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HomeMy WebLinkAboutAgenda Report - May 17, 2023 C-11CITY OF Z10 Z CALIFORNIA COUNCIL COMMUNICATION AGENDA ITEM AGENDA TITLE: Adopt Resolution Authorizing City Manager to Execute an Agreement for Workers' Compensation Self -Insurance Third -Party Administrator with Acclamation Insurance Management Services, Inc., of Sacramento, for the Period July 1, 2023, to June 30, 2028 ($893,000) MEETING DATE: May 17, 2023 PREPARED BY: Beverly Jensen, Risk Manager RECOMMENDED ACTION: Adopt resolution authorizing the City Manager to execute an agreement for Workers' Compensation Self -Insurance Third -Party Administrator (TPA) with Acclamation Insurance Management Services, Inc. ("AIMS"), of Sacramento, for the period July 1, 2023, to June 30, 2028 ($893,000). BACKGROUND INFORMATION: Workers' compensation, which is mandated by the State Labor Code, provides medical treatment coverage, temporary and permanent disability payments, survivor's death benefits, and total disability pension benefits for employees, officers, volunteers and elected officials suffering from an industrial injury or illness. The City self -insures for workers' compensation and contracts with a TPA to administer claims. The TPA model allows the City to benefit from professional experienced claims handlers who are able to draw on a large knowledge pool of past experiences and current trends to assist in reducing outside litigation costs. The City has contracted with a TPA since 1976 and periodically solicits competitive proposals to ensure that it is obtaining the best price for the most efficient services. Sedgwick Claims Management Services, Inc. is the City's existing TPA and the current agreement will end June 30, 2023. Following a competitive selection process, staff is recommending that the City Council authorize the City Manager to execute an agreement with AIMS for professional services as the TPA of the City's self-insured workers' compensation program for the period from July 1, 2023 through June 30, 2028. Proposed annual claims administration fee for Fiscal Year (FY) 2023-24 is $165,270.42, with a three percent cost of living adjustment each following year for a total of $877,443.12. There is an additional one-time data conversion fee of $15,000. The total not -to -exceed cost of the contract over five years is $893,000. The Risk Management Division of the City Attorney's office issued a request for proposals for Workers' Compensation TPA services to nine different companies. Six companies responded. All proposals were reviewed by an evaluation panel made up of City staff from Risk Management, Human Resources, Police and Fire Departments as well as an outside subject matter expert, the Risk Manager from the City of Livermore. Staff solicited references from all of the proposers as well. After an initial review of the responses and APPROVED: Steve schwabauer Stephen Schwabauer, City Manager Adopt Resolution Authorizing City Manager to Execute an Agreement for Workers' Compensation Self -Insurance Third -Party Administrator with Acclamation Insurance Management Services, Inc., of Sacramento, for the Period July 1, 2023, to June 30, 2028 ($893,000) May 17, 2023 Page 2 of 2 references, the panel invited the three highest scoring firms to participate in a presentation/panel interview. The firms selected for interviews were, AIMS, Innovative Claims Services, Inc. and Tristar Risk Management. The panel considered various factors in making a selection, including the annual claims administration fee to the City, the cost for additional services (including bill review and utilization review), the staffing levels offered by the TPA as part of the flat annual claims administration fee, TPA's experience working with public entities, the TPA's recommendations for reducing the City's overall expenditures on workers' compensation claims, and recommendations by other current public entity clients. Based on these factors, staff recommends AIMS as the best qualified to meet the City's needs and administer the workers' compensation program. AIMS has been in business for over fifty years and has extensive experience with self-insured municipalities. Based on a review of AIMS's detailed written proposal, the presentation by AIMS staff and discussions with current public entity AIMS clients, staff believes that entering into an agreement with AIMS will, over the course of the agreement, promote financial stability by reducing the current inventory of open claims, resolving future claims before the litigation stage and ensuring that injured City employees receive early aggressive medical treatment. In addition to the claims administration services, and consistent with the City's existing TPA contract, AIMS will also offer medical cost containment services. These services include medical bill review, utilization review and nurse injury triage. The fees for these services are separate from the annual claims administration fee of the agreement and are billed to individual claim files as is the industry standard. The goal of these additional services is to reduce the overall cost to the City for medical care and comply with State Medical Fee schedule while ensuring injured City employees receive appropriate and high-quality medical care. Bundling these services with the TPA provider allows for seamless integration and provides for more efficient customer service, faster authorizations for care and ultimately better outcomes for injured employees. FISCAL IMPACT: Total not -to -exceed of $893,000 for the proposed five-year agreement FUNDING AVAILABLE Funding is budgeted in the Workers' Compensation Insurance Fund 66525100.72450. Andrew Keys Andrew Keys Deputy City Manager/Internal Services Director Katie Lucchesi Janice D. Magdich City Attorney AGREEMENT FOR PROFESSIONAL SERVICES ARTICLE 1 PARTIES AND PURPOSE Section 1.1 Parties THIS AGREEMENT is entered into on 20 by and between the CITY OF LODI, a municipal corporation (hereinafter "CITY"), and Acclamation Insurance Management Services, Inc. (AIMS) (hereinafter "CONTRACTOR"). Section 1.2 Purpose CITY selected the CONTRACTOR to provide the services required in accordance with attached Scope of Services, Exhibit A, attached and incorporated by this reference. CITY wishes to enter into an agreement with CONTRACTOR for Workers' Compensation Third Party Claims Administration (hereinafter "Project") as set forth in the Scope of Services attached here as Exhibit A. CONTRACTOR acknowledges that it is qualified to provide such services to CITY. ARTICLE 2 SCOPE OF SERVICES Section 2.1 Scope of Services CONTRACTOR, for the benefit and at the direction of CITY, shall perform the Scope of Services as set forth in Exhibit A. Section 2.2 Time For Commencement and Completion of Work CONTRACTOR shall commence work pursuant to this Agreement, upon receipt of a written notice to proceed from CITY or on the date set forth in Section 2.6, whichever occurs first, and shall perform all services diligently and complete work under this Agreement based on a mutually agreed upon timeline or as otherwise designated in the Scope of Services. CONTRACTOR shall submit to CITY such reports, diagrams, drawings and other work products as may be designated in the Scope of Services. CONTRACTOR shall not be responsible for delays caused by the failure of CITY staff to provide required data or review documents within the appropriate time frames. The review time by CITY and any other agencies involved in the project shall not be counted against CONTRACTOR's contract performance period. Also, any delays due to 1 weather, vandalism, acts of God, etc., shall not be counted. CONTRACTOR shall remain in contact with reviewing agencies and make all efforts to review and return all comments. Section 2.3 Meetings CONTRACTOR shall attend meetings as may be set forth in the Scope of Services. Section 2.4 Staffing CONTRACTOR acknowledges that CITY has relied on CONTRACTOR's capabilities and on the qualifications of CONTRACTOR's principals and staff as identified in its proposal to CITY. The Scope of Services shall be performed by CONTRACTOR, unless agreed to otherwise by CITY in writing. CITY shall be notified by CONTRACTOR of any change of Project Manager and CITY is granted the right of approval of all original, additional and replacement personnel at CITY's sole discretion and shall be notified by CONTRACTOR of any changes of CONTRACTOR's project staff prior to any change. CONTRACTOR represents t is prepared to and can perform all services within the Scope of Services (Exhibit A) and is prepared to and can perform all services specified therein. CONTRACTOR represents that it has, or will have at the time this Agreement is executed, all licenses, permits, qualifications, insurance and approvals of whatsoever nature are legally required for CONTRACTOR to practice its profession, and that CONTRACTOR shall, at its own cost and expense, keep in effect during the life of this Agreement all such licenses, permits, qualifications, insurance and approvals, and shall indemnify, defend and hold harmless CITY against any costs associated with such licenses, permits, qualifications, insurance and approvals which may be imposed against CITY under this Agreement. Section 2.5 Subcontracts Unless prior written approval of CITY is obtained, CONTRACTOR shall not enter into any subcontract with any other party for purposes of providing any work or services covered by this Agreement. Section 2.6 Term The term of this Agreement commences on July1, 2023 and terminates upon the completion of the Scope of Services or on June 30, 2028, whichever occurs first. K ARTICLE 3 COMPENSATION Section 3.1 Compensation CONTRACTOR's compensation for all work under this Agreement shall conform to the provisions of the Fee Proposal, attached hereto as Exhibit B and incorporated by this reference. CONTRACTOR shall not undertake any work beyond the scope of this Agreement unless such additional work is approved in advance and in writing by CITY. Section 3.2 Method of Payment CONTRACTOR shall submit invoices for completed work on a monthly basis, or as otherwise agreed, providing, without limitation, details as to amount of hours, individual performing said work, hourly rate, and indicating to what aspect of the Scope of Services said work is attributable. CONTRACTOR's compensation for all work under this Agreement shall not exceed the amount of the Fee Proposal. Section 3.3 Costs The Fee Proposal shall include all reimbursable costs required for the performance of the Scope of Services. Payment of additional reimbursable costs considered to be over and above those inherent in the original Scope of Services shall be approved in advanced and in writing, by CITY. Section 3.4 Auditing CITY reserves the right to periodically audit all charges made by CONTRACTOR to CITY for services under this Agreement. Upon request, CONTRACTOR agrees to furnish CITY, or a designated representative, with necessary information and assistance needed to conduct such an audit. CONTRACTOR agrees that CITY or its delegate will have the right to review, obtain and copy all records pertaining to performance of this Agreement. CONTRACTOR agrees to provide CITY or its delegate with any relevant information requested and shall permit CITY or its delegate access to its premises, upon reasonable notice, during normal business hours for the purpose of interviewing employees and inspecting and copying such books, records, accounts, and other material that may be relevant to a matter under investigation for the purpose of determining compliance with this requirement. CONTRACTOR further agrees to maintain such records for a period of three (3) years after final payment under this Agreement. 3 ARTICLE 4 MISCELLANEOUS PROVISIONS Section 4.1 Nondiscrimination In performing services under this Agreement, CONTRACTOR shall not discriminate in the employment of its employees or in the engagement of any sub CONTRACTOR on the basis of race, color, religion, sex, sexual orientation, marital status, national origin, ancestry, age, or any other criteria prohibited by law. Section 4.2 ADA Compliance In performing services under this Agreement, CONTRACTOR shall comply with the Americans with Disabilities Act ;ADA) of 1990, and all amendments thereto, as well as all applicable regulations and guidelines issued pursuant to the ADA. Section 4.3 Indemnification and Responsibility for lama - e CONTRACTOR to the fullest extent permitted by law, shall indemnify and hold harmless CITY, its elected and appointed officials, directors, officers, employees and volunteers from and against any claims, damages, losses, and expenses (including reasonable attorney's fees and costs), arising out of performance of the services to be performed under this Agreement, provided that any such claim, damage, loss, or expense is caused by the negligert acts, errors or omissions of CONTRACTOR, any subcontractor employed directly by CONTRACTOR, anyone directly or indirectly employed by any of them, or anyone for whose acts they may be liable, except those injuries or damages arising out of the active negligence, sole negligence, or sole willful misconduct of the City of Lodi, its elected and appointed officials, directors, officers, employees and volunteers. CITY may, at its election, conduct the defense or participate in the defense of any claim related in any way to this indemnification. If CITY chooses at its own election to conduct its owr defense, participate in its own defense, or obtain independent legal counsel in defense of any claim related to this indemnification, CONTRACTOR shall pay all of the costs related thereto, including without limitation reasonable attorney fees and costs. The defense and indemnification obligations required by this Agreement are undertaken in addition to, and shall not in any way be limited by the insurance obligations set1forth herein. Section 4.4 No Personal Liability Neither the City Council, nor any other officer or authorized assistant or agent or City employee shall be personally responsible for any liability arising under this Agreement. 4 Section 4.5 Responsibility of CITY CITY shall not be held responsible for the care or protection of any material or parts of the work described in the Scope of Services prior to final acceptance by CITY, except as expressly provided herein. Section 4.6 Insurance Requirements for CONTRACTOR CONTRACTOR shall take out and maintain during the life of this Agreement, insurance coverage as set forth in Exhibit C attached hereto and incorporated by this reference. Section 4.7 Successors and Assi ans CITY and CONTRACTOR each bind themselves, their partners, successors, assigns, and legal representatives to this Agreement without the written consent of the others. CONTRACTOR shall not assign or transfer any interest in this Agreement without the prior written consent of CITY. Consent to any such transfer shall be at the sole discretion of CITY. Section 4.8 Notices Any notice required to be given by the terms of this Agreement shall be in writing signed by an authorized representative of the sender and shall be deemed to have been given when the same is personally served or upon receipt by express or overnight delivery, postage prepaid, or three (3) days from the time of mailing if sent by first class or certified mail, postage prepaid, addressed to the respective parties as follows: To CITY: City of Lodi 221 West Pine Street P.O. Box 3006 Lodi, CA 95241-1910 Attn: Beverly Jensen, Risk Manager To CONTRACTOR: Acclamation Insurance Management Services, Inc. 10445 Old Placerville Road Sacramento, CA 95827 Attn: Dominic L. Russo, President & CEO Section 4.9 Coo eration of CITY CITY shall cooperate fully and in a timely manner in providing relevant information it has at its disposal relevant to the Scope of Services. Section 4.10 CONTRACTOR is Not an Employee of CITY CONTRACTOR agrees that in undertaking the duties to be performed under this Agreement, it shall act as an independent contractor for and on behalf of CITY and not an employee of CITY. CITY shall not direct the work and means for accomplishment of 5 the services and work to be performed hereunder. CITY, however, retains the right to require that work performed by CONTRACTOR meet specific standards without regard to the manner and means of accomplishment thereof. Section 4.11 Termination CITY may terminate this Agreement, with or without cause, by giving CONTRACTOR at least ten (10) days written notice. Where phases are anticipated within the Scope of Services, at which an intermediate decision is required concerning whether to proceed further, CITY ray terminate at the conclusion of any such phase. Upon termination, CONTRACTOR shall be entitled to payment as set forth in the attached Exhibit B to the extent that the work has been performed. Upon termination, CONTRACTOR shall immediately suspend all work on the Project and deliver any documents or work in progress to CITY. However, CITY shall assume no liability for costs, expenses or lost profits resulting from services not completed or for contracts entered into by CONTRACTOR with third parties in reliance upon this Agreement. Section 4.12 Confidentialit CONTRACTOR agrees to maintain confidentiality of all work and work products produced under this Agreement, except to the extent otherwise required by law or permitted in writing by CITY. CITY agrees to maintain confidentiality of any documents owned by CONTRACTOR and clearly marked by CONTRACTOR as "Confidential" or "Proprietary", except to the extent otherwise required by law or permitted in writing by CONTRACTOR. CONTRACTOR acknowledges that CITY is subject to the California Public Records Act. Section 4.13 Applicable Law, Jurisdiction, Severability, and Attorney's Fees This Agreement shall be governed by the laws of the State of California. Jurisdiction of litigation arising from this Agreement shall be venued with the San Joaquin County Superior Court. If any part of this Agreement is found to conflict with applicable laws, such part shall be inoperative, null, and void insofar as it is in conflict with said laws, but the remainder of this Agreement shall be in force and effect. In the event any dispute between the parties arises under or regarding this Agreement, the prevailing party in any litigation of the dispute shall be entitled to reasonable attorney's fees from the party who does not prevail as determined by the San Joaquin County Superior Court. G Section 4.14 Cit Business License Requirement CONTRACTOR acknowledges that Lodi Municipal Code Section 3.01.020 requires CONTRACTOR to have a city business license and CONTRACTOR agrees to secure such license and pay the appropriate fees prior to performing any work hereunder. Section 4.15 Captions The captions of the sections and subsections of this Agreement are for convenience only and shall not be deemed to be relevant in resolving any question or interpretation or intent hereunder. Section 4.16 Integration and Modification This Agreement represe-its the entire understanding of CITY and CONTRACTOR as to those matters contained herein. No prior oral or written understanding shall be of any force or effect with respect to those matters covered hereunder. This Agreement may not be modified or altered except in writing, signed by both parties. Section 4.17 Contract Terms Prevail All exhibits and this Agreement are intended to be construed as a single document. Should any inconsistency occur between the specific terms of this Agreement and the attached exhibits, the terms of this Agreement shall prevail. Section 4.18 Severabilit The invalidity in whole or in part of any provision of this Agreement shall not void or affect the validity of any other provision of this Agreement. Section 4.19 Ownership of Documents All documents, photographs, reports, analyses, audits, computer media, or other material documents or data, and working papers, whether or not in final form, which have been obtained or prepared under this Agreement, shall be deemed the property of CITY. Upon CITY's request, CONTRACTOR shall allow CITY to inspect all such documents during CONTRACTOR°s regular business hours. Upon termination or completion of services under this Agreement, all information collected, work product and documents shall be delivered by CONTRACTOR to CITY within ten (10) calendar days. CITY agrees to indemnify, defend and hold CONTRACTOR harmless from any liability resulting from CITY's use of such documents for any purpose other than the purpose for which they were intended. 