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832 -CorVel Corp-Work CompWORKERS' COMPENSATION MANAGED CARE SERVICE AGREEMENT FOR The City of Sanford THIS AGREEMENT made and entered into effective 06/01/00 between CorVel Corporation whose principal offices are at Irvine, Califomia, hereinafter referred to as "CorVel" and The City of Sanford, herein referred to for the purpose of this agreement as "The City of Sanford" with principal offices located in Dunedin, Florida. WITNESSETH that WHEREAS CorVel operates a managed care business which provides First Report of Loss Preparation/Filing/Transmission services here'maf[er referred to as "First Report Services;" and Early Intervention Case Management services, hereinafter referred to as "Early Intervention;" Outpatient and Inpatient 'UtiliTation Review services, hereinafter referred to as "Uffiization Review;" medical audit and review services hereinafter referred to as "MedCheck;" and on-site medical case management and vocational rehabilitation services, hereinafter referred to as "Case Management;" and WHEREAS The City of Sanford desires to employ CorVel from time to time, to provide said services for the benefit of The City of Sanford and/or the benefit of its insureds and/or their injured employees; and WHEREAS CorVel desires to be so employed by The City of Sanford to provide said managed care services. NOW, THEREFORE, in consideration of the premises hereof; and the mutual promises and agreements made herein, the parties hereto, intending to be legally bound, hereby agree as follows: OBLIGATIONS OF CORVEL 1. FIRST REPORT/EARLY INTERVENTION SERVICES 1.1 The City of Sanford shall provide First Report services internally. 1.2 Cases identified during the First Report of Loss process as meeting the criteria for Early Intervention services, will be referred on a case by case basis at ISAC's direction for such services. The criteria for referral, i.e., lost time cases or other predefmed criteria, will be established by ISAC in consultation with CorVel and The City of Sanford. Direct referral from ISAC field offices for Early Intervention services involving cases that are not referred via the First Report of Loss service may also occur.' At the direction of ISAC, the Early Intervention service components for lost time claims include: 1. An initial contact with employee/employer to gather data for first report of injury preparation/submission (optional). 2. The channeling of patients to PPO network providers. 3. A multi-point (employee, employer, claims handler, prorider) contact to gather medical and treatment plan data. 4. A review of the provider treatment plan to determine medical appropriateness and set outpatient treatment parameters. 5. A CorVel RN Case Manager completes an assessment report with recommendations for submission to The City of Sanford within two weeks. These recommendations will outline the next course of action (e.g., medical management, utilization review, IME, vocational rehabilitation, etc.), if warranted. At the direction oflSAC, the Early Intervention service for med-only claims include: 1. Initial contact with employee/employer to gather data for first report of injury submission, if required. 2. Channel patient to PPO network. 3. Contact employee, and if necessary, the treating physician to gather sufficient information to determine potential for serious and/or lost time situations. 4. Confirm reed-only status or recommend additional intervention as required 1.7 All other aspects of CorVel's first report/early intervention services not addressed herein shall be provided in accordance with CorVel's service proposal and/or marketing materials. 2. UTILIZATION REVIEW SERVICES 2.1 CorVel shah provide utilization review services set forth herein to The City of Sanford on an non-exclusive basis upon receipt by CorVel of specific requests from The City of Sanford. During the term of this Agreement, The City of Sanford shall provide CoNel with instructions regarding the scope and extent of the utiliTation review services to be provided. 2.2 Aided by CorVel's proprietary outpatient medical treatment protocols and "Expert Systems" technology, our utiliTation review nurses evaluate proposed treatment plans for appropriateness, care setting, and duration of care. If treatment is "certified," the provider is advised of the length of treatment/number of visits that are being authorized. When utilized in conjunction with our MedCheck provider bill review program, actual treatment rendered is monitored on an ongoing basis to assure compliance with pre-authorized treatment. Services rendered which exceed established parameters are disallowed at the time the bill is reviewed for Fee Schedule or U&C compliance. The City of Sanford will be provided with a monthly out patient utilization review report which will document projected savings. 