R12-125 i
1 RESOLUTION NO. R12 -125
2
3
4 A RESOLUTION OF THE CITY COMMISSION OF
5 BOYNTON BEACH, FLORIDA, APPROVING THREE -
6 YEAR AGREEMENTS FOR PROFESSIONAL
7 SERVICES FOR THIRD PARTY ADMINISTRATION
8 FOR WORKERS COMPENSATION CLAIMS WITH
9 COMMERCIAL RISK MANAGEMENT, INC., AND AN
10 AGREEMENT FOR PROFESSIONAL SERVICES FOR
11 ADJUSTER SERVICES FOR PROPERTY AND
12 CASUALTY CLAIMS WITH GALLAGHER BASSETT
13 SERVICES, INC.,; AUTHORIZING THE INTERIM CITY
14 MANAGER AND CITY CLERK TO EXECUTE SAID
15 AGREEMENTS; AND PROVIDING AN EFFECTIVE
16 DATE.
17
18
19 WHEREAS, a Request for Proposals was issued on October 18, 2012 and responses
20 were opened by Procurement on November 8, 2012; and
21 WHEREAS, a review committee was established and has analyzed and is
22 recommending three year Agreements for Third Party Administrator services for Workers'
23 Compensation (WC) claims with Commercial Risk Management, Inc., and Adjuster Services
24 for Property and Casualty claims with Gallagher Bassett Services, Inc; and
25 WHEREAS, the City Commission of the City of Boynton Beach deems it in the best
26 interest, health, safety and welfare of the citizens and residents of Boynton Beach to enter into
27 three -year Agreements for Professional Services for Third Party Administration for Workers'
28 Compensation with Commercial Risk Management, Inc., and Adjuster Services for Property
29 and Casualty Claims with Gallagher Bassett Services, Inc.
30 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF
31 THE CITY OF BOYNTON BEACH, FLORIDA, THAT:
32 Section 1. Each Whereas clause set forth above is true and correct and
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1 incorporated herein by this reference.
2 Section 2. The City Commission of the City of Boynton Beach, Florida hereby
3 approves and authorizes the Interim City Manager and City Clerk to execute three -year
4 Agreements for Professional Services for Third Party Administration for Workers'
5 Compensation with Commercial Risk Management, Inc., and Adjuster Services for Property
6 and Casualty Claims with Gallagher Bassett Services, Inc, a copy of said Agreements are
7 attached hereto as Exhibits "A" and "B" respectively.
8 Section 3. That this Resolution shall become effective immediately upon passage.
9 PASSED AND ADOPTED this 4 day of December, 2012.
10 CITY • F BOYNTON BEACH, FLORIDA
11
12 4IP ' dor i..,
13 Mayo • . • ow �
14
15
16 ice Mayor — ; cCray
17
18
19 Com ��. <. ione
20
21 / /<iJ
22 Commission- ; — St -NT- olz an
23
24
25 ommissioner — Marlene Ross
26 ATTEST:
27
28
29 e.
30 or M. Prainito, MMC
31 Clerk
32 GX T Y :O
33
34 A o t` eal) ,
35 �
36 r� ,, \RESQ greement tJ: • - 3rd Party Admin Workers Comp and PC doc
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AGREEMENT FOR PROFESSIONAL SERVICES
FOR
ADJUSTER SERVICES FOR PROPERTY AND CASUALTY CLAIMS
THIS AGREEMENT is entered into between the City of Boynton Beach, hereinafter referred to
as "the City ", and GALLAGHER BASSETT SERVICES, INC., hereinafter referred to as "the
Adjuster ", in consideration of the mutual benefits, terms, and conditions hereinafter specified.
1. PROJECT DESIGNATION. The ADJUSTER is retained by the City to perform SERVICES
in connection with the RFP For A Three Year Contract Third Party Administration for
Workers' Compensation and Adjuster Services for Property and Casualty.
2. SCOPE OF SERVICES. ADJUSTER agrees to perform the services, identified on Exhibit
"A" attached hereto and incorporated herein by reference, including the provision of all labor,
materials, equipment and supplies. No modifications will be made to the original scope of
work without the written approval of the City Manager or his designee.
3 TIME FOR PERFORMANCE Work under this Agreement shall commence upon the giving
of written notice by the City to the ADJUSTER to proceed. ADJUSTER shall perform all
services and provide all work product required pursuant to this Agreement effective January
1, 2013.