7 Section 4.20 Authority The undersigned hereby represent and warrant that they are authorized by the parties to execute this Agreement. Section 4.21 Federal Transit Funding Conditions ❑ If the box at left is checked, the Federal Transit Funding conditions attached as Exhibit D apply to this Agreement. In the event of a conflict between the terms of this Agreement or any of its other exhiLits, and the Federal Transit Funding Conditions, the Federal Transit Funding Conditions will control. Section 4.22 Counterparts and Electronic Signatures This Agreement and other documents to be delivered pursuant to this Agreement may be executed in one or more counterparts, each of which will be deemed to be an original copy and all of which, when taken together, will be deemed to constitute one and the same agreement or document, and will be effective when counterparts have been signed by each of the parties and delivered to the other parties. Each party agrees that the electronic signatures, whether digital or encrypted, of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as manual signatures. Delivery of a copy of this Agreement or any other document contemplated hereby, bearing an original manual or electronic signature by facsimile transmission (including a facsimile delivered via the Internet), by electronic mail in "portable document format" (".pdf') or similar format intended to preserve the original graphic and pictorial appearance of a document, or through the use of electronic signature software will have the same effect as physical delivery of the paper document bearing an original signature. 8 IN WITNESS WHEREOF, CITY and CONTRACTOR have executed this Agreement as of the date first above written. ATTEST: OLIVIA NASHED City Clerk APPROVED AS TO FORM: JANICE D. MAGDICH, City Attorney By: CITY OF LODI, a municipal corporation STEPHEN SCHWABAUER City Manager Acclamation Insurance Management Services Inc. (AIMS) By: — Name Title: Dominic L. Russo President & CEO Attachments: Exhibit A – Scope of Services Exhibit B – Fee Proposal Exhibit C – Insurance Requirements Exhibit D – Federal Transit Funding Conditions (if applicable) Funding Source: 66525100-72450 (Business Unit & Account No.) Doc ID: CA:Rev.04.2022.LT 9 W i i i City of Lodi Request for Proposals for Third •� r �, Party Administration Services for Workers' �-� Compensation Exhibit A—Scope of Services SCOPE OF SERVICES In narrative form, 1)lcase Indicate I)rol)osei's compliance/acceptance of the following requirements (see below under program development). klen:ily and describe any special or unique features or value added alternatives or options. AIMS understands the City is seeking a qualified firm to perform Workers' Compensation Claims administration services as required by law and in accordance with the City's policy, including adherence to the LAWCX Claims Management policies, for its self-insured workers' compensation program in the manner required by the California State Department of Industrial Relations. As a Third Party Claims Administrator, AIMS is experienced and successful in handling like sized public agencies. AIMS has fifty (50) years of experience providing Workers' Compensation Claims administration and proactively manages sophisticated programs like the City's and have developed cost- effective, proactive programs that have achieved superior results for our public agency Clients. We understand this environment and know how to achieve the best possible results for both your injured employees and the City. AIMS will provide the City with a professional Claims management team who will support the program with "value added" components of the organization such as our dedicated Client Services Division, Internal Audit Unit, Information Technology Group, and our Senior Management Team. We believe our qualifications, best practice performance standards and state-of-the-art technology collectively will be significant in providing the City with the tools to maintain a cost effective and proactive Workers' Compensation program providing overall "best value" to the City with measurable results. AIMS will act as the City's representative in connection with the investigation, adjustment, processing, supervision and resolution of Workers' Compensation Claims asserted by employees against the City; and will adhere to the Local Agency Workers' Compensation Excess Joint Powers Authority (LAWCX) Claims Management policy as referenced in the RFP's EXHIBIT F, 1. Program Development Proposershall regularly consult with the Risk Manager orthcirdesignee and assist in developing the necessary procedures, practices and coordination to implen)ent the City's workers' con)pensation program and to meet legal requirements of the State of California. March 15, 2023 25 City of Lodi Request for Proposals for Third Party Administration Services for Workers' 1 I� Compensation ^ •,I l ) I II li I II it 1 1. "6N N,A. \1 MK\IfN AIMS has reviewed this requirement and agrees to comply. AIMS will assist the City's staff in the development of the necessary procedures, policies, practices and coordination efforts to manage the Workers' Compensation program. A customized Special Account Instructions document will be created for the City. This document will include an outline of the standards we will use in a customized approach to the City's Claims administration program such as specific procedures and protocols as outlined in the RFP and as required by the City. This customized approach to Claims administration will include specific Claims handling instr.ictions, communication instructions, and interface specifications that meet the goals of the City. Describe in detail how proposer will initiate and complete the rile conversation or claims data transfer when assuming this 11CW account 10 The formal Transition Process will include discussion topics such as; banking procedures, Trust Fund replenishment process, Special Funding Requests, Vendor panel choices, reporting/reports requirements, training on the Ventiv Claims Risk Management Information System, identification of Client contact for each area of specialty, payment schedule for coordination of benefits, settlement authority process, meet/greet with AIMS team & Client Team, training of what to expect with AIMS with key Client personnel. AIMS has extensive experience in the transitioning of large programs from other third party administrators and/or carriers. We adhere to estimated industry guidelines for transfer of Claims administration. We normally recommend thirty (30) to sixty (60) days for a smooth transition of existing Claim files. This includes a complete, detailed, conversion of all Claims, and financial data from the prior administrator. Some Clients require faster transitions. We are able to begin managing Claims much sooner as long as we have the Claims files and all required payment information. To faclitate the transfer of Claims administration for an effective date of July 1, 2023, AIMS will utilize the following process described below to ensure uninterrupted benefit delivery to the City's injured employees. ✓ Implementation/Transition Process Upon notification of award of contract, a series of implementation/orientation meetings will be scheduled immediately with all key Client personnel. Orientation meetings are conducted with our new Clients to introduce our staff and provide all parties with the opportunity to become acquainted. We recommend a minimum of weekly meetings during implementation, monthly meetings the first year, and quarterly •neetings thereafter to review Claims status, identify where improvements can be made and provide on-going support of the Workers' Compensation program. We attend additional meetings as needed and requested with all Client departments. We start by creat ng a spreadsheet of all of the items that need to be completed. This includes a timeline and list of who is responsible for the completion of the noted task, sample of this timeline and list of task and responsible staff is provided in the March 15, 2023 26 Exhibit noted below. City of Lo- Request for Proposals for Third Party Administration Services for Workers' �. { Compensation AIMS will work with the City to deve op a customized, mutually agreed upon, formal plan and schedule. The formal transition plan will address the following critical areas and more: • Staff introductions to our Client Program orientation Data conversion ■ Physical file transfer ■ Banking program procedures The AIMS transition team will include Tricia Baker, AIMS Assistant Vice President of Operations, who is experienced and thoroughly familiar with the assumption and implementation of new Clients. Kim Silas, Claims Manager/Supervisor, will be a critical link to the transition as the City's main point of contact. Kim will coordinate all efforts, meet with the City regularly (weekly, possibly more often), conduct interviews, oversee training, as well as being the touch point for establishing the new Client and AIMS team. Tina Patterson, Director of Data Delivery Services, would be responsible for all aspects of Claims Management System interface, banking, Client services, training, and report generation. ■ Lynn Cavalcantl, Sr. Vice President Operations has over thirty (30) years of experience managing Workers' Compensation Claims programs. • Kim Silas, Claims Manager/Supervisor has over thirty (30) years of experience administering Workers' Compensation. • Kristina ("Tina") Patterson, Director of Data Delivery Services, has over fifteen (15) years of Workers' Compensation Claims expertise, • Patricia ("Tricia") Baker, Assistant Vice President Operations has over thirty (30) years of Workers' Compensation Claims experience. Together, Kim and Tricia will provide the knowledge, expertise, and the philosophy on Claims management that the City is looking for to effectively manage its Claims program. ✓ Pandemic Proof Implementation In light of the recent pandemic conditions and protocols, our intention, if necessary, is to utilize our existing transition plan (please see noted Exhibit), while replacing any "in-person" meetings with electronic communications (i.e., Web -Ex like conference meetings, on-line training sessions, telephone conference calls, direct phone calls, e-mail). It is also important to note the vast majority of our pre -pandemic transition plans already utilize these communication methods in tandem 'Nith the use of various other document/correspondence transmittal services such as USPS, UPS, FedEx, etc. ✓ Transition -Related Meetings March 15, 2023 27 City of Lodi Request for Proposals for Third Party Administration Services for Workers' /, P Compensation Orientation meetings are conducted with new Clients to introduce our staff and provide all parties with the opportunity to become acquainted. Implementation meeting discussion tcpics will include but are not limited to: • Discuss employees and the current/preferred staffing plan • Confirm banking procedures, exchange financial information Determine Claims systems specifics, etc. Determine vendor panel • Discuss work flow • Establish goals for program • Review and determine reports required, to whom and the frequency to be provided • Determine schedule for annual evaluation, Client training and Claim reviews AIMS will work with our new Client to develop a customized mutually agreed upon formal plan and schedule. The plan will include step-by-step instructions for the transition of all Claims and financial data from the prior administrator. At AIMS, we studiously follow the accepted practices espoused by the Department of Self -Insurance Plans when effecting an orderly transition. Our Clients experience a seamless Claims handling transition and the injured employees receive timely benefits with no disruption; all Claims received are triaged by senior technical staff who will identify key facts, issues and develop a proactive action plan to move the Claim towards closure. Reserves are reviewed and allocated for probable ultimate cost and through this formal process, to help us achieve significant and immediate cost reductions and file closures. AIMS will provide the City service of all rea uired notices upon transition of their program. Our formal transition plan ensures prompt written notification, two (2) weeks prior to effective date, to all City injured employees with open Claims, vendors and other applicable parties informing them AIMS will be the new TPA, ✓ Claim Reporting Kits AIMS will provide Claim Reporting Kits, which include the following forms and information: • Welcome Letter • Employers Report of Work Injury or Illness (5020) • Employee's Claim Form (D INC 1) • Facts About Workers' Compensation pamphlets • Work Injury posters • Informational pamphlets about AIMS and the Claims team • Instructions for reporting Claims ✓ Data Conversion Our Claims Risk Management Information System is compatible with other existing systems March 15, 2023 28 City of Lodi Request for Proposals for Third Party Admkiistration Services for Workers' l ' Compensation for continuity of data and transferring of historical data. This includes a complete, detailed conversion of all Client's Claims and f nancial data from the prior TPA. We have performed numerous Claims data conversions from other systems, which include iVOS, David DOS, Gensource, Talisman, and other proprietary systems. AIMS has experience sharing data with Clients and other exchange partners, including insurance carriers, brokers, program directors, actuaries, banks, and regulatory agencies. Upon notification of award, we will meet with our new Client to confirm the sequence of the transition plan for both the physical files and electronic data. We will then immediately request the electronic data tape, file layout and codes from the prior TPA and have them begin preparing the physical files for transfer. Once the data is received, it will be converted and loaded into our test database for testing reconciliation. We can review and make customized changes to a new Client's current Claim coding and location structures if desired. The conversion and testing reconciliation is completed thirty (30) days in advance of the effective date of the program. Please see Exhibit 9 - Sample Trans itlonllmplementation Plan The City has a current annual claim frequency count of I04 total claims; this is based on the Public Self Insurer's Annual Report of FY 2021-22. Please provide a sample staffing model that will effectively and aggressively manage claims. The City believes that in order to effectively administer benefits for its in worl<ers, the caseloads should be no more than 150 cases per adjuster. In addition, the City requires that the dedicated claims adjusters for our Claims have experience witli working with sworn safety/Labor Code 4850 caseloads. As previously stated AIMS intent is to always allocate a staffing model that is responsive to the requirements of our Client's Workers' Compensation program. In the case of the City, this allocation is based upon the current Claim information provided in the RFP and the City's requirements. Such as Claims Examiners handling a maximum caseload of a hundred and fifty (150) open indemnity Claims. Additionally, our technical personnel are well versed and trained in those special areas of Workers' Compensation that relate to California public employees, education employees (Education Code), safety officers (Labor Code § 4850, et al), multiple salary continuation scenarios, Public Employee Retirement System (PERS), and other public employee retirement programs. This includes ensuring our Clients are informed of any relevant changes in the Labor Code, case law, and other regulations that would potentially affect the City. Please describe: a How many claims adjusters will be dedicated specifically to work on the City account? One Claims Examiner will be designated specifically to work in the City of Lodi account. w I -low many claims assistants for the medical only tiles and maintenance tiles? One Claims Assistant will be designated for the Medical Only files and maintenance files. March 15, 2023 29 City of Lodi Request for Proposals for Third VF — Party Administration Services for Workers' Compensation How many clerical support stafrto do mail, answer telephones and file? Tasks such as processing mail, answering telephones, and filing are standard to the infrastructure of the services we provide to Clients. As a matter of practice, the necessary corporate management, Claims management/supervision, IT management, Clerical staff and other support staff are assigned to a Client's program. In this case the City would share in the use of an office receptionist, file clerk and mail room staff. How soon are calls and cinails returned by staff`? AIMS Best Practices requires all calls and emails are acknowledged within twenty-four (24) hours of receipt (or within one business day). We strive to take the call before it goes to voice- mail as we know it takes twice as loig to return a call as it does to handle the call when placed. Our teams know the importance of being available and being responsive. We are trained and retrained on Exceptional Client Service techniques, which include acknowledging a message even if it will take time to gather the information and provide an answer. The call/email is acknowledged so the Client knows k was received and being worked on, with a deliverable date provided. AIMS' staff is accessible by telephone and email during standard business hours 8:30 AM to 5:00 PM Pacific Time. During non -business hours, a telephone voice message machine is available to facilitate the needs of non -emergency callers. We also provide a contact number for emergencies that occur during -ion-business hours. AIMS can provide telephone coverage to accommodate the City, by telephone (1-800#), facsimile, and 24/7 online reporting. Who will oversee reserve changes, settlement evaluations, denials, dairy reviews, and other related areas and how often these duties are performed? Kim Silas, Claims Manager/Supervisor will serve as the City's primary representative. She has over thirty (30) years of experience administering workers' compensation claims for both public and private accounts. Kim supports and assists both the Claims team and the City in assuring quality, service, and results as well as compliance with regulatory and Client -specific program performance standards. Kim is responsible for covering the identified duties: Reserve changes: The Claims Examiner completes a reserve worksheet based upon the probable ultimate cost (derived from available information) and presents the suggested reserve to the Claims Supervisor for approval within seven days of the assignment. Settlements: Once a Claim has reached the point of serious settlement negotiations, we will collect all pertinent data and present it to authorized City personnel along with our settlement recommendation contained in a clear and concise settlement package. Included in our settlement package will be reserve documentation indicating the adequacy of the reserves for eventual settlement offers, a summary of paid -to -date amounts, any disability ratings, if applicable, medical reports, a synopsis written by the handling Claims Examiner and approved by the Claims Supervisor and a complete risk assessment with any available March 15, 2023 30 City of Lodi Request for Proposals for Third r Party Administration Services for Workers' t'► - f r Compensation alternative options authored by defense counsel (if applicable). The settlement recommendation package will be presented to the City in a timely fashion and in a format customized to meet the needs of the City. AIMS will not enter into any settlement negotiation without prior approval from the City authorized representative. I Denials: AIMS will meet with the City periodically to discuss specific file issues and all Claim denials will be approved by the Claims Supervisor prior to the denial being made. a