2.3 The CorVel pre-admission certification program is a review service which verities the medical necessity of proposed hospital admissions and determines the appropriate length of stay. The CorVel staff of utiliTation review nurses and reviewers, assisted by an automated medical rules/protocols system and backed up by physician consultants, individually evaluates every hospital admissions request. Pre-certification objectives include the following: determine appropriateness of proposed treatment plan. determine the medical necessity for hospital admission/inpatient care. explore alternatives to inpatient treatment. prevent unnecessary inpatient hospitalizations and save customer dollars. if inpatient care is required, determine the appropriate length of stay and monitor the patient's condition throughout the hospitalization to prevent unnecessary inpatient days. channel the patient to a CorVel PPO provider/facility. develop and implement a timely discharge plan. educate the employer and employees regarding physicians and services available, the claims process, and how utilization review is implemented so that good decisions regarding medical care and services can be made at the time of injury. Documentation of all utilization review activities in the form of written correspondence shall be communicated to the referring claim professional. A monthly savings summary that documents all inpatient and outpatient hospital admissions shall also be provided to The City of Sanford. 2.4 All other aspects of CorVel's utiliTation review services not addressed herein shall be provided in accordance with CorVel's service proposal and/or marketing materials. 3. MEDCHECK 3.1 Fee schedule bill review will be performed in-house at the third party administrators, ISAC. MedCheck shall provide hospital and medical bill audit/review services set forth herein to The City of Sanford on a non-exclusive basis upon receipt by MedCheck of specific requests from ISAC. During the term of this Agreement, ISAC shall provide MedCheck with a copy of the bill(s) to be audited, along with instructions regarding the scope and extent of the audit to be conducted by MedCheck. 3.2 The audit, if performed by MedCheck on-site at the local The City of Sanford branch claim office, shall be completed within 48 business hours from receipt by MedCheck, unless MedCheck requires additional time due to information deficiencies beyond its control. If service is provided on a mall-in basis, bills shall be processed and mailed to The City of Sanford within 3 to 5 days of receipt by MedCheck unless MedCheck requires additional time due to information deficiencies beyond its control 3.3 MedCheck will be responsible for monitoring and "flagging" duplicate billings of medical bills. Any bills previously audited will be retumed to The City of Sanford with a notation that the returned bill is a "duplicate" or has been previously submitted and/or audited. There will be no charge to The City of Sanford for total duplicate bills, however partial duplicates covering new dates of service are charged. 3.4 Any conflicts or complaints from medical providers concerning bill audits completed by MedCheck will be handled directly by MedCheck. All complaints will receive an initial response within 24 hours of receipt of the complaint by MedCheck. MedCheck will keep The City of Sanford apprised of any complaints it receives and the response thereto. MedCheck will send a written response to the complainant within five working days outlining the nature of the complaint and the resolution of same by MedCheek. A copy of this response will be sent to the attention of the designated The City of Sanford representative. The parameters of MedCheck's authority hereunder must be established in consultation with and subject to the express agreement of The City of Sanford. Further, The City of Sanford shall have the right, but not the obligation, at any time, to interject itself into the dispute between MedCheck and the service provider and to resolve the dispute in a manner acceptable to The City of Sanford at its sole discretion. 3.5 At all times, MedCheck will provide at a minimum, off-site, telephonic supervision for all of its personnel located on or within The City of Sanford claim operations. 3.5.1 MedCheck assumes responsibility for the activities of its employees and personnel while they are present at The City of Sanford's premises. The supervisory personnel provided by MedCheck shall have full authority over MedCheck personnel and shall be responsible for the activities of MedCheck personnel on the The City of Sanford premises. 3.5.2 MedCheck hereby agrees to indemnify and hold harmless The City of Sanford and its officers, directors, and employees from and against any and all losses, claims, damages, or expenses, including attomeys' fees, arising from injury caused by the negligence of employees of MedCheck on The City of Sanford's premises, including injuries suffered by MedCheck personnel which may occur on The City of Sanford's premises; provided however, that The City of Sanford shall not be held harmless pursuant to this section 3.5.6 for its gross negligence or willful misconduct or that of its employees or officers. 3.6 CorVel shall provide its Preferred Provider Networks as an integrated component of MedCheck for the benefit of The City of Sanford, its insureds and their employees during the term of this Agreement as outlined in MedCheck service descriptions. 3.7 In those jurisdictions where MedCheck cannot provide a suitable Preferred Provider Organization (PPO) to The City of Sanford, MedCheck shah make best efforts to accommodate an alternate PPO selected by The City of Sanford. The City of Sanford shall make best efforts to create the ability for MedCheck to integrate the provider identification and discount information into its bill review system. 3.8 As CorVel continues to expand its PPOs through the development of proprietary networks, The City of Sanford will be notified of their availability in writing and shall be provided immediate access to them, replacing the then-current PPO, if applicable. 