4. TERM. This Agreement shall be for a period of three (3) years commencing January 1,
2013, with optional renewals for three (3) one -year terms at the discretion of the City and
based on mutually agreed upon rates
5 PAYMENT The ADJUSTER shall be paid by the Provider /City for completed work and for
services rendered under this Agreement in accordance with Exhibit "B" Compensation for
Services
a. Payment for the work provided by ADJUSTER shall be made promptly on all invoices
submitted to the City properly, provided that the total amount of payment to ADJUSTER
shall not exceed the total contract price without express written modification of the
Agreement signed by the City Manager or designee.
b. The ADJUSTER may submit invoices to the City once per month during the progress of
the work for partial payment. Such invoices will be checked by the City, and upon approval
thereof, payment will be made to the ADJUSTER in the amount approved
c The ADJUSTER'S records and accounts pertaining to this Agreement are to be kept
available for inspection by representatives of the City and State for a period of three (3)
years after the termination of the Agreement. Copies shall be made available upon request.
i
6. OWNERSHIP AND USE OF DOCUMENTS. All documents, drawings, specifications and
other materials produced by the ADJUSTER in connection with the services rendered under
this agreement shall be the property of the City whether the project for which they are made
is executed or not. The ADJUSTER shall be permitted to retain copies, including
reproducible copies, of drawings and specifications for information, reference and use in
connection with ADJUSTER'S endeavors
7. COMPLIANCE WITH LAWS ADJUSTER shall, in performing the services contemplated by
this Agreement, faithfully observe and comply with all federal, state and local laws,
ordinances and regulations that are applicable to the services to be rendered under this
agreement
8 INDEMNIFICATION ADJUSTER shall indemnify, defend and hold harmless the City, its
offices, agents and employees, from and against any and all claims, losses or liability, or
any portion thereof, including attorneys fees and costs, arising from injury or death to
persons, including injuries, sickness, disease or death to ADJUSTER'S own employees, or
damage to property occasioned by a negligent act, omission or failure of the ADJUSTER
9 INSURANCE. The ADJUSTER shall secure and maintain in force throughout the duration of
this contract comprehensive general liability insurance with a minimum coverage of
$1,000,000 per occurrence and $1,000,000 aggregate for personal injury; and $1,000,000
per occurrence /aggregate for property damage, and professional liability insurance in the
amount of $1,000,000 per occurrence to $2,000 000 aggregate with defense costs in
addition to limits
Said general liability policy shall name the City of Boynton Beach as an additional named
insured and shall include a provision prohibiting cancellation of said policy except upon thirty
(30) days prior written notice to the City Certificates of coverage as required by this section
shall be delivered to the City within fifteen (15) days of execution of this agreement
10. INDEPENDENT CONTRACTOR The ADJUSTER and the City agree that the ADJUSTER
is an independent contractor with respect to the services provided pursuant to this
Agreement. Nothing in this Agreement shall be considered to create the relationship of
employer and employee between the parties hereto Neither ADJUSTER nor any employee
of ADJUSTER shall be entitled to any benefits accorded City employees by virtue of the
services provided under this Agreement The City shall not be responsible for withholding or
otherwise deducting federal income tax or Social Security or for contributing to the state
industrial insurance program, otherwise assuming the duties of an employer with respect to
ADJUSTER, or any employee of ADJUSTER
11 COVENANT AGAINST CONTINGENT FEES The ADJUSTER warrants that he has not
employed or retained any company or person, other than a bona fide employee working
solely for the ADJUSTER, to solicit or secure this contract, and that he has not paid or
agreed to pay any company or person, other than a bona fide employee working solely for
the ADJUSTER, any fee, commission, percentage, brokerage fee, gifts, or any other
consideration contingent upon or resulting from the award or making of this contract
For breach or violation of this warranty, the City shall have the right to annul this contract
without liability or, in its discretion to deduct from the contract price or consideration, or
otherwise recover, the full amount of such fee, commission, percentage, brokerage fee, gift,
or contingent fee
11
12 DISCRIMINATION PROHIBITED. The ADJUSTER, with regard to the work performed by it
under this agreement, will not discriminate on the grounds of race, color, national origin,
religion, creed, age, sex or the presence of any physical or sensory handicap in the
selection and retention of employees or procurement of materials or supplies
13 ASSIGNMENT. The ADJUSTER shall not sublet or assign any of the services covered by
this Agreement without the express written consent of the City.
14. NON - WAIVER. Waiver by the City of any provision of this Agreement or any time
limitation provided for in this Agreement shall not constitute a waiver of any other
provision.
15. TERMINATION.
a The City reserves the right to terminate this Agreement at any time by giving thirty
(30) days written notice to the ADJUSTER
b In the event of the death of a member, partner or officer of the ADJUSTER, or any of its
supervisory personnel assigned to the project, the surviving members of the ADJUSTER
hereby agree to complete the work under the terms of this Agreement, if requested to do
so by the City. This section shall not be a bar to renegotiations of this Agreement
between surviving members of the ADJUSTER and the City, if the City so chooses
16 DISPUTES. Any disputes that arise between the parties with respect to the performance of
this Agreement, which cannot be resolved through negotiations, shall be submitted to a
court of competent jurisdiction in Palm Beach County, Florida. This Agreement shall be
construed under Florida Law.
