07/26/2000
..CLERK'S ORIGINAL
WORKERS' COMPENSATION MANAGED CARE
SERVICE AGREEMENT
FOR
Monroe County
THIS AGREEMENT made and entered into effective October 1, 2000 between CorVel
Corporation whose principal offices are at Irvine, California, hereinafter referred to as "CorVel"
and Monroe County, herein referred to for the purpose of this agreement as "Monroe County"
with principal offices located in Key West, Florida. Monroe County and its Third Party
Administrator, ISAC, and CorVel Corporation as the managed care network have read and
understand the Managed Care Plan of Operation as submitted for Monroe County.
WITNESSETH that
WHEREAS CorVel operates a managed care business which provides First Report of Loss
Preparation/Filing/Transmission services hereinafter referred to as "First Report Services;" and
Early Intervention Case Management services, hereinafter referred to as "Early Intervention;"
Outpatient and Inpatient Utilization Review services, hereinafter referred to as "Utilization
Review;" medical audit and review services hereinafter referred to as "MedCheck;" and on-site
medical case management and vocational rehabilitation services, hereinafter referred to as "Case
Management;" and
WHEREAS Monroe County desires to employ CorVel from time to time, to provide said services
for the benefit of Monroe County and/or the benefit of its insureds and/or their injured employees;
and
WHEREAS CorVel desires to be so employed by Monroe County to provide said managed care
services.
NOW, THEREFORE, in consideration of the premises hereof: and the mutual promises and
agreements made herein, the parties hereto, intending to be legally bound, hereby agree as
follows:
OBLIGATIONS OF CORVEL
1. FIRST REPORT/EARL Y INTERVENTION SERVICES
1.1 CorVel shall provide First Report services set forth herein to Monroe County on a non-
exclusive basis upon receipt by CorVel of specific requests from Monroe County. Prior to
the implementation of Cor Vel services and as required during the term of this Agreement,
Monroe County shall provide CorVel with instructions regarding the scope and extent of
the First Report and Early Intervention services to be performed by CorVel.
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1.2 CorVel shall receive telephone calls from Monroe County, its insureds, and/or their
employees via a toll free 1-800 number, to gather the information required to complete the
First Report of Loss forms.
1.3 CorVel shall maintain at all times sufficient staff to handle all incoming calls within
established quality assurance standards. Furthermore, CorVel shall be prepared to
complete First Report of Loss forms for all applicable states.
1.4 Once the appropriate information is gathered by a CorVel representative, First Report of
Loss forms will be submitted to the applicable Monroe County branch claim office or if
desired, to a central Monroe County location and/or if desired, the applicable state
industrial accident board or commission as required by law. Whenever possible, this
information shall be electronically transmitted to the applicable state industrial accident
board or commission. Furthermore, CorVel will submit this information in a format
acceptable to Monroe County.
1.5 Any questions or concerns from an industrial accident board or commission concerning
First Reports of Loss completed by CorVel will be handled directly by CorVel. All
complaints will receive an initial response within 24 hours of receipt of the complaint by
CorVel. CorVel will keep Monroe County apprised of any complaints it receives and the
response thereto. CorVel will send a written response to the complainant within five
working days outlining the nature of the complaint and the resolution of same by CorVel.
A copy of this response will be sent to the attention of the designated Monroe County
representative. The parameters of CorVel's authority hereunder must be established in
consultation with and subject to the express agreement of Monroe County. Further,
Monroe County shall have the right, but not the obligation, at any time, to interject itself
into the dispute between CorVel and the industrial accident board or commission and to
resolve the dispute in a manner acceptable to Monroe County at its sole discretion.
1.6 Cases identified during the First Report of Loss process as meeting the criteria for Early
Intervention services, will be referred on a case by case or automatic basis (at Monroe
County's preference) for such services. The criteria for referral, i.e., lost time cases or
other predefined criteria, will be established by Monroe County in consultation with
CorVel. Direct referral from Monroe County field offices for Early Intervention services
involving cases that are not referred via the First Report of Loss service may also occur.
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The Early Intervention service components for lost time claims include:
1. An initial contact with employee/employer to gather data for first report of injury
preparation/submission (optional).
2. The channeling of patients to PPO network providers.
3. A multi-point (employee, employer, claims handler, provider) contact to gather
medical and treatment plan data.
4. A review of the provider treatment plan to determine medical appropriateness and set
outpatient treatment parameters.
