENOXYLATE HYDROCHLORIDE AND ATROPINE SULFATE Recent: N/A Recent N/A Recent Advanced Diagnostics Center Recent: N/A Recent: Advanced Diagnostics Center Recent: N/A Recent: N/A Recent One Call Medical Prescribed: 4/1/2014 Last Appt N/A Last Appt N/A Scheduled: 411/2014 Admitted: N/A Last Appt NIA Last Appt N/A Ordered: 4./17/2014 Ordered: N/A Next Appt: 4/22/2014 Next Appt NIA Discharged: N/A Next Appt 4/ 28/2014 Next Appt: N/A Delivered: N/A Delivered: N/A 36 Medication Anticipated Or Medication Prescribed Anticipated Qty Unit Date 01 Birth: 05/22/1962 (Age: 51) Test Medication First Review Discontinued Type Frequency Route Pharmaey Prescribed On On On DIPHENOXVLATE HYDROCHLORIDE 20.00 milligrams Generic AC PO Mail 4/1/2014 4/18/2014 AND ATROPINE SULFATE Medication . Anticipated Prescribed Medication DIPHFNOVtLATE HYDROCHLORI - Dosage Qty 20,00 Method By Mouth First Prescnbed 4/1/2014 Review On 4/18/2014 dotal Allowed 2,00 Authorized By Vasconcetas, Vrwane variance Pharmacy Mail Unit milligrams Frequency Before meals Discontinued Terminated 0n Termination Reason Prescribed By Abrams, Vivian Comment In Network Update Cancel Dale of Binh, OS222/1962 (Aye 511 Test Treatment Plan Schedule rndoy. AF0 16, '0J13 - Sunday, Apn129, 2 38 Fri J9 Set SMTWT F S 1 2 3 4 5 6 2 e 9 hi 11 12 13 1.1 15 16 17 10 19 29 22 22 23 2.1 25 26 27 26 29 30 .11 To. -day 3,r11. !! ,'c:.j.t 29 Sun 2I P.kn Sunday Apia 23 3614 - Sunday Apnt 27 2V11 22'I at tINNSMil 23 Wtd 21 Thu Day Wu& Whey Week Mmab sundry, April 22, 21;11 25Yri 26 Sat 27 Sur. 38 Automated case notes from Treatment Plan changes Case Notes - l-1 Jai Tvaa . v 417. *J'.4 Ireatnrem Afars Tree n art EIP.n P:1eoilehon This Medication is: Anticipated Pharmacy Mal in Setwork Medication DIPHEv.OYYLATE HYDROCHLORIDE AND ATROPINE SULFATE Type Genetic Dosage-'2000 (nits- ml�gramss Method By Mouth Frequency Before meals First Presudml 4-1.2014 Discommmed Resiew Oa 418'2014 Terminated On. Total Allowed 2 00 Termination Reason Authorized Bg•:'vasconcelos, Sisiane Ptescrlbed Br Abrams, V iian Va fiance Comment It 417-?7,1 treatment Plan Treatment plan lrua Phyaroan Care This Physician Care as Aiiii ated Provider ➢orchnk, Sohn In Network N Specialty Family Practice Time Seea ! Frequency Weekk Initiated On 4'7`2014 Terminated On: Renew On 4,23 201 i Last Appointment Neat Appoint -nett 4'22 2014 Total Allowed 1.00 Termination Reasnn Authorized By lasconcelos, Vniane Prescribed By Allen, Vivian Variance Comment 4,17-2•A4 Treatment Alan 4:17014 Treatment Plan 417:2311 Treatment Alen 4.11.2014 Treatment Plan 4/17,3114 treatment Plan 1170014 Treatment Alan Treatment Plan lnlnoi Tharerte Treatmenr pkn - Inrtrai Tranrpodatrea Treatment Plan - Tranapnarmn Changed treatment Kan - Trampodahcn Changed Teeatmene Plan - N-x Uh7€.Ittm Trealmenr Plan -ERNE r"loamall Attar hmert Y T Starting Address Kirby smith road, orlando, It Radius (miles) 25 Specialties Anesthesiology Audiology Brain Injury Rehabilitation 12 Cardiac Surgery 12 Cardiology ® Cardiology/Interventional Cardiovascular Disease Cardiovascular Surgery (' a Chiropractic 1 Dermatology Emergency Medical Services .! Emergency Medicine Endocrinology FndocrinologyiDiahetes and Metabolism Family Practice I Foot and Ankle Surgery '1 Foot Surgery Gastroenterology f 1!I tinseled All Select All Find Providers Provider listing j,., Hunters 1'seek sM+wf raMwrlal Kissimmee Galewsy Airport (sod) Kissimmee 92 ti [ 1.7 +r Pwu . 8effl .J 11e 4 OE Buena ° •'' s' i Ventura lakes ' b" Mkt' } �y 4 Mw..A �.��w+ I•� �•� 4 ti�+CL ri take roteopek Aga P • t 40 AmeriDoc Provider List ltareing,lwdraaa K„hyrmnrr , ,, ..tamer. to RadNn irrdeil 25 Spnl.11ka Anntheawlogj I Audiology 1 I gran Injury keh.b,lltancn ■ tarduc Stngery ® Caldtitlagt Cutiro lag, 0mwr:trawnal ®Gneh men tiler Dinette Celdnemenles Surgery ' Chimp/kart I Demonology Flosing emy Medical Senecas Emergent). Medicine I Endocrinology Endacnndlogy711rahelee end Metabolism Fan* Pinner Feat and Ankle Surgery 5s.rgery =s:xemerottiff, .. Unselect All Select Ad find Pro Aden Provider Search Results iepem to feed a miles ly+me Address OS/ '+ Y 10 Mathias, Far,nk F M9 1515I 171h SI Ste Saint Cloud Stars 73p Phone fan e 1 ♦ 1 FL 3476S Ui 109 7ulluw, Dianne i, k117 310:171h $t Sam [kern F1 3474A 10.d Ka1u, Fatlma Kesat,, Mt1 310217tn St Sant Lloud FL 34719 mend° tteart and knaular Ctr FS 1lA 1k 11311 La. Underhill Rd Ste WO [Mande FL i7ss?5 1.SA L Aarda Heart Ct And Vascular r 7727 Lake Undmhill ad 9dantle FL 17�2 11,7 Ana K She Mitt,. S'tl Hnda Se Stela Kgsrmmee FL 34711 12.2 FL.°Intl 7unnen. MD 1A2,2 2a1n03, Co Ste 7 Orlando Fl 37306 123 K.ktu SundM MD 12.3 tulles, Dianne S, MD 12.3 R.yu, Pectin+ lamer,. M37 12.1 ldethiar. Patrick F. M3) 12.5 Puma Pas&na Kern. Mt) 12l Accost Maim. 9. MD 311 VI Slat Sr KnF.mmee FL 31741 3111N Oak St &resimoee FL 24711 31 t W Oat St Knsernmee Ft h741 501 Oak Commons bt:d Knontmet Fl 36711 710WOak Si Shia: Kisvmmee Ft 31711 334 WMA.gnolla St Kissimmee F1 35741 Fd Cj Spee mime C ardarlogy 'imc,vcnl,enal,Ca Cauterauuler Di+au C'ard,u.ascula, Druase Cardiology Ins en roan n.l C er d, o IugyfIn t ereentso n al Linda...cuter Drune E7 I' C atd,mrase timer Disease terdOvnculir Neese Cerdanneurular (Mean Cerd,a.ewrrlar [Meese C ardielagyrlmerrennanel.Ca Caeditramtiler 959ea1{ Cardorugy Calthol.94 7+mero L1 10se ATTACHMENT 5 USIS Sample Reports (4)pUSIS SAMPLE REPORTS TABLE OF CONTENTS ITEM NUMBER Employer Report 1 Claim Analysis Report 2 Check Register Report 3 Savings/Activity Cost Containment Savings Report 4 Legal Report 5 Recent Return to Work 6 ADDITONAL REPORTS AVAILABLE Employer Reports Employer Report Employer Report— Grand Total Employer Report — Year Totals Claims Reports Claim Analysis Report Claim Status Report Claim Statistics Status Report Payment History Claim Statistics —Totals by Payroll Class Claim Statistics — List Claims Claim Statistics —Totals by Unit, Year Claim Statistics —Totals by Adjuster Claim Statistics —Totals by Body Part Injured Claim Statistics —Totals by Nature of Injury Claim Statistics —Totals by Cause of Injury Claim Statistics —Totals by Claimant Claim Statistics —Totals by Attorney Claim Statistics — Attorney Expenses by Claim Check Register Reports Exceptions Register Check Register Check Register Totals by Unit Check Register Totals by Year Savings / Activity Reports Cost Containment Savings Report RTW Savings Report Medical Bill Review Activity Report Savings Report by Payer Employer Report 4�. 'usis Account: XXX - CLIENT NAME Unit 04250 - CLIENT NAME Serviced by USIS Employers Report - Loss Run 2/12/2015 thru 2/12/2016 Page 1 of 291 211212016 204 PM Policy Year 0 thru As of Date: 2/12/2016 Policy Number: ALL Policy Year: ALL Claim Status: ALL Claim Type: ALL Gain III: 10fIFL20130002416 Claimant Name: SSN: Date of Birth: Job Code: Occupation: Injury Date: Recieve Date: Claim Type: Claim Status: Accident Decription: Part: Cause: Nature: 8810 CIVILIAN EMPLOYEE 9/29/2015 10/112015 LT C EE had a seizure while working in his office. No injuries were sustained. EE has a history of seizures and is under his Doctor's care, He was transported to the hospital. MULTIPLE - Insuffiicent Info to Classify MSC - Other Miscellaneous, NOC All Other Cumulative Injuries, NOC Claim IC: 108F14014000>e888 Claimant Name: SSN: Date of Birth: Job Code: Occupation: Injury Date: Recieve Date: Claim Type: Claim Status: Accident Decription: Part: Cause: Nature: 7720 DEPUTY SHERIFF 1/5/2016 1/5/2016 LT 0 While Deputy Sheriff Cordero was at a drive through ATM with his arm extended out the window he was rear ended, causing his vehicle to move forward about 5ft. He has a tingling feeling in his Llshould MULTIPLE - Multiple Body Parts MV - Motor Vehicle, NOC Multiple Physical Injuries Only Jurisdiction: ALL tndemnity: M diwtf txletiaet. KOS: T: Max Incurred: ALL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 274.60 18.06 0.00 0.00 292.66 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 PIT) Reserves Recoveries 0.00 491.35 18,06 0.00 0.00 509.41 0.00 3.008.65 0.00 2,500.00 0.00 5,740.59 0.00 0.00 0,00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.613 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.500.00 18.06 2.500.00 0.00 6.250.00 Unit 04250 Totals Open: Closed: Reopen: Total: Comp Med Other Total 1 0 0 1 1 0 0 1 0 0 0 0 2 0 0 2 Current: PTD: Reserve: Total: Compensation 0.00 0.00 0,00 0.00 Medical Expense 274.60 18.06 491.35 18.06 3,008.65 0.00 3.500.00 18.06 Legal 0 00 0.00 2.500.00 2,500.00 KOS 0.00 0.00 0.00 0.00 Total 292.66 509.41 5,740,59 6.250.00 UsIs Account: XXX- CLIENT NAME CLIENT NAME Employers Report - Loss Run 2/12/2015 thru 2/12/2016 Page 2of291 2,120016 204PM Policy Year thru Policy Year 0 Totals Comp Med Other Total Open: 1 0 0 1 Closed: 1 0 0 1 Reopen: 0 0 0 0 Total: 2 0 0 2 Current: PTO: Reserve: Total: Compensation 0.00 0.00 0.00 0.00 Medical Expense 274.60 18.06 491.35 1806 3,008.65 0.00 3,500.00 18.06 Legal 0.00 0.00 2,500.00 2,500.00 KOS 0.00 0.00 0,00 0.00 Total 292.66 509.41 5,740,59 6,250.00 Claim Analysis Report tfrUsjs., Account: XXX - CLIENT NAME CLIENT NAME Serviced by USIS Claims Analysis As of 2/12/2016 Page 1 of 1 2J1212018 1:16 PM Policy Year. 2015 Ihru 2016 Policy Year 2015 Totals Percent of Total Lost Time Policy Year 2015 Totals Percent of Total Lost Time ReOOfi OAIIIY Ailkidi Policy Year 2015 Totals Percent of Report Only 18 36 54 18 33% 36 67% 37 47 37 47 44% 56 % 54 84 64 Okend O T41� Policy Year 2015 Total incurred Total Claims Average Incurred per Claim Total Incurred on Open Claims Total Open Average Incurred per Open Claim Total Incurred on Closed Claims Total Closed Average Incurred per Closed Claim 56 1 56 1 98% 2 % 57 195 $482,489 54 $8.935 $429,329 36 $11.928 $53,151 18 $2,953 57 120 80 49 a 140 100 60 20 ■ 2015 Compared to Recent 5 yr Avg Red Over, Green Unden 300 250 200 150 100 0 50 120 2015 Compared to Recent 5 yr Avg IRed Over, Green Under) 80 100 40 60 20 0 • 2015 Compared to Recent 5 yr Avg ;lied Over. Green Under, 28% $178,697 84 $2,127 3150,883 47 $3,210 $27,814 37 $752 43% $0 57 $0 SO 1 $0 So 56 $0 29% $661,177 195 $11.062 $580212 84 $6.907 $80,965 111 $729 Check Register 4usis IIIL Account: 119 - DEMO Company DEMO Company Serviced by USIS Check Register From 511/2016 thru 5/31/2016 Pagel of 4 6r16/2016 402PM Policy Year (Top 5 by Amt) ME 2015-1 2016-2 iffill 2014 - 3 NM 2000 - 4 2001 - 5 Policy Year Amount 2015 2016 2014 2000 2001 Checks Written Voids/Stop Pays UnVoids/Stop Reversals 48, 860.26 23, 742.27 23,268.57 177.50 99.12 Regular Group Total 50 40 90 0 1 1 0 0 0 Total Transactions 232 Payments % by Reserve Category Reserve Category ME EX LE CO CO EX '. LE MN ME Amount 63.16% 16.16% 14.32% 6.36% Group Transactions 182 60, 730.24 15,533.20 13,766.87 6,117,41 Indemnity Total 6,117.41 Payment Category (Top 5 by Amt) Payment Category 60730.24 29.300.07 PH 5V DC HL TR MIN PH - 1 SV-2 ® DC-3 HL-4 TR-5 Amount 96 ,147.72 44, 723.51 15,485.22 13,713.37 10,332.94 3,345.16 DEMO Company Serviced by USIS Check Register From 5/112016 thru 5/31/2016 Account: 119 - DEMO Company Page 2 or 4 6r1612016 402PM First Group By: None Jurisdiction: PaymentCategory: ReserveCategory: Year St Claim # 2015 GA 119GA20150000891 2016 GA 119GA20160001026 2014 GA 119GA20140000432 2015 GA 119GA20150000675 2016 GA 119GA20160001006 2015 GA 119GA20140000562 2015 GA 119GA20150000891 2016 GA 119GA20160001031 2016 GA 119GA20150000978 2015 GA 119GA20150000865 2015 GA 119GA20150000581 2016 GA 119GA20150000980 2015 GA 119GA20150000941 2016 GA 119GA20150000978 2014 GA 119GA20140000432 2015 GA 119GA20150000675 2016 GA 119GA20160001026 2016 GA 119GA20160001026 2015 GA 119GA20150000649 2014 GA 119GA20140000259 2015 GA 119GA20140000562 2016 GA 119GA20150000978 2016 GA 119GA20160001011 2015 GA 119GA20150000865 2001 GA 119GA20010000876 Check Register (Detail) Claimant Trans DI Svc From Svc TO Payee Type Amount Chk ID Demo Claimant 512/2016 419/2016 4/9/2016 Demo Payee PH 485.00 102425 -==Group Check=== 5/2/2016 Demo Payee 149.44 102426 ===Group Check=== 5/2/2016 Demo Payee 272.32 102427 Demo Claimant 5/2/2016 4/8/2016 4/14/2016 Demo Payee TT 78454 102428 Demo Claimant 5/3/2016 5/4/2016 5/10/2016 Demo Payee PP 525.00 102429 Demo Claimant 5/3/2016 5/3/2016 5/9/2016 Deno Payee TT 290.74 102430 Demo Claimant 5/4/2016 4/12/2016 4/12/2016 Demo Payee DM 737.04 102431 ===Group Check=== 5/4/2016 Demo Payee 1,360.21 102432 ===Group Check=== 5/4/2016 Deno Payee 36.80 102433 ===Group Check=== 5/5/2016 Demo Payee 541.50 102434 ===Group Check=== 5/5/2016 Demo Payee 1,066.80 102435 Demo Claimant 5/5/2016 5/972016 5/15/2016 Demo Payee PP 525.00 102436 ===Group Check=== 5/6/2016 Demo Payee 69.58 102437 Demo Claimant 5/6/2016 12/22/2015 211/2016 Demo Payee MCFM 1,045.10 102438 ===Group Check=== 5/9/2016 Demo Payee 287.10 102439 ===Group Check=== 5/9/2016 Demo Payee 456.00 102440 Demo Claimant 5/9/2016 4/16/2016 4/16/2016 Demo Payee PH 485.00 102441 ===Group Check=== 5/9/2016 Demo Payee 568.74 102442 Demo Claimant 5/9/2016 4/12/2016 4/12/2016 Demo Payee PH 1.208,42 102443 Demo Claimant 5/912016 1/20/2016 1/20/2016 Demo Payee PH 59.09 102444 Derno Claimant 5/9/2016 12/9/2015 1/10/2016 Demo Payee SV 53.25 102445 ===Group Check-== 5/9/2016 Demo Payee 3,418.72 102446 Demo Claimant 5/912016 4/7/2016 4/7/2016 Demo Payee PH 143.04 102447 Demo Claimant 5/9/2016 4/23/2016 511I2016 Demo Payee SV 1,360.00 102448 Demo Claimant 5/9/2016 4/5/2016 4/5/2015 Demo Payee PR 210.00 102449 ===Group Check=== 5/10/2016 Demo Payee 8,375.61 102450 -Group Check=== 5/11/2016 Demo Payee 488.94 102451 ===Group Check=== 5/11/2016 Demo Payee 186.49 102452 Demo Claimant 5/11/2016 5/11/2016 5/16/2016 Demo Payee PP 525,00 102453 Demo Claimant 5/11/2016 5/10(2016 5/16/2016 Demo Payee TT 290.74 102454 Demo Claimant 5/11/2016 5/6/2016 5/12/2016 Demo Payee TT 392.27 102455 Demo Claimant 5/12/2016 4122/2016 4/22/2016 Demo Payee SH 11.18 102456 Demo Claimant 5/12/2016 5/5/2015 5/5/2015 Demo Payee PH 189.88 102457 ===Group Check=== 5/12/2016 Demo Payee 7,598.68 102458 ===Group Check=== 5/12/2016 Demo Payee 306.24 102459 Demo Claimant 5/13/2016 4/23/2016 4/26/2016 Demo Payee SV 2,685.17 102460 Demo Claimant 5/13/2016 5/16/2016 5/22/2016 Demo Payee PP 525.00 102461 ===Group Check=== 5/16/2016 Demo Payee 483.62 102462 Demo Claimant 5/16/2016 4/12/2016 4/12/2016 Demo Payee PH 630.50 102463 Demo Claimant 5/16/2016 4/21/2016 4/21/2016 Demo Payee PH 450.00 102464 ==-Group Check=== 5/1612016 Demo Payee 1.174.85 102465 ===Group Check=== 5/16/2016 Demo Payee 268.17 102466 -==Group Check=== 5/16/2016 Demo Payee 7,660.65 102467 ===Group Check=== 5/16/2016 Demo Payee {7,660.65) 102467 VD Demo Claimant 5/16/2016 12(18(2015 12/18/2015 Deno Payee HL 141.53 102468 ===Group Check=== 5/16/2016 Derno Payee 1,242.91 102469 ==-Group Check=== 5/16/2016 Demo Payee 537.02 102470 ===Group Check=== 5/16/2016 Demo Payee 5,101.39 102471 Demo Claimant 5/16/2016 4/20/2016 4/20/2016 Demo Payee PH 99.12 102472 Fee �-4) us Account: 119 - DEMO Company DEMO Company Serviced by USIS Check Register From 5/112016 thru 5/31/2016 Page 3 of 4 6/16/2016 402PM ...Group Check 5/16/2016 Demo Payee 41272.102473 2014 GA 119GA20140000124 Demo Claimant 5/16/2016 5/6/2016 5/6/2016 Demo Payee MC 150.00 102474 2016 GA 119GA20160001026 Demo Claimant 5/16/2016 5113/2016 5/19/2016 Demo Payee TT 392.27 102475 2016 GA 119GA20160001009 Demo Claimant 5/17/2016 4/1/2016 4/1/2616 Demo Payee PH 98.47 102476 2015 GA 119GA20150000629 Demo Claimant 5117/2016 4/131.2016 4/13/2016 Demo Payee SV 3,011.29 102477 2015 GA 119GA20150000714 Demo Claimant 5/17/2016 4/15/2016 4/15/2016 Demo Payee PH 103.94 102478 ==-Group Check.-.. 5/18/2016 Demo Payee 1,622.22 102479 ...Group Check=== 5118/2016 Demo Payee 37D.50 102480 2016 GA 119GA201 50000999 Demo Claimant 5/18/2016 2/27/2016 2/27/2015 Demo Payee HL 313.2Q 102481 -==Group Check=== 5/18/2016 Demo Payee 349.83 102482 2016 GA 119GA20150001004 Demo Claimant 5/18/2016 3/6/2016 3/6/2016 Demo Payee PH 423.89 102483 1,777.23 2016 GA 119GA20160001026 Demo Claimant 5/19/2016 4/1/2016 4/1/2016 Demo Payee PH 102484 2016 GA 119GA20160001040 Demo Claimant 5/19/2016 4/21/2016 4/21/2016 Demo Payee PH 492,61 102485 2014 GA 119GA20140000432 Demo Claimant 5/19/2016 5/18/2016 5/24/2016 Demo Payee PP 525.00 102486 2015 GA 119GA20150000675 Demo Claimant 5/19/2016 5/17/2016 5/23/2016 Demo Payee TT 290.74 102487 2015 GA 119GA20150000675 Demo Claimant 5/19/2016 5/17/2016 5/23/2016 Demo Payee TT 290.74 102488 2015 GA 119GA20150000824 Demo Claimant 5/20/2016 10/7/2015 10/7/2015 Demo Payee PH 138.50 102489 ...Group Check=== 5120/2016 Demo Payee 385.76 102490 2015 GA 119GA20150000881 Demo Claimant 5/20/2016 10/23/2015 10/23/2015 Demo Payee TR 562.25 102491 2016 GA 119GA20160001026 Demo Claimant 5/20/2016 5/2/2016 5/2/2016 Demo Payee PH 153.12 102492 ===Group Check=== 5/20/2016 Demo Payee 780.61 102493 2016 GA 119GA20160001038 Demo Claimant 5/20/2016 4/16/2016 4/16/2016 Demo Payee PH 225.35 102494 2015 GA 119GA20140000562 Demo Claimant 5/20/2016 5/2312016 5129/2016 Demo Payee PP 525.00 102495 2016 GA 119GA20150000972 Demo Claimant 5/20/2016 1/28/2015 4112/2016 Demo Payee TR 172.00 102496 ===Group Check=== 5/25/2016 Demo Payee 2.076,02 102497 2015 GA 119GA20150000891 Demo Claimant 5/25/2016 4/1112016 4/11/2016 Demo Payee HL 9,492.45 102498 ===Group Check=== 5/25/2016 Demo Payee 3,301.36 102499 ===Group Check=== 5/25/2016 Demo Payee 66,35 102509 2015 GA 119GA20150000891 Demo Claimant 5/25/2016 4/14/2016 4/14/2016 Demo Payee PH 98.47 102501 ===Group Cheek=== 5/25/2016 Demo Payee 10,068.59 102502 ===Group Check=== 5/25/2016 Demo Payee 677.63 102503 ===Group Check.-- 5/26/2016 Demo Payee 677.38 102504 ===Group Check=== 5/26/2016 Demo Payee 378.52 102505 ===Group Check=== 5/26/2016 Demo Payee 4,832.16 102506 2016 GA 119GA20160001036 Demo Claimant 5/26/2016 4/18/2016 4/18/2016 Demo Payee PH 99.07 102507 ===Group Check=== 5/27/2016 Demo Payee 430.07 102508 ==Group Check=== 5/27/2016 Demo Payee 162.96 102509 2016 GA 119GA20150000972 Demo Claimant 5411/2016 4/11/2016 4/11/2016 Demo Payee PH 78.89 102510 ===Group Check=== 5/31/2016 Demo Payee 1.141.32 102511 2016 GA 119GA20160001032 Demo Claimant 5/31/2016 4/12/2016 4/12/2016 Demo Payee PH 682.30 102512 2016 GA 119GA20150000970 Demo Claimant 5/31/2016 2/11/2016 2/11/2016 Demo Payee PH 238.93 102513 2016 GA 119GA20160001026 Demo Claimant 5/31/2016 4/1/2016 4/7/2016 Demo Payee TT 235.37 102514 Total Amount: 96,147,72 VD - Void UV - Unvoid us' .J Account: 119 - DEMO Company DEMO Company Serviced by USIS Check Register From 5/1/2016 thru 5/31/2016 Page 4of4 6/16/2016 4'02 PM Regular Transactions Group Transactions Indemnity Total Medical Total Other/Legal Amount Total 232 182 6.117.41 - 60,730.24 Regular Group Total Checks Written 50 40 90 Voids/Stop Pays 0 1 1 UnVoidsIStop Reversals 0 0 0 29,300.07 96,147.72 Cost Containment Savings Report Account: xxx =CLIENT NAME CLIENT NAME Serviced by US1S Cost Containment Savings Report 1 /1 /2016 thru 2/12/2016 Page l of 2 2l1212016 1:12 PM Amount Charged Fee Schedule Reductions Fee Schedule Other Reduans Reductions Amount Paid Bills 3,114,977.74 1,316,933.52 1,798, 044.22 23,524.33 Provider Type Description Fee Schedule Reductions Ambulatory Surgical Center Cert Regis. Nurse/Advanced Nurse Practitioner Chiropractor Doctor Durable Medical Equipment Home Health 1 Skilled Nursing Hospital Hospital/Trauma Cntr Independant Lab Other Pharmacy Physical Therapy Skilled Nursing Facility Prow Two Dencdribort Ambulance Ambulatory Surgical Center Cert Regis. Nurse/Advanced Nurse Practitioner Chiropractor Dentist Doctor Durable Medical Equipment Home Health / Skilled Nursing Hospital Hospital/Trauma Cntr Independant Lab Other Pharmacy Physical Therapy Skilled Nursing Facility Translation/Interpretation Transportation Ptmvider Type" Description Dentist Doctor Hospital Physical Therapy Transportation 207,475.64 19,120.56 869.00 442,089.22 231.33 48,755.25 483,515.12 1,578.82 654.03 774.46 4.43 101,178.55 10,687.11 Nettrtatyrk Reductions 315.30 3,992.15 153.52 106.95 22.04 37,269.28 13,922.47 (36.115.00) 64,479.88 5,901.03 1,126.19 330, 87 13,892.10 24,818.49 216.00 6,359.70 9,939.81 Other Redtuc ions 55.51 22,710.09 614.98 33.12 110.63 146, 730.78 1,627, 789.14 Fee Schedule Reductions 7,592 Ambulatory Surgical Center Cert Regis. Nurse/Advanced__. Chiropractor Doctor Durable Medical Equipment i Home Health / Skilled Nur... Hospital 111.1 Hospital/Trauma Cntr pm Independent Lab = Other Pharmacy =I Physical Therapy Skilled Nursing Facility Network Reductions Ambulance Ambulatory Surgical Center Cert Regis, NurselAdvanced... NM Chiropractor Dentist t Doctor Durable Medical Equipment NM Home Health / Skilled Nur.. En Hospital Hospital+'Trauma Cntr Independent Lab ® Other Pharmacy Physical Therapy Its Skilled Nursing Facility its Translationllnterpretetion Transportation Other Reductions Dentist Doctor Hospital MI Physical Therapy Transportation Legal Report uses Account: - DEMO