17 NOTICES Notices to the City of Boynton Beach shall be sent to the following address
Lori LaVerriere, Interim City Manager
City of Boynton Beach
P.O Box 310
Boynton Beach, FL 33425 -0310
Notices to ADJUSTER shall be sent to the following address
Gallagher Bassett Services, Inc
5405 Cypress Center Drive
Suite 205
Tampa, FL 33609 -1052
ATTN Don Navin
111
INTEGRATED AGREEMENT This Agreement, together with attachments or
addenda, represents the entire and integrated Agreement between the City and the
ADJUSTER and supersedes all prior negotiations, representations, or Agreements written or
oral. This Agreement may be amended only by written instrument signed by both City and
ADJUSTER
CITY OF BOYNTON BEACH
Date
By. City Manager NAME OF COMPANY
Attest /Authenticated
By (Signature)
Name
City Clerk
Date
Approved as to Form: (Corporate Seal)
City Attorney Attest /Authenticated
Corporate Secretary
iv
Oct. 23. 2012 5:26PM GALLAGHER BASSETT SERVICES No,5359 P. 4/4
INTEGRATED AGREEMENT. This Agreement, together with attachments or
addenda, represents the entire and integrated Agreement between the City and the TPA
and supersedes all prior negotiations, representations, or Agreements written or oral. This
Agreement may be amended only by written instrument signed by both City and TPA.
CITY OF BOYNTON BEACH:
D D/
Date
6411 61 . 'i �c�� ,,T,tC .
B . Ci Manager NAME OF COMPANY
G` I 0
Attest/Authenticated: V
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, y (figtu re)
�� , ( ) , N'' Name
erk
L∎titty'2,
Date
Approved as to Form (Corporate Seal)
City Atto'ney Attest/Authenticated:
Co , orate Secretary
iv
EXHIBIT "A"
SCOPE OF SERVICES
A. PROPERTY & CASUALTY CLAIMS ADJUSTING AND INVESTIGATING SERVICES
A.1. LIABILITY DEFINITIONS
Claim: Any report of an accident (first or third party) alleging or resulting in injury,
damage, or Toss which could give rise to a demand for the payment of money The claim
charge is applicable on a per occurrence, per claimant, per line of coverage basis
Discretionary Settlement: The Adjusting Service is not authorized to make payment,
for loss or expense, without the prior approval of the Risk Manager of the City of
Boynton Beach
Qualified claim or Toss: The Adjusting Service shall investigate and adjust any loss or
claim reported within the service term, provided the loss or claim type is identified
Allocated expenses: Will be the responsibility of the City of Boynton Beach and
include, but not be limited to.
• legal fees
• professional photographs
• medical record
• experts' rehabilitation costs
• accident reconstruction
• architects, contractors
• engineers
• police, fire, coroner, weather, or other such reports
• property damage appraisals
• extraordinary costs for witness statements
• official documents and transcripts sub rosa investigations
• medical examinations
• extraordinary travel made at City of Boynton Beach's request
• court reporters
• fees for service of process
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• pre -and post - judgment interest paid
• chemists
• 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 City of Boynton Beach
A.2. LIABILITY PROPOSER'S RESPONSIBILITIES
The Adjusting Service shall perform the following services
1 Review each claim and loss report submitted by the City of Boynton Beach during
the term of this Contract.
2. Assign a qualified, experienced, Florida licensed adjuster within 24 hours of receipt
of claim
3 Contact claimant within 48 hours of assignment of claim
4 Conduct an investigation of each qualified claim or loss to the extent deemed
necessary by the Adjusting Service.
5 Maintain a file for each qualified claim or loss which shall be available for review by
the City of Boynton Beach.
6 Adjust, settle or resist all qualified claims or losses with the specific approval of the
City of Boynton Beach
7 Perform necessary and customary administrative and clerical work in connection
with each qualified claim or loss, including the preparation of checks or vouchers,
releases, agreements and other documents to finalize a claim.
8. Establish and update claim reserves as needed.
9 Notify City of Boynton Beach, City of Boynton Beach agent or excess insurer(s), as
designated by the City of Boynton Beach, of all qualified claims or losses which
may exceed the City of Boynton Beach retention and, if requested, provide
information on the status of those claims or losses
10. Coordinate investigations on litigated claims with attorneys representing the City of
Boynton Beach and with representatives of the excess carrier, as required. It is
expressly understood that all legal costs and loss payment will be charged to the
City of Boynton Beach
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11. Have internal product support staff review large and unusual claims at no
additional cost to the City of Boynton Beach, unless specified
12. Maintain an automated loss and information system, and provide the City of
Boynton Beach with electronic access to claim reports.
