HomeMy WebLinkAboutI. Emergency Services
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: January 20, 2010
Division:
Emergency Services
Bulk Item: Yes ~
No
Depmiment: Fire Rescue
Staff Contact PersonlPhone#: Camille Dubroff X 6010
AGENDA ITEM WORDING: Request BOCC direction to either: 1) Authorize the waiver of the
purchasing policy requiring a request for qualifications, approve the early termination of the current service
agreement with Advanced Data Processing Inc.-Intermedix (ADPI) and approval of a new contract with ADPI
for rescue ground and air transport billing and related professional services for three (3) years, effective January
1,2010 through December 3 I, 2012, with the option to renew for two (2) additional one-year periods, to al low
for a reduction in the collection rate percentage from 7% to 6.25%; or, 2) Direct the division to solicit a request
for qualifications for rescue air and ground transport billing to be effective June 1,20 I O.
ITEM BACKGROUND: The medical insurance industry's reporting and coding changes have become
increasingly more complex and require extensive expertise in the field of patient billing. To maximize the user-
fees collected for ground and air ambulance transports, it is vital for Monroe County to have a billing agency
that is national leader in the industry and has a proven track record in addressing the unique needs of the
Florida Keys and the south Florida region. ADPI has been providing billing services to Monroe County for 9
years and has been providing this service nationally for more than 25 years. ADPI serves more than 250
communities across the United States, 59 ofwhich are in the state of Florida resulting in ADPI processing more
patient accounts in the State of Florida than all other competitors combined. ADPI is the largest EMS billing
company in the country by a factor of more than twice than their nearest competitor.
The existing ADPI contract expires June 1,2010. The current ADPI contract compensation is 7% of
total collections and $11.40 per Medicaid account. Research shows the industry average for contracting with a
new ambulance billing company is 8% to 10% of what is collected. Marathon and Islamorada's rate is 8.25%
and Key Largo's rate is 8.65% through another billing company.
To renew the contract for an additional 3-5 year period, ADPI has offered to reduce the County's rate to
6.25% oftotal collections and $10.00 per Medicaid account. This approximates an 11 % rate reduction and
results in additional user-fee dollars for Monroe County. In addition, this eliminates the costs and technical
challenges related to transitioning to a different billing company for computer software, hardware and technical
training. Attachment A provides additional details regarding ADP1' s services and the possible challenges
related to a change to another billing company.
PREVIOUS RELEVANT BOCC ACTION: On May 20,2009 the Board approved the final renewal
clause from June 1,2009 through May 31, 2010. On April 21, 2008 the Board approved the first one year
renewal clause from June 1,2008 through May 31,2009. On April 20, 2005 the Board approved to enter into a
contract for three years (3) effective June 1, 2005 through May 3], 2008 with the option to renew for two (2)
additional one year periods.
CONTRACT/AGREEMENT CHANGES: Early termination of the current contract with Advanced Data
Processing Inc. - I ntermedix and a new contract for three (3) years effective January 1,2010 through December
3], 2012 with the option to renew for two (2) additional one year periods.
STAFF RECOMMENDATIONS: Staff recommends option 1 in order to immediately realize contractual
savings for rescue ground and air transpOlt billing.
TOTAL COST: 6.25% of total collections INDIRECT COST: N/A BUDGETED: Yes ~No
and $10.00 per Medicaid Account
DIFFERENTIAL OF LOCAL PREFERENCE: N/A
COST TO COUNTY: Ground $33,600.00; Air $96,000.00 SOURCE OF FUNDS: Billing Collection
REVENUE PRODUCING: Yes No X AMOUNT PER MONTH Year
APPROVED BY: County Atty ~ OMB/Purchasing _ Risk Management~
DOCUMENTATION: Included ~ Not Required
DISPOSITION:
Revised 07/09
AGENDA ITEM #
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS!
BOARD OF GOVERNORS FIRE AND AMBULANCE DISTRICT 1
CONTRACT SUMMARY
Contract with:
Advanced Data
Processing Inc. - Intermedix
J Contract #_
Effective Date:
Expiration Date:
Ja'uary 1, /2010
Yeccellib-e~r 31,fl012
Contract Purpose/Description:
Contract for rescue air and ground transport billing and related professional servicesl
Contract Manager: Camille Dubroff
(Name)
6010
(Ext. )
Emergency Services I Stop 14
(Department/Stop #)
for BOG meeting on
1/20/2010 I
I
Agenda Deadline: 1/5/2010
CONTRACT COSTS
Total Dollar Value of Contract: $
Budgeted? Y es~
Grant: $
County Match: $
NoD
6.25% of total Current Year
collections and I Portion: $
$10.00 per Medicaid
accounts
Account Codes: 13001 530340 Ground / [1001 530340 Air ./
. L 33/000 L c\ it 1 0 0 O.
- - - -
~~-----
ADDITIONAL COSTS
Estimated Ongoing Costs: $_/yr For:
(Not included in dollar value above) (eg. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Changes
Date In Needed.-/ ~
Division Director //-~:~ '7 . YesDNo~ _ _.. _ ~
Risk Mana~e~~nt \0 d-9.6J YesD No~ '"
~ \J ~ \t1~lO(){-'~
O.M.B./Purchasing -l YesD NoQZl . , ~
IO~ YesDNoB ~tM -t-
r<1b u.i ve ~.Jtqr~ 16 rw Q1JJ;.QJiJ)c.1 pot '0-/,
Date Out
County Attorney
*,
Comments: wdl
OMB Form Revised 2/27/01 MCP #2
Attachment A to the Agenda Item Summary
To the Board of County Commissioners,
Respectfully request authorization to waive the purchasing policy and continue to contract with Advanced Data
Processing Inc.-Intermedix (ADPI) for air and ground transport billing and related services. Below outlines
information related to ADPls credentials and services provided to Monroe County, and the possible challenges
related to changing billing agencies.
As the insurance indust-y repOlting and coding changes become increasingly more complex and require
extensive expertise in the field of patient billing, it is vital to have a national agency that is a leader in the
industry with a proven track record in the Florida Keys and South Florida. This is what we have with ADPI as
reflected below.
ADPI has been the contracted billing agency for Monroe County Fire Rescue since September 1,2000. Previous
to this, Monroe County Fire Rescue did its own user-fee billing, which required two ful1 time employees. For the
entire nine-year period, plicing has been 7% of what is collected and an additional $11.40 per Medicaid account.
Locally, Marathon and Islamorada's rate is 8.25% and Key Largo's rate is 8.65% with another company.
Research shows the industry average for contracting with a new ambulance billing company is 8% to 10% of
what is collected.
In recognition of the nine-year relationship, ADPI has offered a reduction to 6.25% of what is collected and
$10.00 per Medicaid account to extend the contract for thl'ee (3) years with the option for two (2) additional one-
year renewals. This lower rate will result in additional user-fee revenue to the county. In addition, it would
eliminate additional expenses and lost productivity related to converting to another billing company.
ADPI-Intermedix credentials:
· ADPI has been providing billing services and teclmology to agencies across the count.y for more than
25 years. Nine years for Monroe County.
· ADPI serves more than 250 communities across the United States, of which 59 are in the state of
Florida.
· ADPI processes more patient accounts in the State of Florida than all other competitors combined.
· ADPI is the largest EMS billing company in the country by a factor of twice more than their nearest
competitor.
· ADPI's clients include large and small agencies; including Miami-Dade, Palm Beach and
Duval/Jacksonville counties and small cities with under 1500 t'ansports annually, such as Lighthouse
Point, Oviedo, and Maitland.
· Monroe County and ADPI Comparable data
· ADPI-Intermedix has collected over $5.1 million over the approximate 9-year contract peliod.
· Monroe County's revenue per transport for ground is around $301 compared to the rest of Florida
around $255.
· Monroe County Trauma Star revenue per air transport is around $4,063 compared to the rest of
Florida (air transports only) around $2,775.
· The County's collection rate is currently around 57% and the average for all Florida ADPI clients is
around 56%.
What ADPI is currently provides for Monroe County
ADPI provides both ground and air ambulance billing. ADPI has customized their billing program to be
completely compatible with Monroe County's EMS billing software. This allows elect-onic t'ansfer of billing
files to a secure ADPI site. This secure site allows the exchange of patient information in compliance with
HIP AA laws and is in compliance with the new Federal Trade Commissions Red Flag Rules. This electTonic
t-ansfer of information is immediate and eliminates delays in the receipt and processing of reports for billing
purposes. Additionally, it eliminates Monroe County Fire Rescue's need to use and store paper reports and the
expense to mailing paper reports to ADPI.
1
ADPI has a sound relationship with insurance agencies which facilitates billing between insurance companies,
ADPI and Monroe County. ADPI is linked to both MCFR lockboxes where payments are received and has an
established working relationship with the bank to receive patient payments and account infol111ation to expedite
crediting patient accounts. This exchange of infOlwation is done on a daily basis through a secure server. ADPI
provides a hospital liaison to facilitate the collection of any missing billing information and all other missing
patient infol111ation is located through a skip tracing program. Once billings have been maximized, ADPI then
provides electronic infonnation monthly to Monroe County's collections agency through a secure site for
outstanding accounts. ADPI also coordinates the County's Trauma Star Fee Waiver Program.
ADPI is extremely responsive to Monroe County's need both for billing and statistical repOliing, and has
dedicated professionals assigned to the account that allows for quick follow up and answers to any questions.
Additionally, two dedicated toll-free phone lines are assigned to Monroe County for patients to call to discuss
either ground or air accounts and a website is available so patients can enter insurance information ifneeded.