Office and telephone hours ofoperation. Offlce: 10360 Old Placerville Road, Sacramento, California 95827 Hours of Operation: AIMS' staff is accessible by telephone and email during standard business hours 8:30AM to 5:OOPM Pacific Time. During non -business hours, a telephone voice message machine is available to facilitate the needs of non -emergency callers. We also provide a contact number for emerlencles that occur during non -business hours. AIMS can provide telephone coverage to accommodate the City, by telephone (1-800#), facsimile, and 24/7 online reporting. In compliance with all rules ind regulations governing the administration of self insurance pursuant to Labor Code Section 2700, and the California Administrative Procedures Act. the proposer will: Prepare Special ACC71.111t Instructions (SAI). The SAI shall function as a workers' compensation program operating manual for the City's use. This manual shall specify claims activities and processing, organization of files, and procedures for reporting industrial injury claims. AIMS has reviewed this requirement and agrees to comply. AIMS works with every Client to deve op policies and procedures relating to their specific needs and their Workers' Compensation Claims program. As part of the implementation process and yearly thereafter, AIMS discusses the overall program goals, defines clear Claim handling objectives and creates processes & procedures for any special Claim handling instructions. This is formalized into a written document, approved, and shared electronically with all participants. While AIMS has vast experience in C aim handling procedures, each Client brings their own creativeness and objectives to the table. It is our commitment to capture, communicate and deliver these through a combined effort between our Client and our Claims Team. A Regularly review program progress with the City's Risk Manager, March 15, 2023 31 City of Lodi Request for Proposals for Third Party Administration Services for Workers' Compensation including identification ol'problem areas and recommend solutions thereof. AIMS has reviewed this requirement and agrees to comply, Quarterly/Annual Program Overview Updates: AIMS will conduct meetings with key identified departments to discuss program findings, key areas of improvement and annual successes. AIMS will prepare all necessary reports and graphs to provide a visual statement of the City's Workers' Compensation performance activity on a quarterly or annual basis or as requested. A sample of these reports are included with this response, Please see Exhibit 10 — AIMS Sample Claims Reports e Upon mutual agreement, meet with City staff and designated department staff to perform a claims rile reviewofoutstanding claims at least quarterly. AIMS has reviewed this requirement and agrees to comply. It is AIMS policy to meet with a Client as often as necessary to ensure contract compliance and Client satisfaction. It is also our recommendation that File Reviews be performed every sixty (60) days with all key personnel from the City. CLAIM REVIEW PROCEDURES: In preparation for a Client meeting, the following protocol is to be used: • Client Claim review meetings are calendared to ensure proper and timely preparation for the meetings. ■ Approximately thirty (30) days prior to a scheduled Claim review the Supervisor/Manager shall communicate with the Client to confirm the date, time and location of the meeting, and confI rm the claims to be review. ■ Claim re views are presented in a format approved by the Company or as specified by the Client but must include a document that provides a current financial picture of the claim and Plan, of Action Update. • For quality control purposes, all claims review documents shall be submitted to the Supervisor/Manager in advance of the meeting for review. ■ A copy o� the claims review documents shall be made available to the Client at the time of review, or before in accordance with prior agreements, If issues are raised during the meeting which requires action, an action list is generated which includes the task required, the individual(s) responsible and a completion date. All attendees should have the same information. March 15, 2023 32 i City of Lodi Request for Proposals for Third Party Administration Services for Workers' Compensation ' i w Provide City staff with in-service training on changes, proposed changes and statutes, rules and regulations affecting the City's responsibility under a self insured workers' compensation program. AIMS has reviewed this requirement and agrees to comply, AIMS will be happy to include the City in any or all of its in-house technical training, but also will coordinate on-site training for key personnel in the Risk Management Division and/or Departments. Many issues can be resolved before they escalate if all parties know the law, regulations and what is expected from the system. The Claims Manager/Supervisor, Kim Silas would be the main contact to schedule these types of training. Our management staff is responsible for our in-service training. When requested, training sessions on proper reporting, new case law or changes in the methodology the State expects the delivery of Workers' Compensation services to be accomplished is an integral part of our value-added partnership. These training sessions may be held at our offices, Client locations or other specific areas designed to accommodate a number of our local Clients who share the same need for up-to-date status on the ever changing climate of Workers' Compensation in California. This service comes at no additional charge. OA Review program )"ogress with the City's Risk Manager, including identification of problem areas, department injury trends and recommend solutions thereof. AIMS has reviewed this requirement and agrees to comply. As part of the quarterly meetings we conduct with the City, we present customized "Stewardship" reports. This is a program analysis presenting hard data to benchmark results and determine strategies to improve and optimize the program we specifically developed for the City. We are also available to assist n preparation and presentation of these reports to the governing body. Samples of these reports are included in the exhibit noted below. Please see Exhibit 11 — Sample Stewardship Report Provide customizeC loss and injury reports for each City department and division. This should include frequency and severity charts that will help City staff to establish loss reduction goals and present the charts at each claims file review. AIMS has reviewed this requirement and agrees to comply. March 15, 2023 33 t w 11 + City of Lodi Request for Proposals for Third r 't �{ Party Administration Services for Workers' Q�� .L l ►—a Compensation —:11t V V,- v a '.1fn Ind N1 " F AIMS can provide various standard monthly reports and custom reports upon request for each department and division requested by the City. Our Claims Risk Management Information System is an extremely powerful data management for both standard and ad hoc report generation. Our web -based system, provides convenience and access to real-time and "point in time" financials for generating custom zed ad hoc reports, multiple program reports for data downloads and monthly loss reports which can be exported into other applications such as PDF or Excel. Please see Exhibit 10 — AIMS Sample Claims Reports When requested by a department director, participate in workshops with the City staffto educate departments pertaining to the requirements of the Labor Code for timely reporting of injuries or other aspects of the workers' compensation claims process. AIMS has reviewed this requirement and agrees to comply. AIMS recognizes that the only way to ensure compliance with Workers' Compensation laws, regulations and statutes is to maintain a high level of continuing education and training, which is why AIMS provides training to our Clients and participates in workshops for Client staff. AIMS has developed a variety of training programs for employers that can be customized and incorporated into the Client's own training programs. These programs are overseen by our Workers' Compensation Corporate Compliance Division and our Senior Vice President Operations, Lynn Cavalcanti, The Co,porate Compliance Division provides training on a wide range of topics including: California Education Code Benefits, "Workers' Comp 101", legislative changes, fraud prevention, return -to -work (RTW), and State laws, etc. Lynn Cavalcanti, Sr. VP Operations is responsible for in-service training and education on a Client level and hosts the bi-annual Lunch & Learn Seminars. Describe in cletail, the procecures for advising initial treating physician and the injured employeeoftheCity's tcmporarymodified duty program. Includeprocedures for notifying the City of an employee who is returned to modified cluty. AIMS' staff must confirm disability, either Temporary Total Disability (TTD) Benefits or Temporary Partial Disability (TPD) Beiefits, before any Temporary Disability (TD) payment is made. This information is obtained from the Client, the treating doctor, and the injured employee (in non -litigated cases). • The treating physician shall provide information regarding treatment, medical bills, and authorizations of lost time for injured employee. • Each Client has a designated representatives) who is our contact and is the primary source of information regarding work related injuries. Information, such as dates of the Employee's last day worked, return to work date, modified duty availability and March 15, 2023 34 City of Lodi Request for Proposals for Third r f Party A dir, inis (ration Services for Workers' too _ I Compensation „e other information necessary to allow AIMS to provide benefits to the employees. The Employee's supervisor often serves as the source of the information. We work with our Client in determining the customized workflow for all Claims including those with 4850 benefits. • The Claims Examiner's coltact with the injured employee also serves as a source of useful information. The Claims Examiner may be able to clear up questions about actual lost time, medical treatment, and the facts of the injury. The Claims Examiner will not rely solely on the injured employee when administrating TD benefits. All indemnity payments are scheduled through an automated, computer generated diary system to ensure prompt payment of benefits. Various levels of security are required for payment requests. Describe in detail, the procedures for notifying the City Of an injured employee who has permanent restrictions or has reached Maximum Medical Improvement. Include the timeframe of notification to the Cit.. A successfully administered Claim is one where there has been a consistent plan of action throughout and includes resolving all issues and culminating in Claim resolution. AIMS' examining team formulates clear objectives for issues such as return to modified duty status, full duty status, Maximum Medical Improvement (MMI) status and Claim settlement. This helps the Claim move forward in an organized fashion and all participants make decisions to support these objectives. With clear goals in mind, the AIMS Claims Examiner activity is proactive and creates the opportunity to continually discuss outstanding issues and push the Claim to resolution. A large part of this process involves communication with the Client to determine if the goals and objectives should remain the same as new information is developed. From the onset of the injury, the Claims Examiner manages the processes aggressively and clearly to achieve fie resolution and seeks appropriate authority approval with the Client. Notice of MMI: • Within five (5) working days from notice of MMI and notice of work restrictions, the Claims Examiner will notify the employer via email of the employees' work capabilities and or restrictions. A diary is set for twenty (20) days to follow up with the employer to determine if a decision has been made concerning an offer of work. The offer must be made within thirty (30) days from TTD being cut off and or the finding of MMI, even if the employee has previously returned to work. ■ The Claims staff can assist the employer with the completion of the applicable offer of work forms (but should have something in writing from the employer as documentation of what is being offered). • The Claims staff will file and serve a copy of the offer on all parties with a proof of March 15, 2023 36 1 w , City of Lodi Request for Proposals for Third Party Administration Services for Workers' —a Compensation service. Proposer will set and maintain appropriate reserves, and discuss reserve changes over a specified amount with the Risk Manager (amount of change to be determined). AIMS has reviewed this requirement and agrees to comply. Provided below are general guidelines used by AIMS for establishing reserves. These guidelines are modified as needed to meet specific Client requirements. The Client's criteria will always take precedence, especially if those requirements are more stringent than our guidelines. Additional, at the request of the Client, we -provide notification of any reserve change that exceeds a specified amount. Reserves are an estimate of future liability that is made more accurate by the experience level of the reserve establisher and relevant facts involved. The Claims Examiner has the ultimate responsibility for recommending all initial and subsequent reserve changes. AIMS Recommended Guidelines: 1. All reserves settings or changes are to be accompanied by a reserve computation analysis form to be completed on the Claims Risk Management Information System (Ventiv System). 2. At the time of any reserve change, the Reserve Worksheet must reflect all rationale for any increases/decreases. This document is the controlling information which supports the entered changes. 3. Reserves are to be set,'reviewed at least at the following times: a. File set up upon receipt of an Employer's First Report of injury or accident. b. Receipt of medical information or a report indicating a change the status of the Claim (extending disability, finding of permanent residuals, vocational rehabilitation potential, etc.). c. Receipt of information indicating the Claim will involve litigation or applicant's counsel. d. Upon completion of settlement negotiations. e. Upon payment/reconciliation of an award. f. Every ninety (90) day Plan of Action Review. g. Upon notice of any fact which influences the dollar value of the Claim. h. In any event, no more than three (3) months from the last reserve computation analysis form. 4. In cases where there is apportionment of permanent disability, reserves should be reduced to the appropriate exposure only where legal apportionment has been established. March 15, 2023 36 City of Lodi Request for Proposals for Third [.,. Party Administration Services for Workers' Compensation 5. In reserving lifetime medical awards, determine the most accurate annual medical costs and use the most current life expectancy table as the guide. Also, please complete the following: A Describe how adjusters establish reserves. Please see above response. A Describe who reviews incl approves the reserves. All staff designations have a maximum amount of reserve authority allocated. Once this maximum is reached the reserve changes cannot be implemented on the Claims Risk Management Information System (Ve.ntiv System) without an escalation to the next higher authority level. This procedure is done exclusively on the Ventiv System and tracked through the Pending Financial Transactions module. Claims Supervisors and Claims Managers frequently check this screen throughout the day to approve reserve changes that exceed their team's authority. e Describe how superx isory and management authority on reserving is obtained, Reserves are reviewed every ninety (30) days when the Claims Examiner completes their updated Plan of Action (POA) and is documented in our Claims Risk Management Information System. Even if no reserve changes are needed, the requirement of the review is to explain why the reserves are adequate at the time of the review. If changes are being made, it is mandatory that the Claims Examiners complete the Reserve Worksheet inside of the Claims Management System, which documents the reserve change rationale. This worksheet describes any increase or decrease being recommended. This is reviewed by the Claims Supervisor and given to the Claims Examiner to reestablish the diary. AIMS has in place computer audits including user -defined red flags, automatic diaries and reminders. A report is generated bi-monthly that lists any Claim which is off diary. The criteria that mandates review of reserves is based on the level of authority by position. Provided below are the corporate guidelines applied to reserving: Claims Examiner $0 - $ 7,500 Senior Claims Examiner $0 - $250,000 Claims Supervisor $0 - $500,000 Claims Manager $0 - $750,000 A Describe how often the reserves are reviewed. Extracted below is the specific section of AIMS Time Performance Standards table, which March 15, 2023 37 City of L.oli Request for Proposals for Third �. Party Administration Services for Workers' �--a Compensation 1 identifies how often reserves are reviewed. Performance Time Frame Standards - Reserves TASK PERFORMED Reserves TIMEFRAME At initial file setup. Within seven (7) days for any event that triggers the need for a reserve change. Reserve reviews required at a maximum of every ninety (90) days. Status Reports/ Plans of Action Every ninety (90) Supervisory File Reviews Ata maximum of every hundred and twenty (120) days. Home Office Reserve Notification f Within one (1) day of any reserve change over $750,000, w Explain process to notify the City of a reserve change. Reserve worksheets are prepared to support any changes made in reserving amounts and can be viewed by the City in support of a reserve increase or other change. If the City desires, a custom report can be generated ideitifying all reserve changes exceeding a specific amount. Claims and Medical Administration. Services and Control: Proposer will take an active part in handling initial medical control, coordinatc and contact by telephone initial treatment providers, and/or redirect claims where the injured worker has not pre -designated a personal physician. AIMS has reviewed this requirement and agrees to comply. The AIMS Claims Examiner is well versed on monitoring medical treatment for all injured employees. Our constant interaction with the treating physician ensures that the treatment prescribed is reasonable and necessary to provide cure and relief to the patient. We will follow- up with the treating facility on a bi-weekly basis to ascertain progress and continued disability. If there is a question concerning the appropriateness of the treatment or diagnosis, we may involve, with prior approval, a nurse case manager or a medical director to validate treatment protocols. At the beginning of the involvement with the treating physician, we routinely acquaint him or her with our expectation with regard to timely reporting in accordance to Title 8, CCR Section 9785. Bills are first reviewed prior to forwarding them to our re -pricing division for compliance with the Official Medical Fee Schedule. AIMS will always make the necessay medical appointments when managing a claim involving treatment as well as provide all required notices to the injured employee in a timely manner. March 15, 2023 38 ILI i City of Lodi Request for Proposals for Third ■ ii yr Pad Administratior7 Services for Workers' [, ! 