5. A CorVel RN Case Manager completes an assessment report with recommendations
for submission to Monroe County within two weeks. These recommendations will
outline the next course of action (e.g" medical management, utilization review, 1MB,
vocational rehabilitation, etc.), if warranted.
The Early Intervention service for med-only claims include:
1. Initial contact with employee/employer to gather data for first report of injury
submission, if required.
2. Channel patient to PPO network.
3. Contact employee, and if necessary, the treating physician to gather sufficient
information to determine potential for serious and/or lost time situations.
4. Confirm med-only status or recommend additional intervention as required
1.7 All other aspects of CorVel's first report/early intervention services not addressed herein
shall be provided in accordance with CorVel's service proposal and/or marketing
materials.
2. UTILIZATION REVIEW SERVICES
2.1 CorVel shall provide utilization review services set forth herein to Monroe County on an
non-exclusive basis upon receipt by CorVel of specific requests from Monroe County.
During the term of this Agreement, Monroe County shall provide CorVel with instructions
regarding the scope and extent of the utilization review services to be provided.
2.2 Aided by CorVel's proprietary outpatient medical treatment protocols and "Expert
Systems" technology, our utilization review nurses evaluate proposed treatment plans for
appropriateness, care setting, and duration of care. If treatment is "certified," the provider
is advised of the length of treatment/number of visits that are being authorized. When
utilized in COtUunction with our MedCheck provider bill review program, actual treatment
rendered is monitored on an ongoing basis to assure compliance with pre-authorized
treatment. Services rendered which exceed established parameters are disallowed at the
time the bill is reviewed for Fee Schedule or U&C compliance. Monroe County will be
provided with a monthly out patient utilization review report which will document
projected savings.
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2.3 The CorVel pre-admission certification program is a review service which verifies the
medical necessity of proposed hospital admissions and determines the appropriate length
of stay. The CorVel staff of utilization review nurses and reviewers, assisted by an
automated medical rules/protocols system and backed up by physician consultants,
individually evaluates every hospital admissions request.
Pre-certification objectives include the following:
- determine appropriateness of proposed treatment plan.
- determine the medical necessity for hospital admission/inpatient care.
- explore alternatives to inpatient treatment.
- prevent unnecessary inpatient hospitalizations and save customer dollars.
. if inpatient care is required, determine the appropriate length of stay and monitor the
patient's condition throughout the hospitalization to prevent unnecessary inpatient days.
- channel the patient to a CorVel PPO provider/facility.
- develop and implement a timely discharge plan.
- educate the employer and employees regarding physicians and services available, the
claims process, and how utilization review is implemented so that good decisions
regarding medical care and services can be made at the time of injury.
Documentation of all utilization review activities in the form of written correspondence
shall be communicated to the referring claim professional. A monthly savings summary
that documents all inpatient and outpatient hospital admissions shall also be provided to
Monroe County.
2.4 All other aspects of CorVel's utilization review services not addressed herein shall be
provided in accordance with CorVel's service proposal and/or marketing materials.
3. MEDCHECK
3.1 MedCheck shall provide hospital and medical bill audit/review services set forth herein to
Monroe County on a non-exclusive basis upon receipt by MedCheck of specific requests
from Monroe County. During the term of this Agreement, Monroe County shall provide
MedCheck with a copy of the bill(s) to be audited, along with instructions regarding the
scope and extent of the audit to be conducted by MedCheck.
3.2 The audit, if performed by MedCheck on-site at the local Monroe County branch claim
office, shall be completed within 48 business hours from receipt by MedCheck, unless
MedCheck requires additional time due to information deficiencies beyond its control. If
service is provided on a mail-in basis, bills shall be processed and mailed to Monroe
County within 3 to 5 days of receipt by MedCheck unless MedCheck requires additional
time due to information deficiencies beyond its control.
3.3 MedCheck will be responsible for monitoring and "flagging" duplicate billings of medical
bills. Any bills previously audited will be returned to Monroe County with a notation that
the returned bill is a "duplicate" or has been previously submitted and/or aud~~~ ~fe= 0
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will be no charge to Monroe County for total duplicate bills, however partial duplicates
covering new dates of service are charged.
3.4 Any conflicts or complaints from medical providers concerning bill audits completed by
MedCheck will be handled directly by MedCheck. All complaints will receive an initial
response within 24 hours of receipt of the complaint by MedCheck. MedCheck will keep
Monroe County apprised of any complaints it receives and the response thereto.
