Item C31
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: September 17.-2003
Division:
Manal!ement Services
Bulk Item: Yes ~ No
Department: Group Insurance
AGENDA ITEM WORDING: Approval of contract renewal with Kevs Phvsician-Hospital
Alliance HA for the em 10 er- rovider networ utilization review and case mana ement
effective October 1. 2003 throul!h September 30. 2004.
ITEM BACKGROUND: Current contract effective October 1. 2002 throul!h September 30. 2003
with renewals for FY 03-04 & FY 04-05. The County is currentlv preparinl! RFP's for a fullv-
insured and self-insured ro ram. If u on com letion of the RFP the Coun desires to
terminate the current KPHA contract a (90) dav written notice must be l!iven.
PREVIOUS RELEVANT BOCC ACTION: BOCC directed that RFP be done March 2001 and
a roved Ke s Ph sician-Hos ital Alliance as the em 10 er- rovider network utiIization review
and case manal!ement January 2002.
CONTRACT/AGREEMENT CHANGES: This is the rust-Year renewal. Books and Records
clause amended so that the Coun as well as Acordia National will have access to all records
and other data for the purpose of periodic audits.
STAFF RECOMMENDATIONS: Approval
TOTAL COST: $27.000.00
BUDGETED: Yes-K-
No
COST TO COUNTY: $27,000.00
SOURCE OF FUNDS: Primarily Ad Valorem
REVENUE PRODUCING: Yes No X AMOUNTPERMONTH_ Year
APPROVED BY: County Atty fit OMB/Purchasing _ Risk Management'&--
DlVISIONDIRECTORAPPROVAL: ~".~_ /J~.A ::
Sheila A. Barker
DOCUMENTATION:
Included L
To Follow .,
Not Required_
DISPOSITION:
AGENDA ITEM #
CJl
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract #
Effective Date:October 1. 2003
.-
Contract with: Keys Physician-Hospital
Alliance
Expiration Date:September 30. 2004
Contract Purpose/Description:Renewal for the employer-provider network and utilization review
and case management for the Group Insurance Program.
Contract Manager:Maria Z. Fernandez
(Name)
4448
(Ext. )
Administrative Services
(Department)
for BOCC meeting on Seotember 17 2003 Agenda Deadline: Seotember 2. 2003
CONTRACT COSTS
Total Dollar Value of Contract: $27.000.00
Budgeted? YeslZl No 0 Account Codes:
Grant: $N/ A
County Match: $N/ A
Current Year Portion: $_
502-08002-530310-_-_
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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 YesO No
Risk Management r 11103 YesO NoB-
O.M.B./Purchasing ~1..!J./IJ!;, Y es~
County Attorney WP3 Y esO No~
Cornments:Ql1J/!;: S-b ee.u ~.eA~ ~.J
rlJd6;lfl1!)) IWOIS {/abUeenn
OMB Form Revised 9/11/95 MCP #2
RENEWAL AGREEMENT
This renewal agreement is entered into by and between Board of County Commissioners of
Monroe County, Florida; 1100 Simonton Street, Room 2-268; Key West, Florida 33040 (hereafter
Employer) and the Keys Physician-Hospital Alliance; P.O. Box 9107; Key West, Florida 33040
(hereafter KPHA).
WHEREAS, on October 1,2002, the Employer and KPHA entered into an agreement (hereafter
the original agreement) whereby the KPHA performs Utilization Review and Case Management Services
and provides an Employer-Provider Network for the Employer's employee welfare benefit plan; and
WHEREAS, the current contract will expire on September 30, 2003 and the Employer desires to
extend the original agreement for another year, therefore, the parties agree as follows:
I. The Books and Records clause will be amended so that KPHA shall make available to
claims administrator (Acordia National) and the County of Monroe (employer) all
records and other data relating to both the network and utilization review and case
management services for the purpose of periodic audits of KPHA's services.
Information/data will be maintained, as required, to assure confidentiality and compliance
with all applicable regulations.
2. In all other respects the terms and conditions of the original agreement remain in full
force and effect.
3. This first one-year renewal term will commence immediately upon the expiration of the
current contract. Therefore this renewal will become effective October 1, 2003, and will
expire September 30, 2004.
