Commonwealth of Pennsylvania
Department of General Services
RFP-2011-6100019739
WC Claims Administration Services
PRE-PROPOSAL QUESTIONS
# / RFP Reference/Question / Commonwealth of PA Answer /1. / Claims Data / How many medical bills have been processed per year over the last three complete years? / The below numbers represent total bills paid. These numbers do not include denials or duplicate bills submitted and not paid; that data is not tracked.
Fiscal Year 2010/11 -127,421
Fiscal Year 2009/10 - 137,049
Fiscal Year 2008/09 - 132,844
2. / Prescriptions / With whom is the RX interface built? Is it one interface? / There is an outbound and inbound interface with Medco; they are the current pharmacy benefit carrier for most employees. However, the pharmacy benefit contract is being rebid by the Pennsylvania Employees Benefit Trust Fund (PEBTF), so there is no guarantee that the interface will be with Medco. The data fields for the current interface are provided in Appendix G; the successor pharmacy benefit carrier will be required to utilize these fields for the interfaces.
3. / Claims Data / What is the reason for the significant increase in the number of open indemnity claims and medical only claims since June 30, 2008? / There are likely two reasons for the increase: (1) Standards were set for closing claims with the last contract which began 7/1/09. Those standards require a claim to remain open for at least 30 days after return to work and until the claimant stops treating and all known bills are paid. (2) The Commonwealth chose to settle fewer claims in the time period noted.
4. / Cost Proposal / Will the cost be evaluated for a three year period or for a one year period as the cost proposal worksheet implies? / Costs will be evaluated for a three year period. The committee will use the data supplied by the Offeror and multiply it by three years. The only item that will not be an annual recurring cost is the data transfer cost, which is a one-time cost. See also answer to Question #62.
5. / Claims Data
And Compromise and Releases / How many compromise and release agreements which included medicals were executed in each of the last three (3) years of the contract? / This data is not tracked. Because of the manual effort involved in reviewing each one, we are only providing the most recent fiscal year’s data. There were 40 that included medical in fiscal year 2010/11.
6. / Compromise and Releases / On the compromise and release agreements that included medicals, who was the company that prepared the MSA for submission to CMMS on applicable files?
Was the fee for the coordination and preparation of the MSA paid as an allocated expense on the claim file? If not, where was the fee for the service paid? / Occupational Resource Specialists (ORS) is the company who spear heads the MSA process. They may do this in-house or refer the work to other companies.
The fee was paid as an allocated expense as part of the individual claim costs. It also will be paid as an allocated claim expense under this procurement.
7. / Miscellaneous / What would the Commonwealth identify as their top three (3) priorities for improving the outcomes of their workers compensation program? / These are provided in no particular order: controlling prescription costs; identifying new or innovative ways to return claimants to work sooner; and using structured settlements earlier in the claim to prevent it from becoming a long-term claim.
8. / Incentives and Damages / For each of the past three (3) years, what was the net incentive/disincentive paid to the incumbent TPA? / Service level agreements are assessed as often as monthly, but incentives are not paid until the data is fully analyzed after the end of the fiscal year. All of the incentives under the current contract for fiscal year 2010/11 have not been determined. Also, keep in mind that the incentives and damages under the previous contract, three years ago, and proposed in this RFP are different than those provided in the current contract. With that understanding, the net payments are:
Fiscal year 2008/09 - $978,719
Fiscal year 2009/10 - $1,122,300
Fiscal year 2010/11 - Undetermined
9. / Claim Payments / What percentage of indemnity payments were made via ACH vs. check? / This number is growing. However, on the last payment cycle, just over 7% were paid by ACH.
10. / Cost Proposal / Please provide the pricing for the current TPA in the management of this program. / The pricing structure is provided below. Keep in mind that the terms and requirements of the previous RFP and contract are slightly different than this one. Some of these fees are not permissible under this RFP.
New Indemnity - $950
New Medical - $425
IME Set-Up - $300
Fraud Investigation - $1500
Direct Deposit Set-Up - $29
Physician/Hospital Bill Guaranteed Savings – 10%
11. / Payment to Incumbent / What did the Commonwealth pay for WC Claims Administration Services for Fiscal Years, 2009, 2010 and 2011? (Please be specific)
Were any bonuses paid out during any of these periods? Is so, how much? (Appendix F Section of the specifications) / Keep in mind that the payment structure under the previous contract, three years ago, as well as the payment structure under the current contract is different than that of this RFP. These numbers do not include a reduction for damages assessed.
Fiscal year 2008/09 – Medical claims - $729,150
- Indemnity claims - $761,200
- Converted claims - $189,990
- Managed care - $1,726,900
- Incentives paid - $993,677
Fiscal year 2009/10 – Medical claims - $2,128,525
- Indemnity claims - $1,398,800
- Converted claims - $279,250
- Managed care - $57,550
- IME set-up - $176,700
- Incentives paid - $1,135,526
Fiscal year 2010/11 – Medical claims - $1,924,675
- Indemnity claims - $1,502,875
- Converted claims - $225,750
- IME set-up – $176,700
- Direct deposit – $2,871
- Incentives paid – undetermined at this time
12. / Claims Data / What was the total number of medical bills processed for the calendar year 2010? / Data is not tracked by calendar year. See answer to Question #1.
13. / Claims Data / What was the total number of non-medical bills processed for the calendar year 2010? / Data is not tracked by calendar year. The number of non-medical bills processed in fiscal year 2010/11 was 15,188.