13. Assist the City of Boynton Beach in selecting appropriate experts or specialists as
the claims may require
14 Provide personnel needed to perform the services agreed to herein
15 Maintain a comprehensive database of all claims reported. This data shall belong
to the CITY OF BOYNTON BEACH and shall be made available to the CITY OF
BOYNTON BEACH at any time. Upon termination of the Contract, the TPA shall
provide the CITY OF BOYNTON BEACH with an electronic copy of the data in
ASCII format.
A.3. RISK MANAGEMENT SOFTWARE / REPORTING:
1 The Adjusting Service is required to provide monthly and annual summaries of claims
by type of risk and should recap each year's experience, including prior years, to
date The reports shall be on a fiscal year basis (October 1st - September 30th) in
an acceptable format to City of Boynton Beach, and shall be prepared in accordance
with the provisions below:
a Claims Experience Reports should be provided within 15 days of the end of the
period for which each report applies
b. Adjusting Service shall provide a report of accounts for aggregate Toss
experience analysis.
c. City of Boynton Beach requires the ability to provide a breakdown of
experience for each department Supplemental claims documentation should provide,
in plain English, sufficient information to indicate what happened, to whom or what
and how much has been paid or is expected to be paid.
2 Online and real time access to the administrator's claim system, including all
adjuster's notes is viewed as critical by the City of Boynton Beach Adjusting Service
to have a software product that is able to allow the City of Boynton Beach's ability to
access the administrator's automated claim files to include adjuster's notes,
payments, claim notes, Imaging of invoices and messaging capabilities
3 OSHA reporting capabilities should include the ability to separate OSHA reportable
claims from Record Only claims
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4. Adjusting Service to have staff available that can create Reports when requested by
the City
A.4. CITY OF BOYNTON BEACH CONTROL:
1 City of Boynton Beach reserves the right to direct the Adjusting Service regarding
settlement of all claims.
2 Legal Services The City of Boynton Beach reserves the right to assign legal counsel to
all claims
3 City of Boynton Beach shall have the right to inspect or audit the files, including
the right to utilize an outside auditor for these functions on City of Boynton
Beach's behalf. It is the preference of City of Boynton Beach for the files to be
electronically stored with access provided to City of Boynton Beach of all stored
document images, faxes, incoming email attachments, and all documents generated by
the Claims Management System.
4 Claims Records as Property of City of Boynton Beach
All claims files and other records, documents, lists, supplies, etc , pertaining to claims
are the property of City of Boynton Beach and will be delivered to City of
Boynton Beach upon contract termination with no additional fee to the City
B. MEDICARE REPORTING SERVICES
Upon designation as City's Medicare Agent, the ADJUSTER shall provide the City
assistance with updating the Medicare Agent status within the statutory timeframes
required by the Centers for Medicare & Medicaid Services (CMS) under the Affordable
Care Act
As the City's designated Medicare Agent, the ADJUSTER will initiate a test file interface
with CMS within the statutory timeframes required by CMS.
Upon successful completion of the test file interface, the ADJUSTER will commence an
ongoing monthly query process on behalf of the City of Boynton Beach where the
ADJUSTER will transmit through the CMS Query Tool certain basic claims data
elements (claimant name, social security number, date of birth, and gender) on all of
City's open medical claims for CMS to determine if such claim data elements match a
valid CMS record indicating Medicare eligibility The ADJUSTER Service will report the
results of such query on Adjusting Service data system for claims staff to review
Once it is determined through the CMS Query Tool that a claimant is Medicare eligible,
the Adjusting Service will commence the transmission of mandatory quarterly electronic
claims reporting of those claimants to the Claims Administrator (CA) on the City's behalf
within the specific 7 day reporting period assigned to the City by CMS The CA will
confirm either acceptance of the Medicare eligible claims thus reported or return any
files for which data is missing or incorrect The Adjusting Service shall post on Adjusting
Service data system any error reports from the CA showing such files containing missing
or incorrect data for the Adjusting Service claims staff to research and correct directly on
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the Adjusting Service data system Once corrected, the TPA/Adjusting Service will
resubmit such files to the CA during the next quarterly reporting file
The Adjusting Service, as City's designated Medicare Agent, will continue to
electronically transmit to the CA on a quarterly basis all new and updated claims
identified through the CMS Query Tool as City's Medicare eligible claims.
The Adjusting Service, as City's designated Medicare Agent, will also electronically
transmit to the CA any monetary settlement data received from CITY on City's Medicare
eligible claims
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EXHIBIT "B"
SCHEDULE OF FEES
VI
R►a - fq5
AGREEMENT FOR PROFESSIONAL SERVICES
FOR
THIRD PARTY ADMINISTRATION FOR WORKERS' COMPENSATION
THIS AGREEMENT is entered into between the City of Boynton Beach, hereinafter referred to
as "the City ", and COMMERCIAL RISK MANAGEMENT, hereinafter referred to as the "TPA" in
consideration of the mutual benefits, terms, and conditions hereinafter specified.