IN WITNESS WHEREOF, the parties hereto have executed this Renewal Agreement this
, 2003.
day of
ATTEST: DANNY L. KOLHAGE, CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By
Deputy Clerk
By
Mayor/Chairman
WITNESS:
KEYS PHYSICIAN-HOSPITAL ALLIANCE
STEPHEN KRA THEN, DO
By
Witness
By
President
MONROE COUNTY ATTORNEY
~
~UZA E . HUTTON
Date ASSISTA"(~~TTORNEY
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 bid on a contract to provide any goods
or services to a public entity, may not submit a bid on a contract with a public entity for the
construction or repair of a public building or public work, may not submit bids on
leases of real property to public entity, may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant 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, for CATEGORY TWO for a period of36 months from the
date of being placed on the convicted vendor list."
ATTACHMENT B
! ~'.
l,. .
EMPLOYER-PROVIDER NETWORK
AND
UTll..IZATION REVIEW AND CASE MANAGEMENT SERVICES
AGREEMENT
THIS AGREEMENT is entered into as of this first day of OCTOBER 2002 by and
between Keys Physician-Hospital Alliance ("KPHA") and the County of Monroe
("County"), hereon referred to as "Employer".
RECITALS
WHEREAS, the KPHA has established a network of participating health care
providers, which providers, pursuant to the terms and conditions of provider agreements
with KPHA, have agreed to deliver medical services in a cost effective manner to persons
covered under the health benefit plans and policies of Employer.
WHEREAS, KPHA has agreed to provide utilization review and case management
services to Employer and personnel, dependents, Cobra beneficiaries and eligible retirees
covered under the health benefit plans and policies of Employer.
WHEREAS, Employer administers the health care benefit plans and has the express
authority, by signing this Agreement, to bind the Employer to all of the terms and conditions
of this Agreement.
.,
WHEREAS, Employer desires and agrees to offer KPHA Provider Network to
persons covered under the Employers health benefits plans;
Now, THEREFORE, the parties agree as follows:
1. RECITALS. The foregoing recitals are hereby incorporated by reference and
made a substantive part hereof.
2. LIST OF PARTICIPATING PROVIDERS. KPHA shall provide Employer
with a list of Participating Providers, to include hospitals, physicians, dentists, pharmacies,
and other ancillary health services, and shall provide Employer with periodic updates of the
Network roster of Participating Providers from time to time. Such updates will be at least
semi-annually and in such a printed format as distributable to persons covered under the
Employers health benefits plans.
Page 1
OUT-OF COUNTY PROVIDER$. KPHA agrees to negotiate and contract with
"Dimension Network". in Dade, Broward and Palm Beach Counties for discounted fee
arran.gements with physicians, hospitals, and other ancillary health services as needed for the
benefit of the Employer. If the "Dimension Network" is not utilized, or becomes unacceptable to
the Employer, KPHA will propose other alternative arrangements for such out of county
services.
3. UTILIZATION MANAGEMENT AND QUALITY ASSURANCE. KPHA shall
provide for Employer Utilization Review services to include
· Review of inpatient admissions and of continued hospital stay
· Discharge planning
· Data collection and reporting
· Review of supportive or treatment services
· Review of office visits, ambulatory surgery and diagnostic or other outpatient
services
· Review of billing practices and appropriateness of charges of network providers
· Large Case Management services
The monthly capitation fee for such services will be $1.35 per employee per month. This fee will
be payable by the County to KPHA by the 20th of each month beginning on the 20th day of
October, 2002. The number of enrollees will be determined on the 1 st business day of each
month.
KPHA shall provide for Large Case Management services for a fee of$55.00 per hour on an as-
needed basis. Large Case Management services may be pre-approved by the County on a case by
case basis and billings for such fees incurred shall be provided monthly with details of all
charges.
Utilization Review and Large Case Management services will be performed according to pre-set
protocols developed in conjunction with the claims administrators (Acordia National's) standards
and will be documented in the claims administrators' computer system.
4. WELLNESS PROGRAMS AND OTHER EDUCATIONAL SERVICES. KPHA
shall design and implement with the coordination of Employer's staff, the Worksite Wellness
Program and other similar services to the Employer and Covered Persons to promote healthy
lifestyles and preventative health Care. The Worksite Wellness Program will include, at no
additional charge to Employer or Covered Persons, a health risk assessment for each employee
and may include, for a charge by a Participating Provider, Health Physical Packages. Health Fair
coordination and implementation or other services as negotiated and deemed to promote healthy
lifestyles and preventative health care may also be included in this service.
Page 2
5. PARTICIPATING PROVIDER COMPENSATION. Employer shall compensate
Participating Providers for covered services minus any plan participant responsibilities.
