CITY OF DELAND FLORIDA REQUEST FOR COMMISSION ACTION Se tember Approved by. SUMMARYHIGHLIGHT for Worker s Z

Transcription

1 Department Human Resources Subject for Worker s Compensation Managed Care Services CITY OF DELAND FLORIDA REQUEST FOR COMMISSION ACTION Se tember Attachments Consideration re Contract Renewal X Contract Prepared by Approved by VVCf 1 Gait PUJ Mark Hayward HR Director City Manager SUMMARYHIGHLIGHT for Worker s Z The City of DeLand contracts with Managed Medical Equipment Inc MME Compensation managed care services MME is approved by the Agency for Health Care IR Administration to provide such services in the State of Florida Services provided include a 24 WW hour call center electronic filing of first report of injury with the State of Florida telephonic case management and scheduling of medical and rehabilitation appointments for injured City V employees MME charges the City only for services rendered Example costs include 25 for each first report of injury and 425 for each injury that requires case management The Cite is billed through Multi Line Claims Service its Worker s Compensation Third Party Administrator and costs are tracked as a part of individual injury claims The combination of services provided by Managed Medical Equipment and MultiLine Claims is invaluable to the City as it would require at least one additional fulltime employee to provide these services internally STRATEGIC PLAN FOCUS AREA ACTION STEP This item abides by the High Value Government Strategic Focus Area Under Organizational Improvement one of the continuation action steps is to systematically and continuously review City functions for improved efficiency and effectiveness ZO FISCAL IMPACT The fiscal impact of this item varies based on the number of injury claims the City experiences These costs are included in the claims cost within the Workers Compensation Self Insurance Fund RECOMMENDATION It is recommended that the City Commission approve the renewal contract for Worker s Compensation Managed Care Services with Managed Medical Equipment Inc

2 Page 2 of SUBJECT Consideration re Contract Renewal for Worker s Compensation Managed Care Services BACKGROUNDDISCUSSION NA

3 Workers Compensation Managed Care Services Agreement This Workers Compensation Managed Care Services Agreement Agreement made and entered into as of October by and between Managed Medical Equipment Inc MME whose address is 7200 Lake Ellenor Dr Suite 207 Florida and City of DeLand whose address is 120 South Florida Avenue DeLand Florida In exchange for mutual and valuable consideration the receipt and adequacy of which each party hereby acknowledges the parties hereby mutually agree as follows RECITALS A City of DeLand is an employer authorized pursuant to applicable state law s to selfinsure its workers compensation liabilities City of DeLand desires to aitange for the managed delivers of certain services to injured workers who are entitled to receive workers compensation health care benefits under applicable workers compensation laws and B MME operates an integrated workers compensation managed care arrangement pursuant to Chapter 440 including a provider network consisting of physicians institutional facilities allied health care providers and C City of DeLand wishes to contract with MME for the utilization of the MME provider networks and for certain other managed care services and MME wishes to contract with City of DeLand to provide network access and managed care services to City of DeLand AGREEMENT NOW THEREFORE in consideration of the above recitals and covenants hereinafter set forth it is mutually agreed by and between parties as follows ARTICLE I DEFINITIONS As used in this Agreement the following definitions will apply 1 Administrative Procedures means the procedures developed and agreed upon by City of DeLand and MME applicable to notification pre certification and authorization of treatment payment procedures documentation time frames and other administrative procedures to be followed and or provided by each party 12 Covered Services means medical treatment care and attendance which employees are entitled to receive in accordance with the applicable state workers compensation law 13 Iniured Worker means an employee of City of DeLand who at all pertinent times nicets City of DeLand s employment eligibility requirements and the applicable provisions of the state workers compensation law Page 1 of 10