1. PROJECT DESIGNATION The TPA is retained by the City to perform SERVICES in
connection with the RFP For A Three Year Contract Third Party Administration for
Workers' Compensation and Adjuster Services for Property and Casualty.
2. SCOPE OF SERVICES TPA agrees to perform the services, identified on Exhibit "A"
attached hereto and incorporated herein by reference, including the provision of all labor,
materials, equipment and supplies No modifications will be made to the original scope of
work without the written approval of the City Manager or his designee.
3. TIME FOR PERFORMANCE. Work under this Agreement shall commence upon the giving
of written notice by the City to the TPA to proceed TPA shall perform all services and
provide all work product required pursuant to this Agreement effective January 1, 2013
4 TERM This Agreement shall be for a period of three (3) years commencing January 1,
2013, with optional renewals for three (3) one -year terms at the discretion of the City and
based on mutually agreed upon rates
5. PAYMENT. The TPA shall be paid by the Provider /City for completed work and for services
rendered under this Agreement in accordance with Exhibit "B" Compensation for Services.
a. Payment for the work provided by TPA shall be made promptly on all invoices submitted
to the City properly, provided that the total amount of payment to TPA shall not exceed the
total contract price without express written modification of the Agreement signed by the City
Manager or designee
b The TPA may submit invoices to the City once per month during the progress of the work
for partial payment. Such invoices will be checked by the City, and upon approval thereof,
payment will be made to the TPA in the amount approved.
c The TPA's records and accounts pertaining to this Agreement are to be kept available for
inspection by representatives of the City and State for a period of three (3) years after the
termination of the Agreement Copies shall be made available upon request
i
6 OWNERSHIP AND USE OF DOCUMENTS All documents, drawings, specifications and
other materials produced by the TPA in connection with the services rendered under this
agreement shall be the property of the City whether the project for which they are made is
executed or not. The TPA shall be permitted to retain copies, including reproducible copies,
of drawings and specifications for information, reference and use in connection with TPA's
endeavors
7 COMPLIANCE WITH LAWS. TPA shall, in performing the services contemplated by this
Agreement, faithfully observe and comply with all federal, state and local laws, ordinances
and regulations that are applicable to the services to be rendered under this agreement.
8 INDEMNIFICATION. TPA shall indemnify, defend and hold harmless the City, its offices,
agents and employees, from and against any and all claims, losses or liability, or any portion
thereof, including attorneys fees and costs, arising from injury or death to persons, including
injuries, sickness, disease or death to TPA's own employees, or damage to property
occasioned by a negligent act, omission or failure of the TPA
9 INSURANCE The TPA shall secure and maintain in force throughout the duration of this
contract comprehensive general liability insurance with a minimum coverage of $1,000,000
per occurrence and $1,000,000 aggregate for personal injury, and $1,000,000 per
occurrence /aggregate for property damage, and professional liability insurance in the
amount of $1,000,000 per occurrence to $2,000.000 aggregate with defense costs in
addition to limits.
Said general liability policy shall name the City of Boynton Beach as an additional named
insured and shall include a provision prohibiting cancellation of said policy except upon thirty
(30) days pnor written notice to the City. Certificates of coverage as required by this section
shall be delivered to the City within fifteen (15) days of execution of this agreement
10 INDEPENDENT CONTRACTOR The TPA and the City agree that the TPA is an
independent contractor with respect to the services provided pursuant to this Agreement.
Nothing in this Agreement shall be considered to create the relationship of employer and
employee between the parties hereto Neither TPA nor any employee of TPA shall be
entitled to any benefits accorded City employees by virtue of the services provided under
this Agreement The City shall not be responsible for withholding or otherwise deducting
federal income tax or Social Security or for contributing to the state industrial insurance
program, otherwise assuming the duties of an employer with respect to TPA, or any
employee of TPA
11 COVENANT AGAINST CONTINGENT FEES The TPA warrants that he has not employed
or retained any company or person, other than a bona fide employee working solely for the
TPA, to solicit or secure this contract, and that he has not paid or agreed to pay any
company or person, other than a bona fide employee working solely for the TPA, any fee,
commission, percentage, brokerage fee, gifts, or any other consideration contingent upon or
resulting from the award or making of this contract
For breach or violation of this warranty, the City shall have the right to annul this contract
without liability or, in its discretion to deduct from the contract price or consideration, or
otherwise recover, the full amount of such fee, commission, percentage, brokerage fee, gift,
or contingent fee
11
12 DISCRIMINATION PROHIBITED The TPA, with regard to the work performed by it under
this agreement, will not discriminate on the grounds of race, color, national origin, religion,
creed, age, sex or the presence of any physical or sensory handicap in the selection and
retention of employees or procurement of materials or supplies
13. ASSIGNMENT The TPA shall not sublet or assign any of the services covered by this
Agreement without the express written consent of the City
14 NON - WAIVER. Waiver by the City of any provision of this Agreement or any time
limitation provided for in this Agreement shall not constitute a waiver of any other
provision.