Company DEMO Company Serviced by USIS Legal Report AsOfDate: 5/31/2016 Page 1 of 2 6/23/2016 216 PM Summary Claim Type (Top 5 by Incurred) 31 - FALL - Fall, Slip. Trip. NOC-1 29 - FALL - On Same Level -2 I= 56 - INJ - Lifting - 3 27 - FALL - From Liquid or Grease Spills - 4 99 - MISC - Other Miscellaneous, NOC - 5 Claim Type 31 - FALL - Fall. Slip, Trip, NOC 29 - FALL - On Same Level 56 - INJ - Lifting 27 - FALL - From Liquid or Grease Spills 99 - MISC - Other Miscellaneous, NOC Incurred 658,539.43 452, 549.39 422,226.60 405,681.26 368, 572.15 5000000 4000000 3000000 1- 2000000 1000000 0 Incurred by Policy Year 2014 2015 2016 Axis Title Claim Cnt 4 Incurred 5,368,174.30 Incurred Recent Return to Work j,:us!s Recent Return to Work Parameters Dates: 05/24/2016 thru 06/23/2016 Totals 119 Total Account Full Duty Count Claim Id 119 119GA20160001088 119 119GA20160001086 119 119GA20160001074 119 119GA20160001085 119 119GA20160001062 119 119GA20150000759 119 119GA20160001078 119 119GA20160001083 119 119GA20160001082 21 21 Light Duty Count Claimant First Name John John John John John John John John John 2 2 91.30 % Claimant Last Name Doe Doe Doe Doe Doe Doe Doe Doe Doe Recent Return to Work by Type In Full Duty Light Duty • Claimant Injury Date 06/16/2016 06/13/2016 06/02/2016 06/13/2016 05/21/2016 07/17/2015 06/03/2016 06/09/2016 06/07/2016 8.70 % Return To Work Date Work Status 6/17/2016 Full Duty 12:00:00 AM 6/15/2016 Full Duty 12:00:00 AM 6/15/2016 Light Duty 12:00:00 AM 6/14/2016 12:00:00 AM 6/13/2016 12:00:00 AM 6/10/2016 12:00:00 AM 6/9/2016 12:00:00 AM 6/9/2016 12:00:00 AM 6/8/2016 12:00:00 AM Full Duty Full Duty Light Duty Full Duty Full Duty Full Duty 119 119GA20160001077 119 119GA20160001079 119 119GA20160001080 119 119GA20160001075 119 119GA20160001073 119 119GA20160001070 119 119GA20160001076 119 119GA20160001071 119 119GA20160001072 119 119GA20160001066 119 119GA20160001067 119 119GA20160001069 119 119GA20160001068 119 119GA20160001063 John John John John John John John John John John John John John John Doe Doe Doe Doe Doe Doe Doe Doe Doe Doe Doe Doe Doe Doe 06/06/2016 06/06/2016 06/06/2016 06/04/2016 06/01/2016 05/28/2016 05/31/2016 05/30/2016 05/30/2016 05/29/2016 05/29/2016 05/29/2016 05/23/2016 05/19/2016 6/7/2016 12:00:00 AM 6/6/2016 12:00:00 AM 6/6/2016 12:00:00 AM 6/4/2016 12:00:00 AM 6/2/2016 12:00:00 AM 6/1/2016 12:00:00 AM 5/31/2016 12:00:00 AM 5/30/2016 12:00:00 AM 5/30/2016 12:00:00 AM 5/29/2016 12:00:00 AM 5/29/2016 12:00:00 AM 5/29/2016 12:00:00 AM 5/26/2016 12:00:00 AM 5/24/2016 12:00:00 AM Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty Full Duty ATTACHMENT 6 Reference Letters OFCBI - ruur ► orkerr ( ri.rtJlen:,7trf..1 1rslaKtnua" P.O. Box 189 Alachua, EL 32615 (386)462-5171 November 22, 2016 To Whom It May Concern: Re: USIS, Inc. We have been requested to provide a Letter of Reference regarding the services being provided by USIS, Inc., as our claims management organization. We initiated our partnership with USIS in 2000. Speaking on behalf of the Board and Management of Florida Citrus, Business & Industries Fund (FCBI), we have been and remain extremely pleased with the committed professionalism and attention to quality service provided by USIS. They know their business and are dedicated all day, every day to serving our best interests. We are constantly rewarded by their superb claims handling. As you deliberate this important decision, if I can be of any further assistance to you regarding the attributes and quality service provided by USIS to our organization, please feel free to contact me directly at 3 8 6.4 6 2.5171. Thank you. ralee-zLec9Lc Sincerely, Debra Cerre-Ruedisili CEO, FCBI Fund Chief Executive Officer Debra Cerre-Rucdisili debra.ruedisiliv I"cbifund.com Orange County Public Schools MEMO Workers' Compensation Department March 3, 2016 TO: Whom it May Concern FROM: Regina Cochrane, Manager, Workers' Compensation SUBJECT: Reference Letter for USIS It is with great pleasure that 1 am writing this letter of recommendation for USIS. USIS has worked with Orange County Public Schools as our TPA for workers' compensation since June 1, 1996; that is almost 20 years. OCPS is extremely satisfied with the remarkable service that USIS has provided and value their partnership. In these past 20 years, USIS has provided a dedicated team to work with OCPS that includes one claims manager, who has been on the account since the beginning, one claims supervisor, who has been on the account 17 years, two lost time adjusters, one of which has handled the OCPS account for 15 years, and one medical only adjuster. The team works closely with OCPS. We have monthly cases reviews for current claims and two semi-annual reviews for one-year and older claims. USIS provides quarterly reports to OCPS that is followed up with a meeting to discuss outcomes. Monthly reports are provided for specific departments. USIS always accommodates any special report requests. USIS provides stellar customer service. There is communication between the OCPS workers' compensation staff and the adjusters on a daily basis through emails or phone calls. The staff is always friendly and goes the extra mile to provide exception service to the OCPS account. I highly recommend USIS. if you have any specific questions, please contact me. Best regards, Regina Cochrane Manager, Workers' Compensation Orange County Public Schools 445 West Amelia Street Orlando, FL 33801 Contact information: repina.cochran oci s.net or 407.317.3918 ATTACHMENT 7 Resumes/Licenses, Job Descriptions RON WARBLE Orlando, Florida CAREER SUMMARY Ron began his career working with disabled soldiers during the Vietnam War and, as a veteran, he finished his rehabilitation education in nursing. His extensive experience in medical field over the years and knack for strategic business analysis has culminated in the founding of a multi - pronged disability management systems company that provides specialized consulting services to insurance entities and employer groups. AmeriSys serves customers primarily in the southeastern United States. (Note: Brown & Brown Insurance acquired AmeriSys in April, 2000. Ron continues as Executive Vice President). Ron maintains his clinical edge and acts as a Consultant in Risk Management and managed care systems design. His knowledge has lead to service as a guest speaker in professional arenas and conferences where cutting edge issues in health and claims management are discussed. CREDENTIALS & LICENSES ■ Florida Registered Nurse ■ Certified Disability Management Specialist ■ Certified Life Care Planner ■ Certified Case Manager ■ Health Care Risk Manager EXPERIENCE 2000-PRESENT USIS/AmeriSys 140 Alexandria Blvd., Suite H., Oviedo, FL 32765 Executive Vice President Ron currently serves as Executive Vice President for USIS overseeing claims, information systems and the medical management and cost containment programs offered. His role includes working closely with customers to develop and implement successful models for their claims programs. 1986 —2000 AmeriSys 140 Alexandria Blvd., Suite H., Oviedo, FL 32765 President Responsible for the overall leadership, management and ongoing development of a regional disability management company. Initiated twenty-two years ago as a firm providing rehabilitation and field case management services. In response to the evolution in health care in the United States, the company grew to include a managed care division offering services in hospital bill review, pre -certification, utilization review and on site case management services. 1978-1986 MCR Systems, Inc., a software application and system technology subsidiary, was added in 1996 to provide technical solutions to the arena of health care management. Multiple Clinical Settings Registered Nurse Nursing experience which included trauma and psychiatric clinical management. Most of the clinical settings were inpatient hospital but also included community nursing. ■ Memorial Hospital School of Nursing, Danville, Virginia ■ Graduated June 1978 ■ Institute of Medical Law ( Health Care Risk Management Program) • Intellicus (Life Care Planning 120 post graduate hours) COMMUNITY/CIVIC • Past Member of Board of Trustees for the City of Winter Springs Pension Fund • Member of the Chairman's Advisory Board for Workers' Compensation for the State of Georgia RELEVANT PROJECTS CLIENT NAME PROJECT DESCRIPTION ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE RELEVANT PROJECTS CLIENT NAME PROJECT DESCRIPTION Columbus Consolidated Government Third Party Claims Administration Services, Medical Management Services (MCO) and Medical Bill Review Services. Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 3/1/2014 and continue to date. ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE RELEVANT PROJECTS CLIENT NAME PROJECT DESCRIPTION ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE RELEVANT PROJECTS Palm Beach Sheriff's Office Third Party Claims Administration Services, Medical Management Services and Medical Bill Review. Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 7/30/2003 and continue to date. Forsyth County Third Party Claims Administration Services, Medical Management Services and Medical Bill Review. Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 1/1/2016 and continue to date. CLIENT NAME PROJECT DESCRIPTION ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE City of Carterville (GA) Third Party Claims Administration Services, Medical Management Services and Medical Bill Review. Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 8/1/2009 and continue to date. RELEVANT PROJECTS CLIENT NAME PROJECT DESCRIPTION ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE RELEVANT PROJECTS CLIENT NAME PROJECT DESCRIPTION ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE RELEVANT PROJECTS City of Hapeville (GA) Third Party Claims Administration Services, Medical Management Services and Medical Bill Review. Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 6/3/2001 and continue to date. City of Jacksonville (FL) Medical Management Services and Medical Bill Review. Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 10/1/2013 and continue to date. CLIENT NAME PROJECT DESCRIPTION ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE RELEVANT PROJECTS MARTA Medical Management Services (MCO) and Medical Bill Review Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 11/2003 and continue to date. CLIENT NAME PROJECT DESCRIPTION ROLE OF THE INDIVIDUAL PROJECT ACTUAL OR EXPECTED COMPLETION DATE Additional projects available upon request. State of Georgia (DOHS) Medical Management Services (MCO) Executive Vice President responsible overall operations within USIS/AmeriSys. Services started 8/1/2002 and continue to date. JENNY ROSS Orlando, Florida CAREER SUMMARY Jenny Ross has over 22 years of experience in the Workers' Compensation insurance claims industry. Beginning her career in a support role with Executive Risk Consultants in 1991, she was steadily promoted within the industry and has been with USIS, a leading Third Party Administrator, since 1996. Jenny is currently Claims Manager with USIS, managing several workers' compensation teams and programs. One key component of her job is dealing directly with clients to ensure a high quality of service and support in all areas. Her knowledge and experience in the insurance claims industry has been significant in ensuring the continued success of USIS as a TPA. In 2011 Jenny was the recipient of the Brown and Brown nationwide Claims Professional award. EXPERIENCE 1996 — USIS, Inc. PRESENT Claims Manager Responsible for the leadership of claims personnel in the workers' compensation department ensuring compliance with the guidelines of State, client, company and corporate culture. Duties include personnel training, evaluations, claim reviews, approval of reserves, settlements, recoveries and closures, as well as direct contact with clients to ensure quality assurance. Starting as a Lost Time adjuster handling large elite accounts, Jenny has advanced progressively throughout her successful career with USIS. Also responsible for overseeing Brown and Brown's internal nationwide workers' compensation claims; dealing directly with the adjusters at Travelers, coordinating claims reviews, approving reserves and settlement authority. 1991-1996 ERC Claims Adjuster Started as a file clerk in 1991 and was steadily promoted through the ranks until becoming a lost time adjuster in 1994 handling approximately 160 files. Responsible for initial investigations, determining compensability and bringing files to closure in the most cost effective way possible while keeping the insureds closely informed. PROFESSIONAL CREDITS • All Lines 5-20 license • Continuing educational classes for CEU compliance • 2011 recipient of Brown and Brown's nationwide Claims Professional award FLORIDA DEPARTMENT OF FINANCIAL SERVICES JENNIFER L YNN R OSS License Number : A226466 Resident Insurance License Issue Date .0524 -ADJUSTER - WORKERS COMP 08/06/1994 Please Note: A licensee may only transact insurance with an active appointment by an eligible insurer al employer. II you are acting as a surplus lines agent, public adjuster, or reinsurance intermediary manager/broker, you should have an appointment recorded in your own name on tile with the Department. If you are unsure of your license status you should contact the Florida Department of Financial Services Immediately This license will expire If more than 48 months elapse without an appointment for each class of insurance listed. It such expiration occurs, the individual will be required to re -qualify as a first-time applicant. If this license was obtained by passing a licensure examination offered by the Florida Department of Financial Services, the licensee is required to comply with continuing education requirements contained in 626.2815 or 648.385, Florida Statutes. A licensee may track their continuing education requirements completed or needed in their MyProfiie account at httpslldice,fldfs.com. To validate the accuracy of this license you may review the Individual license record under "Licensee Search" an the Florida Department of Financial Services websile at http .Lwww.MyFloridaCFO.cam/Division/Agents 2611144c4" JetfAtwater Chief Financial Officer State of Florida TERRI SNAPP Orlando, Florida CAREER SUMMARY Terri has over 26 years of experience in the Workers' Compensation insurance claims industry. Beginning her career as a file clerk with Leatherby Insurance Co., she was steadily promoted within the industry and has been with USIS, a leading Third Party Administrator, since 1988. Terri is currently a Claims Manager with USIS, supervising the work product of over 18 adjusters and supervisors. One key component of her job is dealing directly with clients, a lot of which are public entities, to ensure a high quality of service and support. Her knowledge and experience in the insurance claims industry has been significant in ensuring the continued success of USIS as a TPA. EXPERIENCE 1988 — USIS, Inc. PRESENT Claims Manager Responsible for all managerial/supervisory functions over claims personnel in dept administering Workers' Compensation claims pursuant to client, company and State regulations within guidelines of company and corporate culture. Duties include personnel training, evaluations, claim reviews, approval of reserves, settlements and closures; direct contact with clients to ensure quality assurance — all in the best interest of the client. 1986-1988 1984-1985 1980-1984 Associated Risk Services Claims Adjuster Responsible for adjusting Workers' Compensation files and clerical duties relating to marketing and claims management. Travelers Insurance Claims Clerk Clerk for liability and PIP unit. Responsible for payment to providers, claimants, etc. File structure and organization. Orange County Clerk of Circuit Courts Sr. Clerk General office management duties, maintenance of legal files including discussion of files with attorneys. PROFESSIONAL CREDITS Licensed Florida 5-24 A248183 Continuing educational classes for CEU compliance FLORIDA DEPARTMENT OF FINANCIAL SERVICES TERESA JEAN SNAPP License Number : A248183 Resident Insurance License Issue Date • 0524 - ADJUSTER - WORKERS COMP 02/11/1989 Please Note: A licensee may only transact insurance with an active appointment by an eligible insurer or employer. 11 you are acting as a surplus lines agent, public adjuster, or reinsurance intermediary manager/broker, you should have an appointment recorded in your own name on file with the Department. If you are unsure of your Eicense status you should contact the Florida Department of Financial Services immediately. This Eicense will expire if more than 48 months elapse without an appointment for each class of insurance listed. 11 such expiration occurs, the individual will tie required to re -qualify as a first-time applicant. If this license was obtained by passing a licensure examination offered by the Florida Department of Financial Services, the licensee is required to comply with continuing education requirements contained in 626.2815 or 648,385, Florida Statutes.. A licensee may track their continuing education requirements completed or needed in their MyProfile account at httpsyldice.fldfs.com. To validate the accuracy of this license you may review the individual license record under "Licensee Search" on the Florida Department of Financial Services website at http://www.MyFloridaCFO.com/Division/Agents Jeff Atwater Chief Financial Officer State of Florida YARIXA ELIASON Accomplishments Senior Claims Representative/Liability Supervisor/ Account Manager All lines adjuster license. Experienced in handling property and casualty losses. Experience in handling claims for commercial auto, general liability, employment liability and governmental entities. Experience in field work and in house. Experience in investigating claims by taking recorded statements of claimants, insureds and witnesses and obtaining information in order to evaluate the Toss. Manage litigation files and defense counsel's activities, attending and actively participating in mediations as needed. Experienced in reviewing and assign claims and task to staff. Experienced in review job performances and merit reviews. Administrative Experienced in all areas of office administration, telephone skills, customer relations, filing system and office management skills. Secretarial Skilled in all the areas of secretarial duties and have worked for a personal injury attorney and litigation attorney. Experienced in legal research and paralegal work. Employment Preferred Governmental Claims Services, Lake Mary, Florida Senior Claims Representative/Liability Supervisor/ Account Manager National General Insurance Company, Cleveland, Ohio Senior Claims Representative — Commercial Unit Johns Eastern Company, Inc., Miami, Florida Senior Claims Representative David H. Burstyn, P.A., Miami, Florida Receptionist and Office Administrative Assistant Education Valdosta State University, Valdosta , Georgia Major: Masters of Public Administration Florida State University, Tallahassee, Florida Bachelor of Science Major: Criminology and Criminal Justice Miami -Dade Community College, Miami, Florida Major: Criminal Justice Languages Fluent in Spanish Licenses Florida , North Carolina, South Carolina and Texas References Available upon request FLORIDA I)E:}!