Item D05
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: Mav 18. 2005
Division:
Mana2ement Services
Bulk Item: Yes X No
Department: Group Insurance
AGENDA ITEM WORDING: Approval of contract amendment with the Keys Phvsician-
Hospital Alliance (KPHA) .
ITEM BACKGROUND: BOCC approved current contract in March 2004. This contract has
two automatic renewals.
PREVIOUS RELEVANT BOCC ACTION:
CONTRACT/AGREEMENT CHANGES: Amend wordin2 under #3 - Utilization Mana2ement
and Quality Assurance to reflect chan2e in procedure with re2ards to utilization and lar2e case
mana2ement documentation retention.
STAFF RECOMMENDATIONS: Approval
TOTAL COST:
none
BUDGETED: Yes ~
No
COST TO COUNTY:
none
SOURCE OF FUNDS:
REVENUE PRODUCING: Yes
No
AMOUNTPERMONTH_ Year
APPROVED BY: County Atty _ OMB/Purchasing _ Risk Management
DIVISION DIRECTOR APPROVAL:
Sheila A. Barker
Division Director Management Services
DOCUMENTATION:
Included X
To Follow_
Not Required_
DISPOSITION:
AGENDA ITEM #
Revised 1/03
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract #
Contract with: Kevs Physician-Hospital Effective Date:March 1, 2005
Alliance
Expiration Date:February 28, 2006
Contract Purpose/Description:Contract 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 May 18, 2005
Agenda Deadline: May 3,2005
CONTRACT COSTS
Total Dollar Value of Contract: $27,000.00
Budgeted? Y es~ No D 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 Y esD No~
Date Out
County Attorney
YesDNo0
YesD No~
YesG:rNoD
Risk Management
O.M,B./Purchasing
Comments:_
OMB Form Revised 9/11/95 MCP #2
CONTRACT MffiNDMENT
This amendment to is made and entered into this 18th day of May, 2005, between
the BOARD OF COUNTY C01vfMISSIONERS OF MONROE COUNTY, FLORIDA, hereinafter
referred to as "EMPLOYER" PHY SICIAN-HO SPIT AL ALLIANCE, hereinafter referred
to as "KPHA".
WHEREAS, EMPLOYER and
purpose of providing a provider network,
into an
reVIew
on March 1, 2004 for the
case management; and
WHEREAS, it is now necessary the
documentation in their system;
to retain large case and utilization review
Now therefore, the parties agree as follows:
1. Paragraph four under #3 - Utilization Management and Quality Assurance of the agreement
dated March 1, 2004 shall be revised, effective May 1, 2005, to read as follows:
"Utilization Review and Large Case Management services will be performed according to pre-
set protocols developed in conjunction with the claims administrator's (Acordia National)
and the KPHA."
All other provisions of the Agreement entered March 1, 2004, not inconsistent herewith, shall
remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this agreement amendment the day fIrst
written above.
ATTEST: DANNY KOLHAGE,CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
Dixie
PHYSICIAN-HOSPITAL
EMPLOYER-PROVIDER NETWORK
AND
UTILIZATION REVIEW AND CASE MANAGEMENT SERVICES
AGREEMENT
TillS AGREEMENT is entered into as of this first day of MARCH 2004 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.
OUT-OF COUNTY PROVIDERS. KPHA agrees to negotiate and contract with
"Dimension Network" in Dade, Broward and Palm Beach Counties for discounted fee
arrangements 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.
KPHA agrees to negotiate and contract with or work collaboratively with a national network
for discounted fee arrangements with physicians, hospitals, and other ancillary health
services as needed for the benefit of the Employer. If the current 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
Participation in the review of billing practices and appropriateness of charges of network
providers in conjunction with the Claims Administrator if requested
· 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 March, 2004. 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 administrator's (Acordia National)
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 W orksite 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.
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. Physician UCR charges will be based upon
the "P.H.C.S" fee schedule, formerly known as "HlAA". 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.