15 TERMINATION
a. The City reserves the right to terminate this Agreement at any time by giving thirty
(30) days written notice to the TPA.
b. In the event of the death of a member, partner or officer of the TPA, or any of its
supervisory personnel assigned to the project, the surviving members of the TPA hereby
agree to complete the work under the terms of this Agreement, if requested to do so by
the City. This section shall not be a bar to renegotiations of this Agreement between
surviving members of the TPA and the City, if the City so chooses
16 DISPUTES Any disputes that arise between the parties with respect to the performance of
this Agreement, which cannot be resolved through negotiations, shall be submitted to a
court of competent jurisdiction in Palm Beach County, Florida. This Agreement shall be
construed under Florida Law.
17 NOTICES. Notices to the City of Boynton Beach shall be sent to the following address
Lori LaVerriere, Interim City Manager
City of Boynton Beach
P O. Box 310
Boynton Beach, FL 33425 -0310
Notices to TPA shall be sent to the following address
Commercial Risk Management
P O Box 18366
Tampa, FL 33679
ATTN Susan E Theis
ill
INTEGRATED AGREEMENT This Agreement, together with attachments or
addenda, represents the entire and integrated Agreement between the City and the TPA
and supersedes all prior negotiations, representations, or Agreements written or oral. This
Agreement may be amended only by written instrument signed by both City and TPA
CITY OF BOYNTON BEACH:
Date
A w vo ._ Cocrmercial Risk Management, Inc.
By City Manager 0` 1 Y NAME OF COMPANY
Attest/Authenticated: X ' +
/
151 U ~ %�
:y Signature)
Wl . 4 /1-01,4 Susan E. Theis
IG• Name
City lerk
January 8, 2013
Date
Approved as to Form (Corporate Seal)
_X ,
-- 7 4 "/
b./
City Attorney Attest /Authenticated:
„, ik
Corporate Secretary
iv
EXHIBIT "A"
SCOPE OF SERVICES
A. WORKERS COMPENSATION CLAIMS ADJUSTING AND INVESTIGATION SERVICES
Upon receipt or notice of all workers' compensation claims, the TPA, on behalf of the City, will
perform the following services
1 The City requires that the TPA hire and retain competent, qualified, experienced,
licensed in Florida professionals to handle their claims The City requires that
specific adjusters be assigned to their account. These adjusters should be
assigned only workers' compensation claims
2 The City requires the TPA to keep the overall number of cases an adjuster would
handle to a reasonable number based on the industry standard of 150 -200 Medical
Only and 100 -150 Lost Time cases
3 The Adjuster would be responsible for obtaining recorded statements from the
claimant and any witnesses if the Claims Administrator requests that it be done
The City will maintain contact with the employee at all times to assist the
employee in returning to work. The adjuster and /or telephonic nurse case
manager and /or field case manager will make doctor's appointments, therapy
appointments, etc., in those cases where the employee has reached MMI and
is in litigation.
4. The TPA will be responsible for filing all the appropriate forms with the State
(DWC1, etc )
5 The TPA is responsible for ensuring compliance with all reporting requirements by
regulatory agencies including but not limited to Medicare Secondary Reporting Act
of 2007 and all subsequent revisions
6 The TPA will assist the City with any written correspondence that the City requests
them to send to the injured worker or medical provider regarding the benefits
7 The TPA will accept or deny all reported claims for employees' injuries on behalf of
the City in accordance with the applicable Workers' Compensation Statutes The
decision to controvert a claim must first be discussed with and approved by the
City
4
8 All lost time claimant's checks will be issued by the TPA on a weekly basis from the
City of Boynton Beach fund The verification of any checks for wage loss must be
received by the City before 5.00 P M on the Tuesday of a City payroll week
9 Currently, the City requires that all medical or ancillary service providers submit
their bills to the TPA bill review unit for processing and payment. All provider
Payments will be reviewed weekly by the City via the weekly TPA check register
before the provider checks can be released
10 The City will be responsible for employing any outside vendors such as
surveillance companies and field case management experts to assist in the
investigation and medical coordination of claims Payment of the bills will be made
by the TPA from the loss fund as an allocated expense but not without prior
approval by the City.