ADPI has a dedicated Compliance Team to assist with legal matters that may arise related to compliance issues
with Insurance, Medicaid, Medicare or other industry changes; and is HIP AA compliant and security conscious.
As p31i of the ADPI commitment to compliance and client service, they provides live webinars to their clients to
keep abreast of new regulations and how these regulations will affect services and provides consultation on
establishing accurate and equitable fee structures through comparisons of fee shuctures in other similar counties
in Florida. ADPI suggests rate changes as needed to keep in line with the allowable reimbursements guidelines
set by Medicaid and Medicare.
Challenges that may arise in the change over in billing agencies:
There will be a financial burden to the county to set up any new agency to work with Monroe County's EMS
reporting software including numerous staff hours to facilitate the successful and accurate transition ofpatient
reporting to the new agency through the EMS reporting software and the subsequent changes in information and
follow-up to insurance companies, banking, and collection's agency.
For comparison purposes, when the county changed collection agencies, it took six months to complete the
change over and transfer of the first accounts to them from the former contractor, and to implement elech"onic
data h'ansfer tlu'ough ADPI after implementing software program changes. This was without requiring any
changes to Monroe County's EMS reporting program software and processes.
A loss of revenue is probable while the change over in billing companies occurs due to these and other factors:
I. All ADPI accounts would have to be closed and transfened to the new billing agency resulting in
potentially reduced revenues during the transition.
a. All patients who have set up monthly payments with ADPI could potentially be lost. Cun'ently
there are 77 patients that have monthly payment agreements with ADPI.
b, All accounts, including those in the billing process, would have to be closed and sent to the new
agency. Those with pending insurance claims would likely be closed resulting in the new
agency having to start the billing process anew. This could result in a loss of revenue if not
billed in a timely manner because most insurance companies have a timeliness ofbilling rule.
The quicker accounts are billed, the most likely billed amounts are received.
2. Software Incompatibility. ADPI's software fully integrates with Monroe County's EMS reporting
program software which enables paperless, electronic billing with streamlined processing. If a new
agency is awarded the contract, they will have to have compatible software and be willing to work with
the IT department to modify their systems to work with Mom-oe County's EMS repOliing program.
They would also have to be able to receive electTonic files and provide a secure site to do so.
3. Going to RFP could potentially result in a higher percentage rate than that offered by ADPI to extend the
contract.
2
I
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Org Code Expenditure Detail Item Budget grouped by Business Center, Business Unit
Board f Count ommissioners
Expenditure Detail flam Descriptio n
Sarvice
Level Issue #
FY 2010
Budget
I
12 Emergency Services
FY 201'1
Budget
FY 2012
Budget
I
I
02) Medical Director($31,500). Professional Emergency Services Inc. agreement including a 5% increase above last year
as contract dictates.
03) Sheriff Budget ($1.272,992). 'NOTE> this was the FY 09 Budget. Sheriff's Office will be giving the MCSO FY10 Budget
to us in June and this figure could increase at this time.
I
04) Municipal Services Bureau ($1,000). Collection agency for delinquent Air Ambulance ACCOUnts
530400 Travel And Per Diem
01) Flight Paramedic Certification Exam Travel
02) Flight Nurse Certification Exam Travel
~
1,200 1,200 1,200
1,200 1.200 1 ,200
530400 Travel And Per Diem 2,400 2,400 2,400
Nnl",,' 01} Flight Paramedic Certification Exam Travel ($1,200). Approx. cost for Hotel. fuel and meals $400/pp x 3 = $1,200
02) Flight Nurse Certification Exam Travel ($1.200), Approx. cost for Hotel, fuel and meals $400/pp x 3 = $1,200
530409 Vehicle Maintenance Chrl!s
01) Vehicle Maintenance . 1 1,000 1,000 1.000
Nnt...". 01) Vehicle Maintenance: ($1,000) This is an estimate based on previous year. Fleet Management will update this line item
this to the correct figure for FYi O. (Air Medical Chief vehicle)
530410 Phone & POslal!e/freil!ht
01} Nextel
02}AT&T
03) AT&T Ethemet
04) AT&T IPHONE
05) Postage
05) Postage (100) - Historical $100
530440 Rentals And Leases
01) Air Gas South 852 852
Nnt..... 01} Air Gas South: ($852) Lease of liquid oxygen tanks used far refilling Trauma Star's anboard oxygen tanks.
month x 12 = $852.00
530460 Repair And Maintenance
01} Repair to Ventilator
02} Repair to IV Pumps
530410 Phone & Posloge/freight
Nnt...", 01) Nextel ($420). FIt Medics. $35/mo x 12" $420
420
600
2,184
1,500
100
4.804
02) AT&T ($600) - Station (Hangar) phone - $50/mo x 12 = $600
03) AT&T Ethernet ($2,184) (Internet to Hangar) . $1821mo x 12" $2,184
04} AT&T IPHONE ($1,500) - Air Medical Chief - $125/mo x 12 = $1,500
530460 Repair And Maintenance
Nnl..", 01) Repair to Ventilator ($150) resulting from Preventative Maintenance
150
1,500
1,650
420
600
2,184
1,500
100
4,804
150
1,500
1,650
420
600
2,184
1.500
100
4,804
852
$71 per
150
1,500
1.650
1.200
1,200
2,400
1,000
420
600
2.184
1,500
100
4,804
852
150
1,500
1,650
1.200
1,200
2,400
1,000
420
600
2,t84
1.500
100
4,804
852
150
1,500
1,650
02) Repair to IV Pumps ($1,500) resulting from Preventative Maintenance
530470 Printinl! And Bindine:
01) Printing and Binding 1 370 370 370 370 370
Nnl",,' 01) Printing and Binding ($370) Historical experience.
530498 Advertisine:
01) Advertising 1 190 190 190 190 190
Nnt..". Of} Advertising ($190) - far open positions. Historical experience.
530510 Office Supplies
01) Office Supplies 500 500 500 500 500
Nnt..". 01) Office Supplies ($500) Historical experience,
530512 Medicine & Drue:s
3
10/2/2009
GovMax
Expenditure Detail Item Description
Service
Level Issue :I
FY 2010
Budget
Org Code Expenditure Detail Item Budget grouped by Business Center, Business Unit
Monroe Count Board of Count Commissioner.
12 Emergency Services
1130 EMS Administration i
13001 Lk & Mk Ambulance
530316 Medical Services
01) Drug screen, exposure testing
02) Annual Physicals/Stress Tests
2,000
15,698
17,698
530316 Medical Services
Nnt"", 01) Drug screen, exposure testing: ($2,000) Historical experience,
FY 2011
Budget
2,000
15,698
17,698
FY 2012
Budget
2,000
15,698
17,698
2,000
15,698
17,698
02) Annual Physicals/Stress Tests. Career: ($15,698) Within cost center 13001,47 total personnel. Over 40 years old
requires an annual stress test, 23 x $200 = $4,600 and Physicals 23 x $358 = $8,234. Under 40 years old requires physical
v ree ears. 24 personnel are under 40, average 8 per year x $358 - $2,864,
530340 Other Contractual Service
01) Advanced Data Processing, Inc, (ADP1) Contract
UnlClpa. ervlces ureau Contract
03) Medical Director
04) Medical Director - Meetings
05) Zoll Data EMS Reporting System Licensing
33,600 33,600 33,600
2,300 2,300 2,300
27,025 27,025 27,025
2,500 2,500 2,500
8,850 8,850 8,850
530340 Other Contractual Service 74,275 74,275 74,275
Nnt"". 01) Advanced Data Processing, Inc, (ADPI) Contract: ($31,000) To process ambulance bills and collect moneyon all
accounts, (FY 09 $28,881.00)
33,600
2,300
27,025
2,500
8,850
74,275
02) MunicipaJ.Services Bureau Contract: ($2,300) To collect money on delinquent accounts deemed uncollectable by billing
agent ADPI.
