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.