Employer has the responsibility for implementation of the applicable claims payment submitted
by Participating Providers for services rendered or for any billing or other function related to the
health care services provided by Participating Providers to Covered Persons. All claims for
covered services, whether payable by the Employer or a Covered Person will receive a discount
off of provider billed charges as specified in Attachment A. This discount will be rescinded if
an appropriately documented and non-contested claim is not paid to the Participating Provider
within thirty (30) days of being received by the claims administrator (Acordia National).
NON-APPROPRIATIONS CLAUSE. Monroe County's performance and obligation
to pay under this contract is contingent upon an annual appropriation by the BOCC. Monroe
County may not deny payment for valid and accurate claims properly submitted and rendered
during the plan year.
PROVIDER REIMBURSEMENT TERMS. KPHA shall use best efforts to ensure that
the Participating Provider's physician Usual Customary and Reasonable (VCR) charges will not
change during the term of one year. Thereafter, KPHA agrees to provide a ninety (90) day
notification in the event of a charge increase. Physician UCR charges will be based upon "the
Medicode database." The above agreed upon discount will be applied to the billed charge, not to
exceed the UCR charge for a service.
KPHA further agrees that no other self-insured employer contracting with KPHA will be
provided with better overall terms than what is being here agreed. If however, better terms are
provided to another self-insured employer contracting with KPHA, such terms will also be
extended to the Employer.
6. COVERED PERSON IDENTIFICATION. Employer shall supply Covered Persons
with identification cards or other means of identification which clearly identifies KPHA, reflects
the Covered Person's coverage under the applicable Employers health benefit plan, and reflects
the Covered Person's eligibility to receive services from Participating Providers in accordance
with the terms of this Agreement. Employer shall also provide such other services as may be
required in order for Participating Providers promptly to verify the status of individuals as
Covered Persons, the terms of the Covered Person's health care benefrts, including but not
limited to the applicable terms of coverage, deductible status and co-insurance.
7. NETWORK EXCLUSIVITY. During the course of the agreement Employer agrees not
to participate or enter agreements to utilize other provider networks other than that agreed upon
with KPHA and the Employer. Employer during the term of this Agreement shall not seek to
negotiate with individual network members for care or services outside of contractual provisions
without prior notification to KPHA.
Page 3
8. BOOKS AND RECORDS. KPHA shall make available to claims administrator
(Acordia National) all records and other data relating to both the network and utilization review
and case management services for the . purpose of periodic audits of KPHA's services.
Information/data will be maintained, as required, to assure confidentiality and compliance with
all applicable regulations.
9. RESPONSmn.ITY FOR HEALTH CARE SERVICES. Employer agrees that KPHA
shall not have any responsibility or liability for any act, omission, or decision related to medical
services rendered by Participating Providers to a Covered Person.
10. TERM. This Agreement shall continue in effect for one (1) year from the date first
above written. Thereafter, the Agreement shall renew for two (2) consecutive one (1) year terms.
KPHA agrees to provide the Employer with at least ninety (90) days.written notice of the intent
to terminate, non-renew, or amend this Agreement. The Employer agrees to provide KPHA with
at least ninety (90) days written notice of the intent to terminate or non-renew this agreement.
Any modification of the terms of this agreement may occur upon the mutual' agreement of the
parties.
BREACH AND CURE. Notwithstanding the foregoing, this Agreement may be
terminated by either party upon a material breach of this Agreement by the other party, providing
that. the breaching party does not cure the breach within thirty (30) days following receipt of a
written notice from the non-breaching party specifying the nature of the breach and requesting
that it be cured.
11. GENERAL PROVISIONS.
A. THIRD PARTIES: The terms and provisions of this Agreement are for the
benefit of the parties hereto and are not intended to provide any other person with any right or
cause of action on account thereof.
B. NOTICES: Any notice required to be given pursuant to the terms and provisions
thereof shall be in writing and shall be hand-delivered, with return receipt thereof, or sent by
certified or registered mai~ return receipt requested and first-class postage prepaid to the
addresses as follows:
Employer:
County of Monroe
Manager- Employee Benefits
Public Service Building
5100 College Road, Stock Island
Key West, Fl33040
Page 4
KPHA:
Keys Physician-Hospital Alliance
c/o Lower Florida Keys Physician Hospital organization, Inc.
P.O. Box 9107
Key West, Florida 33041-9107
Attn.: Ronald Bierman, Secretary
C. ASSIGNMENT: This Agreement may not be assigned, subcontracted,
delegated, transferred by either party without the express written consent of the other party, and
any attempted assignment, subcontract, delegation or transfer shall be void.