03) Medical Director: ($27,025) Total contract $61,421 diVided by 2 CO!;t centers: $34,396 (11500), $27,025(13001) This is
a 5% increase over last year as the contract dictates,
05) Zoll Data EMS Reporting System Licensing: ($8,850) This is the EMS tablet PCR reporting system
annual licensing and tech support fee,
530400 Travcl And Pcr Dicm
01) Travel & Per Diem 2,000 2,000 2,000
Nnt"". 01) Travel & Per Diem: ($2,000) Historical experience. These funds cover incidental training opportunities or out-of-county
meetings that are impossible to project as much as 17 months in advance,
530409 Vehicle Maintenance Chrl!S
01) Vehicle Maintenance 1,000 1,000 1,000
Nntfl'" 01) Vehicle Maintenance: ($1,000) This is an estimate based on previous year. Fleet Management will update this line item
this to the correct figure for FYi o. (Battalion Chief of Ops vehicle)
530410 Phone & Postal!effreil!ht
01) AT&T
02) Nexlel Phones - Rescue Units
03) AT&T VPN Internet
04) Fed Ex
05) Suncom
06) UPS Service
07) Verlzon Wireless Aircard
AT&T -IPHONE - Battalion Chief
AT&T Ethernet
10) AT&T Circuits
04) Medical Director - Meetings: ($2,500) To cover special meetings
1
1
1
1
1
1
1
1
1
1
7,920
5,400
4,632
600
60
832
504
1,500
6,348
3,792
31,588
530410 Phone & Poslage/freight
34
7,920
5,400
4,632
600
60
832
504
1,500
6,348
3,792
31,588
7,920
5,400
4,632
600
60
832
504
1,500
6,348
3,792
31,588
2,000
1,000
7,920
5,400
4,632
600
60
832
504
1,500
6,348
3,792
31,588
t-
Budgel
2,000
15,698
17,698
33,600
2,300
27,025
2,500
8,850
74,275
2,000
1,000
7,920
5,400
4,632
600
60
832
504
1,500
6,348
3,792
31,588
101212009
CONTRACT BETWEEN
THE BOARD OF COUNTY COMMISSIONERS
AND
THE BOARD OF GOVERNORS FIRE AND AMBULANCE DISTRICT 1
OF MONROE COUNTY, FLORIDA
AND
ADVANCED DATA PROCESSING, INC. (DBA ADPI-INTERMEDIX)
FOR RESCUE AIR AND GROUND TRANSPORT BILLING
AND RELATED PROFESSIONAL SERVICES
THIS CONTRACT, hereinafter "CONTRACT OR AGREEMENT" is made and entered into
this day of ,2010 by and between the BOARD OF GOVERNORS
OF FIRE AND AMBULANCE DISTRICT 1, MONROE COUNTY, a political subdivision of
the State of Florida, with principal offices located at 490 63rd Street, Marathon, FL 33050 (the
District and Monroe County are hereinafter referred to collectively as the "COUNTY"), and
ADVANCED DATA PROCESSING, INC. (DBA ADPI-INTERMEDIX), a Delaware
corporation with principal offices located at 6451 North Federal Highway, Suite 1002, Ft
Lauderdale, Florida 33308, hereinafter referred to as "CONTRACTOR";
WITNESSETH:
WHEREAS, the COUNTY intends to enter intp an agreement for the provision of rescue air
and ground transpOli billing and related professional services by the CONTRACTOR to the
COUNTY; and,
WHEREAS, the CONTRACTOR represents that it is capable and prepared to provide such
Services:
NOW THEREFORE, in consideration of the promises contained herein, the parties hereto
agree as follows:
1. CONTRACT PERIOD AND RENEWAL - The term oftrus Agreement shall be for a three
(3) year term from January L 2010 through December 3 L 2012, with the option to renew for
two (2) additional one year periods, subject to cancellation as provided herein. The
COUNTY'S performance and obligation to pay under this contract, is contingent upon an
annual appropriation by the Board of County Commissioners.
2. SERVICE TO BE PERFORMED BY CONTRACTOR - The CONTRACTOR shall perform
the services as specifically stated in the Scope of Services (Attachment A) without requirement
for the issuance of any additional work orders. Additional services may be issued in the form
of a Work Order. Each Work order will set forth a specific Scope of Services, amount of
compensation, deliverables and completion date and shall be subject to the approval of the
COUNTY. CONTRACTOR shall perform no additional services until any applicable Work
Order is obtained from the COUNTY and countersigned by the CONTRACTOR.
3. COMPENSATION - COUNTY shall pay CONTRACTOR in accordance with Attachment
B, Compensation for Services, which is attached hereto and incorporated by reference as part
of this Agreement.
4. STANDARD OF CARE - CONTRACTOR shall exercise the same degree of care, skill, and
diligence in the perfOlmance of Services as is ordinarily provided by a professional
1
CONTRACTOR, offering services for local governments in South Florida, under similar
circumstances and CONTRACTOR shall, at no additional cost to the COUNTY, re-perform
services which fail to satisfy the foregoing standard of care.
5. INDEPENDENT CONTRACTOR - The CONTRACTOR is an independent contractor and
not an employee or agent of the COUNTY except that CONTRACTOR shall be authorized as
an agent as follows: To the extent necessary to fulfill its billing and collection efforts under this
Agreement, the CONTRACTOR is authorized to execute the following types of standard forms
and correspondences only: probate filings; letters to patients or their representatives verifying
that an account is paid in full; forms verifying the tax-exempt status of the COUNTY; and
insurance filings and related forms. The CONTRACTOR has no authority to sign any other
document's except as specifically authorized by the COUNTY.
CONTRACTOR undertakes performance ofthe Services as an independent contractor and
shall be wholly responsible for the methods of performance. CONTRACTOR shall work
closely with the COUNTY in performing Services under this Agreement.
The CONTRACTOR shall retain full control over the employment, direction, compensation
and discharge of all persons assisting in the performance of service by CONTRACTOR. The
CONTRACTOR shall be fully responsible for all matters relating to payment of employees,
including compliance with Social Security, withholding tax and all other laws and regulations
governing such matters. The CONTRACTOR shall be responsible for its ovm acts and those
of its agents and employees during the term of this contract. The CONTRACTOR shall not
receive any the COUNTY benefits, stipend or privileges afforded by the COUNTY employees.
6. COMPLIANCE WITH LAWS - In performance of the Services, CONTRACTOR will
comply with applicable regulatory and other applicable requirements including federal, state,
and local laws, rules regulations, orders, codes, criteria and standards.
7. ADDITIONAL REQUIRED STATEMENTSNERIFICA TIONI AFF ADA VITS - Attached
hereto in Attachments C, D, E, F, and G are Non-Collusion Affidavit, Public Entity Crime
Statement, Drug Free Workplace Form, Conflict of Interest Clause and Indemnification to
Hold Harmless.
8. INSURANCE - During the term of this contract, the CONTRACTOR must keep in force
and affect the insurance required by Attachments H. Attachment H is attached and
incorporated into this contract.
The insurance coverage and conditions afforded by this policy(s) shall not be suspended,
voided, canceled or modified, except after thirty (30) days prior written notice by Certified
Mail Return Receipt Requested, has been given to the COUNTY department that originated
this contract.
Certificates of Insurance meeting the specific required provision specified within this
Contract/Agreement shall be forwarded to the COUNTY department that originated the
contract, and approved prior to the start of any work or the possession of any the COUNTY
property or the commencement of services, as application.
9. MONROE COUNTY'S RESPONSIBlLITIES - The COUNTY, during the term ofthis
Agreement, shall:
A. Supply the "Run Report" attached hereto identified as Attachment A to
CONTRACTOR with the necessary patient information on a timely basis for those
patients that have been transported by Fire-Rescue Services and in sufficient detail to
support diagnosis and procedure coding and make reasonable efforts to provide patient
2
demographic information necessary for accurate patient identification including name,
address, social security number, date of birth, and telephone number.
B. Provide CONTRACTOR with its approved billing policies and procedures including
fee schedules and collection protocols. The COUNTY shall be responsible for engaging
any third party collection service for uncollectible accounts after CONTRACTOR has
exhausted its collection efforts.
C. Make reasonable efforts to timely process refunds identified by CONTRACTOR for
account overpayments.
D. Provide a Lock Box address to CONTRACTOR and will instruct Lock Box to forward
all Lock Box documents to CONTRACTOR for processing.
E. Provide for CONTRACTOR to have daily bank: balance reporting capabilities via
internet access with bank:.
F. Comply and cooperate with CONTRACTOR in all matters to ensure proper compliance
with all Federal, State and local laws rules and regulations as applicable to the services
being contracted for.
10. TERMINA TrON OF AGREEMENT - During the time of this Agreement either party may
terminate this Agreement for convenience by first giving to other party at least thirty (90) days
prior written notice. Upon notice of termination CONTRACTOR shall take all steps necessary
to close out any accounts with an open balance and will be responsible for complying with all
provisions of this contract until the termination date. CONTRACTOR will not assume new
accounts after such notice of termination. CqNTRACTOR will be paid for its services through
the termination date and CONTRACTOR will not incur any expense after notice of termination
except those necessary to properly wind up its obligations under this contract and properly
perform this contract. All money received on accounts by CON1RACTOR after the
termination date will be forwarded to the COUNTY without regular compensation being paid
to the CONTRACTOR. CONTRACTOR will further cooperate with any successor by turning
over all records and any other documents or equipment in hard copy to useable electronic
format to the COUNTY or the new billing company. CONTRACTOR will pay the COUNTY
all funds due and owing to it as the termination of this contract. The provision for
CONTRACTOR to turn over documents and to provide all funds due and owing the COUNTY
will survive the termination of this contract.
In the event the acts constituting default are a violation oflaw, CONTRACTOR shall be
subject to immediate termination. Notwithstanding the provisions above, the COUNTY shall
not have any right to cancel this contract without cause.
Upon termination, the CONTRACTOR shall submit an invoice(s) to the COUNTY in an
amount(s) representing fees for services actually performed or obligations incurred to the date
of effective termination for which the CONTRACTOR has not been previously compensated.
Upon payment of all sums found due, the COUNTY shall be under no further obligation to the
CONTRACTOR, financial or otherwise.
11. NONDISCLOSURE OF PROPRIETARY INFORMATION - CONTRACTOR shall
consider all information provided by the COUNTY and all reports, studies calculations, and
other documentation resulting from the Contractor's performance of the Services to be
proprietary unless such information is available from public sources or is a public record under
Florida law. CONTRACTOR shall not publish or disclose proprietary information for any
3
purpose other than the performance of the Services without the prior written authorization of
the COUNTY or in response to legal process or orders of a court of competent jurisdiction.
Public Access -The County and Contractor shall allow and permit reasonable access to, and
inspection of, all documents, papers, letters or other materials in its possession or under its
control, which are public records and which are subject to the provisions of Chapter 119,
Florida Statutes, and made or received by the County and Contractor in conjunction with this
Agreement; and the County shall have the right to unilaterally cancel this Agreement upon
violation of this provision by Contractor.