•1RTNIE;N-I" OF FINANCIAL, SE:RV'ICES i RIX ! AROCIl0 I.irenie Number: EW646 Resldent Insurance License •0620-ADJUSTER -ALL LINES Issue Date 1011512015 260 IA Am slur 1'hol'rimrKrat irfhccr Stagy aI rkrndi Please Note A licensee may only transact insurance with an active appointment by an eligible insurer or employer. if you are acting as a surplus ones agent. public adiusler, or reinsurance intermediary manager/broker, you should have an appointment recorded in your own name an file with the Department_ If you are unsure of your license status you should contact the Florida Department oI Financial Services immediately. This license wig expired more than 48 months elapse without an appointment for each class of insurance listed. II such expiration occurs. the individual will be required to re -qualify as a first -lime applicant. If this license was obtained by passing a Vicensure examination offered by the Florida Department of Financial Services, the licensee is required 10 comply with continuing education requirements contained le 626.2815 er 648.385_ Florida Statutes. A licensee may track their continuing education requirements completed or needed in then MyProlile account at https,1Mice.fidfs,com. To validate the accuracy of this license you may review the individual license record under 'Licensee Search" on the Florida Department of Financial Services websrle at Infloffaiww.fidyFforidaCFO.com/DivisionlAgents MICHELLE COTTO Orlando, Florida CAREER SUMMARY Michelle Cotto obtained a Bachelor of Science degree in Accounting from the University of Central Florida in 2007. Michelle has been with USIS for 8 years; promoted to Accounting Manager from Accounting Supervisor and from Accounting Assistant. EXPERIENCE 2007 — USIS, Inc. PRESENT Accounting Manager Responsible for all managerial/supervisory functions and leadership in the Accounting Dept. Responsibilities include Sarbanes-Oxley oversight for Accounting and IT environments, oversight of internal controls (SSAE 16), excess reimbursement filing, and interface with excess carrier representatives and auditors. Duties also include leadership of a team dedicated to quality control and overseeing the performance audit of each adjuster. Also charged with the responsibility of maintaining bank accounts for each customer and securing funding from the customers for timely claim payments. PROFESSIONAL CREDITS Bachelor of Science degree in Accounting University of Central Florida, 2007 VIVIANE RUIZ Orlando, Florida CAREER SUMMARY Viviane Ruiz joined the company in 2007 as a Manager of Information Systems for USIS. Recently promoted to Director of Information Services, she is responsible for an IT staff of web developers, system analysts, database administrators, network administrators, application support technicians, and computer operators. Prior to USIS, Viviane had nine years of experience managing a telecommunications team; teaching Information Systems as well as business courses for undergraduate and graduate students. EXPERIENCE 2007 — PRESENT 2001-2007 2001-2002 1999-2001 USIS, Inc. Director of information Services Responsible for all managerial/supervisory functions and leadership in the Information System departments at USIS. With exceptional skills in Project Management, Viviane is an excellent liaison between the IS staff and the business staff. She takes pride in meeting deadlines and sets a high priority on quality of work. Viviane is responsible for maintaining current systems, and ensuring the implementation of all state and medical rules guidelines, as well as leading new initiatives and keeping USIS/AmeriSys on the cutting edge of technology. DeVry University Network Manager, Adjunct Faculty Responsible for the networking and helpdesk teams at the Orlando campus who maintained the academic and administrative networks, in support of students, professors and administrative staff. Responsible for the maintenance of the learning centers and labs by ensuring up time and up to date technology. Negotiated, renewed and maintained all software and hardware agreements for the University. Taught network, business, and IT courses on campus as well as online for undergraduate and graduate students. Century 21 Real Estate Technical Support Analyst Responsible for all of the technical support of software, equipment, and website: responsible for maintaining the network, upgrading equipment, and maintaining the website. Tyler Co Database Asst Administrator Assisted in maintaining Lotus Notes databases. Responsibilities included ensuring security, reliability and integrity of data. Additional functions included database report writing for internal and external users. PROFESSIONAL CREDITS • Bachelor's Degree in Computer Information Systems, DeVry University, 2001 • Master's Degree in Business Administration, Keller Graduate School of Management, 2003 Master's Degree in Information Systems with concentration in Health Information Technology, Keller Graduate School of Management, 2012 • Becker Professional Education - Co-Editor/Subject Matter Expert (Project) for the the IT Chapter of the Becker book distributed to every CPA student nationwide. ■ Tri-lingual - fluent in Portuguese and Spanish. 067JUSIS, INC. Job Description USIS/AmeriSys Job Title Claims Supervisor Dept #/name 539,542,544 Claims Reports to: (mgr/supv) Claims Manager Office Location: Orlando B&B Job Title Team Leader B&B Job Code TL FLSA Status Exempt (Administrative) EEO Code Professional _ Summary/General Description: Responsible for all supervisory functions over claims personnel in a claims unit administering Workers' Compensation claims pursuant to client, company and State regulations within guidelines of company and corporate culture. Requires independent decision making and a high level of discretion and judgment in claim handling functions on behalf of clients for claims service business operations, ensuring excellent customer relationships and quality customer service. Primary/Essential Duties & Functions: • Responsible for the oversight and supervision of claims adjusters to ensure company, client and State policies, procedures, rules and regulations are met. This includes monitoring workflow, creating/recommending procedures for effective running of dept; training of adjusters; generating reports and monitoring outcomes as necessary. • Build and maintain rapport with clients to ensure excellent customer service and client retention, ensuring that adjusters are also building effective relationships with clients for excellent customer service and client retention. • Ensure that adjusters adhere to all policies and procedures set forth by the company and the client, including consistent file documentation in system by adjuster & on supervisor reviews; timely compliance of form reporting to State & CPS requirements, timely transfer of MO to LT files, timely 3-point contact, proper diary use. • Maintain proper and current diary use on supv diary and on adjuster diary including timely and appropriate completion of supervisor claim reviews per company policy. • Ensure QC audit scores on all job functions are maintained by adjusters to meet the performance standards. • Responsible for supervision of personnel within the unit, including timely and effective performance reviews, monitoring attendance and other personnel -related functions - coordinated with manager. • Authorize and review all aspects of reserves and reserves changes, ensuring system documentation. • Frequent contact with employers, claimants, attorneys and doctors. • Review files for settlement, ensuring system documentation & adherence to company & client -specific procedures. • Responsible for review of all closings. • Coordinate and attend status reviews with clients as necessary. • Perform special projects as assigned by management. • Perform other duties as assigned. Competencies - Knowledge, Abilities and Skills: Must be self directed and able to work independently. Maintain knowledge of current laws and statutes. Ability to effectively operate a personal computer and related claims and business software. Good communication skills, both oral and written. Team player. Good attendance. Good customer service skills. Effective management skills. Able to deal with people in mature, fair and confidential manner. Assertive self starter, with strong leadership skills, dedicated to company and corporate culture. Minimum Qualifications: 3-5 years of Workers' Compensation claims handling experience with a consistent high level of performance and achievement. A four year college degree or equivalent work experience is preferred. Active Adjuster license (FL 5-24 or 5-20), and/or as required by any other state in which handling claims Ability to effectively lead and coach a business department Supervisory experience preferred To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. Additional Notes: Smoke -free work place May have to assist with adjuster duties during absences. Physical Requirements Necessary on a Regular Basis: Manual dexterity, arm and upper body range of motion sufficient for use of a keyboard, mouse and telephone 7-8 hours per day. Speech and hearing sufficient for in -person and telephone communication 7-8 hours per day. Vision sufficient for use of computer monitors 7-8 hours per day. Ability to sit at a desk and perform duties effectively 7-8 hours per day. This job description is not intended to be an all-inclusive statement of the duties of the position listed above. Other appropriate duties may be performed as necessary to meet the ongoing needs of the organization. I acknowledge that 1 have reviewed this job description and can perform the essential duties with, or without, reasonable accommodation. Signature Print Name Date USIS/AmeriSys Job Title Claims Supervisor Dept #/name 539,542,544 Claims O67IUSIS, INC. Job Description USIS Job Title Adjuster II Dept #/name 539 Ind Claims Reports to: (mgr/supv) Claims Manager/Claims Supervisor Office Location: Orlando B&B Job Title Adjuster II B&B Job Code ADJ II FLSA Status Exempt (Administrative} EEO Code Professional Summary/General Description: Responsible for the investigation, evaluation, disposition and settlement of Workers' Compensation claims for self insured and public entity accounts, including complex and high exposure claims, with minimal supervision. This includes the investigation, determination and evaluation of coverage, liability and damages, and the setting of proper reserves. Requires independent decision making and a high level of discretion and judgment in claim handling functions on behalf of clients for claims service business operations, ensuring excellent customer relationships and quality customer service. Primary/Essential Duties and Functions: • Analyze the claims exposure to determine the proper course of action and to appropriately settle or close the claim in accordance with state, company and client policy and procedure. • Build and maintain rapport with client contacts to ensure retention; perform in manner to meet/exceed client expectations, following policy and procedure per client. • Interact extensively with various parties involved in the claim process. • Evaluate fifes for reserve potential and for settlement (effective knowledge of MSAs and structured annuities). • Ability to report accurate information to COBC. • Manage EDI requirements per state and company protocol in a timely, proper fashion. • Manage and direct the claim file including determination of indemnity, calculate loss of income; whether medical is related and appropriate; evaluate treatment plan, testing, surgery, surveillance, attorney involvement, return -to -work, light duty; proper calculation of all benefits. • Handle legal aspects of the file in negotiation of settlement; develop litigation/defense strategies with attorneys assigned to the claim file. Handle depositions, mediations and hearings. • Identify and pursue SDF, subrogation, fraud, vocational/field case mgmt involvement. • Comply with Excess carriers' limits and reporting requirements. • Have the ability to solve problems, plan and organize activities, serve clients, negotiate, effectively communicate verbally and in writing, and embrace new challenges. Handle claims consistent with client, state and company policy and procedure, and also in accordance with any statutory, regulatory and ethics requirements. Document and communicate all claim activity timely and effectively and in a manner which supports the outcome of the claim file; document and follow plan of action. Maintain system diary, keeping all files current according to company standards and State timefrarnes to ensure no late payments or fines. • Ability to properly handle status reports/claim reviews with clients; travel as required. • Maintain current knowledge of law and statute, maintain CEUs and license in current status related to state in which handling claims. • Perform other duties as assigned. Competencies - Knowledge, Abilities and Skills: 3-5+ years in a claims environment handling lost time claims including litigated files Extensive knowledge of accepted industry standards and practices including case law. Ability to successfully negotiate the settlement and disposition of serious claims, including the ability to interpret related documentation. Maintains knowledge of current trends, standards and law changes Ability to effectively operate a personal computer and related claims and business software. Technically competent with systems. Familiarity with paperless work environment helpful. Must be self directed and able to work independently with the ability to successfully present to in claims meetings with client, etc. Good communication skills, both oral and written; good customer service skills. Assertive self-starter with excellent organizational skills. Fast and accurate. Team player. Good attendance. Minimum Qualifications: Three to five years of Florida claims -related experience with a consistent high level of performance and achievement A four year college degree or equivalent work experience is preferred. Active Adjuster license (FL 5-24 or 5-20) To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. Additional Notes: Smoke -free work place Physical Requirements Necessary on a Regular Basis: Manual dexterity, arm and upper body range of motion sufficient for use of a keyboard, mouse and telephone 7-8 hours per day. Speech and hearing sufficient for in -person and telephone communication 7-8 hours per day. Vision sufficient for use of computer monitors 7-8 hours per day. Ability to sit at a desk and perform duties effectively 7-8 hours per day. This job description is not intended to be an all-inclusive statement of the duties of the position listed above. Other appropriate duties may be performed as necessary to meet the ongoing needs of the organization. acknowledge that I have reviewed this job description and can perform the essential duties with, or without, reasonable accommodation. Signature Print Name Date USIS Job Title Adjuster II Dept #/name 539 Ind Claims 067/USIS, INC. Job Description USIS/AmeriSys Job Title Adjuster — Medical Only r Dept #/name 539, 542 Claims Reports to: (mgr/supv) Claims Manager/Claims Supervisor Office Location: Orlando B&B Job Title Adjuster B&B Job Code ADJUST FLSA Status Non -Exempt EEO Code Professional Summary/General Description: Responsible for the set up and administration of Workers' Compensation Medical Only claims: clerical duties to assist LT adjusters as required. Primary/Essential Duties and Functions: • Issue medical payments to providers confirming relatedness and appropriateness, pursuant to Statute and company policy. • Process form letters and state forms. • Handle all incoming mail and pay medcal bills, pursuant to Statute, in a timely manner. • Maintain system diary, and keep up to date on a daily basis. • Document and communicate all claim activity timely and effectively and in a manner which supports the outcome of the claim file. • Communicate directly with employers, claimants and doctors to obtain information to complete assignments. • Demonstrate the ability to make decisions pertaining to claims handling. • Analyze work content to determine the most efficient means of completing and expediting the assignment. • Show initiative by developing an understanding of the claims process. • Perform the following duties in a timely and correct manner: Set up medical appointments as needed. Contact individual employers and/or physicians as necessary. • Assist LT adjusters as required. • Maintain current knowledge of law and statute, maintain CEUs and license in current status. • Perform miscellaneous administrative/support functions as designated by supervisor. • Ability to properly handle claim review meetings with clients; travel as required • Perform other duties as assigned. Competencies - Knowledge, Abilities and Skills: Working knowledge and experience handling Medical Only Workers' Compensation claims in Florida. Good communication and typing skills. Knowledge of FL Workers' Compensation statutes. MS Office knowledge helpful. Ability to effectively operate a personal computer and related claims and business software. Good communication skills, both oral and written; good customer service skills. Excellent organizational skills. Team player. Good attendance. Ability to learn and process FL requirements for handling MO claims Ability to work accurately in a fast -paced position ensuring all policies and procedures are managed to expected timeframes Minimum Qualifications: High School Diploma, 1-2 years of MO claims handling experience in Florida WC law. 1-2 years of office experience. Active Adjuster license for Florida (5-24 or 5-20) To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. Additional Notes: Smoke -free work place Fast paced work environment Physical Requirements Necessary on a Regular Basis: Manual dexterity, arm and upper body range of motion sufficient for use of a keyboard, mouse and telephone 7-8 hours per day. Speech and hearing sufficient for in -person and telephone communication 7-8 hours per day. Vision sufficient for use of computer monitors 7-8 hours per day. Ability to sit at a desk and perform duties effectively 7-8 hours per day. This job description is not intended to be an all-inclusive statement of the duties of the position listed above. Other appropriate duties may be performed as necessary to meet the ongoing needs of the organization. I acknowledge that I have reviewed this job description and can perform the essential duties with, or without, reasonable accommodation. Signature Print Name Date USIS/AmeriSys Job Title Adjuster — Medical Only Dept #iname 539, 542 Claims Job Title: Claim Supervisor Reports To: Manager Profit Center: FSLA Status: Exempt Date: March 1, 2013 Dept: PGCS Claims Operations Position Overview Supervises an adjusting, administrative or technical support staff while adhering to all Profit Center policies and procedures. Interact with clients. Essential Job Functions • Interviewing and training of new staff in procedures and job -related functions • Review and assign claims or tasks to staff • Maintain file diary and keep all reporting current • Communicate information to staff and customers. • Identify problem areas related to performance and personnel issues • Identify and participate in training and developmental needs of staff • Review job performance, hiring and merit reviews subject to manager's approval Skills Excellent quantitative, analytical, communication and interpersonal skills. Strong knowledge of all job -related functions. Demonstrate proficiency in P/C equipment including Microsoft Word & Outlook. Demonstrate adjusting, negotiating skills and a thorough knowledge of PGCS claim handling procedures and state regulations. Qualifications College degree or equivalent and five years adjusting experience Supervision of Others Senior Claim Specialists, Claim Specialists I, Claim Specialist II, Claim Assistants, and Technical Assistants Note: This job description is not intended to be all-inclusive. Employee may perform other related duties as negotiated to meet the ongoing needs of the organization. Job Title: Senior Claim Specialist — Liability Reports To: Claims SupervisorfAsst Manager Profit Center: FSLA Status: Exempt Date: October 16, 2007 Dept: Claims Operations Position Overview Responsible for the investigation, evaluation, disposition and settlement of the most complex and highest exposure claims with minimal supervision. This includes the investigation, determination and evaluation of coverage, liability and damages, and the setting of proper reserves. Requires independent decision making and a high level of discretion and judgment in regards to the claim handling function. Essential Job Functions Analyze the claims exposure, to determine the proper course of action and to appropriately settle the claim • interact extensively with various parties involved in the claim process • Develop litigation/defense strategies with attorneys assigned to the claim file • Has the ability to solve problems, plan and organize activities, serve clients, negotiate, effectively communicate verbally and in writing and embrace new challenges • Handles claims consistent with our clients and PGCS policies and claims procedure manual and also in accordance to any statutory, regulatory and ethics requirements • Documents and communicates all claim activity timely and effectively and in a manner which supports the outcome of the claim file Skills Extensive knowledge of accepted industry standards and practices. Ability to successfully negotiate the settlement and disposition of serious claims, including the ability to interpret related documentation. Ability to effectively operate a personal computer and related claims and business software. Qualifications Five or more years of claims related experience with a consistent high level of performance and achievement required. A four year college degree or equivalent work experience is preferred. Supervision of Others Not applicable Note: This job description is not intended to be all-inclusive. Employee may perform other related duties as negotiated to meet the ongoing needs of the organization. ATTACHMENT 8 SSAE 16 excerpt A A-LIGN INDEPENDENT SERVICE AUDITOR'S REPORT