MB-4184 - USA (New York) - Worker Compensation On-Call Performance and Operational Claims Review Services - Deadline July 24,2020

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-4184

Government Authority located in New York; USA based organization looking for expert vendor for worker compensation on-call performance and operational claims review services.

[A] Budget: Looking for Proposal

[B] Scope of Service:

(1) Vendor needs to provide worker compensation on-call performance and operational claims review services.
- Review record-keeping and reporting electronic claims system (as applicable) and determine whether it sufficiently meets all applicable law and policy requirements, including privacy protections;
- Review financial accounts created for claims or fund administration to ensure they are set up and being managed in accordance with board specifications, proper business practices, and legal requirements;
- Evaluate staffing rosters to ensure employees are qualified and meet board experience, licensing, and training requirements;
- Compare the monthly and quarterly invoices submitted to the Board by the administrator or fund, to the internal records and data kept by such administrator or fund and highlight any inconsistencies or inaccuracies contained within such records and invoices;
- Determine whether claims administration and claims management tasks were handled in accordance with WCB requirements, written policy requirements, industry standards, and all applicable laws. Such tasks may include, but not be limited to, making of indemnity payments, medical bill review and review of requests for authorization of medical treatment. Where mismanagement is found, qualify which standards of management were breached and how, and quantify the effect of the breach;
- Report instances where benefits (i.e. indemnity, medical, etc.) were incorrectly, untimely, or otherwise improperly paid and, to the extent practicable, determine the cause and impact of the error(s);
- Review and report on all instances where penalties were assessed, which were related to, could impact or have impacted an administrator’s or fund’s provision of services to the board, and provide an opinion as to the immediate and root causes of such errors or omissions which resulted in the penalties;
- Determine whether claims were properly reserved, including claims and age-related reserve adjustments. Where claims were improperly reserved, qualify what standards of reserving were breached and how, and quantify the effect of the breach;
- Review, evaluate, and document claim closure practices, back-to-work programs, fraud procedures, and other cost prevention measures, report on the frequency with which these practices and procedures are followed and applied, and report the associated success rate;
- Review and evaluate the administrator’s or fund’s utilization of subcontractors or specialized services. Report on whether investigative, legal, bill review, independent medical examiner (IME), Medicare Set-Aside, and any other such specialized claims administration services (regardless of whether these are performed by administrator or fund or a subcontractor on behalf of such administrator or fund) are being utilized in every appropriate instance, including whether there is over- or under-utilization, and evaluate the efficiency and success rate associated with such utilization;
- Determine whether all appropriate third-party recoveries were actively pursued and received (special funds, excess coverage, and other third-party actions). Where third-party recoveries were not properly and actively pursued, state the resulting impact of the failure to actively pursue the recoveries (i.e. whether due diligence and adherence to industry standards would have resulted in a recovery being received);
- Analyze and reconcile any other pertinent data and documentation related to the claims handling;
- Perform advisory services regarding claims management, prevention of loss development and cost containment;
- Review and evaluate the compliance and performance of other entities registered with or providing services for the Board, including Board-registered IME entities, to ensure compliance with applicable laws and regulations;
- Deliver presentations to the various stakeholders which describe the approach to and results of the various reviews performed; and
- Provide status updates as outlined in each individual scope of work; status updates shall be bi-weekly, at a minimum, unless the board agrees that less frequent updates are sufficient to meet the requirements of the individual assignment.  
(2) All questions must be submitted no later than June 15, 2020.
(3) A filing notice of intent to bid will be held on June 15, 2020.
(4) Contract term will be three years.

[C] Eligibility:

- Onshore (USA Organization Only);

[D] Work Performance:

Performance of the work will be Offsite. Vendor needs to carry work in their office location.

Expiry Date : Friday, 24 July, 2020

Question Answer Deadline : Monday, 15 June, 2020

Category : Medical Billing and Coding

Country : USA

State : New York

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