12. UNCONTROLLABLE FORCES - Neither the COUNTY nor CONTRACTOR shall be
considered to be in default of this Agreement if delays in or failure of performance shall be due
to Uncontrollable Forces, the effect of which, by the exercise of reasonable diligence, the non-
performing party could not avoid. The term ''Uncontrollable Forces" shall mean any event
which results in the prevention or delay of performance by a party of its obligations under this
Agreement and which is beyond the reasonable control of the non-performing party. It
includes, but is not limited to fire, flood, earthquakes, hunicanes, storms, lightning, epidemic,
war, riot, civil disturbance, sabotage, Acts of God and governmental actions.
Neither party shall, however, be excused from performance if non-performance is due to forces
which are preventable, removable, or remediable and which the non-performing party could
have, with the exercise of reasonable diligence, prevented, removed, or remedied with
reasonable dispatch. The non-performing party shall, within a reasonable time of being
prevented or delayed from performance by an uncontrollable force, give written notice to the
other party describing the circumstances and uncontrollable forces preventing continued
performance of the obligations of this Agreement.
13. MISCELLANEOUS
A. Non Waiver - A waiver by either the COUNTY or CONTRACTOR of any breach of
this Agreement shall not be binding upon the waiving party unless such waiver is in
writing and duly signed by both patties to this agreement. In the event of a written
waiver, such a waiver shall not affect the waiving party's rights with respect to any
other or further breach. The making or acceptance of a payment by either party with
knowledge ofthe existence of a default or breach shall not operate or be construed to
operate as a waiver of any subsequent default or breach.
B. Severability - The invalidity, illegality, or unenforceability of any provision of this
Agreement, or the occurrence of any event rendering any portion or provision of this
Agreement void or voidable, shall in no way affect the validity or enforceability of any
other portion or provision of the Agreement. Any void or voidable provision shall be
deemed severed from the Agreement and the balance of the Agreement shall be
construed and enforced as if the Agreement did not contain the particular portion or
provision held to be void. The parties further agree to reform the Agreement to replace
any stricken provision with a valid provision that comes as close as possible to the
intent of the stricken provision.
The provisions of this section shall not prevent the entire Agreement from being held
void should a provision which is of the essence of the Agreement be determined to be
void by a court of competent jurisdiction.
C. Political Campaigns - During the term of this Agreement, the CONTRACTOR or any
employee or associate, shall not be involved in any political campaign for the
COUNTY elective office nor make financial contribution to any such campaign.
4
D. Contractor Records - Contractor shall maintain all books, records, and documents
directly pertinent to performance under this Agreement in accordance with generally
accepted accounting principles consistently applied. Each party to this Agreement or
their authorized representatives shall have reasonable and timely access to such records
of each other party to this Agreement for public records purposes during the term of the
Agreement and for four years following the termination of this Agreement. If an
auditor employed by the County or Clerk determines that monies paid to Contractor
pursuant to this Agreement were spent for purposes not authorized by this Agreement,
the Contractor shall repay the monies together with interest calculated pursuant to Sec.
55.03, FS, running from the date the monies were paid to Contractor.
E. Attorney's Fees and Costs - The County and Contractor agree that in the event any
cause of action or administrative proceeding is initiated or defended by any party
relative to the enforcement or interpretation of this Agreement, the prevailing party
shall be entitled to reasonable attorney's fees, court costs, investigative, and out-of-
pocket expenses, as an award against the non-prevailing party, and shall include
attorney's fees, courts costs, investigative, and out-of-pocket expenses in appellate
proceedings. Mediation proceedings initiated and conducted pursuant to this
Agreement shall be in accordance with the Florida Rilles of Civil Procedure and usual
and customary procedures required by the circuit court ofMomoe County.
F. Binding Effect - The terms, covenants, conditions, and provisions of this Agreement
shall bind and inure to the benefit of the County and Contractor and their respective
legal representatives, successors, and assigns.
G. Authority - Each party represents and warrants to the other that the execution, delivery
and performance ofthis Agreement have been duly authorized by all necessary County
and corporate action, as required by law.
H. Claims for Federal or State Aid - Contractor and County agree that each shall be, and
is, empowered to apply for, seek, and obtain federal and state funds to :further the
purpose of this Agreement; provided that all such applications, requests, grant
proposals, and funding solicitations shall be approved by each party prior to
submission.
I. Adjudication of Disputes or Disagreements - County and Contractor agree that all
disputes and disagreements shall be attempted to be resolved by meet and confer
sessions between representatives of each of the parties. lfno resolution can be agreed
upon within 30 days after the first meet and confer session, the issue or issues shall be
discussed at a public meeting of the Board of County Commissioners. If the issue or
issues are still not resolved to the satisfaction of the parties, then any party shall have
the right to seek such relief or remedy as may be provided by this Agreement or by
Florida law.
J. Cooperation - In the event any administrative or legal proceeding is instituted against
either party relating to the formation, execution, performance, or breach of this
Agreement, County and Contractor agree to participate, to the extent required by the
other party, in all proceedings, hearings, processes, meetings, and other activities
related to the substance of this Agreement or provision of the services under this
Agreement. County and Contractor specifically agree that no party to this Agreement
shall be required to enter into any arbitration proceedings related to this Agreement.
5
K. Nondiscrimination - County and Contractor agree that there will be no discrimination
against any person, and it is expressly understood that upon a determination by a court
of competent jurisdiction that discrimination has occurred, this Agreement
automatically terminates without any further action on the part of any party, effective
the date of the court order. County or Contractor agree to comply with all Federal and
Florida statutes, and all local ordinances, as applicable, relating to nondiscrimination.
These include but are not limited to: 1) Title VI of the Civil Rights Act of 1964 (PL
88-352) which prohibits discrimination on the basis of race, color or national origin; 2)
Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-1683,
and 1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of
the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits
discrimination on the basis of handicaps; 4) The Age Discrimination Act of 1975, as
amended (42 USC ss. 6101-6107) which prohibits discrimination on the basis of age; 5)
The Drug Abuse Office and Treatment Act of 1972 (PL 92-255), as amended, relating
to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse
and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (pL 91-616), as
amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7)
The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and
290ee-3), as amended, relating to confidentiality of alcohol and drug abuse patent
records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC s. et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; 9) The
Americans with Disabilities Act of1990 (42 USC s. 1201 Note), as maybe amended
from time to time, relating to nondiscrimination on the basis of disability; 10) Monroe
County Code Ch. 13, Art. VI, prohibiting discrimination on the bases ofrace, color,
sex, religion, disability, national origin, ancestry, sexual orientation, gender identity or
expression, familial status or age; and 11) any other nondiscrimination provisions in
any Federal or state statutes which may apply to the parties to, or the subject matter of,
this Agreement.
L. Covenant ofN 0 Interest - County and Contractor covenant that neither presently has
any interest, and shall not acquire any interest, which would conflict in any manner or
degree with its performance under this Agreement, and that only interest of each is to
perform and receive benefits as recited in this Agreement.
M. Code of Ethics ~ County agrees that officers and employees of the County recognize
and will be required to comply with the standards of conduct for public officers and
employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited
to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized
compensation; misuse of public position, conflicting employment or contractual
relationship; and disclosure or use of certain information.
N. No Solicitation/Payment - The County and Contractor warrant that, in respect to itself,
it has neither employed nor retained any company or person, other than a bona fide
employee working solely for it, to solicit or secure this Agreement and that it has not
paid or agreed to pay any person, company, corporation, individual, or firm, other than
a bona fide employee working solely for it, any fee, commission, percentage, gift, or
other consideration contingent upon or resulting from the award or making of this
Agreement. For the breach or violation of the provision, the Contractor agrees that the
County shall have the right to terminate this Agreement without liability and, at its
discretion, to offset from monies owed, or otherwise recover, the full amount of such
fee, commission, percentage, gift, or consideration.
6
O. Privileges and Immunities - All of the privileges and immunities from liability,
exemptions from laws, ordinances, and rules and pensions and relief, disability,
workers' compensation, and other benefits which apply to the activity of officers,
agents, or employees of any public agents or employees of the County, when
performing their respective functions under this Agreement within the territorial limits
of the County shall apply to the same degree and extent to the performance of such
functions and duties of such officers, agents, volunteers, or employees outside the
territorial limits of the County.
P. Legal Obligations and Responsibilities: Non-Delegation of Constitutional or Statutory
Duties - This Agreement is not intended to, nor shall it be construed as, relieving any
participating entity from any obligation or responsibility imposed upon the entity by
law except to the extent of actual and timely performance thereof by any participating
entity, in which case the performance may be offered in satisfaction ofthe obligation or
responsibility. Further, this Agreement is not intended to, nor shall it be construed as,
authorizing the delegation ofthe constitutional or statutory duties of the County, except
to the extent permitted by the Florida constitution, state statute, and case law.
Q. Non-Reliance by Non-Parties - No person or entity shall be entitled to rely upon the
terms, or any of them, of this Agreement to enforce or attempt to enforce any third-
party claim or entitlement to or benefit of any service or program contemplated
hereunder, and the County and the Contractor agree that neither the County nor the
Contractor or any agent, officer, or employee of either shall have the authority to
inform, counsel, or otherwise indicate that any particular individual or group of
individuals, entity or entities, have entitlements or benefits under this Agreement
separate and apart, inferior to, or superior to the community in general or for the
purposes contemplated in this Agreement.
R. Attestations - Contractor agrees to execute such documents as the County may
reasonably require, to include a Public Entity Crime Statement, an Ethics Statement,
and a Drug-Free Workplace Statement.
S. No Personal Liability - No covenant or agreement contained herein shall be deemed to
be a covenant or agreement of any member, officer, agent or employee of Monroe
County in his or her individual capacity, and no member, officer, agent or employee of
Momoe County shall be liable personally on this Agreement or be subject to any
personal liability or accountability by reason of the execution of this Agreement.