4 14 Service Area means the service area described on Schedule B attached hereto as may be modified from time to time with both parties written consent 15 Participatin Provider means an organization network or individual that has contracted directly with MME or its sub contractors to provide medical treatment or drug testing to persons eligible to receive services through MME 16 Non participating provider means an organization network or individual engaged in the provision and delivery of medical treatment or drug testing that is not a participating or a secondary provider ARTICLE II DUTIES OF MME 21 Managed Care Services MME agrees to provide the services identified in Schedule C to this agreement on behalf of City of DeLand including all services required by Florida statute and the Agency for Health Care Administration 2 Participating Providers MME will provide City of DeLand and its injured workers with access to its comprehensive statewide network of credentialed screened and monitored providers in all specialties as required by the Agency for Health Care Administration AHCA in all 67 counties of Florida for the purpose of receiving covered services as may be medically necessary and appropriate pursuant to applicable workers compensation statutes MME will provide all training credentialing certification and quality improvement activities in compliance with requirements as set forth in Florida Statute MME agree that providers will be recredentialed every two years Providers fare profiled on outcomes including return to work patterns by diagnosis 23 Provider Directory and Referral MME will create and maintain a directory of participating providers Upon notification of a worksite injury City of DeLand MultiLine Claims Services or MME will refer the injured worker to the participating provider or providers that are medically and geographically appropriate to the injured worker s medical condition and geographic location In the event that appropriate participating providers are not available City of DeLand Multi Line Claims Services or MME will refer the injured workers to an appropriate non participating provider or providers 24 Case Management MME agrees to perform case management through prospective and concurrent reviews for those cases that are referred for telephonic case management This will be accomplished through proprietary software and nurse case management review 25 Management and Employee Training To acquaint City of DeLand management and employees with MME managed care procedures and resources available through the managed care program MME will facilitate training sessions for the City of DeLand and will provided orientation materials MME will provide all City of DeLand injured workers with a handbook that explains City of DeLand managed care procedures 27 Administrative Procedures MME shall develop administrative procedures mutually acceptable to the parties for the delivery of services that are the subject of this agreement Page 2 of 10

5 28 Grievance and Appeals Program MME has developed grievance procedures in accordance with the requirements of Florida Statue and will handle all grievances presented to the Managed Care Arrangement in accordance with those procedures for those cases that been referred to telephonic case management 29 Duality Improvement Program MME agrees to provide and maintain a quality assurance program in accordance with standards and the requirements of Florida Statute including but not limited to provider profiling return to work outcomes by diagnosis training and education as needed for participating providers and all other activities necessary to maintain a quality assurance program ARTICLE III DUTIES OF CITY OF DELAND 31 Retention of Services City of Deland hereby retains MME to provide the services identified in this m agreement including workers compensation edical management and access to participating providers for the delivery of covered services City of DeLand agrees to use its best efforts to educate City of DeLand officers managers insurers and injured workers regarding the MME program including procedures for notification of injury and communication with MME case managers 32 Iniured worker Eligibility City of DeLand will provide all information reasonably necessary to allow MME to verify the eligibility of all persons seeking workers compensation health benefits and services through the MMECity of DeLand This paragraph shall not be construed to vest MME with responsibility for claims administration or compensability determinations 33 Notification of Iniury City of DeLand will report their claims to MME telephonically through the 24 hour call center City of DeLand will make available any information pertaining to cause of injury and the employee s physical condition MME will disseminate the notice of injury to MultiLine Claim Services and the City of DeLand Risk Management Department 34 Claims Administration City of DeLand Multi Line Claims Services shall be responsible for workers compensation claims administration including but not limited to compensability determinations processing of benefit payments claims investigation second injury fund claims and coordination of legal activity 35 Provider Payment City of DeLandMulti Line Claims Services shall be responsible for payment of all providers who render services to City of DeLand injured workers The parties warrant and acknowledge that this agreement shall not authorize or create a right of provider payment from or by MME 36 Compensation of MME Time For Payment City of DeLand shall compensate MME for the services in accordance with Schedule A to this agreement City of DeLand through Multi Line Claim Services will pay all MME invoices within 30 days of the date of receipt Page 3 of 10