D. INDEPENDENT CONTRACTORS: None of the provisions of this Agreement
are intended to create, nor shalt be deemed to, or construed to create any relationship between
KPHA and Employer other than that of independent entities contracting with each other
hereunder solely for the purposes of effecting the provisions of this Agreement. Neither of the
parties hereto, nor any of their respective officers, directors, or employees shall be construed to
be the agent, employee, or representative of the other.
E. GOVERNING LAW: .This Agreement shall be governed in all respects by the
laws of the State of Florida without regard to Florida's choice of law statutes or decisions. Any
action by any party, whether at law or in equity, relating to this Agreement shall be commenced
and maintained, and venue shall be proper, only in Monroe County, Florida.
F. ORDINANCE 10-1990: KPHA warrants that it has not employed, retained or
otherwise had acted on his behalf any former County officer subject to the prohibition in Sec. 2
of Ordinance no. 10- 1990 or any County officer or employee in violation of sec. 3 of Ordinance
10- 1990, and that no employee or officer of the County had any interest, financially or otherwise,
in KPHA except for such interest, pennissible. by law and fully disclosed by affidavit attached
hereto. For breach or violation of this paragraph, the County may, in its discretion, terminate this
agreement 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, percentage, gift or
consideration paid to the former County officer or employee.
G. CONFLICT OF INTEREST: KPHA assures the County that to the best of its
knowledge information and belief, the signing of this agreement does not create conflict of
interest.
Page 5
H. OWNERSHIP OF INFORMATION: All Utilization Review and Case
Management documents which are prepared in the performance of this agreement are to be, and
shall remain, the property of the County and shall be transferred to the County or to a
replacement Utilization Review/Case Management service provider upon request and no later
than thirty (30) days after termination of this agreement. Any patient identifying information
shall not be disclosed without written consent of the patient.
I. INSURANCE REOUIREMENTS: KPHA is required to maintain the types of
insurance identified in Attachment B.
J. SEVERABILITY: If any provision of this Agreement is held to be illegal,
invalid, or unenforceable, under present or future laws effective dUring the term hereof, such
provision shall be fully severable. In such event, this Agreement shall be construed and enforced
as if the illegal invalid or unenforceable provision had never been a part hereof, and the
remaining provisions shall remain in full force and effect unaffected by such severance- provided
that if the illegal, invalid or unenforceable provision is material to the overall purpose and
operation of this Agreement, then this Agreement shall terminate upon the ~everance of such
provision.
K. COUNTERPARTS: This Agreement and any amendment hereto may be
executed in multiple originals, all counterparts together constituting one and the same
instrument.
L. ENTIRE AGREEMENT: This Agreement, along with its exhibits, contains all
the tenns and conditions agreed upon by the parties hereto regarding the subject matter of this
Agreement and supersedes any prior Agreements, promises, negotiations, or representations
either oral or written, relating to the subject matter of this Agreement.
M. HOLD HARMLESS: KPHA shall indemnify and hold the County harmless
from and against any and all losses, penalties, damages, professional fees, including attorney fees
and all costs of litigation and/or judgment arising out of any willful misconduct or negligent act,
error or omission of KPHA incidental to the perfonnance of this agreement or work performed
thereunder. This indemnity shall extend to amounts the County becomes legally obligated to pay
and shall be limited by any sovereign immunity limit applicable to the underlying claim plus
costs of litigation.
In witness wherof, the Employer and KPHA have caused this Agreement to be executed by their
respective corporate officers, effective as of the fIrst day of October 2002.
Page 6
. ZANN%E 0UTTON
, t::J II 0 2-
DATE --'- .-
Employer:
Board of Co
of Monroe
ommissioners
Florida
By:
Its:
a,n 9-/ ~-~ :l
~
By:
Its:
Ro..s~dtnL
-~.I..)
'T: DANNYL kOlHAGE CLERK
1:lY-
-~iok.,....,___..
Page 7
Attachment A
Reimbursement . Schedule
KPHA Members
85% of blUed charges with the cap of the 90tll percentile of the Medicode
Fee Schedule.
In County Providers (IPN)
85% of blUed charges with the cap of the 90tll percentile of the Medicode
Fee Schedule.
Out-of-County Providers (IPN) 70% of blUed charges with the cap of the 90tll percentile of the Medlcode
Fee Schedule.
Dimension Providers
Dimension Network Fee- Scbedule
Fisherman's Hospital
75% of billed cbarges.
Lower Keys Medical Center
75% of billed cbarges.
A list of specific providers and discount percentages win be provided to Acordia National by KPHA for
implementation.
T
//-I'~
Date
Stepben Krathen, D.
KPHA President
o q ( Jt;'-/ 0;)"
Date