1 Compensation I Proposer will provide toll-free telephone number for City employees. AIMS has reviewed this requirement and agrees to comply. AIMS can provide the following toll-free telephone number to accommodate City employees: 1- 800-444-6157. e Proposer will be required to manage ancillary services associated with the administration of workers' compensation claims, i.e. nurse case managemcnt. special investigation units, bill review, utilization review, etc. AIMS has reviewed this requirement and agrees to comply. AIMS coordinates Clients' vendor panels and approvals in advance and all referrals to vendors in accordance with the Clients' requirements as part of an integrated cost containment solution, which entails managing ancillary services and coordinating programs such as: • Medical Bill Review • Utilization Review • Nurse Case Management • Return to Work (includes on-site programs) • Loss Control • Workplace Safety • Occupational Health Clinics ■ Job Task Banks • Employee Training and Medical Provider Networks (MPN) Also, AIMS continuously evaluates vendor/ancillary services to ensure performance -levels and continued value -add to our Clients. For medical Managed Care Services AIMS will recommend its sister company, Allied Managed Care, Inc. (AMC). AIMS and AMC are part of the wholly owned subsidiary organization of LJR Holdings, Inc. (LJRH). ` AMC was established in 1995 and offers Medical Bill Review (BR), Preferred Provider Organization (PPO) networks, Utifzation Review (UR) — both Nurse and Peer, Telephonic Case Management (TCM), and Field Case Management (FCM), customized Medical Provider Networks (MPN), Allied Rx (Prescription Management), Allied Care Complete (Early Intervention), Call Center Services such as Nurse Center 24/7 through CarivaCare, Nurse Triage, TeleHealth, and all :he necessary ancillary services to maximize all areas of March 15, 2023 39 i City of Lodi Request for Proposals for Third y Party Administration Services for Workers' Compensation I•.II WIN, I medical cost containment, which bring real savings back to our Clients. AMC enjoys a superior comprehensive understanding of the needs and requirements of Workers' Compensation Claims administration due to the relationship with AIMS, We work side by side to share ideas and challenges. This daily sharing across divisions helps make both companies stronger in that we work together to find solutions for our Clients. AMC understands the importance of making the Claims Examiner's job more efficient. Together we work hard to accomplish program enhancements such as access to imaged and stored documents, fully integrated Bill Review and Utilization Review, and providing accessibility of Claim and managed care information to appropriate parties. With the involvement of AMC as the medical management provider for the program, needed interfaces among Claims administration, Bill Review, Utilization Review, and Nurse Case Management are already established, which streamlines the implementation. * The City reserves the right to utilize any ancillary service provider it wishes and will not be limited to the proposer's preferred vendors. Vendor Management - AIMS Rapid Referral Program (ARRP): AIMS has developed and utilizes a web -based communication platform that connects our Claims staff with all recommended/allowable service providers, Through this process, we have the ability to monitor assignments to preferred providers fo- quality and cost control. AIMS has researched and vetted service providers for quality and best -value for our Clients and will make our recommendations known to the City. If our Client has preferences for various service providers, AIMS will use the Clients' preferred vendors. The service provider "panel" is pre -approved by our individual Clients. Any exceptions to appropriate assignments are managed on a case-by- case basis. Through this platform, we have the ability to streamline the Claims Examiners workflow as well as track, manage, and run reports on service provider usage. Proposer will review all initial claims and rnalce telephone contact with the injured employee, the City, and the medical provider within 24 hours of receipt of claim. AIMS has reviewed this requirement and agrees to comply. AIMS promotes communication and outreach to the injured employee so they are informed about their medical treatment and benefits. From the initial contact, which is completed within twenty-four (24) hours of our receipt, to the finalization of the Claim, the Claims Examiner is communicating with the injured emplcyee. We do not want to waste anyone's time so, we find opportunities to create these conversations, such as when a benefit notice is issued — contact is made with the injured employee - or when medical services are requested and approved — contact is made to discuss who will be providing the services. March 15, 2023 40 City of Lode Request for Proposals for Third Party Administration Services for Workers' / Compensation Along those same lines, communication with the City is as critical as communicating with the injured employee. All parties need to be informed and involved for a Claim to have a successful resolution. AIMS will be responsible for the communication of key issues, such as release to modified duty status, release to full duty status, and release with permanent restrictions. Communication of these key status cianges provide the Employer with opportunities to control indemnity benefits and support their early return programs, which in return supports earlier Claim resolution. • Briefly describe the procedure for malting the 3 -point contact and what is the proposer's policy when attempts to contact the injured worker have failed. 3 -Point Contact: AIMS Claims Examiners make a 3 -Point contact within twenty-four (24) hours of receipt of a new Workers' Compensation Claim. The key purpose of this contact is to introduce the injured employee to the Claims Examiner assigned to the file and to insure that there is an open line of communication between the Injured Employee and the TPA. And while this call is also to gather all information on the nature and extent of the injury, how the injury occurred and if there are any outside employment factors to consider, it is also to provide assurance of the process and procedures involved with the City's program. The 3 -Point Contact is a stored template in our Claims Risk Management Information System, which prompts the Claims Examiner to ask certain questions and to explain the initial steps involved with a newly reported injury. AIMS believes that frequent and early contact with the injured employee insures that all their questions and concerns are addressed quickly and consistently. The first contact is initiated immediately upon AIMS' receipt of the injury information. This contact is critical in the Claims handling process, to establish who we are, what we do, and how we can help them achieve a return to work status. And while the Claims Examiner is not the expert on the City's benefits, they will be able to share who at the City is responsible and able to respond to any employer benefits that may also be available during this recovery period. The Claims Examiner then will make contact with the Injured Employee no less than every thirty (30) days when they are on modified duty and no less than every fourteen (14) days while they are on total disability. Any time there is a change in status, the Claims Examiner makes contact with the injured employee to explain and address any issues, concerns or questions they may have. Policy on Failed Contact: 3 -Point contacts are conducted by the assigned Claims Examiner / Medical Only Examiner within twenty-four (24) hours of AIMS receipt of the Claim. Three (3) documented attempts are made and if unsuccessful, a follow-up letter is immediately mailed to the injured employee. The 3 -Point contact call(s) are documented in the Claims Risk March 15, 2023 41 t4 , it; City of Lodi Request for Proposals for Third l ._ ►--a it i i i' i I . + ! ;', , Party Administration Services for Workers' ►—� Compensation Management Information System under the Notepad type; "3 -Pt Contact" indicating on what date(s) the calls were made. Failed attempts to contact the injured employee are followed up with a "Please call me at your earliest convenience letter. " In summary, the Claims Examiner will conduct regular follow-up throughout the life of the Claim file, which will include providing information, guidance, and assistance regarding permanent disability ratings, Qualified Medical Exams and the settlement process. Contact is made verbally and will be followed-up in writing to appropriately document the activity in Claim file. Proposer shall make twice -monthly contact with all employees who remain on temporary disability for more than one week. Should an employee be off For longer than thrze weeks, the proposer shall discuss referral to Nurse Case Manager witV the Risk Manager AIMS has reviewed this requirement and agrees to comply. Claims Examiners are required to contact an injured employee every two (2) weeks if they are receiving disability benefits. If modified duty exceeds thirty (30) days they are also required to make continuous contact every thirty (30) days until they have return to full duty and/or have identified permanent work restrictions. We encourage our Claims Examiners to make contact when a benefit notice is being issued, to explain the contents of the notice and answer any questions, but require the contact when a Claim is denied (unless represented). Contact is required when a Claim is ready for settlement. All of our teams have extensive Client Service Training so they are very willing and able to initiate communication with their Injured Workers. • Proposer will bear :he sole responsibility for any and all penalties incurred as a result of the =ailure of the proposer to comply with statutory laws and/or administrative regulation. AIMS has reviewed this requirement and agrees to comply. AIMS has a robust Penalty Prevention Process, which is augmented by our ability to track incoming documents and scheduled benefit payments. While it is never our intent to incur penalties, in the rare instances when they happen, AIMS immediately corrects the issue and makes the penalty payment. At the same time the payment is made, the Claims Team produces a Penalty Prevention Form which is circulated inside the appropriate departments at Corporate for reimbursement to the Client. It is always our desire to take notice of any penalties rather than being made aware of them thrcugh outside sources. AIMS understands and takes very seriously the fact that these payments are not the fault of the Client and quickly works with our March 15, 2023 42 i, City of Lodi Request for Proposals for Third Party Administration Services for Workers' Compensation " Accounting Department to refund these to the Client Trust Fund. Careful reconciliation of these payments occurs within the Accounting Department and the Claims Risk Management Information System so all parties are aware of the occurrence and reimbursement schedule. a Proposer shall actively assist in rehn•ning the injured employee to employment in regular dUtiCS, temporary light duty or reassignment as early as possible, in coordination with the City's Return to Work Program. AIMS has reviewed this requirement and agrees to comply. AIMS Claims Examiners and their assistants are responsible for ensuring that the Client's return to work programs are enforced. Return to work (RTW) efforts are not segmented from the Claim, but rather are handled directly by the Claims team in the course of managing the entire Claim. Work statuses are obtained on a regular basis and communicated back to our Client. Medical reports are reviewed and our team ensures that the treating doctor understands our Clients modified work programs, Custom forms can also be utilized. We will meet with the City's key staff and develop a step-by-step program to support the City's return to modified work program. It is AIMS policy to proactively work with the Client and the treating physician in an effort to minimize the amount of lost time an employee takes and reduce the amount of lost productivity to the Client resulting from a work injLry. If the primary treating physician has not adequately addressed return -to -work issues, or they continue issuing statuses of temporary total disability which are not supported by the nature and extent of injury, we recommend a telephonic nurse referral be made. AIMS will work with the City to establish the most frequently used letters/forms that are sent to the injured employee in connection with the RTW program. Those communications are stored in our Letters module of our Claims Risk Management System, so all parties are using customized communications for the City's program. Additionally, we would discuss the involvement of the City specifically, what medical and non-medical information is required to assist the City in the performance of their role. Most likely this information would involve medical status reports issued in connection with return to work, which AIMS can make available through our paperless environment o -i a real-time immediate basis, If AIMS is awarded this contract, we will thoroughly discuss the City's RTW program to find solutions to maintain effective communication, availability of information, and role and responsibilities of the examining team to support these efforts. Please complete the following: • Briefly discuss guidelines for referral to the Nurse Case Manager (Telephonic or Field) or review from a Nurse Case Manager upon initial onset of a claim March 15, 2023 43 qr. � City of Lodi Request for Proposals for Third Party Administration Services for Workers' r Compensation """""" "Is �1 AIMS values the assistance of Nurse Case Managers (NCM) in the movement of a Claim to resolution. Like any other tool for the Claims Examiner to use, this one is not applicable for every Claim. The best definition of -he point in time when a NCM should be assigned to a file is when the Claims Examiner cannot achieve the desired outcome alone. We frequently hear that it is the Claims Examiners' function to contact the physician and obtain modified duty restrictions, schedule a surgery and/or have them declare Maximum Medical Improvement (MMI) status. While the Claims Examiner is expected and does make contact for all of these issues there are times when the doctor is not cooperative. These times are when a NCM can assist in moving the file forward because they have a medical professional status that a Claims Examiner does not, they are treated differently and have better access to providers and their staff. These are the points in time when moving the file forward needs the assistance of a NCM to facilitate these events. The use of the NCM on a Claim is utilized only when necessary and, in many instances, in conjunction with consultation from the Client. The average percentage use is relatively small. AMC has several Case Management Programs and we customize depending on the need of each client. AMC's Nurse Case Management Process: Upon receipt of a referral, AMC's Nurse Case Manager will discuss the referral with the Claims Examiner immediately to clearly identify achievable goals and develop a plan of action and then perform three-point contact, as follows: Contact is made with the provider to obtain a clear diagnosis, treatment plan, prognosis, return to work (RTW) projected date as well as a Maximum Medical Improvement (MMI) date. 2. Contact is made with the employer to discuss their RTW program and work with employer on returning the injured employee back to work. 3. Contact is made with the injured employee (if not represented or attorney provides authorization) to assess their perception of the injury, assess any obstacles, address concerns and answer any questions. Claim notes and medical records are reviewed so there is a good understanding of the injured employee's injury and diagnosis. Oice information is received, the Nurse Case Manager completes an assessment with an action plan. All information received is provided to Claims Examiner within twenty-four (24) hours of receipt. Ongoing communication with all parties is required to ensure treatment requests are addressed timely, coordinate treatment which decreases lost time and enhances recovery process, identify barriers to recovery and address these with all the parties, and revise goals with the Claims Examiner as goals are achieved or situations develop, The Nurse Case Manager promptly informs the employer on all restrictions, while assessing March 15, 2023 44 City of Lodi Request for Proposals for Third Party Administration Services for Workers' Compensation RTW possibilities, works with providers to assess progress, discusses alternative treatments, provides information on guidelines, and assists in coordination of UR referrals and treatment, They also work continually with the injured employee to assure they understand the treatment plan, assess benefit of treatment plan, assist in answering questions, and avoid any complications. Three-point contact includes an assessment of the following factors: Employee (if not represented or if approval obtained through applicant's attorney): • Mechanism of injury • Medical History that may impact recovery of current disability • Prior injuries or co -morbidities affecting recovery • Assessment of barriers • Medications, treatment modalities prescribed • Employee's view of injury and motivation for recovery • All AMC personnel are to •eturn phone calls within twenty-four (24) hours and respond to emails within one (1) day Employer: • Usual and customary job duties • Availability of modified or `ransitional work • Discussion of current employee restrictions Treating Physician: • Definitive diagnosis • Prognosis ■ Plan of care Work status/restrictions Next office visit Projected date for Maximum Medical Improvement (MMI) Technical measures have also been defined to ensure utilization management and case management staff complies with identified procedures. These procedures represent documentation of specific data fields that are vital to producing value-added reports to our Clients. On-site visit case management servi"Ies follow the same protocols but involve attending visits with the injured worker and physicians for face-to-face interaction and intervention. After the initial set up, contacts, intervention and reporting, the case manager will provide ongoing support to the injured worker as they navigate the recovery process identifying any barriers to recovery and assisting with expediting approved treatment requests. Updated progress reports will be submitted every thirty (30) to forty-five (45) days depending on dates of next office visits along with ongoing e-mailed updates after any interventional activity has been March 15, 2023 45 City of Lodi Request for Proposals for Third r , Party Administration Services for Workers', , t - Compensation completed by the nurse to the Claims Examiner. • Describe which cases would benefit from medical case management. A list of criteria has been establishes for the Claims Examiner to use when considering referral to a Nurse Case Manager (NCM) and Client approval must be obtained prior to referral. Also, Client preference for referral criteria shall take precedence. Listed below are sample cases: • Anticipated work disability extended beyond original estimate without a reasoning as to the extension of disability, Requests for a change in treating physicians on stress and psychiatric Claims. • Catastrophic injuries with anticipated moderate to severe permanent disability and hospitalization. • Anticipated surgery when the request is for inpatient stay to ensure admittance and dischar6e is timely and discharge instructions are followed and an extended stay in the hospital is avoided. • When modified duty is not reported as an option and the treating physician is not responding to requests to adcress an injured employee's ability to return to modified duty to shorten the length of lost time from work. a What types of acti-dities should the City expect from a Nurse Case Manager. AIMS' sister company, AMC has been providing Medical Case Management services in California since its inception in 1995. AMC has been providing Nurse Case Management (NCM) since 2004 including Telephonic Case Management (TCM) and on-site or Field Case Management (FCM) services. Over :he years, telephonic and field case management services have grown to include customized piarmacy intervention programs, customized early return to work programs, nurse file reviews to assist Claims with settlement issues, life care planning, anticipated treatment requirements on high exposure cases, catastrophic case management, and instructional programs for injured employees. All of AMC's Case Managers are Registered