ON A DESCRIPTION OF USIS, INC.'S SYSTEM AND THE SUITABILITY OF THE DESIGN AND OPERATING EFFECTIVENESS OF CONTROLS To USIS, Inc;_ We have examined USIS, Inc.'s ('USIS' or 'the Company`) description of its Third Party Administration Services System at its Orlando, Florida location for processing user entities' claims for the period Apr9 1, 2015 through March 31, 2016, and the suitability of the design and operating effectiveness of controls to achieve the related control objectives stated in the descnption. The description indicates that certain control objectives specified in the description can be achieved only if complementary user entity controls contemplated in the design of USIS's controls are suitably designed and operating effectively. along with related controls at the service organization_ We have not evaluated the suitability of the design and operating effectiveness of such complementary user entity controls. USIS uses Suntrust Bank for deposit box services and ERIC Systems for primary claims management software ('subservice organizations'). The description in Section 3 includes only the controls and related control objectives of USIS and excludes the control objectives and related controls of the subservice organizations. Our examination did not extend to controls of the subservice organizations_ In Section 2 of this report, USIS has provided an assertion about the fairness of the presentation of the description and suitability of the design and operating effectiveness of the controls to achieve the related control objectives stated in the description. USIS is responsible for preparing the description and for the assertion, including the completeness. accuracy. and method of presentation of the descnption and the assertion. providing the services covered by the description, specifying the control objectives and stating them in the description, identifying the risks that threaten the achievement of the control objectives, selecting the criteria, and designing, implementing, and documenting controls to achieve the related control objectives stated in the description_ Our responsibility is to express an opinion on the fairness of the presentation of the description and on the suitability of the design and operating effectiveness of the controls to achieve the related control objectives stated in the description, based on our examination. We conducted our examination in accordance with attestation standards established by the American Institute of Certified Public Accountants_ Those standards require that we plan and perform our examination to obtain reasonable assurance about whether, in all material respects, the description is fairly presented and the controls were suitably designed and operating effectively to achieve the related control objectives stated in the descnption for the period April 1, 2015 through March 31, 2016. An examination of a description of a service organization's system and the suitability of the design and operating effectiveness of the service organization's controls to achieve the related control objectives stated in the description involves performing procedures to obtain evidence about the fairness of the presentation of the description and the suitability of the design and operating effectiveness of those controls to achieve the related control objectives stated in the description. Our procedures included assessing the risks that the description is not fairly presented and that the controls were not suitably designed or operating effectively to achieve the related control objectives stated in the description. Our procedures also included testing the operating effectiveness of those controls that we consider necessary to provide reasonable assurance that the related control objectives stated in the description were achieved. An examination engagement of this type also includes evaluating the overall presentation of the descnption and the suitability of the control objectives stated therein, and the suitability of the criteria specified by the service organization and described in Section 2. We believe that the evidence we obtained is sufficient and appropnate to provide a reasonable basis for our opinion. Propnerary and Corifidenbai 12 Because of their nature, controls at a service organization may not prevent, or detect and correct, all errors or omissions in processing or repotting transactions. Also, the projection to the future of any evaluation of the fairness of the presentation of the description, or conclusions about the suitability of the design or operating effectiveness of the controls to achieve the related control objectives is subject to the risk that controls at a service organization may become inadequate or fail. In our opinion, in all material respects, based on the criteria described in USIS's assertion in Section 2 o1 this report, • the description fairly presents the system that was designed and implemented for the penod April 1, 2015 through March 31, 2016_ • the ccgnlrols related to the control objectives stated in the description were suitably designed to provide reasonable assurance that the control objectives would be achieved if the controls operated effectively for the period April 1, 2015 through March 31, 2016 and user entities applied the complementary user entity controls contemplated in the design of USIS's controls for the period April 1, 2015 through March 31, 2016. • the controls tested, which together with the complementary user entity controls referred to in the scope paragraph of this report, if operating effectively, were those necessary to provide reasonable assurance that the control objectives stated in the description were achieved. operated effectively for the period April 1, 2015 through March 31, 2016. The specific controls tested and the nature, timing, and results of those tests are listed in Section 4. This report. including the description of tests of controls and results thereof in Section 4. is intended solely for the information and use of USIS, user entities of USIS's system during some or ail of the period April 1, 2015 through March 31, 2016, and the independent auditors of such user entities. who have a sufficient understanding to consider it along with other information including information about controls implemented by user entities themselves, when assessing the risks of material misstatements of user entities' financial statements. This report is not intended to be and should not be used by anyone other than these specified parties. May 20, 2016 Tampa. Florida Proprietary and Confidential ATTACHMENT 9 Transition Plan City Miami Implementation Timeline ID Task Name I Start 1 Finish IResponsibdity 1 Coordination Meetings Coordination / Initial Meetings Initial Meeting to discuss protocols, issues and deadlines Banking and account funding Indemnity benfits payments in advance thru 3/2/2017 Last date for medical Bill payment by current TPA Medical Bill scanning /forwarding Procedures for Refunds/recoveries/stop payments etc Code Listings submission to USIS Initial submission of sample size data and layouts to USIS (if applicable) Implementaion Progress Implernentaion Progress Progress on File layouts and sample data Claims Administration Protocols Staffing Staff Training - General IT Set up FTP for secure data transfer Is 15 Administrative Tasks Set up new account in DB Verify all contact info , billing rates etc Notify Billing vendors of new account Programming for import/exports City of Miami- (assuming current TPA already has this) Claim data Exports Claim reserve / payment history export Claim Notes Historical data file/ attachments Employer Locations & Contacts Claim Historial EDI import (if applicable) Bill Review / EOB History Data CMS 111 Historical Data File Layouts & sample files File Layouts & sample files FROI intake and transmittal to USIS/AmeriSys Claim/ claimant demograhics file Claim Detailed historical reserve / payment transaction Claim notes data file/ attachments Mon 1/2/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 3/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 U515 / City of Miami USIS / City of Miami City of Miami City of Miami USIS / City of Miami City of Miami City of Miami USIS / City of Miami U5iS / City of Miami USIS / City of Miami USIS USIS USIS USIS USIS City of Miami City of Miami City of Miami City of Miami City of Miami City of Miami City of Miami City of Miami City of Miami City of Miami City of Miami City of Miami 2 3 4 9 6 7 6 9 14 11 12 13 14 15 15 17 18 19 20 21 22 23 24_ 25 26 27 28 29 30 31 32 33 34 35 36 37 38 Page 1 City Miami Implementation Timeline ID Task Name I Start Finish Responsibility 39 USIS/AmeriSys Programming Clalrn data Imports Claim reserve / payment /history import Claim Notes data file/ attachments import Claim EDI import Initial Load of Electronic data files matching all file layouts Initial Load of Electronic data files matching all file layouts Claim/ claimant demograhrics Claim Detailed historical reserve / payment transaction Claim notes data file/ attachments thru EDI & CMS 111 Data Claim level loss runs thru 1/31/2017 Load all data files thru 1/31/2017 & Balance counts Bill Review/ FOB History Data Claims Administration Banking and account funding Set up banking account and funding method Send Signature cards to USIS Send MICR spec sheet from bank to USIS Return signed signature cards to Bank Set up MICR encoding and test check printing Initial Funding of Bank Account Special Check Handling situations Protcols for Refunds, Stop payments, Void etc Develop Claims Protocols FRO] & Initial contact Reserve funding Settlements Required reports & Frequency Final lmplemantatlon Verify request for final data from incumbent to be received by 2/1/2017 Final conference with all units prior to initiation EDI filing data to record change in submitter Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mort 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Mon 1/2/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 Wed 2/1/17 USIS L1515 USIS USIS USIS USIS USIS USIS USIS USIS USIS USIS City of Miami City of Miami City of Miami USIS USIS City of Miami City of Miami USIS USIS / City of Miami USIS / City of Miami USIS / City of Miami USIS / City of Miami USIS USIS USIS 40 41 42 43 44 45 46 47 48 A9 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 Page 2 ATTACHMENT 10 implementation Cheek List New Client Implementation ACCOUNT NAME HERE Administration 1. Account Set Up 2. Contract information 3. Communication - Contacts for all departments (USIS and client) 4. Payment of Benefits during transition 5. Special Handling Instructions 6. Performance Standards 7. Account Management / Contract Manager Claims UR 1. Monthly Reports -Stewardship/Cost Containment Savings 2. Claims Review Timeframes (monthly, quarterly? In person, telephonically?) 3. Reporting of claims - Who will report? How (email, web etc.)? Who gets notification of a claim being reported? 4. Excess Carrier 5. Settlement authority levels 6. Reserving authority levels - initial and subsequent (adjuster / supervisor) 7. Defense assignments - Who? 8. Surveillance assignments -Who? 9. Do we need authority from client for payments, reserves, settlements? 10. ISO searches - When? 11. Recorded statement assignments. When? 12. Which vendors are we utilizing? 13. Field case nurse? 14. Subro Instructions / responsibility 15. SDF Instructions / responsibility 1. Certified Program - No 2. Medical Management Program - Non-MCO/Medical Management 3. Utilization Review Criteria for Treatments and Procedures - No, Non-MCO 4. Medical Director Review Criteria - No specific criteria/as needed 5. Specific Physician Advisor Requirements - None Bill Review/Provider Services 1, Account specific protocol (ie: 100% pays, write off bills) - AmeriSys Ancillary 2. PPO Network? - Dimensions 3. PBM? - myMatrixx 4. Ancillary Services?-AmeriSys Ancillary Services 5. Fee agreements in place (ie; Mayo, Shands) - None 6. Nurse Review Criteria - AmeriSys Protocol Case Management — Te ephonic v Field 1. Certified program — No 2. Medical management program — Non-MCO/Medical Management 3. Telephonic Case Management Assignments per year —13 prior to RFP 4. Field Case Management Assignment per year— None 5. Case Management Criteria — Non-MCO Telephonic> Field> 6. Catastrophic Provisions - Yes 7. Badge Program- Yes or No 8. Secure Program- Yes or No Accounting 1. Bank Account Set Up 2. Funding 3. Check Registers/Reports 4. Bank statement reconciliation Information Technology 1. Systems setup — ERIC / Corrus/ USISiNet 2. Equipment setup - nja 3. Data transfers — n a 4. List of users — Received by account 5. USISiNet Setup • Security Levels Documented - YES 6. Data Conversion Test - YES 7. Data Conversion Production • Documentation of conversion issues - YES 8. EDI — WC AND Medical EDI 4. CMS —SETUP RRE 10. ISO / OFAC Handling Details - YES Processing 1. Claim reporting Method 2. Special instructions for web reporting 3. Special instructions for afterhours reporting Intake 1. Intake Setup 2. Special Handling Instructions 3. Account, Employer, Location information ATTACHMENT 11 myMatrixx Overview of Workers' Compensation Pharmacy Benefit Management Services i • 0 rnyMatrixx good medicine for business Wendy Sumrell Director of Sales wsumrell@mymatrixx.com (770) 597-4277 i• m Matr xx Executive Summary Matrix Healthcare Services, Inc., dba myMatrixx, has been providing pharmacy benefit management services to the workers' compensation industry since 2001. We link our clients' business strategy with our pharmacy program to provide customizable, value -based solutions that benefit our clients and their injured employees. Being an extension of our clients' mission and value statement creates consistency and trust. Our corporate culture of "working with a purpose" focuses on the well-being of injured workers, and keeping the injured worker's best interests at the forefront aligns with myMatrixx core values. We understand the need to take a broader view of the patient's needs, and we promote a holistic patient advocacy approach, including: Awareness: Helping injured employees understand how to navigate the unfamiliar world of workers' compensation Education: Building trust by providing the right amount of information at the right time Technology: Providing user-friendly resources like our prior authorization tool, mobile app, and pharmacy locator Customized network: Enabling better management of out -of -network transactions and physician dispensed medications • Patient -driven collaboration: Encouraging injured workers to take an active role in proper medication therapy management by empowering them with evidence -based information Additionally, our advanced technology and business intelligence enables us to provide meaningful, actionable data to all stakeholders: patients, claims handlers, managed care partners, and clinicians. Technology also allows for adaptability because one size does not fit all. Information can be customized based on demographic data. For example, a 30-year old who was injured on the job at Starbucks may only be interested in bite -size information that is impactful, such as a brief educational video. In contrast, a 60-year old who has been prescribed multiple medications might be more comfortable with detailed information from a trusted provider, such as a pharmacist he or she can speak with over the phone. myMatrixx is leading the conversation on analytics that positively affect patient outcomes. We are also at the forefront of issues that are of particular importance to the workers' compensation industry: the aging workforce, rising rates of physician dispensing, managing comorbidity of conditions, and reducing the use of compounded medications, opioids, and the MED (morphine equivalent dose) of other narcotics. Through the use of interactive dashboards and advanced analytics, our team of business intelligence professionals provides timely insights into key metrics that drive appropriate medication therapy management, utilization, savings, and network penetration. Our PBM platform is the most efficient and easiest to use in the industry, largely because our corporate culture helps us attract talent --both new and seasoned --who are driven to innovate and continually improve our proprietary technology and processes. myMatrixx has successfully developed our programs and systems to strategically handle organic growth, and myMatrixx continues to gain significant share in the PBM marketplace while remaining privately held, financially strong and stable. 02016 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 2 • •• myMatrixx Overview of Pharmacy Benefit Management (PBM) Services myMatrixx provides measurable savings on pharmacy casts, no -risk First Fills, clinical intervention programs to ensure the right drugs are dispensed for the right reasons, and a 24/7/365 support line. Injured workers have access to more than 64,000 participating retail pharmacies, along with an option for convenient mail service/ home delivery of medications. Over the past 15 years, myMatrixx has expanded its offerings to include durable medical equipment (DME) and other ancillary products and services. Clients include public and private self -insured employers, third party administrators, workers' compensation insurance carriers, and managed care organizations. myMatrixx provides: • National network of more than 64,000 pharmacy locations • Innovative clinical programs to improve outcomes and control pharmacy costs 24/7/365 live customer service and clinical pharmacist support • Online portal for 24/7 access, management and real-time reporting of claims data • myMatrixx Mobile app for 24/7 access to claims data —anytime, anywhere • Evidence -based clinical programs and 24-hour clinical support • Customizable workers' compensation formulary Actionable business intelligence and data analytics Accurate, transparent billing No -risk First Fill program Customizable prescription ID cards and communications Injured worker -centric adjudication platform Streamlined, electronic prior authorization process Real-time clinical alerts and status updates for claims handlers Out -of -network Rx management Team approach to implementation and program management By increasing network compliance and supporting the goal of returning employees back to work in an efficient and clinically appropriate manner, we provide our clients with lower costs on pharmacy and better outcomes for their injured workers. urac ACCREDITED woa.rf con arawn and property and cuuay Pharmacy Sowell Unsysmam Emirs* OnO1120S9 ©2016 Matrix Healthcare Services, Inc. All rights reserved. BUSINESS INSURANCE BEST PLA T0W RK Confidential and proprietary information. 