MedCheck will send a written response to the compIainant within five working days
outlining the nature of the complaint and the resolution of same by MedCheck. A copy of
this response will be sent to the attention of the designated Monroe County representative.
The parameters of MedCheck's authority hereunder must be established in consultation
with and subject to the express agreement of Monroe County. Further, Monroe County
shall have the right, but not the obligation, at any time, to interject itself into the dispute
between MedCheck and the service provider and to resolve the dispute in a manner
acceptable to Monroe County at its sole discretion.
3.5 MedCheck will, at Monroe County's preference, provide Monroe County with on-site
MedCheck personnel to handle the services descnbed in Sections 3.1 through 3.4.
Monroe County will provide MedCheck with sufficient office space to conduct MedCheck
services on Monroe County's behalf without charge to MedCheck, the location of which
space shall be detennined by Monroe County. All arrangements for telephone and office
space must be made through Monroe County,
3.5.1 CorVel will be responsible for the provision and installation of its computer equipment in
all applicable Monroe County field claim offices where "on-site" bill processing service is
established. Installation and all related hardware and telecommunications costs are to be
borne by CorVel.
3.5.2 Monroe County may, from time to time, implement rules and regulations designed to
protect the building, its contents, and occupants where MedCheck's employees are
located. MedCheck shall cause its employees assigned to the building to be fully aware of
said rules and regulations and adhere to them. Any MedCheck employee who violates
said rules and regulations may be removed from the premises by Monroe County.
3.5.3 Monroe County shall at all times have the right of entry into, and exclusive control over,
the areas occupied by MedCheck personnel provided however, that Monroe County will
not, unless necessary, exercise such control so as to unreasonably interfere with the
performance of the obligations ofMedCheck under this Agreement.
3.5.4 At all times, MedCheck will provide at a minimum, off-site, telephonic supervision for all
of its personnel located on or within Monroe County claim operations.
3.5.5 MedCheck assumes responsibility for the activities of its employees and personnel while
they are present at Monroe County's premises. The supervisory personnel provided by
MedCheck shall have full authority over MedCheck personnel and shall be responsible for
the activities ofMedCheck personnel on the Monroe County premises. !~ECE1\/ED
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3.5.6 MedCheck hereby agrees to indemnify and hold harmless Monroe County and its officers,
directors, and employees from and against any and all losses, claims, damages, or
expenses, including attorneys' fees, arising from injury caused by the negligence of
employees of MedCheck on Monroe County's premises, including injuries suffered by
MedCheck personnel which may occur on Monroe County's premises; provided however,
that Monroe County shall not be held harmless pursuant to this section 3.5.6 for its gross
negligence or willful misconduct or that of its employees or officers.
3.6 CorVel shall provide its Preferred Provider Networks as an integrated component of
MedCheck for the benefit of Monroe County, its insureds and their employees during the
term of this Agreement as outlined in MedCheck service descriptions.
3.7 In those jurisdictions where MedCheck cannot provide a suitable Preferred Provider
Organization (PPO) to Monroe County, MedCheck shall make best efforts to
accommodate an alternate PPO selected by Monroe County. Monroe County shall make
best efforts to create the ability for MedCheck to integrate the provider identification and
discount information into its bill review system.
3.8 As CorVel continues to expand its PPOs through the development of proprietary
networks, Monroe County will be notified of their availability in writing and shall be
provided immediate access to them, replacing the then-current PPO, if applicable.
3.9 In the case of hospital bills, CorVel shall pre-screen all bills to determine the need for
audit. Pre-screening services shall be provided at no charge to Monroe County. PPO
related hospital bills shall be pre-screened prior to PPO repricing to determine the need for
audit. Where applicable, CorVel shall provide the appropriate hospital bill audit services
involving both PPO and non-PPO providers.
3.10 CorVel agrees to supply Monroe County, at no additional cost, and in accordance with
Monroe County's specifications, a transmission or tape reflecting the results of its bill
review activities which would permit Monroe County to automatically generate provider
reimbursements. Such data shall be provided as to further allow for the application of
MedCheck fees to the individual claim file, the preparation of insured specific savings
reports and the reimbursement of MedCheck fees, or other applications at Monroe
County's discretion.
3.11 All other aspects of Cor Vel's bill review services not addressed herein, shall be provided in
accordance with CorVel's service proposal and/or marketing materials.
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4. CASE MANAGEMENT
4.1 CorVel shall provide medical case management and vocational rehabilitation services set
forth herein to Monroe County on an non-exclusive basis upon receipt by CorVel of
specific requests from Monroe County.