Nurses and many have their Bachelor of Science degree in Nursing and maintain their Certified Case Manager credential. All of AMC's nurses have unlimited access to our Medical Director, Alan Randle, MD. Guidelines: AMC's case management nurses have access to the same guidelines as the Utilization Review team, but they rely mostly on the Official Disability Guideline and Medical Disability Advisor Guideline for length of recovery and return to work. The Predictive Model can factor in co -morbidities which may impact recovery. The case management nurse will review March 15, 2023 46 City of Lodi Request for Proposals for Third, Party Administration Services for Workers' i•' " j Compensation tl • U •I'.If. , , 1:11( < these guidelines whenever there is a change in condition and update the Claims Examiner within twenty-four (24) hours of this change along with any changes in the expected recovery period and complicating factors. Disability management includes all of those activities required to return the injured worker to usual and customary job duties. Coordination of establishing maximum medical improvement (MIDI) and return to work includes incorporating assessments and information from the employee, employer, physician restrictions, and disability management guideline recommendations. The Nurse Case Manager also includes a detailed assessment of the employee's functional capabilities as well as a description of the employee's current job duties and availability of transitional or modified duty from the employer. Once an injured worker returns to either modified or usual and customary duties, the Nurse Case Manager follows -up with the employee and employer to ensure there are no complications with the return to work duty. AMC's Unique Capabilities and Approaches: Customized Nurse Case Manager workflow to meet the needs of each specific Client. One example is that some Clients want the Telephonic Case Management (TCM) nurses to perform embedded Utilization Re -view (UR), The benefit is a quicker review and referral to the providing vendor since the nurse is already aware of the medical condition of the injured worker, lower cost of that UR review, and faster turn -around time so the treatment can be provided sooner which overall sages Temporary Total Disability (TTD) dollars. Another example is to customize triggers for case management intervention such as lost time, modified restrictions not changing, multiple providers, multiple diagnoses, high narcotic use, and other complex issues, D Claims Advice Nurses CAN -Do Program. The Claims Advice Nurse program was designed by AMC's Director of Nursing Services. The program was established to help our Clients understand the current laws and how to manage a specific situatlon. With this program, we are available to answer questions directly from Claims Examiners and Clients without having to send something through Utilization Review. This helps in educating the Claims Examiner and saves our Client's money if something does not have to go through the UR process. This program, makes available AMC's Director of Utilization Review (UR) to answer questions directly. The theory behind this program is that many times the Claims Examiner comes across a scenario that they are not too sure how to manage. The Claims Examiner can pick up the phone and run it by a knowledgeable person. Sometimes the answer will be "Send it through UR." However, many times the answer will be advice about the meaning of the request, how the scenario fits with the rest of the Claim, or that the Claims Examiner may authorize the request. AlliedCare Complete - Nurse Early Intervention. This program provides a comprehensive Nurse Early Intervention triage model that not only impacts the critical beginning stages of March 15, 2023 47 City of Lodi Request for Proposals for Third v Party Administration Services for Workers f; ,l I Compensation medical care but provides ongoing Utilization Management to facilitate and expedite medical treatment within the employer's network of providers. AMC recommends having a licensed Nurse perform triage and initial review of medical issues in coordination with the Claims Examiner. The Nurse will provide medical expertise in evaluating and estimating the medical needs of Claims. In addition the nurse will provide prospective evaluation of any ongoing UR requests for the same file, A When case management services should begin and end We reference Best Practice Guidelines and utilize established Best Practice Standards for Case Management activity and billing. Referrals are generated at the discretion of the Claims Examiner but based on certain triggers and the needs/goals of the file, we may suggest a one time or limited task over a full f=ield Case Management assignment to assist with Claims resolution. Case Management activity should be action oriented and Case Management (CM) file closure is recommended when goals are met or if it is no longer cost effective to continue and if minimal additional CM impact is anticipated. Case Management Case Closure: Case managers are to close the file to activities once AMC or Client -specific criteria are met. These include but are not limited to: • No treatment or return to work issues identified at time of triage • Maximum Medical Improvement (MMI) or Permanent and Stationary (P&S) status has been reached • Return to Work (RTW) full duty, follow up with two (2) weeks, no issues identified • Claims Examiner requests closure • Avenues of assistance to medically manage the Claim have been exhausted and the file can no longer be impacted. Send to Claims Examiner for review and close the file upon approval • Injured employee has expired • Delayed Claim not accepted Rationale for closure is documented n the file and transmitted to our Client through e-mail. Recommendations for future expectations in the course of the Claim are documented as applicable. If verbal contact with Claims Examiner has not been made, the case manager will send a summary including closure rationale and notification of case closure within forty-eight (48) hours. If verbal discussion occurs with Claims Examiner concerning closure, documentation will include rationale t'or closure and discussion with Claims Examiner, to include date of discussion. The case manager will notify the employer and employee that the file is being closed to case management but the Claims Examiner will remain on the file. March 15, 2023 48 City of Lodi Request for Proposals for Third If Party Administration Services for Workers',; t <<} ii Compensation ::;;AMf, ;':` R, 11 1; Describe your managed care/medical cost-containment program including but not limited to: disability tracking, managing and reporting, PPO networks, case management services, utilization review. bill review, and indicate which services are owned, in whop or in part, by the proposer's business, and which services are contracted out. Allied Managed Care, Inc. (AMC) is the only managed care, medical cost-containment company affiliated with AIMS. AMC is a subsidiary of LJRH and was established in 1995 as a sister company to AIMS. AMC's cental goal is to provide professional medical cost containment services that result in lower program costs to AMC's Clients. AMC's objective is to provide comprehensive managed care solutions, which significantly reduce workers compensation payouts. The AMC team is supported by an extensive management, technical and support staff located in multiple offices located throughout the State of California and Hawaii. AMC's expertise in medical cost containment services has produced outstanding results in overall savings for high profile accounts, specifically, the County of Los Angeles, Central San Joaquin Valley Risk Management Authority and more. Th9se public entity Clients have been able to obtain discernible savings as a direct result of AMC's diligence and attention to detail in the area of medical management and cost containment. AMC offers a full menu of integrated post containment services for Workers' Compensation programs, including: • Early Intervention — AlliedCare Complete * Bill Review Hospital Bill Audit • Preferred Provider Organizations (PPO) / Medical Provider Networks (MPN) • Utilization Review ■ Peer Review Addiction Rx Management — AlliedCare Rx • Telephonic and Field Case Management • Ancillary Service Networks • Extensive real time reporting on all services ■ Quality Control AMC recognizes that the most effective Claim outcomes are achieved when aggressive disability and medical management strategies are applied early on in the Claim. What makes AMC cost containment iinique and a benefit to a Client is: • Utilization Review Accreditation Commission (URAC) for Workers' Compensation Utilization Management • Custom program development based upon Client need and specifications March 15, 2023 49 w City of Lodi Request for Proposals for Third Party Administration Services for Workers' �--7 Compensation r Identification of triggers for various cost containment services • Written performance standards for employer, Claims, and cost containment units • Development of quarterly audit tool to evaluate performance of each work unit o Our audits evaluate the global program results, and not just cost containment results to ensure we are meeting all program goals o Analysis of quarte,ly audit results against pre -determined unit indicators and overall program benchmarks o Action plan based on deficiencies identified in the audit o Training of staff required to overcome deficiencies ■ Integrating medical professionals (e.g. nurses, physicians) into all areas of the program • Each AMC cost containment unit (Bill Review, UR, Case Management, and MPN) has strict levels of authority which require escalation of participation to nurses and/or physicians and/or managers to release final AMC work product back to the Examiner AMC has been providing Bill Review services since 1999 and Utilization Review services since 2004 to self-insured insurance carriers and public agencies. AIMS is committed to delivering the highest quality Claim handling services in the industry. We pride ourselves on being proactive in our approach to Claim resolution. And we point this out because the objective for all Claims is to come to a resolution in the most expedited manner possible. Extending the life of a Claim is not the objective, so clearing roadblocks, streamlining processes and making sure all parties understand the path, is the most effective way to handle a Claim. To that end, we will work with the City to create processes that support this goal. Many of these processes involve technology to expedite communication so decisions are made in the quickest possible time frames. AIMS internal IT team has worked closely with AIMS and our sister organization, AMC to create communication pathways which assist in these deliverables. We believe our knowledge of both the TPA and Managed Care environments can provide the City with solutions to address these inefficiencies. • If services are contracted out, does the proposer's business receive commissions and/or other type of compensation from the service provider? Describe any corporations within corporations in which the proposer may have an interest. Indicate fees/charges for services. As distinguished from other service providers, AIMS and AMC price their services on a stand- alone basis. In other words, AIMS prices the Claims administration services without regard to whether AMC's services, as a managed care provider, are being used and vice -versa. The fees are the same whether the services are bundled together or unbundled. This provides for a March 15, 2023 50 w.I City of Lodi Request for Proposals for Third Party Administration Services for Workers' ¢ Compensation transparency for our Clients to cleaey understand what they are paving for. Your ability to receive and report first aid/information only claims and additional costs associated with that service. AIMS will provide a monthly report of all newly reported First Aid Claims. These are identified as a Claimant (injured employee) Type FA (First Aid). In order to properly identify these types of Claims it is best if the Client enter these through our on-line reporting system with a note that they are "First Aid Only". These Claims should require no activity from AIMS but to upload the information into our system so that a payment can be processed through the Client's Trust Account. There is no additional cost associated with this service. Proposer will monitor treatment programs for injured employees, including review of all "Doctor's First Reports" (502 1) to assure that treatment is related to a compensable injury or illness. AIMS has reviewed this requirement and agrees to comply. As part of the 3 -Point contact, AIMS Indemnity/Medical Only Claims Examiners request all medical reports to be compliant with the regulations and carefully review the statements made by the evaluating physician in regards to compensability issues. Proposer will mala referrals to Utilization Review on a case-by-case basis and briefly describe the proposer's procedure for referrals to Utilization Review. AIMS has reviewed this requirement and agrees to comply. AMC provides Clients with UR Protocols developed to assess the frequency, duration, intensity and appropriateness of all modalities and procedures common to workers' compensation. These Protocols identify key services which should be authorized at the examiner level vs. Utilization Review. Many of our competitors suggest that all service requests should be reviewed by or through the Utilizatio-i Review Process. AMC/AIMS take a different approach to this, and instead views this as a medication management tool to be used when necessary. The medical management tool provides the Claims Examiner the ability to send medical service request to Utilization Review when they have concerns over the treatment. At that point, Utilization Review can determine if it is a necessary service. Otherwise, the Claims Examiner is the best advocate for the injured employee to receive the treatment necessary for recovery and should be permitted to authorize services within specified guidelines. Utilization Review Requests are electronically shared between the Claims Risk Management March 15, 2023 51 •---� �, i it ,,, , . City of Lodi Request for Proposals for Third T Party Administration Services for Workers' Compensation � V1.%ti%ir•.i mm i([e Information System (AIMS Ventiv System) and AlliedConnect (AMC's Information System) through a quick referral link within the Ventiv System. This link allows the Claims Examiner to quickly access the AMC AlliedConnect Portal and complete the necessary referral. In addition to having access to make a Utilization Review Referral, the Claims Examiner can also authorize treatment requests which produces an authorization letters which is uploaded to the Claims Risk Management Information System for validation of activity. The AlliedConnect system records all the Claims Examiner aut-�orizations and sends the authorizations for the Claims Examiner as part of their daily delivery procedures. As the two systems "speak" to each other, all of the Claim demographics are pre -entered for the Claims Examiner along with ease of use drop -downs for service requests. On average it takes a Claims Examiner less than five (5) minutes to complete the Utilization Review Process. UR Procedures The complete Utilization Review (UR) Life Cycle begins upon receiving a request for treatment from a provider and ends with the enforcement of the Utilization Review determination by the Bill Review Department, 1. Claims receives a request for authorization (RFA) 2. Claims Examiner approval process 3. Referral to Nurse Utilization Review 4. Referral to Peer Review 5. Utilization Review determinat ons sent to Bill Review for enforcement and payment Claims receives a request for authorization (RFA): AMC works within its own proprietary platform called, AlliedConnect database access services (AlliedConnect). AMC makes available to our Clients at no additional charge the use, of this proprietary Utilization Review software to capture and collect all requests for treatment. This user-friendly software was developed with the Claims Examiner in mind. Capturing all data regarding current and historical Utilization Review determinations help Claim's staff facilitate all Utilization Review issues in one place. Claims Examiner approval process: AMC understands that as much as seventy percent (70%) of all Utilization Reviews are approved at the Claims Examiners level. This is consistent with what the legislature had in mind when Utilization Review was introduced in 2004. The goal is to establish a medically supported base of treatment requests appropriate for authorization at the Claims Examiner level thereby eliminating unnecessary utilization review, delays in treatment, or additional costs to the file. AlliedConnect - Client module helps to track, enforce and report on the Client -specific customized criteria. AlliedConnect also helps to create, file and distribute the Claims Examiner's approval notification letters to the requesting March 15, 2023 52 r _w City of Lodi Request for Proposals for Third � •.ter Party Administration Services for Workers' 11. I j Compensation providers with a proof of service for future auditing. AiliedConnectwill then send the approval data to Bill Review for enforcement. Referral to Nurse Utilization Review: Once a request exceeds the Claims Examiners criteria, the request should be referred to the Utilization Review department for further analysis. First level review is completed by nurse clinicians. AMC has licensed nurses and physi--ians performing all Utilization Review (UR) services. This provides more accurate initial determinations which expedites care to the injured employee and minimizes our Clients' costs. The AMC Utilization Review Program operates under the direction of our Medical Program Director who is a California -licensed physician. Physicians that serve to evaluate treatment plans are licensed and board-certified with experience both as practicing physicians and in managed care/medical management. Specialty appropriate physicians are assigned to evaluate and make reccmmendations on plans of care. Many of our competitors have eliminated the Nurse Review step in hopes of reducing costs in the system. By eliminating the nurse step they are placing a Claims Examiner back into the role of medical decision maker. This results in placing the responsibility back in the hands of the Claims Examiner for obtaining appropriate medical information and interpreting what should be used in applying the evidence -based guidelines. Having a non -medically trained person process either manual or by use of licensed auto authorization software leaves a lot of room for error in applying appropriate guidelines as required by the Utilization Review regulations. Benefits of Nurses in the Utilization Review Process: Utilize medical knowledge, clinical experience, and evidence -based guidelines to determine medical necessity and appropriateness of requested treatment. Review prior medical records as they relate to the current request to assess historical data, changes in medical condition, identify co -morbidities which may impact request and/or outcomes. Identify pertinent records which still need to be gathered to avoid denials based on lack of medical information which in turn only delays treatment and increases costs via appeals and litigation. (Per LC 9792.7 and 9792.9., "if appropriate information which is necessary to render a decision is not provided with the original request for authorization, such information may be requested by a reviewer or non -physician reviewer within five (5) working days from the date of receipt of the written request for authorization to make the proper determination.") Once these additional records are obtained and reviewed at the nurse level, it may be appropriate for the treatment -o be certified by the nurse; thus, saving the Client the cost of the Peer Review. March 15, 2023 63 w City of Lodi Request for Proposals for Third r Party Administration Services for Workers' ��, � .I.I I r Compensation �XIAI i(I, I'I\I It,„ I I'.If '.f\I R\111 FC • Function