6 ARTICLE IV RELATIONSHIP OF PARTIES 41 Aeenev and Independent Contractors MME acts as a non binding agent on behalf of Participating Providers solely with respect to describing the services to be provided by them under this Agreement City of DeLand agrees to hold such Participating Provider harmless in accordance with Paragraph V1 below for any acts and omissions committed by MME within the scope of this agency Similarly MME is not responsible and will not be held liable for claims which may arise from the provision of services to Participants by Participating Providers All other relationships created among the parties hereto shall be that of independent contractor and not employeeemployer or agent principal 42 ProviderPatient ProviderCity of DeLand Relationship The parties warrant and acknowledge that providers are exclusively responsible for the maintenance of the provider patient providercity of DeLand and hospitalpatient relationships with Participants and are solely responsible to such persons for all services they provide ARTICLE V INDEMNIFICATION 51 Hold Harmless City of DeLand agrees to indemnify and hold MME harmless against any and all claims judgments or liabilities that resulted from or may result from City of Deland its employees officers directors or agents negligence failure to act or criminal conduct in connection with or related to the terms of this Agreement The City of DeLand s responsibility to indemnify MME pursuant to any provision of this Agreement is limited to the same amounts as provided for in the limited waiver of sovereign immunity as set forth in Section Fla Stat and may be amended from time to time MME agrees to indemnify and hold City of DeLand Inc harmless against any and all claims judgments or liabilities that resulted from MME its employees officers directors or agents negligence failure to act or criminal conduct in connection with or related to the terms of this Agreement Neither City of DeLand nor MME shall be liable to the other for any claims judgments or liabilities that resulted from the negligence failure to act or criminal conduct of Participating Providers or their employees officers directors or agents ARTICLE VI TERM AND TERMINATION OF AGREEMENT 61 Term This Agreement shall remain in full force and effect for a term of two 2 years frain the date of this Agreement 62 Termination for Breach This Agreement may be terminated by either party if the other party is in default of or breaches any of the terms covenants or provisions contained herein and upon demand the breaching party fails to cure its default or breach of this Agreement The time period for curing the default or breach shall be 30 days Page 4 of 10

7 63 Termination Without Cause MME or City of DeLand may terminate this agreement without cause by written notice to the other to that effect specifying the effective date of termination which sliall be not less than sixty days after the date such notice is given 64 Insolvency if City of DeLand files in any court of competent jurisdiction a petition in bankruptcy or a petition for protection against creditors or files an assignment in favor of creditors or in any way evidences insolvency this Agreement may be terminated at the sole discretion of MME except that if City of DeLand files a petition for Chapter 11 reorganization MME agrees not to terminate this Agreement so long as City of DeLand Inc performs its obligations thereunder 65 Transfer of Records upon Termination In the event of termination of this Agreement TIME shall for a period up to thirty days after the effective date of termination take commercially reasonable steps and shall otherwise cooperate with City of DeLand and the party designated as City of DeLand s new provider of a workers compensation managed care agreement in facilitating the timely and orderly transfer of copies of pertinent records documents reports claim files investigation files billings in either electronic or hard copy format then held by MME and the timely and orderly transfer of MME s duties and responsibilities herein to said party Transfer of such materials information and duties shall be done in a manner intended to mitigate any adverse impact on claimants and City ol DeLand s compliance with workers compensation laws City of DeLand shall pay or reimburse MME for any costs and expenses incurred by MME in connection with this Section 65 that are beyond or in addition to MME s normal or ordinary costs and expenses City of DeLand recognizes and agrees that MME will need and shall be entitled to retain originals or copies of certain pertinent records ARTICLE VII CONFIDENTIALITY 71 Medical Records None of City of DeLand its designated representative or MME shall disseminate information in an employee s medical records to any third party without the consent of the employee in compliance with all applicable state and federal laws and regulations and subject to legal process City of DeLand and its designated representative and MME shall follow appropriate procedures to ensure that employee confidentiality rights are not abridged City of DeLand and MME obligations under this Section 71 shall survive the termination of this Agreement 72 Limited Disclosure Permitted Notwithstanding any other provision of this Agreement MME shall be authorized to disclose at its discretion the nature of its relationship with and services to City of DeLand in order to develop provider and other City of DeLand relationships ARTICLE VIII MISCELLANEOUS 81 Non exclusive Agreement The parties agree that MME is not precluded from entering into other agreements to provide the types of services set forth herein to any other entities persons or organizations Page 5 of 10