3.9 3.10 3.11 4.2 In the case of hospital bills, CorVel shall pre-screen all bills to determine the need for audit. Pre-screening services shall be provided at no charge to The City of Sanford. PPO related hospital bills shall be pre-screened prior to PPO reprieing to determine the need for audit. Where applicable, CorVel shall provide the appropriate hospital bill audit services involving both PPO and non-PPO providers. CorVel agrees to supply ISAC, and no additional cost, and in accordance with ISAC's specifications, a transmission or tape reflecting the results of its bill review activities which would permit ISAC to automatically generate provider reimbursements. Such data shall be provided as to further allow for the application of MedCheck fees to the individual claim file, the preparation of insured specific savings reports and the reimbursement of MedCheck fees, or other applications at The City of Sanford's discretion. All other aspects of CorVel's bill review services not addressed herein, shall be provided in accordance with CorVel's service proposal and/or marketing materials. CASE MANAGEMENT CorVel shall provide medical case management and vocational rehabilitation services set forth herein to The City of Sanford on an non-exclusive basis upon receipt by CorVel of specific requests f~om The City of Sanford. CorVel defines case management as the establishment, coordination and control of the treatment, direction, support, and assistance given to the injured worker from the onset of injury through medical stability, to maximum medical improvement to retum to work. Actual case management services are dictated by both statutory and The City of Sanford requirements. The case management process will generally consist of the following steps: - Information gathering - Data validation/assessment - Plan development - Plan implementation - Plan follow through and outcome assessment - ongoing, timely reporting The following medical case management services may be'utiliTed: - (800) early referral/access systems - Patient assessment - Disability evaluation - Medical care coordination - Discharge planning - Catastrophic case management - Long term care assessment - Life care planning evaluations - Telephonic or on-site service delivery 4.3 Examples of the various services provided in vocational rehabilitation are listed below. These services are available on an unbundled or integrated basis as dictated by the requirement of each case and The City of Sanford preference. - Early return to work programs - Vocational assessments - Job analyses - Job-seeking skills trig - Job development - Job placement - Expert testimony - Labor market surveys - Automated transferable skills analyses - Vocational testimony - SSDI benefit procurement 4.4 All other aspects of CorVers case management services not addressed herein, shah be provided in accordance with CorVel's service proposal and/or marketing materials. 5. INSURANCE 5.1 CorVel, at its sole expense, agrees to maintain, at all times during the term of the Agreement, the required professional liability, errors and omissions, workers' compensation, general, and auto liability insurance coverages as set forth on the Certificates of Insurance attached hereto as Exhibits "C" and "D." The insurance policies in question shall provide that at least sixty (60) days prior written notice of cancellation, change, amendment. or exclusion in any of the insurance coverages required hereunder shall be given to The City of Sanford. 6. OBLIGATIONS OF The Ci~. of Sanford 6.1 The City of Sanford shah refer all inpatient and outpatient provider bills to ISAC. Bills will be provided on a daily basis to allow for timely processing by ISAC. 6.2 All PPO provider bills must be reviewed/repriced exclusively by ISAC. Failure to refer all PPO bills to CorVel for review/repricing (i.e. reprieing bills internally or referring non- PPO provider bills to an alternate PPO) will resttit in the immediate termination of all PPO discounting through CorVel. 6.3 All hospital bills shall be pre-screened by CorVel to determine the need for audit. Should The City of Sanford agree that an audit is applicable, The City of Sanford shall refer the bill to CorVel for such services. 6.4 The City of Sanford shall pay CorVel for services rendered within thirty (30) days of the date of receipt by The City of Sanford of an invoice from CorVel. CorVel charges for such services are as set forth on Exhibits "A" attached hereto. CorVel may amend such charges subject to discussion with and approval of The City of Sanford upon thirty (30) days written notice. Such charges may only be revised once during each twelve month period which is to begin 10/01/00. Payments not received within the thirty (30) day time frame indicated shall be subject to interest at a rate equal to prime plus 2%. Interest shall accrue through the actual date of payment. 6.5 The City of Sanford, at its sole expense, agrees to keep in force comprehensive general liability insurance and professional liability insurance for the term of this Agreement. Upon request by CorVel, The City of Sanford shall furnish CoWel with a certificate of such insurance. It is agreed that The City of Sanford shall be deemed in compliance with this Section 6.5 by being self-insured. 7. TERM AND TERMINATION 7.1 The term of this Agreement is initially from June 1, 2000 to September 30, 2001, thereafter two subsequent one (1) year renewals at The City of Sanford's option. 7.2 This Agreement may be terminated without cause by CorVel or The City of Sanford upon ninety (90) days written notice any time after the expiration of the initial two year term. 7.3 This agreement can be terminated by CorVel or The City of Sanford for cause upon sixty (60) days written notice, i.e. if either party materially breaches this Agreement or fails to abide by its obligations hereunder, and such breach continues for thirty (30) days from the date written notice is given to the breaching party specifying the nature of the breach. 