3 • myINAatr?xx myMatrixx 360°' Online Claims Portal myMatrixx 360° is our robust web portal that provides online access, management, and real-time reporting of pharmacy claims and for ordering ancillary products and services. This proprietary technology was developed with customizable rules that allow clients to uniquely manage all aspects of their injured worker population including pharmacy, formulary, clinical, and other needs. Our system allows an unlimited number of designated users to access the entire lifecycle of a claim from pharmacy First Fill to the closing of the claims. Claims handlers also have convenient 24/7/365 access to view claims for status updates and to place orders. The myMatrixx 360° web portal provides complete transparency and allows the claims handler or nurse case manager to view all information related to a claim at any time including reports, evaluations, nursing notes, prescriptions and more. Claims handlers receive email alerts with status updates and a detailed history at the completion of the claim. Alerts can be customized by group and claims professional, based on requirements, myMatrixx Mobile The proprietary myMatrixx Mobile app, the first tool of its kind designed for both claims handlers and injured workers, enables authorized users to log in to the myMatrixx mobile site to securely access claims information from their smartphone or any other internet-enabled device —anytime, anywhere. The app also allows injured workers to access a digital version of their prescription ID card, as well as our pharmacy locator that includes interactive driving directions. Every eligible injured worker receives a welcome letter with a traditional, paper ID card within 24 hours of receiving a new claim. The myMatrixx Mobile app provides the additional option of downloading their Rx card information to their mobile phone or other wireless device to access their pharmacy card details with no waiting. The myMatrixx Mobile pharmacy locator can be accessed from our web portal or via the myMatrixx Mobile app, providing injured workers with a simple, convenient way to locate an in -network pharmacy close to their home -- and their mobile Rx e-card provides them with instant access to prescription information to present at the pharmacy. Designed for "on the go" users, the secure myMatrixx Mobile environment: Directs injured workers to network pharmacies near their home Enables authorized users to view detailed claims data to make informed decisions when authorizing medications }: Allows for faster prescription authorizations °• Increases network penetration by making it less likely for the pharmacy to process the claim through a third party biller 02016 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 4 • myMatrixx Business Intelligence Capabilities myMatrixx is committed to providing actionable intelligence to our clients. Through our BI (Business Intelligence) solution, we are able to surface key performance indicators using standard reports, custom reports and interactive dashboards. Our BI practice has been developed to provide accuracy, timeliness and flexibility. Our goal at myMatrixx is to assist your company or your client obtain rich analytics that support strategic and operational decisions. Our BI solution incorporates 3 key process steps: Source iwal Data File Oata Enterprise Data ERP Integrate Deliver Analyze Custom oil Dashboards _ Custom ■� Reports I I Business Intelligence Solution Integrate — our data integration strategy enable us to ensure accuracy through validation and cleansing Deliver — we use modern data warehouse technologies such as OLAP to efficiently store and organize data Analyze — by utilizing best -of -breed tools such as Tableau, we are able to mine data, create rich visualizations and ultimately give meaning to data to "tell a story" We have the ability to surface a wide range of key metrics such as savings, formulary utilization, generic efficiency/utilization, physician performance, high -risk patients, geography and much more. We can also provide this metrics at each level within a customer's organization, such as clients, branch and adjuster. The myMatrixx BI solution is part of our overall reporting service. We can provide custom reports in any format as well as custom interactive electronic dashboards. All at no additional cost. Standard and Customized Reports When our clients have a unique reporting need, we provide a no -charge service to create custom reports based on their specific requirements. With this service, our clients always have visibility to data when they want it and in the way they want to see it. All myMatrixx reports, including custom and ad hoc reports, are available to view in real-time and/or print from the myMatrixx 360° web portal, 24 hours a day, 7 days a week, 365 days a year. ©20.16 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 5 Standard pharmacy reports include, but are not limited to: • Savings (Retail, Mail Service & Bill Review) • Network Utilization/Penetration • Generic Penetration • Generic Efficiency Cost per Script {with breakdowns by type) Cost per Claim by Age • Medication Exceptions • Utilization of Opioids/Narcotics • Rejections • Reversals • Pharmacy and Physician Exceptions • Formulary Management • Authorization Overrides • Prescriber Report Card Measurable Results The myMatrixx program provides ease of use for claims handlers, increases network compliance, and supports your goals of returning employees back to work in an efficient and clinically appropriate manner. 88% In -Network Utilization (Penetration) Rate 82.3% Generic Substitution Rate 99.3% Generic Efficiency Rate 8% Mail Service Penetration Rate 25% Average Savings Rate of Clinical Interventions 95% PBM Client Satisfaction Rate 98% Client Retention Rate myMatrixx has a national retail network of over 64,000 pharmacies, including all major chains as well as most regional and independent pharmacies. This represents access to 95.5% of retail pharmacies nationwide. Every pharmacy in our network is electronically connected to myMatrixx to facilitate real-time communications and to simplify and expedite authorization decisions. Examples of participating pharmacy chains {not a complete list) Albertson's Giant Eagle Leader Drug Publix Super D BJ's Pharmacy Hannaford Foods Lewis Pharmacy Raley's Super Rx Costco Happy Harry's Lifechek Drug Randalls Target Cub Pharmacy Harris Teeter Long's Drug Reasors Torn Thumb CVS Health H.E.B. Medicap Rite Aid Tops Pharmacy Dominick's Homeland Medicine Shoppe Safeway USA Drug Drug Emporium Hy-Vee Meijer Sam's Club U-Save Duane Reade Ingles Navarro Discount Say -On Vons Eagle Pharmacy Kaiser Permanente Neighbor Care Schnuck's Walgreens Eaton Apothecary Kerr Drug Osco Shopko Walmart Fred's King Soopers Pathmark ShopRite Wegmans Fred Meyer Kinney Drugs Piggly Wiggly Smith's Food & Drug Weis Pharmacy Fry's Pharmacy Kmart Price Chopper Snyder Food & Drug Winn Dixie Genovese Kroger Price Cutter Stop & Shop Yokes 02016 Matrix Healthcare Services, lnc, All rights reserved. Confidential and proprietary information. 6 • • m l''latr`xx Prior Authorization Process The myMatrixx authorization process is leading the industry by leveraging technology to improve response times, reducing the likelihood of a prescription being reversed and processed through a third party biller. We provide a detailed report of the transactions that were rejected and later approved or denied. We also track and report authorizations by claims handler, the time it took to approve a medication after notification was sent, and the reason a medication was approved or denied. Claims handler is notified that prescription requires Prior Authorization Nurse Case Manager or Claims Handier reviews data and makes informed decision Pharmacy is electronically contacted by myMatrixx with the decision Approved medications are dispensed and claims are processed and billed All decisions are logged into the myMatrixx 360° web portal First Fill Our First Fill program allows injured workers who have not been added to the myMatrixx system via open -claim eligibility to receive up to a 30-day fill of their prescription. We have a standard First Fill formulary that can be customized to meet your needs. myMatrixx goes at risk for all First Fills. Injured Worker Communication myMatrixx representatives call each injured worker as new claims are filed to let them know that a pharmacy card is on its way to them. The pharmacy card is sent as part of a myMatrixx customized welcome letter that explains our pharmacy program. myMatrixx mails the prescription drug card and welcome letter to all eligible injured workers within 24 hours of receiving a new claim. These customizable ID cards are produced in-house and mailed directly from our corporate office in Tampa, Florida. myMatrixx Welcome Packet Customized Rx ID card i- A Question & Answer document detailing the use of both our retail and mail service pharmacies > Listing of nine participating pharmacies closest to injured worker's home > Custom material requested by client, including material produced in Spanish or other languages 02016 Matrix Healthcare Services, Inc. Ali rights reserved. { CLIENT LOGO HERE Processor: myMatrixx BIN l; 014211 Name: Jae Sample Member 10: 129466789 croup#:. 1060XXXX Client Name ft'11yMatf ixx r�l Confidential and proprietary information. 7 Formulary myMatrixx offers standard and custom formularies. We can customize at the injured worker level or by injury type. The myMatrixx Workers' Compensation formulary was developed by our Pharmacy and Therapeutics (P&T) committee, with input from our clinical pharmacists, utilizing dynamic data and analytical tools. Our team reviews the formulary on a quarterly basis and makes necessary adjustments in response to pharmaceutical market changes, generic introductions, brand drug innovations, new drug entities, and clinical effectiveness. Out -of -Network Bill Management All paper bills are checked against previously rejected transactions to eliminate duplication. The bills are integrated with the injured worker's file in the myMatrixx 360° web portal and available for viewing within 48 hours. Our bill review team will re -price any bills based on state fee schedules and/or contracted rates and send an EOB to the pharmacy. This process can be customized to conform to your unique business rules. myMatrixx contacts each network pharmacy via phone and fax to provide the correct billing information and for conversion of all future prescriptions. Our conversion process all but eliminates third party paper bills. The myMatrixx pharmacy outreach program is critical to driving in -network penetration and yields a high probability that the next prescription is processed in -network. IWP (Injured Workers' Pharmacy) is part of the myMatrixx pharmacy network; therefore, myMatrixx will electronically process all IWP transactions at the contracted rate, applying all DUR edits and your business rules. myMatrixx does not currently have any agreements in place with StoneRiver for the following reasons: • Cannot apply discounts • No DUR • Transactions held 30 days • Communication with pharmacy for conversion 90 - 120 days • Guaranteed payment - regardless of cornpensability • Rx claims maintained on different platform myMatrixx requests that all paper bills be sent to us within 30 days of receipt. This ensures that we can immediately contact the retail pharmacy, provide them with our billing information and procedures, and ultimately convert the bill to an in -network transaction. All bills become reviewable for our clinical systems on a go -forward basis. Our seamless bill review program provides full visibility to all out -of -network bills. The bills are integrated with the injured worker's file in the myMatrixx 360° web portal and available for viewing within 48 hours. There are no additional fees for myMatrixx bill review and conversion services. 02016 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 8 • Get Ahead of the Claim Innovative Clinical Programs The myMatrixx evidence -based clinical program, Get Ahead of the Claim, provides a comprehensive approach to drug therapy management, with a special emphasis on reducing the use of opioids. Proactive clinical management enables us to inform and advise physicians and our clients regarding dangerous drug trends, prescribing practices, and high -risk patient activity in order to modify or eliminate unsafe prescribing practices with the following tools and programs: • myRisk Predictor® • m lVMatrixx 33 63% myMatrixx Opioid Trend (Book of Businessl 31.43% 31.20% 41.62% $.37% 28.57°,5 28.66% 2:118 2000 2010 2011 2012 2013 2014 2015 • Step Therapy • Prescriber Report Cards • Alert, Review and Manage (ARM) • One Drug Review • Drug Regimen Review • Peer to Peer (pharmacist to physician) Consultations myRisk Predictor is a proprietary, predictive modeling tool used to identify claims that post a higher risk for opioid abuse, misuse or fraud. By combining predictive modeling with historical data and unique algorithms developed by our clinical team, a customized risk score is produced for each injured worker. Identifying at -risk individuals early in the claims process provides an opportunity to intervene with proactive clinical programs designed to drive down pharmacy costs and improve patient outcomes. The combination of review, intervention, and continued drug therapy management leads to better outcomes. Since the majority of the recommendations made to improve therapy involve weaning and or discontinuation of therapy, financial savings is one measure of outcomes. Step Therapy is also used to help control the costs and risks posed by the overuse and/or abuse of opioids and other prescription drugs. This step approach provides sound clinical options, such as initiating therapy with a lower dose or short -acting opioids and only "stepping up" to agents like OxyContin if the injured patient does not experience relief from pain. This program focuses on managing opioid use and can have a significant impact on cost control for our clients, as well as improving the care and outcome for their injured workers. V2016 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 9 • Prescriber Report Cards To help our clients evaluate physician prescribing practices, myMatrixx uses its extensive database to provide detailed reports on individual prescribing patterns. The Prescriber Report Card, our physician profiling product, provides prescriber -specific reporting data and dispensing metrics compared to national and regional peers such as generic dispensing, formulary usage and targeted clinical initiatives. myMatrixx can integrate the prescriber -specific data into your medical database and the data can be used to influence prescribing patterns to encourage generic substitution. Pre- and post - report views can be utilized over time to determine prescriber behavior changes. Awlanrf Poodle* Mese 161904 11 114 el 14 .. 11 AIM ccw e.. t1,....,. Or.lur4u.T low„ M 114400.4 Nap Mess NOVI MR LMwaw COO 14. GTY- 044,0Pr41Y 90vs :141 •• myMatrixx /.anh [owtl TA1491 1 al l�iilIii. man m1111 M!n 01f1/ ON an Wn\I 414 NM NO 01.n 1 /i :'a : 0 : 6, 7 u : W 2. 1 14 134 fh am v . f+ fl: fe fro w1 11N\ nUNt *ISM 914416 09116 1/146 ai fq 11 014 17 V% 0111n Wat Man 0I yY 1.1111114 00 OM 01 TM 01 aM 011n aN 1. 441 11* 4,1 441 4•.1 1ai IQ OM f)ti }. Hu Woo }+/a OM sot 100 rr awn. 111YW mn1M1 420,6 rf TT 10 OW. HI4" go al" 4014% >r a. ,a ,q 1 1.. 1i Illllllu .•.�, 441 440 .1 1F w n n.Vain MIR AC IN v Pasarlrra Raw. oe ari Alert, Review and Manage (ARM) is a proprietary, customizable program that uses business intelligence to monitor injured worker populations for areas of concern. The myMatrixx ARM program flags prescription claims where targeted intervention with the physician, retail pharmacy, and/or injured worker may be warranted —to assist in changing prescribing patterns based on the alert. Following review of the ARM alert, these cases are managed in a mariner consistent with ACOEM or Official Disability Guidelines (ODG). Our clients receive an alert when an injured worker should be referred for case management, drug screening, One Drug Review, detailed Drug Regimen Review and/or patient -provider agreement (PPAs/opioid contracts). In recent Drug Regimen Reviews completed by myMatrixx, 90% resulted in at least one change in drug therapy, with nearly 39% resulting in discontinuing or weaning a medication. In addition, as part of our clinical outreach program, our pharmacy staff has created a series of customizable opioid intervention letters that are intended to be sent at specified intervals. The myMatrixx pharmacists follow up on the letters with the prescribing physician with a peer to peer teleconsultation. myMatrixx clinical intervention programs save our clients an average of 25% per injured worker. Security All myMatrixx employees receive mandatory HIPAAtraining each year. Moreover, myMatrixx has completed the SSAE 16 Service Organization Controls (formerly SAS70) Type I examination that indicates selected processes, procedures and controls have been formally evaluated and tested by an independent accounting and auditing firm. 02016 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 10 a myMatrixx employs a layered security model designed to protect data. We are committed to an iterative process of testing, reviewing, remediating, and upgrading our data security standards so that our posture continues to change as the security and threat landscape changes. We use outside credentialed partners to perform our analysis as well as engaging in internal threat assessments. User access is controlled via our online web portal, which implements the latest standards in security. Encrypted web access (https) and physical access is not provided to application servers. Injured workers and their claims are created separately from all other groups in the web portal, guaranteeing that only your claims handlers will have access to this information. All data and information systems follow extensive security architecture to ensure the protection of all patients' electronic data. myMatrixx uses Continuous Data Protection (CDP) to safeguard and back up its critical applications and data. All CDP is stored for 7 days. Point in time backups are taken and stored for 7 years in compliance with HIPAA applicable guidelines. To protect the confidentiality, integrity and availability of all data, controls include the following technologies: • Firewalls at all external connection points • All data is kept in a secure, offsite SSAE 16-compliant data center • Managed IDS and IPS sensors P2P data encryption (in motion and at rest) • SSL/SSH encrypted sessions Requirements for complex user IDs & passwords • Third party proactive log management services File integrity monitoring • Virtual private networks • 2048 bit encrypted SSL HIPAA compliance, as applicable Back-up facility • Business continuity with hot site tested annually Data Transmission myMatrixx supports the use of electronic data interchange (EDI) to receive and load claims data. We currently have over 200 different EDI feeds, consisting of batch files and real-time web services. In order to ensure a clean bill export, or accurate data reporting, we collect all required information prior to billing via an alerting system that prompts internal action if any required data is missing, myMatrixx can support a wide range of data transfer formats including comma delimited, Excel, XML and Web Services. Our EDI framework allows for easy customization in order to adapt to any client specification. All data is transferred using a mutually agreed upon method that is safe and secure in compliance with applicable HIPAA requirements. 02016 Matrix Heolthcare Services, Inc. All rights reserved. Confidential and proprietary information. 11 • 1• myMatrixx myMatrixx uses a few standard secure protocols and encryption methods to transfer data between systems. Secure File Transfer Protocol (SFTP) is the preferred method of transfer, but we can also provide FTP with PGP encryption on the file using an additional layer of security through private key exchange. We encrypt the entire system database at rest for an additional measure but also perform several third -party 'scratch' tests to identify any potential gaps or flaws in the current security infrastructure. We invest significantly in monitoring and managing that effort with every implementation. EDI claims feeds greatly reduce the time required to set up new orders and also reduce data entry errors, so we encourage our clients to provide EDI claim feeds (although they are not required). myMatrixx will build an EDI process with your clearinghouse to meet your exact requirements, resulting in a single platform for an unlimited number of authorized users to access all medical and pharmacy data --in real time --to better manage injured workers' care. Network Connectivity The myMatrixx 360° web portal and the myMatrixx Mobile app are available to an unlimited number of designated users 24 hours a day, 7 days week, 365 days a year. Our web portal offers several methods of authenticating user credentials. In addition to the traditional username and password data store, we offer encrypted methods of accessing the system through a single sign - on methodology. Using a blend of SHA-1 hash technology and our own unique hash algorithms, we can offer access into the web portal through a client system or desired access method. myMatrixx has sustained a 99% uptime (excluding scheduled maintenance) over the last 12 months across all systems. Scheduled maintenance outages are handled off -hours and with ample notification if client systems may be affected. Implementation The myMatrixx Implementation team will ensure a smooth transition to our PBM platform by: 1. Mailing prescription ID cards to claimants five business days ahead of the "Go Live" date to ensure claimants receive their Rx card prior to the "Go Live" date 2. Completing pharmacy conversion, mail service conversion, and patient notification calls during the week prior to the "Go Live" date 3. Completing the implementation of EDI bridges ahead of the "Go Live" date to ensure new claims and existing claim updates are communicated in a timely manner The implementation phase to the myMatrixx 360° web portal averages 30-45 days but varies depending on each client's unique requirements. We have extensive experience implementing both existing and new claims, and we customize the approach for each client based on their business needs. During the requirements and discovery kick-off meeting, the myMatrixx implementation team will work with you to determine the best approach to transitioning new and existing claim activity to roll out a program with minimal impact to the end users. C2016 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 12 • •• m Matruxx To ensure a secure and seamless transition, myMatrixx will utilize your current file formats and create customized business rules for you during implementation. For quality assurance, test environments are used throughout the development stages, and we strive to keep the data in parallel to current processes as far ahead as possible. Program Management All clients are assigned to a Client Services Manager and support team who are responsible for program management, training and ongoing support. This team is dedicated to the success of your program and is led by a member of the myMatrixx executive team. The Client Services Manager will ensure an integrated approach across all myMatrixx teams, monitoring service standards and coordinating the overall client relationship, as well as representing the client's interests across myMatrixx by: Developing a procedure manual for your program to handle ongoing processes and protocols. Managing training on the program and web portal. Holding stewardship account review meetings to cover all aspects of the program, including utilization reports and trends. Monitoring all aspects of the myMatrixx service and taking action to resolve any issues. Representing the client's interests within myMatrixx to ensure that service adjustments are made where necessary. Serving as the liaison with other internal myMatrixx departments such as IT, Clinical Services, and Accounts Receivable. Coordination of visits to client sites (with other team members as required). Extensive Initial Training and Ongoing Training Opportunities myMatrixx provides in-depth classroom and one-on-one training on how to use the myMatrixx 360' web portal, which includes hard copy training manuals, online and onsite training for no additional fee. In addition, we offer a variety of beneficial continuing education (CEU) courses for our clients and your claims handlers free of charge. Topics cover areas related to workers' compensation, claims management, and medical services, Client Satisfaction myMatrixx tracks client satisfaction in two ways. First, myMatrixx uses Net Promoter Score's (NPS) to measure client satisfaction. This standard is also used by leaders in other industries, including Apple, Samsung, Costco and Amazon. Each November, myMatrixx sends customer surveys to each of our clients, as well as to all their myMatrixx web portal users. Our annual NPS, along with the accompanying comments provided by our clients and web portal users, give us an objective assessment of our performance from our customers' perspective. We use both the quantitative and qualitative data to develop companywide training initiatives that focus on areas targeted for improvement. 