4.2 CorVel defines case management as the establishment, coordination and control of the
treatment, direction, support, and assistance given to the injured worker from the onset of
injury through medical stability, to maximum medical improvement to return to work.
Actual case management services are dictated by both statutory and Monroe County
requirements.
The case management process will generally consist of the following steps:
Information gathering
Data validation/assessment
Plan development
Plan implementation
Plan follow through and outcome assessment
Ongoing, timely reporting
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The following medical case management services may be utilized:
(800) early referraVaccess systems
Patient assessment
Disability evaluation
Medical care coordination
Discharge planning
Catastrophic case management
Long term care assessment
Life care planning evaluations
Telephonic or on-site service delivery
4.3 Examples of the various services provided in vocational rehabilitation are listed below.
These services are available on an unbundled or integrated basis as dictated by the
requirement of each case and Monroe County preference.
- Early return to work programs
- Vocational assessments
- Job analyses
- Job-seeking skills training
- Job development
- Job placement
- Expert testimony
- Labor market surveys
- Automated transferable skills analyses
- Vocational testimony
- SSDI benefit procurement
4.4 All other aspects of CorVel's case management services not addressed herein, shall be
provided in accordance with CorVel's service proposal and/or marketing materials.
5. INSURANCE
5.1 CorVel, at its sole expense, agrees to maintain, at all times during the term of the
Agreement, the required professional liability, errors and omissions, workers'
compensation, general, and auto liability insurance coverages as set forth on the
Certificates oflnsurance attached hereto as Exhibits "C" and "D." The insurance policies
in question shall provide that at least sixty (60) days prior written notice of cancellation,
change, amendment or exclusion in any of the insurance coverages required hereunder
shall be given to Monroe County.
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6. OBLIGATIONS OF Monroe County
6.1 Monroe County will utilize its best efforts to ensure that its Third Party Adminstrator
utilize CorVel's CorCare Network for repricing and discounting ofall PPO provider bills.
6.2 All hospital bills shall be pre-screened by CorVel to determine the need for audit. Should
Monroe County agree that an audit is applicable, Monroe County shall refer the bill to
CorVel for such services.
6.3 Monroe County shall pay CorVel for services as displayed in Attachment "A" (Fees for
Services) rendered within thirty (30) days of the date of receipt by Monroe County of an
invoice from CorVel.. CorVel charges are as set for in the Request for Proposal "Fees
For Services". Prices will remain firm for the first award year. Subsequent contract
renewal years will be subject to CPI increases not to exceed 5% per year.
7. TERM AND TERMINATION
7.1 The term of this Agreement is for a period of one (1) year from its effective date with two
one year renewals at the sole discretion of Monroe County.
7.2 This Agreement may be terminated without cause by CorVel or Monroe County upon
ninety (90) days written notice.
7.3 This agreement can be terminated by CorVel or Monroe County for cause upon sixty (60)
days written notice, i.e. if either party materially breaches this Agreement or fails to abide
by its obligations hereunder, and such breach continues for thirty (30) days from the date
written notice is given to the breaching party specifYing the nature of the breach.
8. MISCELLANEOUS
8.1 CorVel, at all times hereunder, is acting as an independent contractor. Personnel supplied
by CorVel shall be employees of CorVel and will not be for any purpose employees or
agents of Monroe County. CorVel assumes full responsibility for the actions of such
personnel while performing services pursuant to this Agreement and shall be solely
responsible for the payment of salaries, wages, and benefits.
8.2 Each party agrees to hold in confidence any information obtained by it relating to the
business of the other and agrees to instruct its agents, employees, representatives, and
independent contractors to keep all such information strictly confidential. Each party
agrees that it will not directly or indirectly disclose, communicate, divulge, furnish to, or
use for the benefit of itself, or any other person, :firm or corporation, any of the trade
secrets, designs, improvements, inventions, data, information, know-how, or other things
belonging to the other, or the designs, ideas or processes of manufacture of any product or
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article sold or distributed or any service provided by the other which may be
communicated to it or which it may learn by virtue of its activities under this Agreement.
8.3 During the term of this Agreement and for a three-year period after the termination of this
Agreement, Monroe County shall be entitled to conduct an audit of CorVeJ/MedCheck
files related to Monroe County accounts. CorVeJ/MedCheck will make its files available
for audit by Monroe County at a time and place that is mutually agreeable to both parties.