T. Execution in Counterparts - This Agreement may be executed in any number of
counterparts, each of which shall be regarded as an original, all of which taken together
shall constitute one and the same instrument and any of the parties hereto may execute
this Agreement by singing any such counterpart.
14. INTEGRATION AND MODIFICATION - This Agreement is adopted by the COUNTY
and CONTRACTOR as a final, complete and exclusive statement of the terms of the
Agreement between the COUNTY and CONTRACTOR. This Agreement supersedes all prior
agreements, contracts, proposals, representations, negotiations, letters or other communications
between the COUNTY and CONTRACTOR pertaining to the Services, whether written or
oral. The Agreement may not be modified unless such modifications are evidenced by an
amendment in writing signed by both the COUNTY and CONTRACTOR.
15. OWNERSHIP OF DOCUMENTS - CONTRACTOR shall be required to work in harmony
with other CONTRACTOR'S relative to providing information requested in a timely manner
7
and in the specified form. Any and all documents, records, disks, original drawings, or other
information shall become the property of the COUNTY upon completion for its use and
distribution as may be deemed appropriate by the COUNTY. Failure to turn over such
documents within seven (7) days of when requested may be cause for the COUNTY to
withhold any payments due CONTRACTOR or to enforce this clause by legal remedies.
16. NOTICE - Any notice, demand, communication, or request required or permitted
hereunder shall be in writing and delivered in person or sent by certified mail, postage prepaid
as follows:
As to the COUNTY
MONROE COUNTY EMERGENCY SERVICES
Attention: Fire Chief James Callahan
490 63rd Street Ocean
Marathon, F133050
As to CONTRACTOR
Advanced Data Processing Inc. (DBA ADPI-INTERMEDIX)
6451 North Federal Highway, Suite 1002
Ft Lauderdale, Florida 33308
Notices shall be effective when received at the address specified above. Changes in the
respective addresses to which such notice may be directed may be made from time to time by
any party by written notice to the other party. Facsimile is acceptable notice effective when
received, however, facsimiles received (i.e. printed) after 5:00 p.m. or on weekends or
holidays, will be deemed received on the next business day. The original ofthe notice must
additionally be mailed as required herein.
Nothing contained in this Article shall be construed to restrict the transmission of routine
communications between representatives of CONTRACTOR and the COUNTY.
17. Momoe County's performance and obligation to pay under this contact is contingent upon
an annual appropriation by the Board of County Commissioners of Monroe County, Florida.
18. Venue for any litigation arising under this contract must be in a court of competent
jurisdiction in Momoe County, Florida. This Agreement is not subject to arbitration.
IN WITNESS WHEREOF, each party hereto has caused this contract to be executed by its
duly authorized representative.
(SEAL)
BOARD OF COUNTY COMlVIISSIONERS OF
MONROE COUNTY, FL
ATTEST: DANNY L. KOLHAGE, CLERK
By:
By:
Deputy Clerk
Mayor
8
MONROE COUNTY ATTORNEY
APrtE/illt:J)M
YNTHIA L HALL
ASSISTANT COl,lf\.ITYrTTORNEY
Date ! I~b-:-,O
Approved by MONROE COUNTY on
BOARD OF GOVERNORS OF
FIRE AND AMBULANCE DISTRICT 1
OF MONROE COUNTY, FL
By:
Mayor/Chairman
ADVANCED DATA PROCESSING, INC. (DBA
ADPI-INTERMEDlX)
BY:~ R-
Signature
Do~ Shan/on, frf'sldt'0-1
rint Name and Title
Date:
10/30/0 7
, 2009, Item #
9
Attachment A
SCOPE OF WORK
The CONTRACTOR shall provide the COUNTY with timely and accurate complete medical
billing and accounts receivable management services for the COUNTY'S rescue air and
ground transport billing services and related professional services in accordance with the
responsibilities outlined as follows:
1. Initial Patient Treatment and Information
A On a case by case basis, the COUNTY will respond to patients requiring immediate
medical treatment and emergency medical transportation services. Upon treating each
patient, the COUNTY shall provide the CONTRACTOR with patient information
identified on the "Run Report" attached hereto as Attachment A. CONTRACTOR shall
be solely responsible for retrieving insurance information and any additional patient
information which was not identified on the "Run Report" provided by the COUNTY.
CONTRACTOR shall utilize "Run Report" information and any additional information
retrieved by CONTRACTOR to file proper patient billing and insurance information.
CONTRACTOR shall establish arrangements with hospitals to obtain/verify patient
insurance and contact information. CONTRACTOR shall contact the U.S. Post Office's
National Change of Address (NCOA) files or other similar services to obtain the correct
billing addresses and phone numbers for patients that have left the area, or whom have
invalid information.
B. CONTRACTOR shall reconcile the number of patients that are transported for
emergency medical services with those received. The CONTRACTOR shall report
discrepancies to the COUNTY within three (3) business days ofreceipt.
C. As requested by the COUNTY, CONTRACTOR shall provide the COUNTY'S Fire
Rescue Services Paramedics Personnel with training on the gathering of necessary
information to be adhered on Run Reports for the purpose of assisting CONTRACTOR
with the proper submission and processing of patient data.
2. Patient Billing
A. CONTRACTOR shall mail an invoice to each patient for emergency transportation
service at current rates set forth by the COUNTY as follows:
Ground Ambulance:
$600.00 for Basic Life Support (BLS)
$600.00 for Advance Life Support One (ALSI)
$800.00 for Advance Life Support Two (ALS2)
$12.00 per mile
Air Ambulance:
$5500.00 for Air Ambulance Transport Fee
$80.00 per mile
10
B. The aforementioned rates shall be subject to change at the COUNTY'S discretion at
any time throughout the term of the agreement; the COUNTY agrees to notify
CONTRACTOR a minimum of seven (7) days prior to any rate changes.
C. The CONTRACTOR shall provide all self pay patients with a comprehensive
statement/invoice including a courtesy return payment envelope. The front of the
statement shall describe all charges and payments. The reverse side of the statement
shall have clearly marked entry blocks for information needed to file private insurance
claims. CONTRACTOR shall file claims and send an invoice to all self pay
patient/payors with return envelope and address as specified by the COUNTY within
five (5) days of receipt of incident information. Subsequent invoices to self-pay
patient/payor will be sent at thirty-five (35) day intervals, up to a maximum of six
InVOIces.
CONTRACTOR shall send one initial statement/invoice to a patient for whom
Medicare, Medicaid or private insurance (payor) information is available when an
account is filed to the insurance company. These statements will be mailed at 45 days
from filing the insurance claim. Thereafter, CONTRACTOR will send a maximum of
six invoices to payor.
ln the course oftime that the six invoices are sent to patient/payor and payment in full
has not yet been received, CONTRACTOR shall provide follow-up on rejected and
inactive claims and establish payor remittance accounts and procedures. ln the case of
patients for whom payor information is available, CONTRACTOR at that time shall
resume sending invoices to patient and shall, within fourteen (14) days of receiving a
final decision from the payor, send a maximum of five (5) additional invoices to the
patient every thirty-five (35) days thereafter in an attempt to collect the claim.
Effective October 1, 2009, unless insurance, Medicare, Medicaid or secondary
insurance payment is pending, CONTRACTOR shall on a monthly basis send all
eligible accounts that have not had activity for 210 days or more from the date of
service a Pre-Collection Letter. These accounts have thirty (30) days to respond to the
CONTRACTOR. Once the thirty (30) days have expired, the CONTRACTOR shall
send the COUNTY a list of all accounts along with a complete processing history once
collection efforts are exhausted. These uncollectible accounts will be forwarded by the
CONTRACT onto a third party collection agency named by the COUNTY for further
attempts at collecting.
D. CONTRACTOR shall negotiate and arrange modified payment schedules for patients
unable to pay the full amount when billed. CONTRACTOR shall not reduce the
amount owed and shall not negotiate settlements. All settlement requests shall be
forwarded to the COUNTY for review, processing and BOARD approval.
E. CONTRACTOR shall process refund requests within the month following an
overpayment and provide the COUNTY with documentation substantiating each
refund requested.
F. Where CONTRACTOR has found no method ofpayrnent for a patient after all
insurance avenues are exhausted including State Medicaid and local HRS or municipal
programs, such cases will be submitted to the COUNTY in writing for final resolution
along with appropriate documentation (i.e. hospital credit status, credit file
11
information, activity file). At the instruction of the COUNTY, CONTRACTOR shall
write off any amounts or make any adjustments to a bill, including, but not limited to;
patient disputes regarding mileage, special handling charges or the bill in its entirety.
G. CONTRACTOR shall provide the COUNTY with real-time read only electronic look-
up access of CONTRACTOR'S patient data and billing information system.
CONTRACTOR shall provide the facilities to receive patient billing information from
the COUNTY electronically. CONTRACTOR- This may be done through email or
other method that meets Patient Privacy requirements.
H. CONTRACTOR shall provide all air ambulance accounts with a Trauma Star Air
Ambulance Resident Fee Waiver Program application in each monthly statement. This
application will be provided to the CONTRACTOR by the COUNTY. The application
contains eligibility requirements for the Trauma Star Resident Fee Waiver Program
and directs the patient on how to apply. The CONTRACTOR will provide the
COUNTY with all completed applications for verification and determination. The
COUNTY will notifY the CONTRACTOR of the conclusion on all applications. The
CONTRACTOR will verify that all billing sources have been exhausted and then place
a hold on all Approved accounts. The CONTRACTOR will adjust balances on these
accounts as directed by the COUNTY.
3. Patient Filing
A. CONTRACTOR shall file all insurance claim forms for all patients based upon
information received from Run Report and research performed by CONTRACTOR.