8 82 Additional Assurances The provisions of this Agreement are self operative and do riot require further agreement by the parties except as may be herein specifically provided to the contrary provided however at the request of either party the party requested shall execute additional instruments and take such additional acts as may be reasonably requested in order to effectuate this Agreement 83 Legal Fees and Costs In the event either party incurs legal expenses to enforce or interpret any provision of this Agreement the prevailing party will be entitled to recover such legal expenses including without limitation attorney s fees including any fees incurred on appeal costs and necessary disbursements in addition to any other relief to which such party may be entitled 84 Choice of Law and Venue Whereas MME s principal place of business and the location of the final act to effectuate this Agreement are in the State of Florida and the parties agree that this Agreement shall be governed by and construed in accordance with the laws of the State of Florida and venue for any litigation shall be Volusia County Florida 85 Force Maieure Neither party will be liable or deemed to be in default for any delay nor failure to perform this Agreement deemed to result directly or indirectly from Acts of God civil or military authority acts of public enemy war accidents fires explosions earthquake hurricane floods failure of transportation strikes or other work interruptions by either party s employees or any other cause beyond the reasonable control of either party 86 Time is of the EssenceNotice Time is of the essence in this Agreement Parties shall perform their obligations within the time specified 87 Severability In the event any provision of this Agreement is held invalid illegal or unenforceable for any reason and in any respect such invalidity illegality or unenforceability will in no event affect prejudice or disturb the validity of the remainder of this Agreement which shall be in full force and effect enforceable in accordance with its terns 8 lntes ration This Agreement represents the entire agreement between the parties and it supersedes all prior written and oral contracts which pertain to the services provided herein This Agreement does not preclude or supersede other agreements with MME its corporate parent or its affiliates for managed care or other services 89 Section and Paragraph Titles The use of section titles in this Agreement is for convenience only and same have no legal effect whatsoever in construing the provisions contained herein 810 Waiver The waiver of either party of a default breach or violation of one of the terms covenants or provisions of this Agreement shall not operate as or be construed to be a waiver of any subsequent default or breach of the same or other provision contained herein 811 Third Party Rights No rights in any third party are created by this Agreement and no person not a party to this Agreement may rely on any aspect of this Agreement notwithstanding any representation written or oral to the contrary 812 Notices Any notice required by this Agreement shall be sent bycertified mail return receipt requested Page 6 of 10

9 813 Warranties Each party hereby represents and warrants to the others that the person executing this Agreement on the former party s behalf has the authority and is authorized to enter into this Agreement on behalf of the legal entity named herein and that as applicable the entity has been duly organized and holds all requested licenses and permits in the state in which the entity is registered licensed or incorporated Further each party shall immediately notify the others of any change which materially affects the entity s registration license or incorporation Each party further represents to the others that this Agreement is the former party s valid and binding legal obligation enforceable against it in accordance with its terms and does not conflict with or violates any other binding obligation of such party In witness whereof the parties hereto have caused this Agreement to be executed in multiple originals by their duly authorized officers or as to City of Deland by a trustee duly authorized hereunto all as of the day and year stated above Managed Medical E uipment Inc City of DeLand B 1i B Y Y Its li iyc t1 t Its Print 641 Ey f Print Date Date ATTEST City Clerk Page 7 of 10

10 SCHEDULE A FINANCIAL AGREEMENT The City of DeLand agrees to pay MME for the services outlined in Schedule C based on the following fee schedule 1 First Report of Injury per call 2 Telephonic Case Management per claim 3 Network Access a Lost Time Claim per claim b Medical Only Claim per claim 4 Bill Review Services 750 per bill 5 The fee for other services will negotiated on a per need basis MME agrees to submit an itemized invoice for services rendered to Multi Line Claim Services broken down by claim by the 5i day of the month following the services rendered This amount is due within 15 days of receipt of the invoice Any Managed Care Arrangement MCA filing fee will be borne by City of DeLand Page 8 of 10

11 SCHEDULE B MME SERVICE AREA The Service Area includes the entire state of Florida Page 9 of 10

12 SCHEDULE C COVERED SERVICES MME will provide workers compensation managed care services through the Arrangement for compensable occupational injuries that are suffered by Injured Workers who on the date of injury are employed by City of DeLand and that occur and are reported on or after the inception of the Agreement and on or before the effective date of termination of this Agreement The following services will be provided I First Report of Injury 2 Telephonic Case Management 1 Provider Network Access 4 Provider Bill Review Services 5 Other services on per need basis as stated in Schedule A All injuries will be reported to ME via MME 24hour call center MultiLine Claim Services based on referral protocols that will be jointly developed by MME City of DeLand and MultiLine Claims Services will direct the assignment of telephonic case management Page 10 of 10