CorVeJ/MedCheck will make any and all Monroe County files available for audit.
8.4 In the event of invalidity of any provision of this Agreement, the parties agree that such
invalidity shall not affect the validity ofthe remaining provisions of this Agreement.
8.5 This Agreement contains the entire contract between the parties, as to the subject matters
hereto, and may not be waived, altered, or modified except by written agreement of the
parties. Any interpretation of this contract shall be governed by Florida statutes and laws.
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IN WITNESS WHEREOF, CorVel and Monroe County have caused this Agreement to be
executed by the persons authorized to act in their respective names.
.: ANNY L KOlHAGE, aERK
o.LdC. ~
OEPUTY CLERK
ISAC ()
BY: i:~ A--w
TITLE: &. ~ 0 t'c--\..
DATE SIGNED:~\ l () ~ @ U
CORVEL CORPORATION
B~~~
Account Executive
DATE SIGNED~ ~ .2.PIn
APPRO~ED AS TO ~ORM
Y
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Attachment" A"
FEES FOR SERVICES
1. CorCare PPO Access Fee 23% ofPPO savings
* Capitated Rate Available Upon Request
( This fee is applicable in addition to per claim or flat fee structure)
* CorVel welcomes the opportunity to discuss a capitated fee for network access. Additional information is
necessary for this type of proposed fee structure.
2. Early Intervention - Per Claim Pricing
* Optional: Annual Flat Rate Pricing is Available
Lost Time Cases
$280/case 130 days
Multi-point (employee, employer, 1SAC adjuster, provider) contact to gather and communicate
treatment plan data.
Review provider treatment plan assisted by automated software system to determine
appropriateness of plan.
Make recommendations to assist in the determination of the next course of action (e.g., case
management, 1ME, vocational rehabilitation, etc.) to complete the early intervention phase.
Enter medical notes I recommended treatment into the 1SAC claims system.
Medical Only Cases
$100/case 130 days
Contact employer / employee to gather sufficient information to determine potential for
serious and/or lost time situations.
ConfIrm med only status or recommend additional intervention if necessary.
Review treatment plan and determine appropriateness of medical care.
3. Utilization Review Services Include:
Pre-Admission Review, Concurrent Stay Review
and Discharge Planning
$140.00/case
4. Mediall Case Management
Telephonic - hourly fee
* Flat Rate Available Upon Request
On-Site - hourly fee
$68.00/hour
$68.00 /IRS mileage rate
(mileage prorated
whenever possible)
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5. Vocational Rehabilitation Services
$68.00 per hour
IRS mileage rate
(mileage prorated
whenever possible)
6. First Notice of Loss
Includes state submission
$25/FNOL
7. Peer Review / IMEs
$175 + Physician fee
8. Medical Bill ReviewlFee Schedule *
Includes sendbacks, duplicates and provider inquiries
$1.30/Iine (no line min)
9. Nurse Review
$68/hour
Medical Bill Review will be provided by [SAC; therefore, eliminating any per line charge. Our CorVel
PPO network discounts are already downloaded into the [SAC fee schedule bill review system. The
[SA C claims system will be utilized, thereby eliminating any online computer linking costs.
For basic ARCA compliance, Momoe County may elect our PPO lease at 23% of savings, which
will include PPO and CorCare channeling, grievances, quality assurance, educational materials,
provider recruitment and provider credentialing. All other services listed may be elected as
optional items.
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1996 Edition
MONROE COUNTY, FLORIDA
Request For Waiver
Of
Insurance Requirements
It is required that the insurance requirements, as specified in the County's Schedule oflnsurance
Requirements, be waived or modified on the following contract.
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County Administrator appeal:
Contractor:
Contract for:
Address for Contractor:
Phone:
Scope of Work:
Reason for Waiver:
Policies Waiver
Will apply to:
Signature of Contractor:
Risk Management:
Date:
Date:
CorVel Corporation
Workers' Compensation Managed Care Services
3504 Lake Lynda Drive, Suite 300
Orlando, FL 32817
(407) 282-4200 Ex!. 3025
Florida Managed Care Arrangement: Bill ReviewIPPO Network,
Utilization Review, Nurse Case Management, Hospital Bill Audits
Additional insured status on this automobile policy. Insured has a
non-owned auto exposure in Florida.
M1J
Not Approved
Approved
Not Approved
Board of County Commissioners appeal:
Meeting Date:
Administration Instruction
#4709.3
Approved
Not Approved