CLEAN CLAIM. A "Clean Claim" means a claim submitted by the Provider/Hospital that
has been properly and accurately completed on the appropriate paper or electronic claim
form, HCFA 1500 and/or DB 92 together with any information that was requested in writing
by Acordia National within 15 days of Acordia National's receipt ofa claim.
NOTIFICATION OF CLAIM STATUS. Payor/Plan shall notify Provider/Hospital within
15 days of receipt of a claim that said claim is not considered "Clean" and reasons therefore.
Failure to do so shall deem the claim being considered "Clean" and set fortimely payment.
DISPUTED CLAIMS. If the Payor/Plan does not object in writing to a claim within 15
days of receipt by the Payor/Plan, the claim will be considered clean and complete. If the
Payor/Plan disputes any portion of the billing for services rendered, Payor/Plan will promptly
seek to resolve the dispute and return the claim to the regular processing status. Should the
claim remain in dispute for more than 30 days, Payor/Plan will pay the Provider/Hospital
90% of the fees as outlined in the "Provider Agreement Amendment! Reimbursement
Addendum" within 7 days with payment for the remaining 10% subject to the outcome of
the dispute. Those items requiring further resolution prior to the remaining payment shall be
reconciled by the Payor/Plan and the Provider/Hospital and the appropriate payments or
adjustments made within 60 days.
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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 benefits,
including but not limited to the applicable terms of coverage, deductible status and co-
msurance.
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.
8. BOOKS AND RECORDS. KPHA shall make available to claims administrator (Acordia
National) and County of Monroe (employer)..all records and other data relating to both the
network and utilization review and case management services for the purposes of periodic
audits of KPHA's services. Information/data will be maintained, as required, to assure
confidentiality and compliance with all applicable regulations.
9. RESPONSIBILITY 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
4
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 mail, return. receipt requested and first-class postage prepaid to the
addresses as follows:
Employer: County of Monroe
Manager- Employee Benefits
Gato Building
1100 Simonton Street, Room 2-268
Key West, Florida 33040
KPHA: Keys Physician-Hospital Alliance
c/o Lower Florida Keys Physician Hospital Organization, Inc.
P.O. Box 9107
Key West, Florida 33041-9107
Attn.: Nicki Will, 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 shall 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 Monro~ 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, permissible 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.
5
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.
H. OWNERSIDP 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.
1. INSURANCE REQUIREMENTS: 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 severance 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.
1. ENTIRE AGREEMENT: This Agreement, along with its exhibits, contains all the
terms 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, incl~lding 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 performance 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 March 2004.
6
Employer:
Board of County Commissioners
~CO(~
By:
,A1o.yo r
,
(1';j~AL) Its:
ATTEST: OANNVf..KOLHAGEC!SiK
8Y~~~C.IJu'Sl~')
O/;PUTY CLeRK .
Keys Physician-Hospital Alliance
.~ -tJ~
V J~c1L'\-\
By:
Its:
~/I"
N A. H 0
ASSISTANT C~TY.%yRNEY
Date '7 ~
7
Attachment A
Reimbursement Schedule
75% of billed charges with the cap of the 90th percentile of the P.H.C.S.
(formerly known as HIAA) Fee Schedule.
75% - 85% of billed charges with the cap of the 90th percentile of the
P.H.C.S. (formerly known as HIAA) Fee Schedule.
Out-of-County Providers (IPN) 70% of billed charges with the cap of the 90th percentile of the P.H.C.S.
(formerly known as HIAA) Fee Schedule.
*KPHA Members
*In County Providers (IPN)
Dimension Providers
Dimension NetworkFee Schedule.
MultiPlan Providers
MultiPlan Network Fee Schedule.
Fisherman's Hospital
75% of billed charges.
Lower Keys Medical Center
75% of billed charges.
*HCPS codes shall be reimbursed at 75% of billed charges.
A list of specific providers and discount percentages will be provided to Acordia National by KPHA for
implementation.
~
James Roberts, County Admin~trator
v- I r:-o~
Date
~~
Robin Lockwood, M.D.
KPHA President
3-3-o-~
Date
??flY
8