11. The TPA and /or Bill Review unit shall review all medical bills and other services for
which a claim is being made for reasonableness and conformity to appropriate
medical and surgical fee schedules and network discounts
12 The TPA will assist the Claims Administrator with light duty cases and for those
City employees who are losing time by providing a report indicating all employees
that are not working in a full duty unrestricted capacity
13 The designated adjusters or team from the TPA will meet with the Claims
Administrator on a quarterly basis to discuss Summary Reports on any or all of the
following
• Any claim in which an employee is not working full duty
• Total incurred value exceeding $25,000
• Potentially controvertible cases
• Claims in which a settlement is recommended
• Changing Claim from Medical Only to Lost time
14 The Risk Manager, and /or designee will attend all Mediation conferences and may
ask the TPA for reports prior to mediation in order to facilitate any settlement.
15 The TPA shall prepare and maintain files necessary for legal defense of claims
and /or other litigation (such as actions for subrogation) or other proceedings
16 The TPA shall pay in a timely fashion, per Florida Medical E D.I guidelines, all
claims and expenses from the loss fund account established by the City, which will
be maintained by the TPA. Fees, interest and civil penalties incurred due to late
payments or adjuster mishandling are to be paid by the TPA unless caused by late
reporting from the City
17 The TPA shall pursue all possibilities of subrogation and liens The Claims
Administrator must be copied on all such correspondence relating to these issues.
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18 The City will assign the attorneys that provide the defense of claims The TPA is to
provide the defense attorney a complete copy of the file in question at the time an
assignment is made. The TPA will provide a monthly report to the City regarding
all legal assignments and the costs associated with them.
The Risk Manager will be responsible for approval for all settlements from
the City per the process determined by City policy and procedures in
coordination with the State Workers' Compensation Statute.
19 The TPA will timely report all claims in accordance with Florida State Statutes to
the City's excess carrier, as required by the carrier's reporting criteria For any late
reporting penalties imposed by the carrier due to late reporting by the TPA, the
TPA will reimburse the City for those amounts
20 The TPA will provide all necessary status reports as required by the City's excess
carrier
21 The TPA will submit requests to the excess carrier for all payments above each
claim's SIR to obtain the proper reimbursement for the City The reimbursement
checks will be forwarded to the City and the amount recovered will be entered into
the claims information system
22 The City will assign Field Case Managers (Qualified Rehabilitation Provider (QRP))
to its cases as needed.
23 The City maintains an exclusive list of providers developed specifically for the use
of the City, which is part of the TPA provider network. The City will use the TPA
provider network as a back -up network for ancillary providers
24 The TPA must provide the City with a toll -free telephone number
25. In all dealings, the City requires the Adjuster to be courteous, responsive and
sensitive to the injured employee. The adjuster is required to return an injured
employee's telephone call within 24 hours, preferably the same day that they called
the TPA
26 Identify claims subject to second injury relief fund (if reinstated during the contract
term or currently applicable), at -fault party subrogation and pursue such recoveries
on behalf of the City of Boynton Beach
27 Provide reports to the City of Boynton Beach's Risk Manager as requested or
provide for system access for ad hoc reporting. Reports shall include
• Loss experience
• Summary of claim and loss experience, broken down by injury type, injury
cause, department, and location of injury
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• Cost, frequency and severity report
• Claim activity summary (new, re- open /closed /disputed, etc.)
• Claim master file listing
• Detail list of claimants including current and prior claim activity
• Retention level analysis
• Reserve analysis detailing rationale and total cost
• OSHA 300 Log
• Lost time analysis
• PPO penetration
• Average cost by medical provider
• Number of Days from DOA Date to MMI Date
B. CLAIMS HANDLING:
1. The TPA shall use its best judgment in managing claims and in setting
reserves for future payment and shall perform the following functions with
regard to claims:
2. Within one (1) working day of receipt of a new claim, all data shall be
entered into the information system, assigned the proper codes and initial
reserves
3 Within 24 hours respond to inquiries from employees and /or injured
parties regarding the status of their claim.
4 Clearly document each file all phone conversations, discussions, and meetings
held on the case.
5. Promptly enter into the computer system all pre- approved payments, reserve
revisions, and file closings.
6. The TPA shall maintain emergency response procedures with the ability to
establish a catastrophic operation center within 48 hours
7 The TPA is expected to be familiar with applicable laws regarding
potential liability for injury or damage or other loss to members of the public
(e g familiarity with Florida's sovereign immunity statutes, Federal law regarding
governmental liability, etc )
8 Firefighters and Police are subject to Occupational Disease Claims and FS
112 181 City of Boynton Beach requires that adjusters handling these types
of claims be educated in the different statutory requirements associated with
these claims
9 Written status reports shall be provided to the City prior to these quarterly claim
reviews
10 The TPA shall maintain claim review procedures in place for supervisors or
auditors within its firm
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11 The TPA shall have established standard reserving practices to assist City
in establishing reserves Reserves shall be reviewed at a minimum of
every 90 days. File notes should reflect reserves were reviewed
12 The TPA shall coordinate a claims funding arrangement that is acceptable to the
City of Boynton Beach
13. Prepare and /or assist City staff with all appropriate responses to and
inquiries of all regulatory agencies.