02016 Matrix Healthcare Services, Inc. All rights reserved. Confidential and proprietary information. 13 • • myMatr'xx Second, the myMatrixx Client Services team monitors all complaints and recognitions on a daily basis. All complaints are resolved to the customer's satisfaction, logged, categorized and used for further enhancements and educational purposes. Through recognizing and taking action on both complaints and positive recognitions, we have been able to continuously enhance the customer experience. myMatrixx offers a report which includes complaints and recognitions in an effort to demonstrate a complete picture of service satisfaction. In our most recent survey, 95% of our clients indicated our PBM services meet or exceed their expectations. 24/7 Customer Service myMatrixx customer service representatives are available 24 hours a day, 7 days a week, 365 days a year to assist claims professionals, injured workers and pharmacies. Delivering an unimaginably great customer experience is our top priority. Comments from the myMatrixx Annual Client Satisfaction Survey: "myMatrixx provides a comprehensive Rx portal that is easy to integrate with. The people I have dealt with have been very friendly and knowledgeable." "The company is proactive in its service and regulatory compliance. Not only cost effective but provides a wealth of information on pharmacy issues. The website is super. The company does not sit on its laurels but strives for continued innovation and success." "I have already recommended you to all my adjusters I assist because your service is amazing. Fast response and friendly customer service." "myMatrixx has been one of the few companies we have worked with that stands behind their word. They are very responsive to calls regarding any issues that we have and are willing to work with us to resolve them promptly." "Excellent customer service, user friendly website for medication approval. Love the whitepapers and web training seminars. You rock!" "You make my job so much easier. Everyone I have ever dealt with at myMatrixx has bent over backwards to assist me above and beyond what I ask for. You have a wonderful team and I consider you a true partner!" Client Retention Rate 2001 - 2015 ©2016 Matrix Healthcare Services, Inc. All rights reserved. Client Satisfaction Rate 2015 Annual Survey Confidential and proprietary information. 14 12 Risk and Insurance, Revitalizing the Program — Teddy Award Winner ATTACHMENT 2015 Teddy Award Winner Revitalizing the Program In three years, the Columbus Consolidated Government was able to substantially reduce workers' compensation claims costs, revamp return -to -work and enhance safety training. By: Janet Aschkenasy I November 2, 2015 • 7 min read Topics: Claims I November 2015 Issue I Public Sector j Return to Work I Safety I Teddy Award WC Cost. Containment I Workers' Comp Anne -Marie Amiel assumed her post at Columbus Consolidated Government in Georgia three years ago, becoming the first risk manager for the consolidated City of Columbus and the County of Muscogee government in over a decade. Since then, she and a colleague have been successfully reconfiguring the government's workers' compensation, liability claims and safety programs. Given the short amount of time she's been working there and her limited resources, it's uncanny how many accomplishments the first consolidated city -county in Georgia has produced. Amiel has not only substantially reduced the time spent by employees on leave by revamping the return -to -work program, but she has reduced costs per claim, enhanced the workers' comp process and begun overhauling safety and training procedures. The reduced volume of lost -time days experienced by the public entity and its 3,000 employees has been a great benefit to Columbus in more than just fewer days off the job. In 2011, the average number of days out of work for government employees was about 109, Amiel said, noting that she took oversight of the program for the entire year in 2013, when the number dropped to 53. In 2014, the number was 28, nearly half of the 59-day figure projected by the Department of Labor's National Disability Guidelines for that year, Amiel said. So how did she do it? An enhanced return -to -work program for employees with limited capacity played a big role. -Often the doctor says that an employee can come back to work but cannot do all Anne -Marie Amiel, Risk manager, Columbus Consolidated Government, Georgia the essential functions of their job," said Amiel. "If someone has a knee injury. for instance, they often can't be driving heavy equipment but could be driving something smaller." Amiel understood that offering light duty to more employees was not only good for the company and its self -insured workers' comp program, but was also psychologically beneficial to workers. "If someone is injured and out of work for more than 12 weeks, psychologically they tend to start thinking of themselves as disabled, and it gets to be harder and harder to bring them back to work," Amiel said. To make the process more effective, she centralized the return -to -work program instead of leaving it to various government divisions to handle their own employees. In the past, Amiel said, many of Columbus' departments would provide only as much light or transitional duty as could be absorbed within their own divisions, meaning that large numbers of employees unable to take on full duties had no choice but to stay at home and collect workers' compensation checks. Under Amiel's supervision, that has changed. "I have worked with all of our departments to allow their employees to be provided light duty in another department when there is none available in their own." One striking example of the new policy resulted in additional monetary benefits to the government. A police officer who was not able to perform her normal duties was placed in the public works department, where she helped create a database of addresses for Columbus, and identified a cross-referencing system failure with a local utility's database. "I have worked with all of our departments to allow their employees to be provided light duty in another department when there is none available in their own." — Anne -Marie Amiel, risk manager, Columbus Consolidated Government, Georgia As it turned out. a local water utility was using an outdated address list, meaning that Columbus' water bill mistakenly included trash collection charges for several new addresses, while Columbus was collecting trash at those locations without pay. Now able to collect accurate fees for services provided, "the increase in Columbus' revenue due to that one light -duty assignment between 2013 and 2014 has been approximately $100,000," Amiel said. "1 am still assigning people from other departments to public works duty to help them with the water department database," said Amiel. "Like most employers these days, we have a lot of tasks that need to be completed but insufficient personnel to perform them," she said. '`Utilizing light -duty employees to accomplish these tasks is beneficial to both employer and employee." Lover Costs Per Claim That was only the beginning. Through Amiel's efforts, the government's total incurred cost per claim (the sum of medical and indemnity benefits and other incurred costs for all claims, divided by the total number of all claims) has dropped dramatically. Costs per claim dropped by more than 60 percent over three years, from $9,971 in 2011 to $3,641 in 2014. After Amiel began exercising oversight of the prograrn, the organization's total medical costs per indemnity claim dropped from $6,307 in 2011 to $2,014 in 2014. An indemnity claim is paid when the employee is out of work and is receiving the wage benefit from workers' compensation. One key step leading to these improvements was a change in Columbus' third -party administrator and a move to managed care in early 2014. Today, Columbus is using USIS/AineriSys as its TPA and managed care organization (MCO). The shift was transformational, said Amiel. CCG's lost days dropped sharply from 2011 to 2014 — from 109 to 28. "Under the old system, the people managing our claims were not medical professionals," she said. "I really wanted a medical professional who could triage with our employees when they were hurt and help guide them to the correct treatment." At ArneriSys, a nurse case manager handles the medical side of all claims -- and only Columbus' claims. That makes a difference, Amiel said. "With a workforce of over 3,000 employees, we need people who understand our culture and who get to know our employees," she said. Also instrumental to Columbus' improvements was moving away from the state's so-called "panel system" "In Georgia. the law says that if you use that system you need a list of six unique medical providers your employees can tap when they are injured," Amiel said. "The panel needs to include one minority member.. for instance. one orthopedic specialist. and one walk-in provider, among others. "The problem has increasingly become we have larger practices buying out smaller ones so it can be difficult to find six quality providers." Managed care acts as an alternative to the panel system for Columbus, she said. "Under managed care. what happens is the MCO gets approval from the state workers' comp board for a whole network of providers and we now have access to over 200 providers," Amiel said. "Our MCO system provides both 24/7 coverage and medical management of claims, plus a larger network of available medical providers than does the panel system. "1 have visited all of our regular medical providers so that I could make sure they know the city has a `face' and someone on whom they could call if they need more information on an employee or if they want to discuss potential light duty work." The new system's utilization review is also "one of the keys to cost control of injury claims." She noted that under the panel system "any dispute brought before the State Board of Workers' Compensation would essentially have a doctor's opinion on one side and a professional adjuster's on the other. If you were a judge" would you not take the opinion of the doctor over the adjuster? 1 know I would," she said. With the MCO system, there is a peer review system at an earlier stage than a court hearing. That peer review can result in medical professionals talking to other medical professionals and corning to a consensus on the appropriate course of treatment. That works to the benefit of the employee and gives the employer a greater confidence on the treatment plan being implemented, she said. "When one utilizes an MCO system there is a much more robust peer review system," Amiel said. Loss Control Strategies Since bringing on the new TPA, Amiel said, she has been tracking accident trends and using that information to discuss potential safety improvements to work environments with Columbus' department heads. "For instance, we have stepped up employee training and workplace inspections provided to our employees, including different forms of'driver training to include not only standard vehicles, but also vans and larger trucks," she said. "I have also rewritten our accident review policy to bring it more in line with national standards," she said. "We have adopted a system that is widely in place nationally, whereby employees are assigned points for various types of at -fault accidents according to the degree of severity. For example, a trash truck that hit a mailbox would be assigned fewer points than the driver of a city vehicle that hit a stopped car at an intersection. "Disciplinary actions are given in a progressive manner," she said. Among those who are impressed by Amiel's efforts is Columbus, Ga. Mayor Teresa Tomlinson. "We have seen a transformation in our workers' comp claims system through a more engaged management effort and best practices techniques," Tomlinson told Risk and Insurance®. "In three years, we are down from [roughly] $10,000 per claim to $4,000 per claim. That comes from having diligent in-house workers' comp personnel and a systematic approach to deal with the injuries and claims of our employees expeditiously. "We are better able to assess their needs and get them healthy and confident to return in just 28 days on average." "Of course," she said, '`the best investment we can make for taxpayers is education and training through our safety plan. If the injury never happens, we are all better off and that's our goal. "In the event of an injury, our efforts turn to investing in a system that gets our valued employees healthy and safely back to work." ATTACHMENT 13 Claims Handling Practices and Liability Claim Procedure Manual S Services PGCS Claim Best Practices To provide our clients with the best claim product and services in the industry, and to positively impact their results with regard to Claim Closure Ratios, Litigation Management, Lost Time to Medical Only Ratios, and Average Length of Disability, we have adopted the following guidelines: ATTITUDE Maintain a proactive claim management environment — driven by positive attitude, customer service, communication and teamwork. FRAUD Claim Personnel Trained in identification of potential fraud indicators. Files with multiple indicators referred to claim supervisor/SIU co -coordinator and client for further direction/handling. DIARY/DOCUMENTATION Same day notepad entries by adjuster and supervisor to document all file activity. Notepad documented by adjuster every 30 days or less; supervisor every 90 days or less. RESERVES Initial reserves established within 14 days. Reviewed every 30 days or earlier if necessary to reflect the probable ultimate payout. Adjuster documents initial and subsequent reserve worksheet detail in notepad identified by indemnity, medical and expense. CUSTOMER SERVICE Telephone calls answered personally within 12 seconds. E-mail/telephone calls returned within one business day. Issues resolved same day or follow-up advising timeframe for resolution. Communication focused on resolution. LARGE LOSS REPORTING One business day notification to carrier/client of serious injury/category type loss. Large Loss Notice sent to carrier/client when incurred exposure meets reporting threshold or 50% of retention amount. Updated every 90 days or as directed by carrier/client. When reimbursement levels are reached, quarterly reimbursement requests are prepared and sent to the excess carrier. Continued follow-up until reimbursement received. INJURY/ACCIDENT REPORTING Provide notification methods for immediate loss reporting — toil free, internet, fax and mail. Review and documentation of coverage verification within one business day. Initial file set-up, assignment to adjuster and claim acknowledgement to client completed within one business day of loss receipt. INVESTIGATION Three-point contact within one business day. Witness and other contacts made within two business days. Compensability/liability determination within 14 days of receipt. Utilization of investigation techniques where appropriate (on -site, activity check, surveillance, etc.) to promote early file resolution. Index bureau check on all lost time and bodily injury cases. Subsequent requests every six months. Follow-up action taken within five business days of receipt, where appropriate. RESOLUTION Action plans developed within 14 days of receipt, which outlines the steps to file closure and updated every 90 days. Execution results documented in notepad. Timely, adjuster -driven proactive resolution techniques — settlement negotiations, mediation, arbitration, structured settlements, and return -to -work strategies. SUBROGATION Subrogation opportunities identified or ruled out by the handling adjuster and documented in notepad. Referral to the subrogation unit for investigation and pursuit, where appropriate. Potential third parties placed on notice. Daily evaluation of new claims to determine subrogation potential RETURN -TO -WORK Bl-weekly contact with injured worker to assess/influence early return to work, full duty work release and file resolution. Ongoing contact with injured worker/employer based on benefits being paid — bi-weekly if indemnity being paid, every 30 days if not. Recurring contact with medical providers based on appointments and change in medical/work status. QUALITY/COMPLIANCE Monitor and control adjuster caseloads, supervisor diaries, adjuster to supervisor and adjuster to support staff ratios and key performance indicators to ensure compliance with claim service agreement protocols and work product objectives. Ensure regulatory and best claim practices are enforced. SUPERVISION Supervisor directed adjuster assignments upon receipt of claim. Continued involvement and documentation within 30 days or sooner, if necessary; 90 days thereafter or less until file closure. Supervisor intervention focusing on adherence to best claim practices, key performance indicators and best probable file resolution. Liability Claim Procedure Manual Page 1 • Table of Contents 1) Introduction 2) The Claims Department 3) Claims Investigation Policy 4) Receipt and Review of New Claims 5) Acknowledgement to the Account 6) Coverage Verification 7) File Structure 8) Claim Diary and Documentation 9) Reserves 10) Reserve Authority Levels 11) Settlement Authority 12) Large Loss Reports 13) Adjuster Investigation 14) Subrogation 15) Fraud 16) Litigation Management 17) Vendor Assignments Page 2 IL Introduction This claim policy and procedures manual has been developed as a general guideline to assist all liability claims personnel in their understanding of Preferred Governmental Claim Solutions (PGCS) claim handling requirements. The manual has been designed to provide all liability claims personnel with a reference guide that clearly illustrates the expectation and requirements of PGCS. This guide will outline all required procedures of the claims process; establish office, management and individual authority levels. It will further establish the reporting requirements, standard and measures for time and task completion. This manual is intended to apply generally to all company liability claim procedures within the state of Florida and on a national basis. PGCS recognizes that at