as a resource for the Claims Examiner to better understand what is being requested, potential risks and complications, expected length of recovery, and set reserves. • Discuss treatment recommendations directly with providers as there is the shared common medical language and understanding. • Understanding and incorporating the Agreed Medical Examiner (AME), Qualified Medical Examiner (QME) and other medical/legal evaluations, implications and recommendations in the determination process as they impact the current treatment requests. • Utilize Best Practices and med cal Standards of Care when a request may marginally exceed a guideline (i.e., treatment request is physical therapy with two or three (2-3) sessions beyond guidelines. Nurse is able to review medical report by the provider, physical therapy progress notes, assess measurable outcomes, and determine additional sessions are medically beneficial; thereby, preventing delay in treatment, additional UR costs and unnecessary review by the Peer physician.) AMC believes the complete Utilization Review Life Cycle begins upon receiving a request for treatment from a provider and ends with enforcement of the Utilization Review determination by the Bill Review Department. We have captured our approach to the UR life cycle process in the Exhibit noted below and share this inf:)rmation with our Clients to make sure it mirrors their expectations. Please see Exhibit 12 — AMC UR RFA Workflow Proposer will reconcile the Workers Compensation bank account on a monthly basis. Briefly desa•ibe proposer's procedure for reconciling the City's workers' compensation bank account on a monthly basis and any additional costs associated with that service. AIMS has reviewed this requirement and agrees to comply. AIMS has extensive expertise establishing Workers' Compensation Trust Fund accounts for our Clients, AIMS Claims Manager/Supervisor will work with the Client to coordinate Client trust funds/checking accounts to ensure accuracy and appropriate funding levels. The Claims Manager/Supervisor function includes providing weekly/monthly check registers directly to Clients. AIMS established procedures support the payment of all benefits and allocated expenses together with appropriate documentation necessary to reconcile a trust fund checking account provided by the City. All payment requests shall be made with the necessary documentation to allow for an audit trail. Banking is managed from a separate and distinct division at our headquarters; thus facilitating March 15, 2023 54 City of Lodi Request for Proposals for Third P Party Administration Services for Workers' 7 i Compensation I'If I IB` If 1 1 additional fund management oversight, security, and monitoring. A monthly reconciliation report is provided to the City detailing trust account activity. The detailed accounting includes the date and check number of all benefits and allocated loss payments. All payment requests are rade with the necessary documentation to allow for an audit trail. The cost for this service is included in our TPA fees in the Exhibit noted below. Please see Exhibit 8 — AIMS Cost Proposal Proposer will audit and authorize timely payments of all medical bills in conformance with the recommended Official Medical Fee Schedule (OMFS) as set forth by the State of California Department of Industrial Relations, Labor Code section 5307.1 and sections 9739.10 et seq. of Title 8, California Code of Regulations. AIMS has reviewed this requirement and agrees to comply. AIMS protocol is for all payments to be made in a timely and comprehensive fashion in conformance with the Official Medical Fee Schedule (OMFS), Labor Code sec. 5307.1 and sections 9789.10 et seq. of Title 8, California Code of Regulations. Paying appropriate and timely benefits is critical in our business. AIMS has multiple levels of assurances in this regard. Before a payment is issued, it is verified for appropriateness, accuracy, and reserve adequacy. When applicable, minimum statutory requirements are adhered to or exceeded. All payments are listed in each file, and distinguished by the following basic categories: Indemnity, Medical, Legal/Allocated, and Vocational Rehabilitation. AIMS policy is all payment documentation is contained within the Claims file. Briefly discuss YOU system's access for the City to review benellit notices and case notes. AIMS utilizes Ventiv System, which is an Internet -based Claims Risk Management Information System built on Microsoft.Net technology, designed for anytime, anywhere access. The system access is web- based and runs on a Structured Query Language (SQL) database platform. Ventiv System has been in operation since 1999. This system is upgraded on a continuous basis. Access to this information allows the City to effectively manage its Workers' Compensation program and to confidently make higi impact risk management decisions. Our Claims Risk Management Information System provides the City with extensive on-line capabilities for reporting Claims, customized report generation, and immediate real time access to key March 15, 2023 55 r� rte, City of Lodi Request for Proposals for Third r Party Ad►rrinistration Services for Workers' .� I Ti i .� Compensation "" \'" 111: .'AI .I '.Ir til li\ It f.S � I information from any location. Ventiv System Access; Access to our system is only gained through user specific security codes; therefore, only select personrel who have been given clearance have access to data and monetary functions. Various sec.irity levels are granted to users, which preclude change of data and generation of payment or reserve changes unless pre -authorized. Also, the system allows password security at the location code level so user can access only their location information. The Client and its users will be provided with direct access to our Claims Risk Management System (RMIS) through the Internet, which will include the Diary, Claim Notepad, Payment & Reserves, correspondence, documert imaging and work status, The Client will be allowed an unlimited number of users on RMIS. Access to the system is provided to our Clients at no additional cost. Your experience with alternative dispute resolution (ADR) or "carve out" program implementation ant coordination and any additional cost ror these services. Alternative Dispute Resolution (ADR] assistance - AIMS has been in the forefront of the ADR/Carve-Out efforts dating back to 2010 when we worked closely with our then new Client, the City of Huntington Beach, to assist in the creation and implementation of their ADR program. AIMS has acquired the most experience with ADR/Carve-Out Programs in the entire California Workers' Compensation Industry. We are leaders in this effort and continually strive to provide our Clients with meaningful solutions to industry concerns, which we believe an effective ADR Program can accomplish. Our examining teams meet regularly to discuss any issues and concerns, which are then shared with the employer. Initial training is always recommended upon take-over or during a new implementation, to meet the Ombudsperson, ADR Administrator, and any key program staff, such as employer personnel responsible for ADR oversight. Additional meetings with key medical providers in the ADR Program may also be scheduled if certain clinics and/or groups are largely responsible for the treatment of the employees covered under the ADR Program. AIMS assists and provides all the Claim details for the ADR Annual Report provided to the State. In addition to this report, we also track key elements of the program to report out on activity, timelines, and outcomes. It is vitally important at the start of a program and/or the take- over of an existing program, to discus and fully understand what elements are to be tracked and what format the report should take. Understanding the fields to be tracked are key in the overall monitoring of the outcomes. March 15, 2023 56 City of Lodi Request for Proposals for Third . I: Party Administration Services for Workers' �--a Compensation: \I l ff a 1 \I \`: .1 I' If',1 11 R\ 11 1 ti 2, Litigation When notification of legal representation is received, proposer will initiate contact with the Risk Manager to discuss referral of the litigation to the City's authorized legal panel. Proposer will participate in all litigated cases fi•om the time an application is filed with the State of California Workers' Compensation Appeals Board (WCAB) until final disposition is rendered. AIMS has reviewed this requirement and agrees to comply. Please complete the following: Describe the procedure to be utilized in determining when special counsel is required. AIMS has formal Litigation Procedures that we incorporate in our handling of litigated Claims in full cooperation with attorneys desigiated by the City. Our Litigation Procedures involve preparing the necessary documentation for transmitting the Claim to Defense Counsel with instructions. The Claims Examiner directs the litigation with input of Defense Counsel and the City. This method of active involvement helps mitigate legal costs associated with unnecessary discovery proceedings, helps to gather all required evidence and witnesses as well as arranges expert testimony from the medical community. We also prepare and report the progress on the Claim to our Client. We recognize the importance of timely notification of scheduled appearances and commit to providirg adequate notice to the handling defense attorney firm within five (5) days from initial receipt of Notice of Hearing, All medical information received from Applicant or his/her attorney will be forwarded within five (5) days from the date of initial receipt. All benefits paid to the Appli-.ant will be summarized and along with the completed Balance Sheet, delivered to the defense counsel at least ten (10) days, if not sooner, prior to the Mandatory Settlement Conference. Subsequent hearings or proceedings mandated by the Workers' Compensation Appeals Bcard (WCAB) will also have the most recent summary of the benefits paid, along with a current Balance Sheet. At what point would proposer recommend referring a case to special counsel, and are There certain types of claims that require immediate referral? AIMS will recommend the use of a defense attorney when there is a need that is beyond the ability of the Claims Examiner such as: the need for a deposition, appearance at the Workers' Compensation Appeals Board (WCAB), and need for an expedited hearing to resolve Medical Provider Network (MPN) or Utilizaticn Review (UR) disputes. While we carefully monitor the activities of the defense attorney and stay completely involved with Claims decision, they are necessary in certain cases to achieve file resolution. March 15, 2023 57 City of Lodi Request for Proposals for Third Party Administration Services for Workers' fj Compensation Describe the procedure to be utilized in riling and serving all medical reports to the defense and applicant attorney. AIMS protocol is for medical reports to be sent to the defense and applicant attorney on a timely basis. Once a Claim becomes litigated, medical reports are to be filed and served upon receipt. Labor Code requires that within six (6) days of receipt medical reports are sent to attorney. AIMS will serve as the coordinating organization on all Claims litigation. AIMS will promptly assign files to legal counsel and we will ensure the attorneys will promptly provide a case summary to AIMS and the City. What procedures WOUld proposer use to manage the quality of worl< and cost of counsel to ti -e City? Legal expense control is one of the primary responsibilities of AIMS. All expenses, procedures, and billings are approved by the Claims Examiner/Supervisor. If an appeal is being considered for an adverse opinion, AIMS is the coordinating force in the decision making process. Procedures: Upon receipt of notice indicating a Claim has become litigated and/or the injured employee has become represented, the following is completed within twenty (25) calendar days of receipt: • Evaluate all reserves ■ Indicate on the physical file that the Claim is litigated and the identity of Defense Counsel. • Make the appropriate adjustments in the Claims Risk Management Information System Database. • If appropriate, file an Answer to the appropriate parties, delineating the areas/issues in dispute and the stipulated facts. In addition: 1. The Claims Examiner is responsible for performing all support functions of the litigation process that do not require the time of counsel. 2. Within their capabilities and as statutes allow, a Claims Examiner or Claims Supervisor may represent a Client before the Appeals Board of California or administrative or judicial body. If the case has a defense attorney assigned, it shall not be necessary for the AIMS Claims Examiner to attend the hearing, unless issues call for their attendance. 3. If assigned to Defense Counsel, an initial status report should be received within fifteen 15 days of assignment. Subse cent reports are to follow eve thin 30days. Within five (5) days following an appearance, a hearing report should be prepared and submitted to the Claims Examiner with the following: March 15, 2023 58 Citli of Lodi Request for Proposals for Third Party Administration Services for Workers' p f / f Compensation V. """'" 14"u, ." V V< • Case caption, time, date, place of hearing ■ Attendees ■ Issues discussed • Disposition 4. The hearing report should be prepared within five (5) days of the hearing or conference, and should be distributed to all interested parties. 5. All branch offices shall establish and maintain an approved legal panel. In addition, each Client Handling Instructions shall contain a list of approved defense firms. 6. An explanation of all issues, background data, and the specific goals of the referral are to be provided to Defense Counsal by the Claims Examiner at the time of referral. 7. The Claims Examiner/Supervisor coordinating the Claim will review and document the Claim status on all cases scheduled to go to trial or hearing at least seven (7) days prior to the trial/hearing date. 8. All Clients shall have the settlement authority provided to AIMS documented in the Client Handling Instructions. 9. Upon receipt of documentation indicating a settlement demand or offer, the Claims Examiner/Supervisor shall evaluate the demand or offer and complete a Settlement Analysis Worksheet to document the Claim file with the recommendation or answer. 10. Ail proposed settlements is discussed with our Client and settlement authority obtained. This is done well in advance o` the formal agreement itself. The authorization is documented in the Claim file/Claim notes. If AIMS has been granted blanket settlement authority up to a designated amount, the file handler shall still inform Client before the act of entering into settlement. 11. A primary responsibility of the Claims Examiner is to control defense costs. Thus, the Claims Examiner is to work closely with defense counsel and provide approval as required to obtain depositions, request medical examinations, conduct discovery, etc. 12. The Examiner has the responsibility to review all defense counsel billings, and recognize excessive time charges for specific legal functions, unnecessary or unauthorized discovery, excessive hourly rates, duplicate charges, mathematical errors, etc. 13. Upon receipt of a Decision or Order, the Claims Supervisor shall make a prompt analysis regarding an appeal. If the Claims Supervisor feels the decision should be appealed, the file should be documented as to the reasons and referred to the Claims Manager/Supervisor. 14. Upon review and approval by the Claims Manager/Supervisor, all decisions to appeal are fully discussed with the Client. If appropriate, Client approval should be solicited and documented. March 15, 2023 59 City of Lodi Request for Proposals for Third , Party Administration Services for Workers', i Compensation A sample of the Settlement Authority Request has been included in the Exhibit noted below Please see Exhibit 13 - Settlement Authority Request At what point waild proposer's claim adjuster make appearances at the WCAB and does proposer charge extra For these appearances? Explain. As a company, we have worked with the Workers' Compensation Appeals Board (WCAB), have attended State hearings, are active with all of the California Workers' Compensation professional organizations and attend all of the Workers' Compensation educational conferences. All of this means we are better prepared to achieve excellent program results for the City. AIMS would make appearances at the WCAB when necessary to support the outcome of a dispute and to assist the City in defense of a Claim. The time of the Claims Examiner is included within the annual fee set forth in the Cost Proposal. Please see Exhibit 8 — AIMS Cost Proposal 3. Aggressive pursuit of all subrogation recovery opportunities Describe proposer procedures in notifying the responsible third party regarding an incident and what is proposer's procedure to make s -ire that the statute does not expire. AIMS will aggressively pursue those responsible persons, agencies and all others, in subrogation actions in an effort to recover any losses suffered by the City due to injuries or illnesses inflicted on any of its represented employees. All attempts to recover costs will be based on an evaluation of potential recovery versus the hazards and delays of litigation, and approved jointly by AIMS and the C ty. All compromised settlements will be subject to the City's approval. AIMS believes in aggressively seek ng subrogation reimbursement and recovering damages from a third -party that is determined to be legally liable for the damages sustained by our Client. AIMS Claims Examiners understand they have the responsibility to review each Claim for possible subrogation potential. Any file which indicates the possibility of subrogation is forwarded to a Claims Supervisor fcr review to determine if further investigation is required. AIMS will review and identify the caise of the accident for each new Claim received and AIMS' assigned Claims Examiner will serve as the main subrogation adjuster. Notice of third -party credit recovery is sent out once the relevant party is identified. A notice letter is also sent out to the injured employee. A diary for the statute of limitation is set as a backup and the file is reviewed online In the maintained diary for subsequent follow up. March 15, 2023 60 City of Lodi Request for Proposals for Third Party Adirninistration Services for Workers' Compensation fj� I h V/ �r I I 11 %14 I\ IN It %\I 1 Upon receipt of the recovery, the Claims Examiner will forward the check with a cover letter indicating the amount of the recovery to be returned to each department. Some of the points considered may iiclude, but not be limited to, the injured employee was injured as a result of: • Injuries away from employer's premises • A motor vehicle accident • An assault ■ Malfunction of a tool or piece of equipment • Use of a type of machinery • Negligence of any other person Y Animal bite In addition. • It shall be the responsibility of the Claims Examiner to periodically request a status report from the attorney who is protecting the third -party interests, or from the attorney who has filed a lien or intervening petition on behalf of our Client. • OIjr Clients will be advised at least semi-annually regarding our efforts to recover moneys which have previously been paid. • Determination shall be made if Client has other damages to recover. Prior to entering into a recovery agreement, approval of the agreement should be given by our Client. This will protect our Client s interest in recovery of all expenses, including damage to company automobiles, etc., as opposed to simple recovery of Workers' Compensation costs. • Uoon receipt of the check or checks from the responsible third -party or parties, these moneys should be made payable to our Client and credited to the Workers' Compensation file in the appropriate category. In the event where a Police Officer is assaulted by a suspect who is later convicted of the crime and is incarcerated, the Claims Examiner will attempt to pursue recovery as a condition of the suspects probation. This arrangement will be made with the local District Attorney's office. 