HomeMy WebLinkAbout2010-227
Resolution No 2010-227
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RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY OF S
BERNARDINO AUTHORIZING THE EXECUTION OF AN AGREEMENT WI
LIEN ON ME, INC. TO PROVIDE BILL REVIEW SERVICES FOR THE CITY'
WORKERS' COMPENSATION PROGRAM.
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BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF
SAN BERNARDINO AS FOLLOWS:
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SECTION 1. The City Manager of the City of San Bernardino is hereby authorized and
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directed to execute on behalf of said City an Agreement with Lien On Me, Inc. for the provision
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of Workers' Compensation medical bill review services for a term of three (3) years with the
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option of two (2), one- (1) year extensions. A copy of the Agreement is attached hereto marked
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Exhibit "A" and incorporated herein by reference as fully as though set forth at length,
SECTION 2. Pursuant to this determination, the Director of Finance or his/her
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designee is hereby authorized to issue an Annual Purchase Order to Lien On Me, Inc., in an
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amount not to exceed $95,000 for Year One (2010/2011); $96,900 for Year Two (2011/2012);
and $98,838 for Year Three (2012/2013).
SECTION 3. The Purchase Order shall reference this Resolution No. 2010-J.Z7 and
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shall read "Lien On Me, Inc. for the provision of Workers' Compensation bill review services,
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Purchase Order No.
not to exceed $95,000 for 2010/2011; $96,900 for 2011/2012;
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and $98,838 for 2012/2013," and shall incorporate the terms and conditions of the Services
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Agreement.
SECTION 4. The authorization to execute the above-mentioned agreement is rescinded
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if the parties to the agreement fail to execute it within sixty (60) days of the passage of this
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Resolution.
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2010-227
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SERVICES AGREEMENT
THIS AGREEMENT is made and entered into this 6th day of July, 2010 ("Effectiye
Date"), by and between the CITY OF SAN BERNARDINO, a charter city ("CITY"), and Lien
On Me, Inc. ("CONSULTANT").
WITNESSETH:
A. WHEREAS, CITY proposes to have CONSULTANT perform the services
described herein below; and .
B. WHEREAS, CONSULTANT represents that it has that degree of specialized
expertise contemplated within California Government Code, Section 37103, and holds all
necessary licenses to practice and perform the services herein contemplated; and
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WHEREAS, CITY and CONSULTANT desire to contract for professional
services as described in the Scope of Services, attached hereto as Exhibit" 1 "; and
D. WHEREAS, no official or employee of CITY has a fmancial interest, within the
provisions of California Government Code, Sections 1090-1092, in the subject matter of this
Agreement.
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NOW, THEREFORE, for and in consideration of the mutual covenants and conditions
contained herein, the parties hereby agree as follows:
18 1.0. SERVICES PROVIDED BY CONSULTANT
1.1. ScoDe of Services. For the remuneration stipulated, CONSULTANT shall
20 provide the professional services described in the Scope of Services attached hereto as Exhibit
21 ~'1" and incorporated herein by this reference ("Services"). If a conflict arises between the
22 Scope of Services document and this Professional Services Agreement (hereinafter
23 "Agreement"), the terms of the Agreement shall govern.
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1.2. P~fessional Practices. All St)rvices to be provided by CONSULTANT pursuant
to this Agreement shall be provided by skilled personnel and in a manner consistent with the
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1 into agreements with other consultants for services similar to the Services that are subject to this
2 Agreement or may have its own employees perform services similar to those services
3 contemplated by this Agreement.
4 1.6. Delegation and Assignment. This is a personal service contract, and the duties
5 set forth herein shall not be delegated or assigned to any person or entity without the prior
6 written consent of CITY, which consent shall not be unreasonably withheld or delayed.
7 CONSULTANT may engage a subcontractor(s) as permitted by law and may employ other
8 personnel to perform services contemplated by this Agreement at CONSULTANT's sole cost
9 and expense.
10 1.7 Duty of Lovaltv/Conflict of Interest. The CONSULTANT understands and
11 agrees that as the CITY's consultant, CONSULTANT shall maintain a fiduciary duty and a duty
12 of loyalty to the CITY in performing CONSULTANT's obligations under this Agreement.