CONTRACTOR shall provide prompt submission of required paperwork to Medicare,
Medicaid, Insurance Companies or Third Party Payers for claims, reviews,
resubmission, provider agreements and other as required within 72 hours after
receiving the requested "Run Report" from the COUNTY. CONTRACOTR shall
submit secondary insurance provider claims after the primary insurance provider has
paid within 30 days after receipt of payment from primary insurer. Upon receipt of
notice of claim denial, requirement for additional information, Explanation of Benefits
reflecting underpayment or other notice requiring submission of documents to the third
party provider CONTRACTOR shall within 45 days re-file Medicare, Medicaid, or
Insurance claims to obtain payment. CONTRACTOR shall maintain responsibility for
obtaining missing or incomplete insurance information. CONTRACTOR shall process
all third party reimbursements within one week after receipt of appropriate billing
information from primary payor.
B. CONTRACTOR shall utilize the most up-to-date knowledge and information with
regard to coding requirements and standards and proper preparation of electronic and
paper insurance filings to ensure compliance with applicable Federal, State and local
regulations.
4. Maintaining Records
A. CONTRACTOR shall maintain records in an electronic format that is readily accessible
by the COUNTY and meets all federal and state requirements for maintaining patient
medical records.
B. CONTRACTOR shall maintain appropriate accounting procedures for reconciling all
deposits, receivables, billings, patient accounts, adjustments and refunds.
12
C. CONTRACTOR shall facilitate proper security of confidential information and further
shred and dispose of materials containing such information.
D. CONTRACTOR shall implement and comply with a Compliance Plan consistent with
the intent and activities included in the U.S. Office ofInspector General (OIG)
Compliance Program Guidance for Third Party Medical Billing Companies 63 FR
70138; (December 18, 1998).
E. CONTRACTOR shall retain all accounts for a minimum of twelve (12) months (unless
otherwise specified by mutual agreement).
F. CONTRACTOR shall ensure that all required documentation and agreements with
payors (e.g. Medicare, Medicaid, Champus, etc.) are filed and maintained and that the
COUNTY is kept apprised of important changes to industry regulations.
G. CONTRACTOR shall be knowledged of different industry insurance plans and shall
ensure the COUNTY that every billable claim is pursued accordingly by
CONTRACTOR.
H. CONTRACTOR shall advise the COUNTY on statutes and industry regulations which
wou1d affect emergency transportation service rates.
5. Customer Service:
A. CONTRACTOR shall provide a toll free telephone number for patients with
CONTRACTOR'S own facilities and workforce. CONTRACTOR'S toll free telephone
number must be a dedicated phone number only for accounts from the COUNTY.
CONTRACTOR shall provide a designated liaison for patient/payor concerns.
B. CONTRACTOR shall conduct all written and verbal communication in the most
professional manner. The CONTRACTOR shall never in any way represent them in a
way that might be interpreted as intimidating or threatening.
C. CONTRACTOR shall respond within three (3) business days of any verbal or written
requests made by Patients and/or the COUNTY for information or records.
CONTRACTOR shall assist patients that are not able to speak the English language.
Difficult calls such as, but not limited to: special insurance issues, taxpayer questions,
irate calls shall be handled in a professional manner by a supervisor employed with
CONTRACTOR'S firm.
D. CONTRACTOR shall provide all customer inquiry services and prepare additional
third-party claims or patient payment arrangements based on this information exchange.
E. At the COUNTY'S request, CONTRACTOR shall pr~vide survey questionnaires or
mail inserts to patients. CONTRACTOR shall mail requested citizen satisfaction
surveys.
F. CONTRACTOR shall provide for facilities to permit dial-up access to retrieve patient
data and billing information.
6. Audits
A. CONTRACTOR shall provide access to the COUNTY for all requested information in
order for the COUNTY to perform appropriate and periodic audits. The COUNTY will
provide CONTRACTOR with reasonable notice for any planned audit and
CONTRACTOR shall conduct audit during normal business hours.
7. Monthly Reports
13
Unless otherwise indicated, CONTRACTOR shall provide the following reports on a monthly
basis as identified and prescribed by the COUNTY. Monthly reports shall be produced after the
month's closing and provided to the COUNTY no later than the tenth of each month.
A. Ambulance Unit Report: On a monthly basis, CONTRACTOR shall provide a report
of number of calls and gross billed by ambulance unit for the current period.
B. Ambulance New Billing Report: CONTRACTOR shall produce a report showing all
billing (new charges) processed alpha sorted by Last Name and summarized total
billing for period. CONTRACTOR shall add column for date received from the
COUNTY.
C. Ambulance Payment Report: CONTRACTOR shall provide a batch oriented listing of
all payments processed including check number and type of payment (self pay,
Medicare, Medicaid, private insurance).
D. Gross Collection Statistics Summary: CONTRACTOR shall provide a running
summary ofInterfacility transactions including monthly amount billed, collected,
Percentage collected, number of Accounts and Gross Billed .
E. Schedule of Transport Charges & Collections: CONTRACTOR shall provide a
running month summary of charge, payment and adjustments for the closing month
period showing gross and net collection percentages for each period. lnfonnation
provided shall be for last five fiscal years only.
F. Report of Accounts Receivable: CONTRACTOR shall provide a summary for period
ending of Accounts Receivable showing gross billing, payments received/processed,
reflected write-offs and adjustments, reversals and ending balance.
G. Monthly Billing and Collection Summary: CONTRACTOR shall produce a report
showing receivables as applied to month running or original billed month. Information
provided shall be for last five fiscal years only.
H. Insurance Receivable Report: CONTRACTOR shall provide a summary of billed
month the number of patient bills having an outstanding insurance balance. This will
show the balance and number of bills outstanding by class.
I. Collection by Financial Class: CONTRACTOR shall provide a running month
summary for the closing month period of collections by Payor Class (Self-Pay,
Medicare, Medicaid and Private Insurance). CONTRACTOR shall denote billing
numbers for each category and total. Information provided shall be for last five fiscal
years only.
J. Collection Schedule: CONTRACTOR shall provide a running summary of collected
amounts to include monthly, fiscal and cumulative amounts.
K. Ambulance Billing Adiustments-Write Offs-Reversals: CONTRACTOR shall provide
a running summary showing all adjustments, write-offs and reversals from Medicare,
Medicaid and Insurance.
L. Report of Accounts Receivable Removed: CONTRACTOR shall provide a report
showing Accounts sent to Collections with Original Amount Billed, Payments made,
Adjusted Amounts and Balance owed. These accounts will have had no activity for 12
months or more. This report will only be provided on the months that the
CONTRACTOR sent accounts to collections.
14
M. Report by Incident Date: CONTRACTOR shall provide a report by account detail of all
accounts outstanding to include Original Amount billed, Adjusted Amount, and
Balance due.
N. Monthlv Refund Schedule: CONTRACTOR shall provide a report by account detail
of associated payments reflecting an overpayment and necessary refund to be
processed.
O. Aging Report: On a monthly basis, CONTRACTOR shall provide a report which lists
patients' accounts receivable amounts by age to alert the COUNTY of any slow paying
patients.
P. Timeliness of Billing Report: On a monthly basis, CONTRACTOR shall provide a
report which lists the number of times invoices were sent to each patient. This report
will be used by the COUNTY to verify compliance with Attachment A Section B2 of
the Agreement.
Q. Air Ambulance Resident Waiver Report: On a monthly basis the CONTRACTOR shall
provide a report which lists the air transport accounts that have been approved for the
Trauma Star Resident Fee Waiver Program. These accounts will be placed on hold until
the COUNTY directs the CONTRACTOR to adjust the balances.
8. Health Insurance Portability and Accountability Act of 1996 (HIP AA)
The CONTRACTOR shall comply with the privacy regulations pursuant to Public Law 104-
191 of August 21, 1996, known as the Health'Insurance Portability and Accountability Act of
1996, Subtitle F - Administrative Simplification, Sections 261, et seq., as amended
("HIP AA"), to protect the privacy of any personally identifiable protected health information
("PHI") that is collected, processed or learned as a result of the Billing Services provided
hereunder.
A. CONTRACTOR shall not use or further disclose PHI except as permitted herein or
required by law.
B. CONTRACTOR shall use appropriate safeguards to prevent use or disclosure of PHI
except as permitted herein.
C. CONTRACTOR shall mitigate, to the extent practicable, any harmful effect that is
mown to CONTRACTOR, its agents or subcontractors of a use or disclosure of PHI by
the CONTRACTOR, its agents or subcontractors.
D. CONTRACTOR shall report to the COUNTY any use or disclosure of PHI not
provided for by this Agreement of which the CONTRACTOR, its agents or
subcontractors become aware.
E. CONTRACTOR shall ensure that any agents or subcontractors to whom the
CONTRACTOR provide PHI or who have access to PHl, agree to the same restrictions
and conditions that apply to the CONTRACTOR with respect to such PHI.
F. CONTRACTOR shall make PHI available to the COUNTY and to the individual who
has a right of access as required under HIP AA within 30 days of the request by the
COUNTY regarding the individual.
G. CONTRACTOR shall incorporate ally amendments to PHI when notified to do so by
the COUNTY.
15
H. CONTRACTOR shall provide an accounting of all uses or disclosures of PHI made by
the CONTRACTOR its agents or subcontractors as required under the HIP AA privacy
rule within sixty (60) days.
I. CONTRACTOR shall make their internal practices, books and records relating to the
use and disclosure ofPffi available to the Secretary of the Department of Health and
Human Services for purposes of determining the CONTRACTOR'S, its agents' and
subcontractors' and the COUNTY'S compliance with HIPAA.