0 At what point would the proposer refer the subrogation file to legal counsel? AIMS recommends that any catastrophic injury involving an outside party and/or equipment or location be mmediately assigned to a subrogation specialist to preserve the evidence and record the events as they occurred. Too frequently the assignment is done much later in the Claim when equipment has been destroyed and/or accident recreation becomes impossible. Routine car accidents can be handled by the Claims Examiner. When authorized by our Client, consultation with AIMS liability specialists to evaluate the March 15, 2023 61 City of Lodi Request for Proposals for Third Party Administration Services for Workers' ? , Compensation strengths and weaknesses of the subrogation will take place • Prior to any settlement conference, proposer and/or defense counsel, whichever is appropriate, shall provide Citywith a written analysis of the case, including options and recommendations for settlement. All permanent disability ratings must be defined in dollars and percentages. TI1e Risk Manager or the City COLI11Cil depending u13011 the 0111O1111t Of SCRIClllellt Must authorize a settlement. AIMS has reviewed this requirement and agrees to comply. AIMS confirms Claim documentation s reflective of the facts of the case, the sequences of events from the start to case resolution. This documentation reflects the Claims Examiner's analysis and strategies, reserve and settlement evaluations, management of disability, medical and legal issues, as well as the Claims Supervisor's thorough analysis, directions and guidance. At each diary, the case is updated concerning the activity that has transpired since the last diary entry and a current Plan of Action documented, all of this is directed at pursuing final disposition of the Claim. Upon receipt of documentation indicating a settlement demand or offer, the Claims Examiner/Supervisor shall evaluate the demand or offer and complete a settlement analysis to document the Claim file with the recommendation or answer. The Claims Examiner must ensure there is a current balance sheat reflecting all indemnity payments issued prior to a Workers' Compensation Appeals Board (WCAB) proceeding and or prior to settlement negotiations. All proposed settlements are discussed with our Client and settlement authority obtained. This is well in advance of the formal agreement itself. The authorization is documented in the Claim file/Claim notes. If AIMS has been granted blanket settlement authority up to a designated amount, the Claims handler will still keep our Client updated on the progress of reaching a final settlement. Once a Claim has reached the point of serious settlement negotiations, AIMS will collect all pertinent data and present it to authorized City personnel along with our settlement recommendation contained in a clear and concise settlement package. Included in our settlement package will be reserve dccumentation indicating the adequacy of the reserves for eventual settlement offers, a summary of paid -to -date amounts, any disability ratings, if applicable, medical reports, a synopsis written by the handling Claims Examiner and approved by the Claims Supervisor and a complete risk assessment with any available alternative options authored by Defense Counsel (if applicable), The settlement recommendation package will be presented to the City in a timely fashion and in a format customized to meet the needs of the City. AIMS will not enter into any settlement negotiations without prior approval from the City authorized representative. All awards are paid within the statutory requirements or within fourteen (14) calendar days, whichever is less. All appropriate accrued interest is included in the award payment unless the approved award has had the interest 'Naived by the parties and the court in the settlement March 15, 2023 62 C� City of Lodi Request for Proposals for Third ., Party Administration Services for Workers w� 1 (' I) ti I' II li 1 Compensation �l ANI I If IN yl IN %,N( 1 ^may k NAf.:P.,ICv, SCR\9! CS document. A sample of the Settlement Authority Request has been included in the Exhibit noted below. Please see Exhibit 13 — Settlement Authority Request 4. Reporting Services Proposer shall provide the City with regular monthly and quarterly administrative reports in the format and number requested by the City. Such reports include, but may not be limited to, the following: Adminish-mlive Reports Annual Report to the State of California Monthly Listing of Open Claims by Department/Division Monthly Listing of Alphabetical Listing of All Active Claims Monthly Listing of Open Indemnity Claims Bi -Weekly Indemnity Payments Report Monthly Listing of Open Medical Only Claims Monthly Detailed Loss Repoit of All Open Claims Monthly List of All Currently Denied Claims List of Delayed Claims to InCAUde Expenses Paid During Delay Period Report of Litigation Referrals CAL/OSHA Log 300, 300 (a; and 301 Subrogation Report Report of Litigation Referrals Report of Litigation Fees Medical Case Management Claims Excess Insurance Claims Custom Reports Graphs for Each City Department Showing Severity and Frequency Graphs Showing Number of Injuries by Nature of Injury for each City Department and Combined Graphs Showing Number of Injuries by Body Part for each City Department and Combined Days Lost Due to Injury by City Department Average Cost of Injury for Each City Department and Combined Weekly: Employees Currently on Modified Duty, Work Restrictions and Next office Visit AIMS has reviewed this requirement and agrees to comply. AIMS supports Clients with a robust report library and can provide various standard monthly reports and custom reports upon recuest. Our Claims Risk Management Information System is March 15, 2023 63 :yri{i City of Lode Request for Proposals for Third Party Administration Services for Workers' a Compensation an extremely powerful data management system for both standard and ad hoc report generation. Our web based system a so provides convenience and access to real-time and "point in time" financials for generating customized Ad Hoc reports, multiple program reports for data downloads and monthly loss reports which can be exported into other applications such as Portable Document Format (PDF) or Microsoft Excel. There are many types of valuable data available electronically: • Claims summary ■ Claims Examiner notes/diaries • Detailed payment information Detailed transaction • Managed Care (UR, Fee Schedule) • Billing information • Prior TPA Information An extensive list of standard reports is available. Selection parameters, such as dates, locations, type of Claim, and status a low the user to create custom reports. Some of the more useful reports utilized by our public sector Clients to effectively manage their program from both a micro and a macro level are listed below: • Claims Cost Detail Reports • Claims Summary by Year Report • Claims Cost Summary • Financial Reconciliation Ledger ■ Management Summary Report • A monthly listing of open Claims by department/division • A monthly listing of open Claims alphabetically by claimant ■ Summaries of all open and closed Claims • Listing of future medical only Claims • Special reports upon request, such as injury analysis by cause, occupation, body part, department, etc. are available on the dashboard • Reserve analysis reports, which include initial reserve, reserve at closing and total amount paid ■ Quarterly penalty reports and reimbursements Reports can be provided at any interval as set forth by the Client through our customized reporting schedule. There is no additional charge for standard reports. Samples of Claims reports have been provided in the Exhibit noted below, Please see Exhibit 10 — AIMS Sample Claims Reports March 15, 2023 64 9=Z!. City of Lodi Request for Proposals for Third fill Party Administration Services for Workers' 4, i; Compensation Can proposer's reports be custo»ized per City request? Will custom reports be included in overall proposal cost? Identiry 4ny additional charges For customized reports. Yes, the AIMS Client Portal also provides ad-hoc access to data elements to analyze and visualize the Claim data. All Ad -Hoc components can be run instantaneously or on a scheduled basis in multiple export formats such as PDF or Excel. There are three components to Ad -Hoc: Information Analyzer: Analyzes and visualizes your data to be used for Client - customized dashboards and reports. Clients are able to group data together in tables, get summary information like totals, and create charts and gauges for the purpose of visualizing and comparing information. 2. Personalized Dashboards (based on User login): Able to be shared amongst team members and/or individually. 3. Visuals (Ad -Hoc Reports): Ability to design and schedule your own reports from data you have analyzed and gathered. Most Ad -Hoc report requests can be completed by our Data Delivery Services (DDS) team without any additional charge to the Client. Should the City have a highly specialized report that requires special programming of the system then the Data Delivery Services DDS will secure and provide an estimate of the fees to complete the request and seek approval from Client before proceeding. All specialized report fees are on a "pass-through" basis. Provide sample reports generated from proposeCs risk management information system indicating li•equency of reports provided (monthly, quarterly, and annually) to the employer. Samples of Claims reports have been provided in the Exhibit noted below. Please see Exhibit 10 — AIMS Sample Claims Reports Annual OSIP Report - Prepare tine Public Entities SCIf-Insurer's Annual Report as required by the Department of Industrial Relations Office of SCID Insurance Plans. AIMS has reviewed this requirement and agrees to comply - The proposer shall maintain all loss information as required by the Workers' Compensation Insurance Rating 6urcau. AIMS has reviewed this requirement and agrees to comply. The proposer shall assist in the preparation of all reports that are now, or will be, required by the State of Cali rornia or other government agencies with respect to self insurance programs. The proposer will also assist in the 1weparation of all reports ror other statistical database March 15, 2023 65 t� City of Lodi Request for Proposals for Third a 0-4 �,j Party Administration Services for Workers' 11.i 0-4 Compensation i I lir i+i ti Q - organizations or excess providers. AIMS has reviewed this requirement and agrees to comply. 5. Record Retention, Ownership and Inspection The proposer will agree that the City shall (lave access to and the right to examine, audit, excerpt, copy, or transcribe any pertinent records pertaining to this agreement at any tinge. AIMS has reviewed this requirement and agrees to comply. All records shall be maintained by the proposer and made available to the City during the term of the agreement and for a period of three years thereafter. All such records shall be delivered to the City in the format and media specified upon termination of the agreement. AIMS has reviewed this requirement and agrees to comply. The recordkeeping, maintenance, and transfer of physical Claim files and electronic data are governed by Title 8 of the California Code of Regulations, Sections 15400 through 5402.4. The physical files and electronic data maintained is the property of our Clients. We have a contractual and legal obligation to maintain accurate and complete records for them. All claim Files, records, reports and other documents or materials pertaining to the City's claims shall be the propsrly of the City and shall be available for the City's use at any time, and shall be delivered to the City upon termination ol'the agreement. AIMS has reviewed this requirement and agrees to comply. The retention of electronic claim files is an integral part of our service to our Clients. Documents shall be indexed in an organized manner that allow for quick access to document retrieval. Proposer must stipulate that all claim files, electronic data processing/nlanageiliem information system records. arxi all records generated on behall'of the City are owned by the City and that claim tileF will be available to the City upon request. AIMS has reviewed this requirement and agrees to comply. Client requirements prevail on the management of claim files, electronic data processing/management information system records, and all records generated on behalf of the City. These requirements will be incorporated in the Client Handling Instructions established for the City. All claim files shall be maintained in accordance with statutory time requirements and the City of f odi's Record Retention Policy, The City shall be notified prior to anydestruction of files to March 15, 2023 66 ' A City of Lodi Request for Proposals for Third r ,� ]�� C� Party Administration Services for Workers' �r .I I � f I 'r l oil 1'o h ;1 T E II Compensation AL I AXITI K. N INSUN: 110 ,�4ANAf;L'.�IC.NT SEFlVI(:CS determine if the City wishes to retain the claim file AIMS has reviewed this requirement and agrees to comply. March 15, 2023 67 I I III I City of Lodi Request for Proposals for Third Party Administration Services for Workers' Compensation Exhibit B — Fee Proposal For CITY OF I C A L I F O R N I A AIMS is proposing a Flat Annual Fee for the Third Party Claims Administration Services part of this RFP, Not to Exceed S893,000 over Five (5) years Y Claims Administration Fees: Flat annual fee for service AIMS proposes a "flat annual fee — no* to exceed" for the Workers' Compensation Third Party Administration Services which includes the handling of all current open Claims, new indemnity Claims, and new medical only Claims daring the life of the contract. A flat annual fee, as opposed to the "per -Claim or broken down fees", will provide a fixed and predictable budget item for the City of Lodi ("the City"). This flat annual fee eliminates the time and expense required to audit the per - Claim fee or other project cost estimates which varies month-to-month. In calculating the estimated flat annual rate for Claims Administration, AIMS first determines what the appropriate staffing requirements are in order to perform the required services. The required staffing is based on the requirements in the City's RFP for 1) Claim volumes listed below and 2) team to include a designated Senior Claims Adjuster/Examiner and the remaining files to be handled by a Medical Only/Future Medical Examiner with associated Claim Supervision & Management. Additional Clerical/Claims Assistant resources will be designated to the program. AIMS is proposing the designated Sr. Examiners to handle Open Indemnity Claims not to exceed a cap of one hundred and fifty (150), and a designated Examiner for Medical Only/Future Medical not to exceed an inventory cap of two hundred and fifty (250); (Future Medical and Medical Only Claims are counted as a 2:1). The estimated staffing cost is then used to determine the total City of Lodi Request for Proposals for ---AAI CI A,V.A11Ohl INSI IRANU Third Party Administration Services for h1ANAQJJL.: NlM Workers' Compensation operating costs related to the program, Lastly, AIMS Corporate overhead and a reasonable profit are added to the total operating costs to determine a reasonable Claims administration fee for the program. This pricing is for a bundled program with AIMS as the Third Party Claims Administrator and Allied Managed Care, Inc. (AMC) to provide any necessary medical cost containment services. If the City were to utilize vendors other than AMC the TPA pricing will change due to the following: AIMS estimates of the required Claims staffing is calculated with the use of our recommended managed care strategic partner, AMC, for medical cost containment services. As a result of signiflcant electronic interfaces with AMC, AIMS typically requires less staff, on a bundled basis, to complete the required work and, therefore, the fees and costs are typically lower on a bundled basis since there is more efficiency built-in for the Claim handlers. AIMS has included the AMC fees for all Managed Care Cost Containment Services below. The pricing below is based upon the staffing requirements as set forth in the subject RFP and any Addendum(s) or additional information provided: Staffing Allocations: o Designated Sr. Claims Examiner o Designated Medical Only/Future Medical Examiner o Clerical Support/Claims Assistant (designated) o Claims Supervisor/Manager (designated) C Inventory: o Indemnity: 66 Files o Future Medical: 71 Flies o Medical Only Reported: 41 Files o Total Open Inventory: 168 The City's AIMS staffing will have the appropriate Claims supervision and Claims Manager to oversee the partially dedicated Claims unit and program. In addition, the necessary corporate management, Claims man agement/supervision, IT management, clerical staff and other support staff will be assigned to the City's program. This fee is premised on, and in reliance on, the staffing requirements and Claims volumes as set forth in the RFP or related information provided. Should the City require additional staffing or the Claim volume changes, then both AIMS and the City will negotiate, in good faith, a reasonable fee adjustment based on any revised required staffing. _0 City of Lodi Request for Proposals for -I I ^4 Third Party Administration Services for 'CI ;;;;;;!';' INS! iklr'!`'F _­I� Workers' Compensation Claims Administration AIMS Proposed Fees: Term Cost Amount Year One Included $ 165,270.42 Year Two Included $ 170,22_8.54* Year Three _ $ 175,335.39* Year Four Included $ 1817,595.45'` Year Five- _ $ 186,(}13.32' _ Fl-otal Included $ 877,443.12 Annual Flat Rate for five (5} Years 1$ 175,488162 Annual cosi of lfvfag adJcrstmen! of 3.0% Should AIMS be selected for consideration to be the Claims administration service provider for the City's program then AIMS is open to negotiating a "best and final" fee arrangement that is based on any updated staffing and/or updated service requirements that will result in a fee arrangement mutually beneficial to both the City and AIMS. The total annual flat fee proposed above contemplates handling all Claims activity in a 12- month period (Claims already open at the beginning of the 12 -month term and any new Claims reported during the 12 -month term). The annual fee will be invoiced in 12 equal monthly amounts in arrears. The flat annual fees quoted above include all the services detailed in this RFP's proposal response including, but not limited to, the following services: Service Cost • Program Implementation (except for data Conversion) Included ■ All Claims Management Functions (currently open & new Claims) Included ■ Client RMIS Access — Unlimited number of Users Included • Data Management T Included • _ Claim File Storage Included • Claim File Retrieval Included • Account Management Included ■ Claim System Reporting Included ■ Public Self -Insurer's Annual Report Included OSHA Reporting Assistance Included + Prepare Federal form 1099 notices Included - _ ■ Custom AIMS "dashboard" Included • Web Site Access (on-line) Included ■ Detailed Stewardship Reports/Presentations f Included • Training Participation Included • MMSEA Reporting Included" City or Lodi Request for Proposals for,--I-I ' --� Third Party Administration Services for x'1.11\ � "K I, Workers' Compensation + File Reviews Included + Monthly Reports Included ■ Excess Reporting/Inquiries Included "Costs associated with MedicareSet Asic'a analysis and so -m- ssion or Medicam Condrlonal Lien negotiations are Allocated expenses ana paid off of the respective Claim files, Program Implementation, including Data Conversion Generally, there is a one-time, direct pass through, fee for data conversion and transfer. This fee will generally not exceed $15,000.00 per source entity, Program Implementation is included in the Flat Annual Fee. y Hourly rate for customization of reports and special reports requests Customization reports: Most ad-hoc report requests can be completed by our Data Delivery Services (DDS) team without any additional charge to the Client. Should the City have a highly specialized report that requires special programming of the system then DDS will secure and provide an estimate of the fees to complete the request and seek approval from our Client before proceeding. A typical hourly rate for these customized reports is approximately $250.00. All specialized report fees are on a "pass- though" basis. Allocated expenses not covered under the base price Allocated Loss Adjustment Expenses In the normal course of administering wor<ers' compensation Claims there will be additional fees for services provided by non-affiliated, Client -approved, service providers that are paid off of and allocated to the respective Claims file. These Allocated Loss Adjustment Expenses (ALAE) or adjustment expenses are linked directly to the processing of a specific Claim. ALAE is included as part to the expense reserves, along with loss reserves, on a Claims file and are included in the calculation for the funding of the loss trust fund in order to pay Claims, both losses and expenses, in a timely manner. Allocated expenses would normally include, but not be limited to, the following: • Costs for independent mecical examination or evaluation for rehabilitation; • Cost of legal transcripts of testimony taken; Cost for copies of any public records or medical records; • Costs of depositions and court reported or recorded statements; • Non -AIMS Costs and expenses of subrogation; • Costs of photographers and photocopy services; ■ Costs of outside investigation, signed or recorded statements; Costs associated with Medicare Set -Aside analysis and submission or Medicare Conditional Lien negotiation; • Any other extraordinary services performed by AIMS at the Client's request; • Investigation or possible fraud, including Special Investigations Unit services and related experses; r= .