13 CONSULTANT, in performing.its obligations under this Agreement, is governed by
14 California's conflict of interest laws, Government Code Section 87100 et seq., and Title 2,
15 California Code of Regulations, Section 18700 'el seq.
16 1.8 CITY Business Certificate. CONSULTANT shall obtain and maintain during
17 the term of this Agreement, a valid CITY Business Registration Certificate pursuant to Title 5
18 of the City of San Bernardino Municipal Code and any and all other licenses, permits,
19 qualifications, insurance and approvals of whatever nature that are legally required of
20 CONSULTANT to practice its profession, skill or business.
21 2.0. COMPENSATION AND BILLING
22 2.1. Compensation. Except as provided herein, CONSULTANT compensation shall
23 be at the rate of $95,000 for year one; $96,900 for year two; and $98,838 for year three.
24 2.2. Additional Services. CONSULTANT shall not receive compensation for any
25 services provided outside the scope of services specified in Exhibit "1" unless the CITY, prior
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to CONSULTANT performing the additional services, approves such additional services in
writing. It is specifically understood that oral requests and/or approvals of such additional
services or additional compensation shall be barred and are unenforceable.
2.3. Method of Billing. CONSULTANT shall submit invoices to CITY for approval.
Said invoice shall be based on the total of all CONSULTANT's services which have been
performed in accordance with the terms of this Agreement during the period covered by such
invoice. CITY shall pay CONSULTANT's invoice within thirty (30) days from tIle date CITY
receives said invoice. The invoice shall describe in detail the services performed and the
associated time for completion. Any additional services approved and performed pursuant to
this Agreement shall be designated as "Additional Services" and shall identify the number of the
authorized change order, where applicable, on all invoices.
2.4. Records and Audits. Records of CONSULT ANT's Services directly relating to
this Agreement shall be maintained in accordance with generally recognized accounting
principles and shall be made available to CITY for inspection and/or audit at mutually
convenient times for a period of seven (7) years from the Effective Date. Any such inspection
shall be conducted at the CITY's expense, during normal business hours and upon reasonable
prior written notice to CONSULTANT. Such audit shall also be subject to the execution of a
confidentiality agreement regarding inadvertent access to confidential information not related to
the CITY.
3.0. TERM AND NOTIFICATION.
" 3.1. Term. This Agreement shall commence on the Effective Date and continue thre
(3) years, with the option of two (2), one- (I) year extensions, unless the Agreement i
previously terminated as provided for herein.
3.2 Termination. CITY or CONSULTANT may terminate the Services provided
under Section 1.1 of this Agreement upon thirty (30) days written notice to the other party. In
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the event of termination, CONSULTANT shall be paid the reasonable value of Services
2 rendered to the date of termination.
3 3.3 Documents. In the event of an early termination of this Agreement, all
4 documents prepared by CONSULT ANT in its performance of this Agreement including, but not
5 limited to, workers' compensation medical bills, shall be delivered to the CITY within ten (10)
6 days of delivery of termination notice to CONSULTANT, at no cost to CITY. Any use of
7 uncompleted documents without specific written authorization from CONSULTANT shall be at
8 CITY's sole risk and without liability or legal expense to CONSULTANT.
9 4.0. INSURANCE
10 4.1. Scope and Limits of Insurance. CONSULTANT shall obtain and maintain
11 during the term of this Agreement all of the following insurance coverages:
12 (a) Commercial general liability, including premises-operations,
products/completed operations, broad form property damage, blanket
contractual liability, independent contractors, personal injury with a
policy limit of One MIllion Dollars ($1,000,000.00), combined single
limits, per occurrence and aggregate.
(b) Automobile liability for owned vehicles, hired, and non-owned vehicles,
with a policy limit of One Million Dollars ($1,000,000.00), combined
single limits, per occurrence and aggregate.
(c) Workers' compensation insurance as required by the State of California.
Endorsements. The commercial general liability insurance policy shall contain
22 or be endorsed, using general policy endorsements, to contain the following provisions:
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(a)
Additional insureds: "The City of San Bernardino and its elected and
appointed boards, officers, and employees are additional insureds with
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respect to their vicarious liability ansmg out of CONSULTANT's
2 performance of the Services hereunder."