times it may be necessary to modify or adjust some of these procedures in order to comply with the state or federal requirements for claims handling. These modifications will be made on an as needed basis with the variances being kept to an absolute minimum. It is understood that this is a Iiving document and as such will be updated periodically to reflect the changes, which may occur within the laws mandated by the State of Florida or the federal government. Page 3 i The Claims Department The claims department consists of four basic levels: The Claims Manager, the Claims Supervisor, the Claims Adjuster and the Claims Assistant. These individuals may also work with various other parties including but not limited to: field adjusters, CAT adjusters, property damage appraisers, special investigative units, nurses, experts and defense counsel. The claims adjusters will be assigned an account(s) for which they will have the responsibility of all services related to the claims handling for that account(s). The claims adjuster will typically handle only fast track, property damage or bodily injury claims. This will allow the adjuster to work on a one on one basis with each account that they service. The claims adjusters are responsible for providing thorough, accurate, timely communication and advice to the account(s) in order to resolve any and all claim related issues. The claims adjuster will handle all cases professionally in order to assure a mutually beneficial resolution in a timely and cost effective manner. The handling of the claims will involve, but not be restricted to: A) Initial investigation to determine liability. B) Investigation to determine the damages. C) Identify and pursue any and all third party (subrogation) possibilities. D) Establish, monitor and assure the accuracy of any reserves. E) Notify the excess carrier of any claim that is catastrophic or has excess potential. F) Adhere to all recommendations provided through the claim review process. G) Prepare and manage all litigation. H) Adhere to the timely filing of any and all legal documents. I) Close all files as deemed appropriate on a timely basis. It is the claims adjusters' responsibility to adhere to all state requirements regarding their adjuster's license and any required continuing education. Any adjuster that allows their license to expire, be suspended, or canceled, will be subject to immediate dismissal. Page 4 PGCS Claims Investigation Policy It is PGCS policy that all reported claims will be investigated to fullest extent warranted. The adjuster will perform the investigation to include all available information from the claimant, the account, witnesses, medical providers and experts if warranted. All determinations of liability and the damages owed will be made in accordance with the laws. On SIR accounts, acceptance or denial of the claim will be discussed with the claims supervisor and the client. On claims where the value exceeds the primary layer, the excess carrier must be consulted before accepting or denying liability. Receipt and Review of New Claims All claims can be called into 800-237-6617, submitted by fax number 321-832-1448 or sent by email to LiabilityClaims(ii PGCS-TPA.com. The preferred format of the report is the ACORD form. 1. Claims will be promptly input into the claims data system - RiskMaster*. 2. Affirmation of coverage is verified. 3. Claims will be reviewed by the Supervisor and assigned to establish immediate contact with the account and claimant. If verbal contact cannot be made after three attempts, a contact letter will be sent advising of the receipt and assignment of the claim. 4. If required, the claim will be assigned to the appropriate field adjuster. Contact and or appointment will be made with the account and claimant within 24 hour of receipt of the claim by the field adjuster. If verbal contact cannot be made after three attempts, a contact letter will be sent advising of the receipt and assignment of the claim. 5. All insured, client, claimant or agent inquiries are to be directed to the liability supervisor or the claims manager. *All contact and investigations are input into RiskMaster, Page 5 Acknowledgement to the Account A letter or e-mail will be forwarded to the client within 24 hours acknowledging receipt of the claim and any assignment made thereof. Coverage Verification Policy and coverage will be affirmed when the claim is initially called in. The claim file will reflect confirmation of coverage to include: carrier, line of coverage, policy limits and any deductible and/or retention. Claims assistant or claims adjuster will document the confirmation. File Structure All physical files will contain and will be structured according to the following: 1. Copy of initial claim notice/ACORD forrn will go on the left hand side of file jacket. 2. Coverage verification will be placed on the [eft side of the file jacket. 3. Medical reports and bills are to be placed on the right hand side of the file jacket. If medical reports and medical bills are voluminous, they can be kept in a separate file enclosed within the claim file. The same is true for any large reports. Legal bills and expense bills will also be kept separately within the claim file. 4. All investigative reports and correspondence regarding damages or received from defense counsel will be placed on the right hand side of the file jacket. 5. All estimates are to be placed on the right hand side of the file jacket. All key docunnents will be tabbed. Claim Diary and Documentation Supervisor diary will be established based on the severity and nature of the claim. Initial diary periods will not exceed thirty (30) days. All claim activity will be documented into the RiskMaster claims system. This activity will include but is not limited to any phone conversations, written correspondence, estimates and appraisals. An Action Plan regarding the resolution of the claim is to be input into RiskMaster. Page 6 Reserves Initial reserves will be established within seven (7) days of receipt of claim. Appropriate adjustment of reserves will be established upon confirmation of exposure/damage and no later than 30 days from receipt of claim. Reserves should reflect the total expected payout on the claim. All reserves will have written support both in RiskMaster and hard copy. Reserve Authority Levels Adjusters will have reserve authority of $10,000.00, Supervisor will have reserve authority of $50,000.00. Authority levels may vary with written management approval. All additional authority will be provided through management. Settlement Authority Settlement authority is assigned by management according to the adjuster's or supervisor's demonstrated experience level. Large Loss Reports Any claim where the claim value/reserve amount equals or exceeds 50% of the insured retention will have a Large Loss Report (LLR) generated within 14 days of receipt of the claim and/or knowledge of excess criteria. The Initial LLR will be supplied to the supervisor, management, underwriting and the appropriate carrier. The LLR must be updated either every 90 days or every 120 days depending on the requirement by the excess carrier and supplied to the supervisor. management and the appropriate carrier. A large loss is determined by the following criteria: A. Fatalities B. Any head injury or brain damage C. Amputations D. Spinal cord injuries involving paraplegia or quadriplegia E. Third degree burns over 50% of the body F. Vision or hearing impairment of 50% or more G. Multiple broken bones or fractures H. Severe internal injuries affecting body organs I. Hospitalizations over 30 days J. Sexual or physical assault or molestation K. Civil Rights claims Page 7 L. Environmental claims M. Occupational Diseases such as Asbestosis. RSD, Black Lung, Toxic Tort or HIV related issues N. Any claims with coverage questions O. Claims that are covered under the Claims Made Policy such as Employment Practices or Public Officials Liability P. Demands in excess of the retention Q. Any claim or suit with allegations of bad faith or improper claim handling Adjuster Investigation The adjuster will perform all investigation warranted including obtaining information from the claimant, the account, witnesses, medical providers and experts. The adjuster will gather documentation and obtain any estimates needed to properly evaluate the claim. This will include but not be limited to: l . Recorded statement where warranted by liability and / or damages. A summary of this statement should be included with the tape. 2. Verification of any physical injuries will be made. With any claim involving a physical injury, a medical release form will be obtained. 3. The police and incident reports will be obtained on all claims. 4. The fire department reports will be obtained on all property claims. 5. Photographs will be taken on all property claims. Photographs will be dated and carry a description. 6. Estimates and/or appraisals will be obtained on all automobile physical/property damage claims. Photographs will be obtained on all automobile claims. Subrogation Subrogation will be pursued aggressively on any claim where evidence supports liability with another party. Written notice of Subrogation will be served on the tortfeasor via certified mail. Subrogation should be on 30-day diary intervals for follow-up. Where warranted, an attorney from PGCS panel will be utilized in the recovery process. All subrogation activity will be documented in RiskMaster. Page 8 Fraud All suspected Fraud will be pursued to the fullest extent available through the law. An attorney from the PGCS approved panel of attorney's will review all potential Fraud cases. SIU assignments will be made upon approval of the supervisor. Litigation Management All litigated claims will be referred to an attorney on the PGCS approved panel of attorney's. All litigated files will be handled in accordance with the PGCS Litigation Management Plan. Any exceptions must be discussed with and approved by management. Vendor Assignments All vendor assignments will be from the PGCS approved panel of vendors. There will be no deviation from this procedure without supervisor approval. The reasoning for the use of the vendor and the approval must be documented in the file. The comprised list will be utilized on a rotation basis. Page 9 ATTACHMENT B1 Claims Administration Price Proposal Schedule Request For Proposals: CLAIMS ADMINISTRATION •VvUSIS SIlt\ ICI BF )NI ME CtINTR-\t:T PRICE PROPOSAL Attachment B1 USIS, Inc. Contact Person: Ron Warble, Executive Vice President Firm's Liaison: Terri Snapp 5728 Major Blvd., Suite 450 Orlando, Florida 32819 Phone: 800.444.9098 ext. 6503 Fax: 407.949.3140 Federal Employer Identification Number: 204580645 City of Miami, Florida RFP No.605386 ATTACHMENT B1 CLAIMS ADMINISTRATION PRICE PROPOSAL SCHEDULE INSTRUCTIONS: The Proposer's price shall be submitted on this form "Price Proposal Schedule", and in the manner stated herein. Proposer is requested to fill in the applicable blanks on this form and to make no other marks. If proposing more than one category of services (Part I or Part 11) Proposer must complete one separate Price Proposal Schedule for each category of service. This Price Proposal Schedule is for Part 1 Services Only: Workers' Compensation Claims and Liability Claims Administration. 1. INITIAL TERM (Years 1 through 3) A. Proposed Total Fees and Costs for Initial Term (Years 1 through 3): The proposed total fees and costs shall include all fees, including one-time and recurring, and value added options, for Part I Services only. 55,518,818 (Total fees and costs should be the aggregate price for the initial three years) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The Proposer shall break down its price for providing the Claims Administration Services as specified in Section 3, Specifications/Scope of Work. The proposed fees shall be based on: a) the three year initial term Agreement; b) approximately 695 new indemnity claims per year; c) approximately 144 new medical only claims per year; d) a flat fee broken down on an annual basis for the initial three (3) year term; e) the cost for anticipated staffing levels, based on the Proposer's proposal; and f) the implementation costs. 1. Proposed Staffing Positions FTE Annual Salary Total Costs 1 Supervisor 1 $103,935 * $207,870 $ 88,560 * $177,120 $ 88,560 * $177,120 $ 88,560 * $177,120 $ 88,560 * $177,120 $ 88,560* $177,120 $ 61,500 * $123,000 $110,700 * $221,400 $ 86,100 * $172,200 $ 86,100 * $172,200 2 Lost Time Adjuster 1 3 Lost Time Adjuster 1 4 Lost Time Adjuster 1 5 Lost Time Adjuster 1 6 Lost Time Adjuster 1 7 Medical Only Adjuster 1 8 Liability Supervisor 1 9 Liability Adjuster 1 10 Liability Adjuster 1 11 12 *Burdened Salary Proposed Total Fees and Costs $1,782,270 City of Miami, Florida RFP No.605386 2. Proposed Annual Costs (inclusive of staffing costs) - Base Cost ($) Projected Increase (%) Total Costs Year 1 $1,782,270 0% $1,782,270 Year 2 $1,782,270 3% $1,835,738 Year 3 $1,835,738 3% $1,890,810 Proposed Grand Total (Years 1-3) $5,508,818 3. Proposed One -Time Implementation Costs Item Description Total Costs 1 Data Transfer from incumbent TPA Claims Data Transfer $10,000 2 $ 3 $ 4 $ 5 $ Proposed Total Fees and Costs $10,000 Notes: 1) The City reserves the right to correct and re -calculate any errors found in Proposer's calculation. 2) Total Fees and Costs from Tables 1, 2, and 3 in Section 1B above, should equal the aggregate costs in Section 1 A above. 2. OPTION TO RENEW YEARS (Two, One -Year Periods - Years 4 and 5) The Proposer shall state its price below for the cost during the optional renewal years. This Price Proposal Schedule is for Part 1 Services only: Workers' Compensation Claims and Liability Claims Administration. A. Proposed Total Fees and Costs for Option to Renew Years (Years 4 and 5): The proposed total fees and costs shall include all fees, and value added options, for Part Services only. $3,943,757 (Total fees and costs should be the aggregate price for the two renewal years) B. Breakdown of Total Fees and Costs for Option to Renew Years (Years 4 and 5) The Proposer shall break down its price for providing the Claims Administration Services as specified in Section 3, Specifications/Scope of Work, during the option to renew years. The proposed fees shall be based on: a) the two (2) additional years of the Agreement; b) approximately 695 new indemnity claims per year; c) approximately 144 new medical only claims per year; d) a flat fee broken down on an annual basis for the two (2) additional years; e) the cost for anticipated staffing levels. 3 City of Miami, Florida RFP No.605386 4. Proposed Staffing Positions FTE Annual Salary Total Costs 1 Supervisor 1 $113,572 * $227,145 $ 96,771 * $193,544 $ 96,771 * $193,544 $ 96,771 * $193,544 $ 96,771 * $ 193,544 $ 96,771* $193,544 $ 67,202 * $134,405 $120,964 * $241,930 $ 94,083 * $188,168 $ 94,083 * $188,168 2 Lost Time Adjuster 1 3 Lost Time Adjuster 1 4 Lost Time Adjuster 1 5 Lost Time Adjuster 1 6 Lost Time Adjuster 1 7 Medical Only Adjuster 1 8 Liability Supervisor 1 9 Liability Adjuster 1 10 Liability Adjuster 1 *Burdened Salary Proposed Total Fees and Costs $1,947,535 *Use additional paper if required 5. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (%) Total Costs Year 1 1,947,535 0.0% $1,947,535 Year 2 1,947,535 2.5% $1,996,222 Proposed Grand Total (Years 4 and 5) $3,943,757 Notes: 1) The City reserves the right to correct and re -calculate any errors found in Proposer's calculation. 2) Total Fees and Costs from Tables 4 and 5 in Section 2B above, should equal the aggregate costs in Section 2A above. 3. Additional Services The Scope of Work outlined herein identifies the work that the selected Proposer shall perform under the Agreement. To address future City requests for any additional services; modifications, or changes outside of the scope of work, please provide not -to -exceed hourly rates for personnel who will be assigned to this contract. 6. Additional Services Proposed Hourly Rates Personnel Not -To -Exceed Hourly Rates Loss Control Consulting Services $120.00 Appraisal Services TBD $ $ $ $ $ $ $ *Use additional paper if required 4 City of Miami, Florida RFP No.605386 A. OTHER SERVICES - ITEMIZED: Proposer shall list the not -to -exceed charge for each Service itemized below in Table 7: 7. Other Services SERVICES CHARGES On-line Access No Charge GB International Claims Services NA Consultative Services Loss Control Consulting Services $120.00 per hour Appraisal Services TBD Fraud Prevention — Special Fraud Investigations - SIU $85 per hour plus expense Surveillance Investigations $75 per hour plus expense Targeted Field Investigations $80 per hour plus expense Targeted Database Investigations Rate per report MSA Workers Compensation Medicare Set -Aside Allocation (WCMSA) $2 200 Rush Fees (MSA completed within 7 days) $450 Revisions: 3 - months free, 150/hour Liability Medicare Set -Aside Allocation (LMSA) $2,000 MSA Submission to CMS $700 Compliance Services Conditional Payment Research (CPR) $200 Conditional Payment Negotiations (CPN) $375 Secure Final Demand for Settlement (SFD) $0 if included in CPR or CPN Otherwise Bundled CP Resolution Services _$350 $700 Benefit Coordination & Recovery Contractor Notification $45 Medicare Eligibility Inquiry (MEI) $150 SSDI Verification $175 Release / Settlement Agreement Review $125/hour max $375 Lien Resolution (Advantage Plan, Medicaid, Part D) $500 Flat Rate per Lein Resolution Taxes (All applicable taxes will be added to the service fees where required) 5 City of Miami, Florida RFP No.605386 Notes: 1. The proposed prices above in Sections 1A, shall be fixed and firm for the initial term of the Agreement. The proposed prices for the option to renew years, in Sections 2A, may be negotiated prior to the renewal of the contract for each option to renew period, at the sole discretion of the City. Any extensions to the Agreement beyond the five year period, will be at the then current rates. 2. All out-of-pocket expenses, including employee travel, per diem and miscellaneous costs and fees, should be included in the Proposer's proposed price, as they will not be reimbursed separately by the City. Refer to CH.112.061 of the Florida Statutes regarding adherence to travel expenses. 3. Sections 1 and 2 will be used to determine the price points for the price criteria as indicated in Section 5.1, Evaluation Criteria of this Solicitation. 4. Notwithstanding the proposed hourly rates in Sections 3, Additional Services, above, the City reserves the right to negotiate the not -to -exceed pricing on a year by year basis, at the City's sole discretion. 5. The positions identified in the table above shall be the same as the key positions identified in the Proposer's proposal. The City expects that the personnel in those positions will be performing the services. 6 City of Miami, Florida RFP No.605386 EXHIBIT C THIRD PARTY CLAIMS ADMINISTRATION SERVICES PRICE SCHEDULE The prices shown below are the charges for Workers' Compensation Claims and Liability Claims Administration Services only, as stated in the Scope of Services (Exhibit C). The prices shall remain firm and fixed for the first two (2) years of the Contract. The City reserves the right to negotiate the rates for Year 3 of the initial term, and for renewal and/or extension periods. 1. INITIAL TERM (Years 1 through 3) A. Total Fees and Costs for Initial Term (Years 1 through 3): The total fees listed below include all fees and costs, including one-time and recurring fees, and value added options. $5,154,575 jYears 1 through 3) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The break down list below is for the aggregate price in Section 1A above. 1. Staffing Positions FTE Annual Salary Total Annual Salary* 1 Supervisor 1 $103,935 $207,870 2 Lost Time Adjuster 1 $88,560 $165,909 3 Lost Time Adjuster 1 $88,560 $165,909 4 Lost Time Adjuster 1 $88,560 $165,909 5 Lost Time Adjuster 1 $88,560 $165,909 6 Lost Time Adjuster 1 $88,560 $165,909 7 Medical Only Adjuster 1 $61,500 $109,785 8 Liability Supervisor 1 $110,700 $211,400 9 Liability Adjuster 1 $86,100 $172,200 10 Liability Adjuster 1 $86,100 $172,200 Total Annual Salary *Total Annual Salary column includes ail costs associated with performance services. $1,703,000* Third Party Claims Administration Rev. 3 20 _2017 2. Total Breakdown of Annual and One -Time Costs (inclusive of staffing costs) Base Annual Cost Projected Annual Increase (%) Total Annual Costs Year 1 $1,703,000 0% $1,703,000 Year 2 $1,703,000 0% $1,703,000 Year 3 $1,703,000 2.5% $1,745,575 One -Time Implementation Cost for Data Transfer $3,000 Grand Total Costs (Years 1-3) $5,154,575 2. OPTION TO RENEW YEARS (Years 4 and 5) The prices shown below are the charges for Workers' Compensation Claims and Liability Claims Administration Services for two (2), one (1) year option to renew periods only, as stated in the Scope of Services (Exhibit C). A. Total Fees and Costs for Option to Renew Years (Years 4 and 5): The total fees and costs include all fees, and value added options, for Workers' Compensation Claims and Liability Claims Administration Services. $3,623,159 (Years 4 and 5) B. Breakdown of Total Fees and Costs for Option to Renew Years (Years 4 and 5) The break down list below is for the aggregate price in Section 2A above. 