� City of Lodi Request for Proposals for° 4f fl AbAI IbPI I NSURANCF Third Party Administration Services for M1 ANAI;L,dL•. �I R1-� C5 Workers' Compensation Medical Cost Containment Services utilizing Allied Maj!Ngeq_Care'In c. _(AMC), Bill Review: Flat fee bill Medical Bill Review/PPO: Official Medical Fee Schedule (DMFS) Review: $6.60 per bill (flat rate per bill) plus PPO access fee (see below) The following is included (t ro additional char ); e Full Duplicates 0 Appeals a Initial Setup • Technology Fees for Interface Client Training • Re-evaluation/Provider Inquiries • Expert Testimony in Defense of Reviews ■ Electronic Data Interface and On-line Access S Courier Service PPO fee for savin s below fee schedule: PPO Network Access Fee: PRIME 18% InterPlan 18% ClarisPointe 18% Procura 18% Anthem Blue Cross - CA 24% First Health/Coventry 24% ASI Flex 18% Specialty Bill Review: Negotiation of Non -DMFS and Line -Item Audit bills, including Inpatient/Outpatient Hospital bills (non -PPO charges): 10% of Savings capped at a maximum of $6,000.00. Utilization Review: Flat fee for UR provided b doctor flat fee far URJ7ro�ided by nurse Utilization Review i R] City of Lodi Request for Proposals for .0, !d f I'•eV.ATI�HJ INSI �Il+d'!f f Third Party Administration Services for "" x.11. 4 tit Workers' Compensation a) Nurse Review: $95.00 per UR (nurse) Referral. This includes unlimited treatment requests and reviews per referral. b) Physician Review: $250.00 per Peer Review Referral. This includes unlimited treatment requests and reviews per_referral. The following is included in the above fees: • Initial set-up at the time of award of contract ■ Customized Special Account Instructions • Documentation letters post UR and Peer Review • Technology Fees for interface • Production Reports & Metrics • Consultation with AMC s Medical Director 9 Client Training Nurse Case Management: Hourly fee for telephonic case management, hourly fee for field case management Medical Management (Nurse Case Management) a) Telephonic Case Management: $107.00 per hour b) Field Case Management: S126.00 per hour* "Travel for Field Case Management (On -Site, services will be charged at the Internal Revenue Service approved rate for mileage at the time the mlleege is incurred Allied Managed Care Service Entity Medical Provider Network(MPN)_. AIMS will work with the City to establish an MPN, based upon the City's needs. AMC can install the MPN as the primary network. AMC offers custom provider networks, both MPN and PPO, to be used exclusively by our individual Clients. SB 863 changes now allow for "Service Entity" MPN certification. On March 11, 2015 AMC received approval from Department of Industrial RBlations, Division of Workers' Compensation Medical Unit for the AMC MPN (MPN Identification #2360). The original approval was valid for a period of four (4) years. On February 2, 2019, AMC was reapproved as a California Medical Provider Network for an additional four (4) year period. City of Lodi Request for Proposals for 4 (I 5A'FI ISI IIS+•N[ F Third Party Administration Services for x.:,(111U,1.,.11. N I'11(I S Workers' Compensation AMC has been approved by the Department of Workers' Compensation (DWC) as a Services Entity MPN. What this means to a Client is that they can now join the AMC MPN without having to file an MPN on their own and take on all the regulatory requirements as an Employer. We hope that the City takes advantage of this great opportunity to join the AMC MPN. Some of the benefits would include: ■ Medical Control for the Life of the Claim, if employee has not predesigned a physician • Elimination of providers that over -utilize narcotics or medical treatment • Quality Care from MPN providers • Per DWC reduced medical care Fnd reduced lost time • Referral to specialists within MPN ■ Quality Care monitoring through PAPN • Medical Access Assistant to assist employees from 7am to 8 pm Monday- Saturday • Bottom-line reduced medical costs for higher quality medical care These Workers' Compensation specific retworks incorporate the medical providers with extensive, specialized experience in dealing with irjuries incurred at the work place or job site. Employees receive the necessary treatment to relieve and resolve the effects of a work related injury. The MPN includes Certification from the State of California and Enrollment Notices to all Employees, complete monitoring of the MPN for State Compliance, and reporting with toll free access/assistance for Employers and Injured Employees and all services listed below. This also includes the continued monitoring of the Enrollment Process for New Hires. Available Services: • Assistance with creating MPN enrollment notices • MPN Application / Certification from State • On-line provider locater • Ten percent (10%) change monitoring • Toll Free Network Access Assistance to help locate providers • Support for Network & Employer provided • MPN roll-out meetings • Reporting We will work collaboratively with our Clients to ensure a smooth transition, including comparing the current MPN to determine which providers are already in our available Networks. Network development can recruit, credential, and contract any specific qualified providers to participate in the City's provider network. In addition to the MPN, AMC has an ever growing list of PPOs to offer and will work with our Client to determine the best PPOs for our Client's program. Our broad menu of network relationships is designed to offer our Clients the ability to match their own experience with the PPO option that would F Zi City of Lodi Request for Proposals for A �I A.MVION I NR I HANCF Third Party Administration Services for frl.ANACI I&V til MIC C� Workers' Compensation maximize cost effectiveness. By not being tied to or owning any network affiliation we can provide that expertise and flexibility to our Client =or all bill types in all jurisdictions. Additionally, the system allows several ways in which we can maintain and support Client specific contractual discounts. AMC's Bill Review software identifies PFO and negotiated fee providers by Tax ID Number. AMC can load virtually any PPO or negotiated tee arrangement by individual provider, by Tax ID Number, into the Bill Review software engine for automated application of discounts. Certain PPO networks are better than others depending on the locations of the providers, type of contracts, specialties of the providers, discounts etc. Allied Managed Care Service Entity Medical Provider Network (MPN) Fee: $2,000.00 per month 2417 First Report of Injury Nurse Trlaa services utilizing CarivaCare Provided below are details and estimated fees for 24/7 Call Center for First Report of Injury & Nurse Triage services if bundled with Third Party Administration services provided by AIMS. CarivaCare, our privately owned 24/7 first report of injury call center offers two pricing models: Per Claim Fee Model: A pricing structure that applies when a call results in an open Claim. The per Claim fee rate is only charged when a call results in an open Claim which allows the call fee to be paid off the Claim file - $166.00 per call. There are no charges for calls that result in report only, no treatment or self-care advice. Per Call Fee Model: A pricing structure that is charged for the initial call regardless if a Claim is made and a discounted rate for call backs if employee needs to call back for nurse triage - $96.00 per call. Follow up call back fees for employee questions or to and from treating facilities - $60.00 per call. EXHIBIT C NOTE. The City of Lodi is now using the online insurance program PINS Advantage. Once you have been awarded a contract you will receive an email from the City's online insurance program requesting you to forward the email to your insurance provider(s) to submit the required insurance documentation electronically Insurance Requirements for Professional Services Contractor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder and the results of that work by the Contractor, his agents, representatives, employees or subcontractors. MINIMUM SCOPE AND LIMIT OF INSURANCE Coverage shall be at least as broad as: 1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property darrage, bodily injury and personal & advertising injury with limits no less than $2,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this projectllocation (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. 2. Automobile Liability: ISO Form Number CA 00 01 covering any auto or if Contractor has no owned autos, then hired, and non - owned autos with limit no less than $1,000,000 per accident for bodily injury and property damage. 3. Workers' Compensation: as required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. 4. Professional Liability (Errors and Omissions) Insurance appropriate to the Consultant's profession, with limits not less than $1,000,000 per occurrence or claim. May be waivec by Risk Manager depending on the scope of services. Other Insurance Provisions: (a) Additional Named Insured Status The City of Lodi, its elected and appointed boards, commissions, officers, agents, employees, and volunteers are to be covered as additional insureds on the CGL and auto policy with respect to liability arising out of work or operations performed by or on behalf of the Contractor including materials, parts, or equipment furnished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to the Contractor's insurance (at least as broad as ISO Form CG 20 10 11 85 or if not available, through the addition of both CG 20 10, CG 20 26, CG 20 33, or CG 20 38; and CG 20 37 if a later edition is used (b) Primary and Non -Contributory Insurance Endorsement The limits of insurance coverage required may be satisfied by a combination of primary and umbrella or excess insurance. For any claims related to this contract, the Contractor's insurance coverage shall be primary coverage at least as broad as ISO CG 20 01 04 13 as respects the Entity, its officers, officials, employees, and volunteers. Any insurance or self-insurance maintained by the Entity, its officers, officials, employees, or volunteers shall be excess of the Contractor's insurance and shall not contribute with it. (c) Waiver of Subrogation Contractor hereby grants to City of Lodi a waiver of any right to subrogation which any insurer of said Contractor may acquire against the City of Lodi by virtue of the payment of any loss under such insurance. Contractor agrees to obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the City of Lodi has received a waiver of subrogation endorsement from the insurer NOTE: (1) The street address of the CITY OF LODI must be shown along with (a) and (b) and (c) above: 221 West Pine Street, Lodi, California, 95240; (2) The insurance certificate must state, on its face or as an endorsement, a description of therp oject that it is insuring. (d) Severability of Interest Clause The term "insured" is used severally and not collectively, but the inclusion herein of more than one insured shall not operate to increase the limit of the company's liability under the Contractors commercial general liability and automobile liability policies. (e) Notice of Cancellation or Chance in Coverage Endo-sement This policy may not be canceled nor the coverace reduced by the company without 30 days' prior written notice of such cancellation or reduction in coverage to the Risk Manager, City of Lodi, 221 West Pine St., Lodi, CA 95240. Page 1 I of 2 pages I Risk: rev. 3/1/2018 (f) Continuity of Coverage All policies shall be in effect on or before the first day of the Term of this Agreement. At least thirty (30) days prior to the expiration of each insurance policy, Contractor shall furnish a certificate(s) showing that a new or extended policy has been obtained which meets the minimum requirements of this Agreement Contractor shall provide proof of continuing insurance on at least an annual basis during the Term. If Contractor's insurance lapses or is discontinued for any reason, Contractor shall immediately notify the City and immediately obtain replacement insurance. Contractor agrees and stipulates that any insurance coverage provided to the City of Lodi shall provide for a claims period following termination of coverage which is at least consistent with the claims period or statutes of limitations found in the California Tort Claims Act (California Government Code Section 810 et seq.). (g) Failure to Comply If Contractor fails or refuses to obtain and maintain the required insurance, or fails to provide proof of coverage, the City may obtain the insurance. Contractor shall reimburse the City for premiums paid, with interest on the premium paid by the City at the maximum allowable legal rate then in effect in California. The City shall notify Contractor of such payment of premiums within thirty (30) days of payment stating the amount paid, the name(s) of the insurer(s), and rate of interest. Contractor shall pay such reimbursement and interest on the first (1st) day of the month following the City's notice. Notwithstanding any other provision of this Agreement, if Contractor fails or refuses to obtain or maintain insurance as required by this agreement, or fails to provide proof of insurance, the City may terminate this Agreement upon such breach. Upon such termination, Contractor shall immediately cease use of the Site or facilities and commence and diligently pursue the removal of any and all of its personal property from the site or facilities. (h) Verification of Coverage Consultant shall furnish the City with a copy of the policy declaration and endorsement page(s), original certificates and amendatory endorsements or copies of the applicab a policy language effecting coverage required by this clause. All certificates and endorsements are to be received and approved by the City before work commences. However, failure to obtain the required documents prior to the work beginning shall not waive the Consultant's obligation to provide them. The City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. Failure to exercise this right shall not constitute a waiver of the City's right to exercise after the effective date. (i) Self-insured Retentions Self-insured retentions must be declared to and app-oved by the City. The City may require the Consultant to provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. The policy language shall provide, or be endorsed to provide, that the self-insured retention may be satisfied by either the named insured or City. (j) Insurance Limits The limits of insurance described herein shall not limit the liability of the Contractor and Contractor's officers, employees, agents, representatives or subcontractors. Contractor's obligation to defend, indemnify and hold the City and its officers, officials, employees, agents and volunteers harmless under the provisions of this paragraph is not limited to or restricted by any requirement in the Agreement for Contractor to procure and maintain a policy of insurance. (k) Subcontractors Consultant shall require and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and Consultant shall ensure that City is an additional insured on insurance required from subcontractors (1) Claims Made Policies If any of the required policies provide coverage on a claims -made basis: 1. The Retroactive Date must be shown and must be before the date of the contract or the beginning of contract work. 2. Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the contract of work. 3. If coverage is canceled or non -renewed, and rot replaced with another claims -made policy form with a Retroactive Date prior to the contract effective date, the Consultant must purchase "extended reporting" coverage for a minimum of five (5) years after completion of contract work. (m) Qualified Insurer(s) All insurance required by the terms of this Agreemert must be provided by insurers licensed to do business in the State of California which are rated at least "A-, VI" by the AM Best Ratings Guide, and which are acceptable to the City. Non -admitted surplus lines carriers may be accepted provided they are included on the most recent list of California eligible surplus lines insurers (LESLI list) and otherwise meet City requirements. Page 2 1 of 2 pages I Risk: rev. 3/1/2018 RESOLUTION NO. 2023-94 A RESOLUTION OF THE LODI CITY COUNCIL AUTHORIZING THE CITY MANAGER TO EXECUTE A PROFESSIONAL SERVICES AGREEMENT WITH ACCLAMATION INSURANCE MANAGEMENT SERVICES, INC., OF SACRAMENTO, FOR WORKERS' COMPENSATION THIRD -PARTY ADMINISTRATION WHEREAS, the City is certified by the State of California Department of Industrial Relations under Labor Code Sections 3700 and 3705 to self -insure for providing statutorily required Workers' Compensation benefits to its employees; and WHEREAS, the City contracts for third -party administration of its self-insured Workers' Compensation Program; and WHEREAS, the City currently has an agreement with Sedgwick to serve as the third -party administrator (TPA) for the City's Workers' Compensation Program and said agreement will expire on June 30, 2023; and WHEREAS, the City issued a Request for Proposals for Workers' Compensation TPA services and received six responses; and WHEREAS, a five -member evaluation panel determined that Acclamation Insurance Management Services, Inc., was the best -qualified respondent. NOW, THEREFORE, BE IT RESOLVED that the Lodi City Council does hereby authorize the City Manager to execute a Professional Services Agreement for Workers' Compensation self- insurance third -party administration with Acclamation Insurance Management Services, Inc., of Sacramento, California, for the period July 1, 2023, to June 30, 2028, in an amount not to exceed $893,000; and BE IT FURTHER RESOLVED, pursuant to Section 6.3q of the City Council Protocol Manual (adopted 11/6/19, Resolution No. 2019-223), the City Attorney is hereby authorized to make minor revisions to the above -referenced document(s) that do not alter the compensation or term, and make clerical corrections as necessary. Date: May 17, 2023 ---------------- ---------------- I hereby certify that Resolution No. 2023-94 was passed and adopted by the Lodi City Council in a regular meeting held May 17, 2023 by the following vote: AYES: COUNCIL MEMBERS — Bregman, Craig, Nakanishi, Yepez, and Mayor Hothi NOES: COUNCIL MEMBERS — None ABSENT: COUNCIL MEMBERS — None ABSTAIN: COUNCIL MEMBERS — None PAMELA M. FARRIS Assistant City Clerk 2023-94