J. CONTRACTOR shall at the termination of the agreement, return or destroy all PHI
received from, or created or received by the CONTRACTOR, its agents or
subcontractors on behalf of the COUNTY and ifreturn is infeasible, ensure that the
protections of this Agreement will extend to such Pill.
K. The specific uses and disclosures of PHI that may be made by the CONTRACTOR, its
agents or contractors on behalf of the COUNTY include:
1) Preparation of invoices to patients, carriers, insurers and others responsible for
payment or reimbursement of the services provided by the COUNTY to its
patients.
2) Preparation of reminder notices and documents pertaining to collections of
overdue accounts.
3) The submission of supporting documentation to carriers, insurers and other
payers to substantiate the health care services provided by the COUNTY to its
patients or to appeal denials of payment for same.
4) Other uses or disclosures of PHI as permitted by the HIP AA privacy rule.
5) Mail HIPAA Notice of Privacy Practices to all emergency transport patients
within the timeframe allowed under the HIP AA and FIIP AA rules.
6) Mail subpoenas, attorney's requests to Fire Rescue immediately upon receipt
16
Attachment B
COMPENSATION OF SERVICES
The CONTRACTOR shall provide to the COUNTY a monthly invoice representing fees
for the services provided computed as:
1. Six point two five percent (6.25%) of all monies collected by the CONTRACTOR,
excluding Medicaid accounts, during the previous month. In compliance with Florida
Statute 409.913 (9), the CONTRACTOR shall include in the same invoice an amount
of $1 0.00 per processed Medicaid account for providing all billing services related to
such accounts processed in the previous month, regardless of whether or not payment
was received.
2. Price shall include but not be limited to; all stationery, fax forms, envelopes, mailings,
postage and. telecommunications/phone facilities/charges.
3. Price for services does not include the cost of "Locked-box" service. The COUNTY
shall bear the cost of the Locked-box.
4. The "Locked-box" service selected shall be at the sole discretion ofthe COUNTY and
shall provide a secure postal address and box for receipt of all correspondence
(especially including all insurance and patient payments, correspondence and benefits
determination and denials). The "Locked-box" service will on a daily basis perform the
following:
A. Open all mail (except clearly marked returned-mail).
B. Make a copy of every check and attach copy with original document accompanying
each check.
C. Deposit all receivables into designated the COUNTY account.
D. Prepare and provide a daily deposit slip totaling and accounting for all receivables
deposited for the identified day.
E. Mail (daily) to the CONTRACTOR separated bundles of; copies of checks attached
to supporting documents, other correspondence and, returned-mail along with
deposit slip.
F. Mail ( daily) to the COUNTY copies of checks and daily deposit slip.
G. Mail (monthly) to the COUNTY reconciliation of account.
5. CONTRACTOR shall maintain daily deposit control sheets and original
documentation.
17
Attachment C
I,
NON- COLLUSION AFFIDAVIT
DOVlr1 )hO-rf"101) ,ofthecityof F~ kwJerdtt-/e
J
_according to law on my oath, and under penalty of peljury, depose and say that;
1) T am bOl4J:SA eLm eN)
described as follows:
, the respondent making the Proposal for the project
~H5 1]}I!Il)~ L (pj/Cl-h'OnS
2) The prices in t lIS proposal have been aITlved at lIldependently wIthout collusion,
consultation, communication or agreement for the purpose of restricting competition, as to any
matter relating to such prices with any other respondent or with any competitor;
3) Unless otherwise required by law, the prices which have been quoted in this proposal
have not been knowingly disclosed by the respondent and will not knowingly be disclosed by
the respondent prior to proposal opening, directly or indirectly, to any other respondent or to
any competitor; and
4) No attempt has been made or will be made by the respondent to induce any other
person, partnership or corporation to submit, 01: not to submit, a proposal for the purpose of
restricting competition; and
5) The statements contained in this affidavit are true and correct, and made with full
knowledge that Monroe County relies upon the truth of tile statements contained in this
affidavit in awarding contracts for said project.
COUNTY OF 8rv/Vtzrcl
~~~lll)
10 }30 jCi1
STATE OF Florl d tL
Date
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
DOL/~ $-ha..(I1ot) who, after first being swom by me, (name of
individ lal signing) affixed his/her signature in the space provided above on this
30
{)( k .6t'tC..
,200Q
hvt-
Mycomm'si expires: 6/12./;Z"13
NOTARY PUBLIC
\3-Y ~tJ Notary Public State of Florida
Cindy R Gardner
:l\JI~: My Commission 00679720
~~""o; Expires 05/1212013
OH"
OMB. Mep FORM #1
18
Attachment D
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list following a conviction
for public entity crime may not submit a proposal on a contract to provide any goods or
services to a public entity, may not submit a proposal on a contract with a public entity for the
construction or repair of a public building or public work, may not submit proposals on leases
of real property to public entity, may not be awarded or perform work as a bidder, supplier,
subbidder, or RESPONDENT under a contract with any public entity, and may not transact
business with any public entity in excess of the threshold amount provided in Section 287.017,
Florida Statutes, for CATEGORY TWO for a period of36 months from the date of being
placed on the convicted vendor list."
By executing this form, I acknowledge that limy company is in compliance with the above.
COUNTY OF !3rou}tzrtl
~~
(Signature of Respondent)
10/30/01
Date
STATE OF Flor/ de<..
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
Do~ :SA a... m Or') who, after first being sworn by me, (name of
indivi al signing) affixed hIs/her SIgnature III the space provided above on this
30
day of OLIv bcr
, 20D '1
My ~:~i!.~lf!;-/:;;OI3
NOTARY PUBLIC
""~ P',- Notary Public State of Florida
._0 ~~"".. ~.
~ ,- Cindy R Gardner
"'- t.;: "p My Commi$slon DD879720
.,.-) o~ f\-ti'" Expires 05/12/2013
19
Attachment E
DRUG-FREE WORKPLACE FORM:
The undersigned Respondent in accordance with Florida Statute 287.087 hereby certifies that:
j/t/v(tJucd D&-I-tr.- (J,t)i."ef:,5,/l C;,;Lnc.. (DbA ADfJI- I/1krmcd, j.)
(Name of Business)
1. Publishes a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the workplace and
specifying the actions that will be taken against employees for violations of such prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the business's policy
of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and
employee assistance programs, and the penalties that may be imposed upon employees for drug
abuse violations.
3. Gives each employee engaged in providing the commodities or contractual services that are
under proposal a copy ofthe statement specified in subsection (1).
4. In the statement specified in subsection (1), notifies the employees that, as a condition of
working on the commodities or contractual services that are under proposal, the employee will
abide by the terms of the statement and will notify the employer of any conviction of, or plea
of guilty or nolo contendre to, any violation of Chapter 893 (Florida Statutes) or of any
controlled substance law of the United States or any state, for a violation occurring in the
workplace no later than five (5) days after such conviction.
5. lmposes a sanction on, or require the satisfactory participation in a drug abuse assistance or
rehabilitation program if such is available in the employee's community, or any employee who
is so convicted.
6. Makes a good faith effort to continue to maintain a drug-free workplace through
implementation of this section.
As the person authorized to sign the statement, I certify that this frrm complies fully with the
above reqUireme~
espondents Signature
/O/3o/0C'f
Date
OMB - MCP FORM #5
20
Attachment F
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETIDCS CLAUSE
)-DP I. .In Jt'r(fJf?c/'1 warrants that hefit has not employed, retained
or otherwise had act on his/its behalf any former County officer or employee in violation of
Section 2 of Ordinance No. 10-1990 or any County officer or employee in violation of Section
3 of Ordinance No.1 0-1990. For breach or violation of this provision the County may, in its
discretion, terminate this contract without liability and may also, in its discretion, deduct from
the contract or purchase price, or otherwise recover, the full amount of any fee, commission,
p=entag~ation paid to the former Couoty officer or employee.
(S ature)
Date: 10 /3 0 / () q
STATE OF FierI d It-
COUNTY OF 8rowtLrd
PERSONALLY APPEARED BEFORE :ME, the undersigned authority,
Do <-1 Cf :; A CL I'h (1) who, after first being sworn by me, affixed his/her
J
signature (name of individual signing) in the space provided above on this 30 day of
o c Iv D f:' ~ ,20 D q .
(!n~ /2. A.-~
NO Y PUBLIC
O~~~~ p.(t~'f, No!ary Public Slate of Florida
~ . Cindy R Gardner
~ c; ,.$ My Commission OD879720
.,.-} OF f~Q'O'. Expires 05(12/2013
My commission expires: S /; ~/ ').(> I .3
OMB - MCP FORM #4
21
Attachment G
MONROE COUNTY, FLORIDA
RISK MANAGE:MENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
Indemnification and Hold Harmless
for
Other Bidders and Subbidders
The Bidder covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners AND Board of Governors for District I, its servants, agents and
employees from any and all claims for bodily injury (including death), personal injury, and
property damage (including property owned by Momoe County) and any other losses,
damages, and expenses (including attorney's fees) which arise out of, in connection with, or by
reason of services provided by the Bidder or any of its Subbidder(s) in any tier, occasioned by
the negligence, errors, or other \VTongful act or omission of The Bidder or its Sub bidders in any
tier, their employees, or agents.
In the event the completion of the project (to include the work of others) is delayed or
suspended as a result of the Bidder's failure to purchase or maintain the required insurance, the
Respondent shall indemnify the County from .any and all increased expenses resulting from
such delay.
The first ten dollars ($10.00) of remuneration paid to the Respondent is for the indemnification
provided for above.