14 The TPA is responsible for ensuring compliance with all reporting
requirements by regulatory agencies including but not limited to Medicare
Secondary Reporting Act of 2007 and all subsequent revisions.
C. DATA, FILING AND REPORTS MANAGEMENT
1 The TPA must prepare, maintain, and file statistical data, records, or reports as
required by excess insurers, City actuaries, and the State.
2 The TPA must prepare, maintain and file statistical information required by the
workers' compensation rating bureaus, including all data required for the
promulgation of the City's experience modification and state assessments.
3. The TPA must prepare and file any other reports as required by the City and the
State relating to claims experience, payments, etc (i.e., DWC -51, Aggregate
Defense Attorney Fee Report due to the state by March 31 of each year).
4. All charges related to these services identified herein are to be included in the
pricing provided for each option Any costs associated with programming changes
that are necessary to create a report required by the City (any report listed in the
Scope of Services) are the responsibility of the TPA
Specialty reports available beyond those identified in the Scope of Services or
requested by the City are to be provided and the City will request a cost proposal
for each report based on the fee structure in the price proposal.
5. All claims data is the property of the City and any data and media will be provided
to the City upon request or upon termination of this agreement at no additional cost
to the City
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D. LOSS FUND MANAGEMENT SERVICES
1. The selected TPA, at their expense, will ensure all claims and payment data is
included in their Toss runs. Historical data from our current TPA's database cannot
be purged. Claims data for all open and closed claims must be transferred
2 Loss runs are to be provided on a monthly basis sorted separately by policy year
and department /location Loss runs should list each claim separately. Specific
summary reports also must be provided The following reports are required
• Claims listing by Department
• Check register
• Cumulative report by line of coverage by year
• Annual summary reports
• Location report
• Large loss or severity report
• Safety report
• Excess insurance report
• Litigation report
• Legal payments report
• Pharmacy Penetration report
• Care Management report (Telephonic /Field)
3 All claims, expense and legal payments will be made by the TPA on checks drawn
on an account set up by the TPA and funded bi- weekly by the City It is
understood that all funds in this account are City funds and are to be returned to
the City upon request or at termination of this contract
4 The monthly reconciliation statement submitted by the TPA to the City will include
the following:
✓ Balance at inception of statement period
✓ Total disbursements which cleared, by date and claimant /payee
✓ Balance at close of statement period
5 The TPA will submit an invoice to the City on a monthly basis which provides an
Itemized listing of all banking fees related to the bank account set up by the TPA
on behalf of the City of Boynton Beach.
E. MEDICARE REPORTING SERVICES FOR TPA
Upon designation as City's Medicare Agent, the TPA shall provide the City assistance
with updating the Medicare Agent status within the statutory timeframes required by the
Centers for Medicare & Medicaid Services (CMS) under the Affordable Care Act.
As the City's designated Medicare Agent, the TPA will initiate a test file interface with
CMS within the statutory timeframes required by CMS.
Upon successful completion of the test file interface, the TPA will commence an ongoing
monthly query process on behalf of the City of Boynton Beach where the TPA will
transmit through the CMS Query Tool certain basic claims data elements (claimant
name, social security number, date of birth, and gender) on all of City's open medical
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claims for CMS to determine if such claim data elements match a valid CMS record
indicating Medicare eligibility. The TPA will report the results of such query on TPA data
system for claims staff to review
Once it is determined through the CMS Query Tool that a claimant is Medicare eligible,
the TPA will commence the transmission of mandatory quarterly electronic claims
reporting of those claimants to the Claims Administrator (CA) on the City's behalf within
the specific 7 day reporting period assigned to the City by CMS. The CA will confirm
either acceptance of the Medicare eligible claims thus reported or return any files for
which data is missing or incorrect. The TPA shall post on TPA data system any error
reports from the CA showing such files containing missing or incorrect data for the TPA
claims staff to research and correct directly on the TPA data system Once corrected,
the TPA will resubmit such files to the CA during the next quarterly reporting file
The TPA, as City's designated Medicare Agent, will continue to electronically transmit to
the CA on a quarterly basis all new and updated claims identified through the CMS
Query Tool as City's Medicare eligible claims
The TPA, as City's designated Medicare Agent, will also electronically transmit to the CA
any monetary settlement data received from CITY on City's Medicare eligible claims
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EXHIBIT "B"
SCHEDULE OF FEES
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