3. Staffing Positions FTE Annual Salary Total Annual Salary* 1 Supervisor 1 $113,572 $227,145 2 Lost Time Adjuster 1 $96,771 $166,768 3 Lost Time Adjuster 1 $96,771 $166,768 4 Lost Time Adjuster 1 $96,771 $166,768 5 Lost Time Adjuster 1 $96,771 $166,768 6 Lost Time Adjuster 1 $96,771 $166,768 T Medical Only Adjuster 1 $67,202 $119,623 8 Liability Supervisor 1 $120,964 $231,930 9 Liability Adjuster 1 $94,083 $188,168 10 Liability Adjuster 1 $94,083 $188,168 Total Annual. Costs *Total Annual Salary column includes all costs associated with performance services. $1,789,214* Third Party Claims Administration Rev. 3 20 2017 City of Miami, Florida RFP No.605386 4. Total Annual Breakdown Costs (inclusive of staffing costs) Base Annual Cost ($) Projected Annual Increase (%) Total Annual Costs Year 1 $1,789,214 0.0% $1,789,214 Year 2 $1,789,214 2.5% $1,833,944 Grand Total Costs (Years 4 and 5) $3,623,159 3. Additional Services Not -to -exceed hourly rates listed below will apply to future City requests for any additional services; modifications, or changes outside of the Scope of Services, for personnel who will be assigned to this Contract. 5. Additional Services Personnel Not -To -Exceed Hourly Rates Loss Control Consulting Services $120.00 Appraisal Services To be determined and negotiated Notes: 1. The prices above in Sections 1A, shall be fixed and firm for the first two (2) years of the initial term of the Agreement. The prices for the third (3rd) year of the initial term, and any extensions, and option to renew years, in Sections 2A, may be negotiated; at the sole discretion of the City. Any extensions to the Agreement beyond the five year period, will be at the then current term's rates. 2. All out-of-pocket expenses, including employee travel, per diem, and miscellaneous costs and fees, are included in the price, as they will not be reimbursed separately by the City. Refer to CH.112.061 of the Florida Statutes regarding adherence to travel expenses. 3. Notwithstanding the hourly rates in Sections 3, Additional Services, above, the City reserves the right to negotiate the not -to -exceed pricing on a year by year basis, at the City's sole discretion. 4. The positions identified in the table above shall be the same as the key positions identified in the Third Party Claims Administrator's proposal. The City expects that the personnel in those positions will be performing the services. 3 Third Party Claims Administration Rev. 3 20 2017 City of Miami, Florida Contract No. RFP 605386 EXHIBIT D INSURANCE REQUIREMENTS 25 Third Party Claims Administration Services City of Miami, Florida RFP No.605386 EXHIBIT D INSURANCE REQUIREMENTS INDEMNIFICATION Third Party Administrator shall pay on behalf of, indemnify and save City and its officials harmless, from and against any and all claims, liabilities, losses, and causes of action, which may arise out of Third Party Administrator's performance under the provisions of the Agreement, including all acts or omissions to act on the part of Third Party Administrator, including any person performing under this Agreement for or on Third Party Administrator's behalf, provided that any such claims, liabilities, losses and causes of such action are not attributable to the negligence or misconduct of the City and, from and against any orders, judgments or decrees which may be entered and which may result from this Agreement, unless attributable to the negligence or misconduct of the City, and from and against all costs, attorneys' fees, expenses and liabilities incurred in the defense of any such claim, or the investigation thereof. The Third Party administrator shall furnish to the City of Miami, c/o Procurement Department, 444 SW 2nd Avenue, 6th Floor, Miami, Florida 33130, Certificate(s) of Insurance which indicate that insurance coverage has been obtained which meets the requirements as outlined below: The Third Party Administrator shall, at its own cost and expense, acquire and maintain during the term of the Agreement, with carriers having an AM Best Rating of A-VII or better, sufficient insurance to adequately protect the respective interests of the parties, including the Third Party Administrator's indemnity obligations. Specifically, the Third Party Administrator must carry the following minimum types and amounts of insurance on an occurrence basis or in the case of coverage that cannot be obtained on an occurrence basis, then coverage can be obtained on a claims -made basis with a three (3) year tail following the termination or expiration of this Agreement: a) Commercial General Liability: Written on an occurrence form, including but not limited to premises -operations, broad form property damage, products /completed operations, contingent and contractual exposures, personal injury and advertising injury, with limits of at least $1,000,000 per occurrence and $2,000,000 general aggregate. This coverage should be written on a primary and non-contributory basis, and should list the City as an additional insured; b) Workers' Compensation Insurance: Statutory Workers' Compensation Insurance and Employers' Liability Insurance in the minimum amount of $1,000,000 each employee by accident, $1,000,000 each employee by disease and $1,000,000 aggregate by disease with benefits afforded under the laws of the state or country in which the services are to be performed. Policy will include an alternate employer endorsement providing coverage in the event any employee of the Third Party Administrator sustains a compensable accidental injury while on work assignment with Company. Insurer for Vendor will be responsible for the Workers' Compensation benefits due such injured employee; c) Commercial Automobile Liability: If an automobile is used by the Third Party Administrator in connection with the performance of its obligations under this Agreement, then Comprehensive Automobile Liability Insurance for any owned, non -owned, hired, or borrowed automobile used in the performance of Third Party Administrator's obligations under this Agreement is required in the minimum amount of $1,000,000 each accident combined for bodily injury and property damage. City of Miami should be listed as an additional insured; 1 Third Party Claims Administration City of Miami, Florida RFP No.605386 d) Professional Errors and Omissions Liability: Insurance in the minimum amount of $10,000,000 per claim and policy aggregate, protecting the City against Third Party Administrator's professional negligence, failure to perform professional duties and breach of contractual obligations under this Agreement, including but not limited to, coverage for claims services and certification that there is no security breach or unauthorized use exclusion on this policy; e) Network Security/Privacy Liability (Cyber Liability): Insurance in the minimum amount of $5,000,000 per occurrence including but not limited to protection of private or confidential information whether electronic or non -electronic; network security and privacy liability; protection against liability for systems attacks; denial or loss of service; introduction, implantation or spread of malicious software code; security breach; unauthorized access and use; including regulatory action expenses; cyber extortion coverage; and notification and credit monitoring expenses f) Employee Dishonesty/Fidelity: Insurance including 3rd Party Liability in the minimum amounts of $1,000,000 each occurrence for acts of all Staff; and g) Excess Umbrella Liability (Excess Follow Form): Minimum limits of $10,000,000 per occurrence/aggregate. This coverage is excess over all applicable liability policies. The above insurance limits may be achieved by a combination of primary and umbrella/excess liability policies. 1. Prior to the execution of this Agreement (or seven (7) calendar days prior to the start of work under this Agreement) and annually upon the anniversary date(s) of the insurance policy's renewal date(s), the Third Party Administrator will furnish the City with a Certificate of Insurance evidencing the coverages set forth above and naming the City, its subsidiaries, affiliates, authorized distributors, directors, officers, employees, partners and agents as an "Additional insured" on the Third Party Administrator's Commercial General Liability and Commercial Auto Liability policies listed above and name the City, its subsidiaries, affiliates, authorized distributors, directors, officers, employees, partners and agents as a "Loss Payee" on the Third Party Administrator's Fidelity policy. 2. The Third Party Administrator shall provide the City thirty (30) calendar days written notice of any cancellation, non -renewal, termination, material change or reduction in coverage. 3. The Third Party Administrator's insurance as outlined above shall be primary and non- contributory coverage. 4. The coverage territory for the stipulated insurance shall be on a worldwide basis. 5. The Third Party Administrator must ensure that any subcontractors or other service Providers the Third Party Administrator engages to provide the services required under this Agreement, acquire and maintain at all times, with insurance companies with a minimum A.M. Best Rating A-VII, the same levels of insurance coverage as are outlined above. The Third Party Administrator and subcontractors of the Third Party Administrator, will cause their insurance companies to waive their right of recovery against the City. 6. The stipulated limits of coverage above shall not be construed as a limitation of any potential liability to Company, and failure to request evidence of this insurance shall not be construed 2 Third Party Claims Administration City of Miami, Florida RFP No.605386 as a waiver of the Third Party Administrator's obligation to provide the insurance coverage specified. BINDERS ARE UNACCEPTABLE. The insurance coverage required shall include those classifications, as listed in standard liability insurance manuals, which most nearly reflect the operations of the THIRD PARTY ADMINISTRATOR. All insurance policies required above shall be issued by companies authorized to do business under the laws of the State of Florida, with the following qualifications: Certificates will indicate no modification or change in insurance shall be made without thirty (30) days written advance notice to the certificate holder. NOTE: CITY RFP NUMBER AND/OR TITLE OF RFP MUST APPEAR ON EACH CERTIFICATE, AND THE CITY MUST BE LISTED AS THE INSURED AND/OR ADDITIONAL INSURED. Compliance with the foregoing requirements shall not relieve the Third Party Administrator of his liability and obligation under this section or under any other section of this Agreement. --If insurance certificates are scheduled to expire during the contractual period, the Third Party Administrator shall be responsible for submitting new or renewed insurance certificates to the City at a minimum of ten (10) calendar days in advance of such expiration. --In the event that expired certificates are not replaced with new or renewed certificates which cover the contractual period, the City shall: (a) Suspend the Agreement until such time as the new or renewed certificates are received by the City in the manner prescribed in the RFP. (b) The City may, at its sole discretion, terminate this Agreement for cause and seek re - procurement damages from the Third Party Administrator in conjunction with the General and Special Terms and Conditions of the solicitation. The Third Party Administrator shall be responsible for assuring that the insurance certificates required in conjunction with this Section remain in force for the duration of the contractual period; including any and all option terms that may be granted to the Third Party Administrator. 3 Third Party Claims Administration BROWN-3 OP ID: JW AW 0 I`,r-- CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 03/2912017 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERT1FiCATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(lea) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in Ileu of such ondorsemont(s). PRODUCER Brown & Brown of Florida, Inc. CONTACT LAURIE KOHLER #17125 NAME' *"CNN , EA): 386-239-7242 rtitc, No: 386-323-9159 Daytona Beach Office P.O.Box 2412 Daytona Beach, FL 32115-2412 E-MAILSS; Ikohlerlabbdaytona.com INSURER(a1 AFFORDING COVERAGE NAIM f M. Decker Youngman INSURER A:Travelers Prop & Cas of Amer 25674 INSURED BROWN & BROWN INC ETAL INSURER B :Continental Casualty Co 20443 D O BOX DAYTONA BEACH, FL 32115 INSURER c ;Travelers Indemnity 25658 INSURER D:XL Specialty Ins Inc. 37885 INSURER E : Allied World Assurance: o Inc 19489 INSURER F : 7 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS SS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE; BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTj ER DOCUMENT Yv1TH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAl6"CLAIMS ' ILTR TYPE OF INSURANCE UNSD WYD POLICY NUMBER POLICY WDOP BFF IMMlDD1YYYY) POIDDI XP IMMIDDlYYYY) UMITS A X COMMERCIAL GENERALLIABILITY X TC2JGL5A9527887417 4jv 01101/2017 - i .kj 1 ) 01 1/2 18 \ EACH OCCURRENCE $ 1,000,000 DAMAGETORENTE❑ PREMISES Efe Occurrence} S 1,000,000 CLAIMS -MADE X OCCUR MED EXP (Any ono person) S 5,000 PERSONAL 8, ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L X AGGREGATE LIMIT APPLIES PRO- PER:., LOC PRODUCTS - COMP/OPAGG S 2,000,000 S A AUTOMOBILE _ X X umatUTY X _ SCHEDULED AUTOS NON -OWNED AUTOS X TC2JCAP95271386217 01/01/2017 01/01/2018 COMBINED SINGLE LIMIT (Ea awldent) S 1,000,000 BODILY INJURY (Par person) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE (Per scddenll $ $ B X UMBRELLA LIAR EXCESS LAB X OCCUR CLAIMS -MADE 6011849429 01/01/2017 01/01/2018 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DE❑ RETENTION $ $ A C` WORKERS COMPENSATION AND EMPLOYERS' LUlBIUTY Y!N ANY PRCPRIETORIPARTNERJEXECIJTIVE (MandatoryOFFICER/MEMBERCLUDED7 'rpm, describe under DESCRIPTION OF OPERATIONS berow NrA TC2JU89517958017 TRKUB9518B76117 01/01/2017 01/01/2017 01/01/2018 01/01/2018 X PER OTH- STATUTE ER E.L. EACH ACCIDENT s 1,000,000 E,LDISEASE- EAEMPLOYEE S 1,000,000 E.L DISEASE - POUCY LIMIT S 1,000,000 D E INS AGENTS E&O CYBER LIABILITY ELU14796717 03080277 01/01/2017 01/01/2017 0110112018 01/01/2018 EACH LOSS 10,000,000 SEE PG 2 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 1a1,. Additional Remarks Schedule, may be attached I1 more ewe la required) NAMED INSURED: USIS, INC. dba AMERISYS RFP 605386 MANAGED CAREIMEDICAL BILL REVIEW/AUDIT SERVICES. CITY OF MIAMI IS ADDITIONAL INSURED ON THE GENERAL LIABILITY ON A PRIMARY & NON-CONTRIBUTORY BASIS, PER FORMS CG 02 48 08 05 AND CG DO 37 04 05 AND ADDITIONAL INSURED ON THE AUTO LIABILITY, PER FORM CA T4 37 08 08. UMBRELLA CERTIFICATE HOLDER CANCELLATION C ITYM-1 CITY OF MIAMI PROCUREMENT DEPT 444 NW 2ND AVE 6TH FLOOR MIAMI, FL 33130 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) CO 1988-2014 ACORD CORPORATION. Ali rights reserved. The ACORD name and logo are registered marks of ACORD LATA BREACH = INFORMATION SECURITY & PRIVACY INSURANCE WITH ELECTRONIC MEDIA LIABILITY NOTEPAD INSURED'S NAME BROWN & BROWN INC ETAL (POLICY AGGREGATE $10,000,000 INCLUDING COVERAGE FOR PRIVACY OTIFICATION COSTS; REGULATORY DEFENSE AND PENALTIES; igEASITE MEDIA CONTENT LIABILITY \g') BROWN-3 PAGE 2 OP ID: JW Data 03/2912017 NOTEPAD: HOLDER CODE CITYM 1 INSUREO`9 NAME BROWN & BROWN INC ETAL BROWN-3 OP ID: JW PAGE 3 °do 03/2912017 POLICY IS FOLLOW FORM OVER THE GENERAL LIABILITY, AUTO LIABILITY, AND EMPLOYERS LIABILITY, PER FORM G-15057-C 0605. OP ID: AT '4` �'RL' CERTIFICATE OF PROPERTY INSURANCE ©A031291TE 201 YI 03l2912017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. If thls certificate Is being prepared for a party who has an Insurable Interest In the property, do not use this form. Use ACORD 27 or ACORD 28. PRODUCER Brown & Brown of Florida, Inc. Daytona Beach Office P.O Box 2412 Daytona Beach, FL 32115-2412 M. Decker Youngman CONTACT NAME:Tyler DeBord PHONE 386-239tii' 703 FAx Fr [Atc. No]: 386-238-8917 ?JAI, DAD RESS, tdebordt@bbdaytona.com PRODUCER BROWN cusmmRlp• INSURERIS] AFFORDING COVERAGE NAIC 0 INSURED BROWN & BROWN, INC., ET AL P.O. BOX 2412 Daytona Beach, FL 32115-2412 INSURER A: Executive Risk Indemnity INSURER e INSURER C : INSURER D : INSURER E : /1 INSURER F : _ COVERAGES CERTIFICATE NUMBER: REVISION UMBER: 1 tki86 552ali glI A l6 f4Ake tilligKVitgb mnn.PaceIsrrquIl d 7 / NAMED INSURED: USIS, INC., DBA AMERISYS / THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT )MTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HHREIN,IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS /� INSR LTR TYPE OF INSURANCE POLICY NUMBER POIICY EFFECTIVE DATE (MMIDDIYYYYI POLICY EXPIRAtON DATE jMMIDg1Y'jfYl COVERED PROPERTY LIMITS PROPERTY CAUSES OF LOSS DEDUCTIBLES ,4 y ` );1 , - BUILDING PERSONAL PROPERTY BUSINESS INCOME EXTRA EXPENSE RENTAL VALUE \BLANKET BUILDING 6LANKET PERS PROP BLANKET BLDG & PP ; ; BASIC BUILDING ; BROAD Contanb SPECIAL ; EARTHQUAKEQ\ ; WWND ; FLOOD ; $ $ lINLAND CAUSES MARINE OF LOSS NAMED PERILS TYPE OF POLICY — — ; i POLICY NUMBER I A X TYPE Commercial CRIME OF POLICY Crime 82220236 01/01/2017 01/01/2018 A Emptoyae Theft 6 1,000,000 $ s 1 BOILER a MACHINERY 7 EQUEPMENT BREAKDOWN $ $ f SPECIAL CONDmONS I OTHER COVERAGES (Awch ACORD 101, Additional Remarks Schedule, S mom apace Is requlnd) CERTIFICATE HOLDER CANCELLATION ClTYM-1 CITY OF MIAMI PROCUREMENT DEPT 444 N.W. 2ND AVE. MIAMI, FL 33130 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / ACORD 24 (2009/09) 1995-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Miami, Florida Contract No. RFP 605386 EXHIBIT E CORPORATE RESOLUTIONS AND EVIDENCE OF QUALIFICATION TO DO BUSINESS IN FLORIDA (To be provided upon document execution) 26 Third Party Claims Administration Services Detail by Entity Name Page 1 of 3 Florida Department of Slate 11 golaffipfri.Org Deparrrnnnt rzt St<sl9 1 Division of corporatiens 1 Search Records 1 Deta a By Documen9 Number I DVISaON OF CORPORATi NS Detail by Entity Name Florida Profit Corporation USIS. INC. Filing Information Document Number P06000044222 FEI/EIN Number 20-4580645 Date Filed 03/27/2006 State FL Status ACTIVE Last Event AMENDMENT Event Date Filed 04/11/2006 Event Effective Date NONE Principal Address 5728 Maior Blvd. Suite 450 Orlando, FL 32819 Changed: 04/13/2015 Mailing Address 220 S Ridgewood Avenue Daytona Beach, FL 32114 Changed: 04/13/2015 Registered Agent Name & Address C T CORPORATION SYSTEM 1200 SOUTH PINE ISLAND ROAD PLANTATION, FL 33324 Name Changed: 03/20/2012 Address Changed: 03/20/2012 Officer/Director Detail Name & Address Title President, Director Boone, Sam R., Jr. 220 S. Ridgewood Avenue Daytona Beach, FL 32114 http://search.sunbi:z.org/Inquiry/CarporationSearch/Se trchResttltDetail?inquirytype=Entity ... 3/23/2017 Detail by Entity Name Page 2 of 3 Title Treasurer Calderon, Jennifer 615 Crescent Executive Court Lake Mary, FL 32746 Title VP Lanni, James 220 S. Ridgewood Avenue Daytona Beach, FL 32114 Title VP, Secretary Lloyd, Robert W. 220 S. Ridgewood Avenue Daytona Beach, FL 32114 Title VP, Assistant Secretary Robinson, Anthony 220 S. Ridgewood Ave. Daytona Beach, FL 32114 Title Executive Vice President Warble, Ronald 140 Alexandria Blvd., Suite H Oviedo, FL 32765 Title VP Watts, Andy 220 S. Ridgewood Ave. Daytona Beach, FL 32114 Annual Reports Report Year Filed Date 2014 04/30/2014 2015 04/13/2015 2016 04/08/2016 Document Images r;.1;y;201e--AI,y,NU L REPORT 04/1312015 -- ANNUAL REPORT O4i30,i2014 -- ANNUAL REPORT 03,•27.2013 — ANNUAL REPORT aA 2,72012 — ANNUAL REPORT 03i2012012 -- Req. Agent Change 04,29,12011 -- ANNUAL REPORT View image PDF format View rmage ,n PDF formai View image in PDF format CView ;rnaye in PDF format View Image in PDF format View image In PDF format View rmage in PDF format http://search.sunbiz.orgfinquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 3/23/2017 Detail by Entity Name Page 3 of 3 04/2912010 - ANNUAL REPORT (Ar01.2009 -- ANNUAL REPORT 94/2412002 -- ANNUAL REPORT 041 172007 -- ANNUAL REPORT 04/ 1 1 t2006 — Amendment 031271200e -- 0cresilc Profit View image in PDF format View image in PDF forniai View image in PDF format View image in PDF format View Image In PDF format View image in PDF format http://search.sunbiz.or;/Inquiry/CorporationSearch/SearchResultDetail?inquiQ type -Entity... 3/23/2017