The extent of liability is in no way limited to, reduced, or lessened by the insurance
requirements contained elsewhere within this agreement.
R~~
10 ) 30 /0 q
Date
TCS
22
Attachment H (J of 4)
INSURANCE REQUIREMENTS
FOR CONTRACT
RESCUE AIR AND GROUND TRANSPORT BILLNG
AND RELATED SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
ADVANCED DATA PROCESSING INC. (DBA ADPI-INTERMEDIX)
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum:
· Premises Operations
· Products and Completed Operations
· Blanket Contractual Liability
· Personal Injury Liability
· Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this
contract. In addition, the period for which claims may be reported should extend for a
minimum of twelve (12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
GL2
23
Attachment H (2 of 4)
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR CONTRACT
RESCUE AIR AND GROUND TRANSPORT BILLNG
AND RELATED SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
ADVANCED DATA PROCESSING INC. (DBA ADPI-INTERMEDIX)
Recognizing that the work governed by this contract involves the furnishing of advice or
services of a professional nature, the Contractor shall purchase and maintain, throughout the
life of the contract, Professional Liability Insurance which will respond to damages resulting
from any claim arising out of the performance of professional services or any error or omission
of the Contractor arising out of work governed by this contract.
The minimum limits ofliability shall be:
$500,000 per Occurrence/$l,OOO,OOO Aggregate
PR02
24
Attachment H (3 of 4)
VEIDCLE LIABILITY
INSURANCE REQUIRE:MENTS
FOR CONTRACT
RESCUE AIR AND GROUND TRANSPORT BILLNG
AND RELATED SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
ADVANCED DATA PROCESSING INC. (DBA ADPI-INTERMEDIX)
Recognizing that the work governed by this contract requires the use of vehicles, the
Contractor, prior to the commencement of work, shall obtain Vehicle Liability Insurance.
Coverage shall be maintained throughout the life of the contract and include, as a minimum,
liability coverage for:
o Owned, Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
VL2
25
Attachment H (4 of 4)
WORKERS' COMPENSATION
INSURANCE REQIDREMENTS
FOR CONTRACT
RESCUE AIR AND GROUND TRANSPORT BILLNG
AND RELATED SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
ADVANCED DATA PROCESSING INC. (DBA ADPI-INTERMEDIX)
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation lnsurance with limits sufficient to respond to the applicable state
statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less
than:
$500,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized
self-insurer, the County shall recognize and honor the Contractor's status. The Contractor may
be required to submit a Letter of Authorization issued by the Department of Labor and a
Certificate of Insurance, providing details on the Contractor1s Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be
required. In addition, the Contractor may be required to submit updated financial statements
from the fund upon request from the County.
WC2
26
ACORD", CERTIFICATE OF LIABILITY INSURANCE r DATE (MMiDDIYYYYj
07/02109
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Wells Fargo Insurance Services USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
4401 Northside Pkwy, Suite 400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Atlanta, GA 30327-3078
770 850-0050 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: St Paul Fire & Marine Insurance Co 24767
MCI Holdings, LLC INSURER B: The Standard Fire Insurance Company 19070
Advanced Data Processlng,lnc. INSURER c:
6451 North Federal Highway, Suite 1002 INSURER 0:
Fort Lauderdale, FL 33308 INSURER E:
'.
CllenW'16916
MelHOLD
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAl D CLAIMS.
TR NSA TYPE OF INSURANce POUCY NUMBER p~r:~~E p~fJl11,tb~~N UMITS
A ~NERA1. LIABIUTV TE06804556 06/30109 06/30/10 EACH OCCURRENCE 51 000.000
X COMMERCIAL GENERAL L1ABR.lTV DAMAGE TO RENTED $250 000
PR
r- W CLAIMS MADE [1tl OCCUR MOO EX? (Any 01'10 person) $10000
PERSONAL & /JDV INJURY 51.000.000
t--
I-- GENERAL AGGREGAlE 52.000.000
nLAGG~En UMIT APn PER: PRODUCTS - COMPiOP AGG $2 000.000
POUCY ~~ lOC
A ~TOMOBIl.E UABIUTV TE06804556 "'30'0. ~ 06130/10 COMBINEO SINGLE UMIT
x.. ANY AUTO (Ea 8Ccld<Int) 51,000,000
- ALL OWNED AUTOS '001 :, ~~u~ BOOIL Y INJURY
> (Por person) 5
- SCHEDULED AUTOS
x.. HIRED AUTOS
~?~ " SODIL Y INJURY $
~ NON-DWNED AUTOS _ l~ (Per accident)
'. ~ ,- PROPERTY DAMAGE - .
(Po, occidont) 5 - -
qGE UABlUTV '. t (UL~ AUTO ONLY - EA ACCIDENT $
ANY AUTO f5'lA'. OTHER THAN EA Ace 5
-
AUTO ONLY: AGG $
A tiJESSlUMBRELI.A LIABIUTV TE06804556 06/30/09 V 06130/10 EACH OCCURRENCE 55.000 000
X OCCUR D CLAIMS MADE CU,~ L.eYA AGGREGATE $5.000000
5
~ DEDUCTIBLE (' /",~ ~wW, \ U... LJ // $
X RETENTION 510000 /f ~ JJ l{)(<J-r ) $
B WORKERS COMPENSATION AND HCUB3240M13609 06130/09'- 06130/10 X J WCSTATU- lOlli-
EMPLOYERS' UABIUTV $500 000
ANY PROf'RIETORiPARTNERiEXECUTIVE E.L EACH ACCIOENT
OFACERlMEMBER EXCLUOED? EL DISEASE. EA EMPLOYEE 5500,000
~~~~~NSbalow E.L DISEASE - POUCY UMIT 5500,000
OTHER
-
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
If required by written agreement, the Monroe County Board of County CommissIoners is
included as an additional insured under the general, automobile, and umbrella liability
insurance.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCeLLED BEFORE THE EXPIRATION
Monroe County Board of DATE rnEREOF, mE ISSUING INSURER WILL ENDEAVOR TO MAIL -.30... DAYS WRITTEN
Commissioners NOTICE TO mE CERTlACATE HOLDER NAMED TO TItE LEFT, BUT FAlWRE TO DO so SHAJ.1.
490 63rd Street, Suite 170 IMPOSE NO OBUGATION OR UABIUTY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
Marathon, FL 33050-1026 REPRESENTATIVES.
~~:;R~:?
ACORD 25 (2001108) 1 of 2
#S1496358/M1492141
ESE01
@ ACORD CORPORATION 1988
.L:JAU..LU.LL .ti
FIRE RESCUE REPORT
Monroe County Fire Rescu.e
490 63rd Street
Marathon, FL 33050
RlllIDl Number:
Patient Name:
Date of Service:
Shift: Nature of Call: Received:
Station: Location: Dispatched:
Level of Care:
Rescue: Destination:
Unit ID: Enroute:
Crew #1: Arrive:
Crew #2:
Crew #3: Pt Contact:
Pt. Transported: Depart:
At Dest:
At Scene Loaded Miles
Reap Delay: it Dest Mileage:
Name:
SSN:
DOB:
Sex:
Weight:
Phone:
Home Address:
Mailing Address:
',"
-
Patient Found:
ChIef ComplaInt:
Cause of Injury:
~elevant Past HIstory:
MedIcations:
. . ".:. ..~.. ..... '. :'" .(~r
111&111......"'......____
"IO?>; ...... '. ."e.." .... .......\.../. ..... '.
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, 4
.!FIRE RESCUE REPORT
Monroe County Fire Rescue
490 63rd Street
Marathon, FL 33050
Run Numberr:
Patient Name:
Date of Service:
II
Bodv Are~
A$lIIt1ssmonf
Bow Arall
AsseslIImant
!3alI
Disclaimer
I,. , aulhorizc any holder of medical or other information about me to release to !he Social Security
Aliministralion and Health Care Financing Administration or its intemlediaries or earners, or any private insurance
company any information needed for Ihis or a related medical claim.
iD!.
I permit a copy of this aulhorization to be used in place of the original and request payment of medical. insurance
benefits to the party who accepts assignment I personally guamntee payment of any charges not covered by heallh care
benefits. According to Medipare regulations, your ambulance transport and related services are subject to review under
the MediclU'C program. The pUrpose oflhis review is to determine whelher or not your transport and related services
meet the guidelines for Medicare payment If it is detennined, under Ihe Medicare Program guidelines that your
transport and related services were not medically necessary, or Ihat non-covered services were provided to you, Ihen,
please be advised that you are personally responsible for payment oflhe transport or Ihe non-covercd services.
Furthc:rmore, [ hereby aCknowledge that I have been provided with a copy of Monroe County's Notice of Privacy
Practices on this date.
Signature
4
-'
FliRE RESCUE lLmPORl'
MOJaIll"oe County Fire Rescue
490 63rd Street Marathon, FL 33050
RVllru Numbeli:
PatHeillt Name:
Date of Service:
1mt
Im!I
Be QA Review
Disclaimer
I have reviewed this report for completeness and accuracy.
Signature
~ Crew 3 Name Certification Signature
.,.
4
JFJIJ?...E RESCUE REPORT
MOIDli'Oe COllllnty Fire Rescue
490 63rd Street Marathon. FL 33050
Phone#(305) 289-6004
RIDIIDl Numbcrr:
Pmtielllt Name:
Date of Service:
Documented By:
Guarantor
Address
58N
Relation
Send Bill To
Insured?
Insurance
Insurance
Company
Employed?
Work Related?
State
Insured's Name
Polley Number
. ,.
f4
Printed on: 01/07/2005 at 12:22