14. / Claims Data / What was the total number of pharmacy bills processed for calendar year 2010? / Data is not tracked by calendar year. The number of pharmacy bills processed in fiscal year 2010/11 was 15,188.
15. / Claims Data / What was the total amount of billed medical charges for the calendar year 2010? / Data is not tracked by calendar year. See answer to Question #16.
16. / Claims Data / For 2010, please provide:
· Gross Billed Amount
· Fee Schedule reduction
· PPN savings
· Other savings
· Fees (TPA fees for processing medical bills)
· Net Paid / While data is not tracked by calendar year, we did have this data for another reason, so we are able to provide it by calendar year.
Gross Billed – $55,197,086
Fee Schedule Amount - $30,709,344
Network Savings - $2,805,610
Other Savings - $48,867
Fees - $0
Net Paid - $27,854,867
17. / Claims Data / What was the number of duplicate and or denied bills for calendar year 2010? / Statistics are not maintained to track duplicate or denied bills.
18. / Prescriptions / Do you anticipate that Medco will remain the pharmacy benefits provider for the Commonwealth? / See answer to Question #2.
19. / Panel Providers / Please describe your current process for posting provider panels at work sites. / The current vendor provides panel updates to the OA by e-mail as often as weekly. Those are distributed to the agency workers’ compensation coordinator who in turn distributes them to contacts in all field locations for posting on bulletin boards. In addition, many agencies provide a link on their intranet sites to the panels which are centrally maintained on the vendor’s website.
20. / Miscellaneous / How many telephonic case management assignments were made in calendar year 2010? / The telephonic case managers do an initial review on all claims (Medical and Indemnity) claims. On select medical and every indemnity claim, the telephonic case managers perform an in-depth review of the claim and medical information.
21. / Settlements / How many Medicare Set Aside Assessments were done in calendar year 2010? / Data is not tracked by calendar year. In fiscal year 2010/11, only four led to a settlement of the medical portion of the claim in addition to the indemnity portion.
22. / Miscellaneous / Does the Commonwealth still have 2,198 boxes in storage at Iron Mountain? If not, please indicate the correct number that the TPA would become responsible for. / While the boxes remain at Iron Mountain today, those records will be purged in accordance with the official records retention schedule before the contract for this RFP takes effect.
23. / Staffing / Please provide the number of staff by position currently dedicated to the Commonwealth of PA program, by the incumbent TPA. / There is one claims manager, four claims supervisors, 18 claims adjusters, four medical only adjusters, and five nurses who are dedicated to the Commonwealth’s account. Keep in mind that this staffing model has evolved, and is based on some negotiated agreements with the incumbent vendor. Therefore, this staffing model may not be appropriate even for the current vendor for the contract that will be awarded from this RFP.
24. / Subrogation / How many subrogation claims are currently open for possible recovery? How many claims were involved in the recovery of $997,013 in FY 2010-2011? / There are 90 claims that have the potential for subrogation, but we do not know of those claims how many claimants actually are pursuing subrogation.
The amount of $997,013 represents recoveries for 74 claimants in fiscal year 2010/11.
25. / Claim Reporting / We note that some agencies do not use the enterprise computer system to report new claims. How many claims per year would you estimate are faxed or emailed? / Based on claims reported during fiscal year 2010/11, 69 would have been reported by a means other than the interface. Most of these claims were likely submitted through a claims reporting system that the current vendor provides for these agencies to use.
26. / Claim Reporting / Please verify whether your standard accident codes (injury type, body part, cause of injury, etc.) conform to NCCI coding or whether the codes are specific to Commonwealth of PA? / Most of the codes are NCCI codes; however, a few have been added to address injuries that did not seem to fit within the standard codes. Appendix H of the RFP provides the list of descriptions used.
27. / System Access / Please indicate the estimated number of users that will be required for each of the following applications:
· First report of injury online
· Risk Management Information Systems (report generation)
· Online view of individual claim files / Most claims are reported through the SAP computer system and then interfaced to the vendor. So, technically, there are no users who will be reporting claims online to the vendor. If the question is related to how many agencies do not report through the interface, there are approximately 14, with the potential of 20 users if the vendor is offering an option to report on-line instead of by fax or e-mail as described in IV-4 g. of the RFP.
For report generation, we estimate the need for approximately 65 users.
For online view of individual claims, we estimate the need for 40 users.
28. / Miscellaneous / Please clarify the level of involvement and coordination you will expect from the TPA with each agency safety coordinator. / The TPA will have minimal involvement with the agency safety coordinator. The safety coordinator should be able to access the vendor’s system for claims data through ad hoc and standard reporting, and therefore, no specific interaction beyond system access may be required.
29. / Voids and Refunds / How does the TPA know when a refund is received? A check voided? A stop pay issued? / Returned and refund checks are provided to the vendor. The vendor identifies and voids or credits the original payment in their claims management system. Once the void or refund is documented, the check is returned to OA with an explanation of the refund, and OA ensures it is deposited in the workers’ compensation account.
Requests for stop payments are initiated by the adjuster when a claimant, provider, or attorney provides notification that the original check was not received. Using the payment details, OA identifies the Treasury check information which allows Treasury to verify the status. If uncashed, the check will be reissued by Treasury; if cashed, a copy of the canceled check is provided. The adjuster is notified of the reissuance of the check or provided with a copy of the canceled check.
30. / Voids and Refunds / What is the current process for refunds, stop pays, voids and deletions between the current TPA and the Commonwealth? / See answer to Question #29 for information about refunds, voids and stop payments.