8. MISCELLANEOUS 8.1 CorVel, at all times hereunder, is acting as an independent contractor. Personnel supplied by CorVel shall be employees of CorVel and will not be for any purpose employees or agents of The City of Sanford. CorVel assumes full responsibility for the actions of such personnel while performing services pursuant to this Agreement and shall be solely responsible for the payment of salaries, wages, and benefits. 8.2 Each party agrees to hold in confidence any information obtained by it relating to the business of the other and agrees to instruct its agents, employees, representatives, and independent contractors to keep all such information strictly confidential. Each party agrees that it will not directly or indirectly disclose, communicate, divulge, furnish to, or use for the benefit of itself, or any other person, firm or corporation, any of the trade secrets, designs, improvements, inventions, data, information, how-how, or other things belonging to the other, or the designs, ideas or processes of manufacture of any product or article sold or distributed or any service provided by the other which may be communicated to it or which it may learn by virtue of its activities under this Agreement. 8.3 During the term of this Agreement and for a three-year period after the termination of this Agreement, The City of Sanford shall be entitled to conduct an audit of CorVel/MedCheck files related to The City of Sanford accounts. CorVel/MedCheck will make its files available for audit by The City of Sanford for a one-week period each calendar year. The City of Sanford will give CorVel/MedCheck at least thirty (30) days written notice of intent to perform the audit. The audit will be conducted a the local The City of Sanford office by The City of Sanford personnel and/or any independent contractor or representative The City of Sanford chooses to employ for audit purposes. CorVel/MedCheck will make any and all The City of Sanford files available for audit. 8.4 In the event of invalidity of any provision of this Agreement, the parties agree that such invalidity shall not affect the validity of the remaining provisions of this Agreement. 8.5 Tills Agreement contains the entire contract between the parties, as to the subject matters hereto, and may not be waived, altered, or modified except by written agreement of the parties. Any interpretation of this contract shah be governed by (Insert Prospect Headquarter State) statutes and laws. IN WITNESS WHEREOF, CorVel and The City of Sanford have caused this Agreement to be executed by the persons authorized to act in their respective names. The City of Sanford B Y: ~~-~ TITLE:/~1/)//Pl/[~'/e6't~ DATE SIGNED: ~,/q4'/~'~" CORVEL CORPORATION Account Executive DATE SIGNED:?,//~ CorVel Corporation FEES FOR SERVICES For The City of Sanford Effective Date: 06/01/00 1. CorCare PPO Access Fee 23% of PPO savings * Capitated Rate Available Upon Request (This fee is applicable in addition to per claim or flatJ~e structure) * CorVel welcomes the opportunity to discuss a capitated fee for network access. Additional information is necessary for this type of proposed fee structure. 2. Early Intervention - Per Claim Pricing * Optional: Annual Flat Rate Pricing is Available Lost Time Cases $280/case / 30 days Multi-point (employee, employer, ISAC adjuster, provider) contact to gather and communicate treatment plan data. Review provider treatment plan assisted by automated software system to determine appropriateness of plan. Make recommendations to assist in the determination of the next course of action (e.g., case management, IME, vocational rehabilitation, etc.) to complete the early intervention phase. Enter medical notes / recommended treatment into the ISAC claims system. Medical Only Cases $100/case / 30 days Contact employer / employee to gather sufficient information to determine potential for serious and/or lost time situations. Confn'm reed only status or recommend additional intervention if necessary. Review treatment plan and determine appropriateness of medical care. 3.Utilization Review Services Include: Pre-Admission Review, Concurrent Stay Review and Discharge Planning $130.00/case 4. Medical Case Management Telephonic - hourly fee * Flat Rate Available Upon Request On-Site - hourly fee $68.00/hour $68.00 L33 per mile (mileage prorated whenever possible) 5. Vocational Rehabilitation Services $68.00 per hour .33 per mile (mileage prorated whenever possible) 6. First Notice of Loss * Includes state submission $25/FNOL 7. Peer Review / IMEs $175 + Physician fee 8. Medical Bill Review/Fee Schedule * Includes sendbacks, duplicates and provider inquiries 9. Nurse Review $1.25/line (no line rain) $67/hour * It is understood that First Notice of Injury will be handled in-house by The City of Sanfont MediCal Bill Review will be provided by ISAC; therefore, eliminating any per line charg~ Our CorVei PPO networh discounts are already downloaded into the lSAC fee schedule bill review systent The I~,4 C claims system will be utilized, thereby eliminating any online computer linMng costs. For basic AHCA compliance, The City of Sanford may elect our PPO lease at 23% of savings, which will include PPO and CorCare channeling, grievances, quality assurance, educational materials, provider recruitment and provider credentialing. All other services listed may be elected as optional items.