3 (b) Other insurance: "Any other insurance maintained by the City of San
4 Bernardino shall be excess and not contributing with the insurance
5 provided by this policy with respect to claims arising solely and directly
6 from CONSULTANT's provision of the Services."
7 4.3. Certificates ofInsurance. CONSULTANT shall provide to CITY certificates of
8 insurance showing the insurance coverages and required endorsements described above, prior to
9 performing any services under this Agreement.
10 4.4. Non-limiting. Nothing in this Section shall be construed as limiting in any way,
11 the indemnification provision contained in this Agreement, or the extent to which
12 CONSULTANT may be held responsible for payments of damages to persons or property.
13 4.5 Notice of Cancellation: CONSULTANT shall provide the CITY thirty (30) days
14 prior written notice of cancellation of or a material change in any of the required coverages.
15 5.0. GENERAL PROVISIONS '.
16 5.1. Entire Agreement: This Agreement, together with Exhibit "1" attached hereto
17 constitutes the entire Agreement between the parties with respect to any matter referenced
18 herein and supersedes any and all other prior writings and oral negotiations. This Agreement
19 may be modified only in writing, and signed by the parties in interest at the time of such
20 modification. The terms of this Agreement shall prevail over any inconsistent provision in any
21 gther contract document appurtenant hereto, including the exhibit to this Agreement.
22 5.2. Notices. Any notices, documents, correspondence or other communications
23 concerning this Agreement or the work hereunder may be provided by personal delivery,
24 deemed served or delivered: a) at the time of delivery if such communication is sent by personal
25 delivery; b) at the time of transmission if such communication is sent by facsimile; and c) 48
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hours after deposit in the U.S. Mail as reflected by the official U.S. postmark if such
2 communication is sent through regular United States mail.
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CITY:
CONSULTANT:
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Linn Livingston,
Human Resources Director
City of San Bernardino
300 North "D" Street
San Bernardino, CA 92418
Telephone: (909) 384-5J61
Fax: (909) 384-5397
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Tess Foley,
President of Client Services
Lien On Me, Inc.
P.O. Box 91630
Pasadena, CA 91109
Telephone: (626) 921-1120
Fax: (626) 921-1132
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5.3. Attornevs' Fees: In the event that litigation is brought by any party in connection
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with this Agreement, the prevailing party shall be entitled to recover from the opposing party all
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costs and expenses, including reasonable attorneys' fees, incurred by the prevailing party in the
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exercise of any of its rights or remedies hereunder or the enforcement of any of the terms,
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conditions, or provisions hereof. The costs, salary and expenses of the City Attorney and
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members of his office in enforcing this contract on behalf of the CITY shall be considered as
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"attorneys' fees" for the purposes ofthis Agreement.
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5.4. Governing Law. This Agreement shall be governed by and construed under the
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laws of the State of California without giving effect to that body of laws pertaining to conflict of
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laws. In the event of any legal action to enforce or interpret this Agreement, the parties hereto
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agree that the sole and exclusive venue shall be a court of competent jurisdiction located in San
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Bernardino County, California.
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5.5. Assignment: CONSULTANT shall not voluntarily or by operation of law
assign, transfer, sublet or encumber all or any part of CONSULTANT's interest in this
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Agreement to an unrelated third party without CITY's prior written consent, which consent shall
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not be unreasonably withheld or delayed. Any attempted assignment, transfer, subletting or
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encumbrance shall be void and shall constitute a breach of this Agreement and cause for
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termination of this Agreement. Regardless of CITY's consent, no subletting or assignment shall
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1 release CONSULTANT of CONSULTANT's obligation to perform all other obligations to be
2 performed by CONSULTANT hereunder for the term of this Agreement.
3 5.6. Indemnification and Hold Harmless. CONSULTANT shall protect, defend,
4 indemnify and hold harmless CITY and its elected and appointed officials, boards,
5 commissions, officers and employees from any and all claims, losses, demands, suits,
6 administrative actions, penalties, liabilities and expenses, including reasonable attorneys' fees,
7 damage to property or injuries to or death of any person or persons or damages of any nature
8 including, but not limited to, all civil claims or workers' compensation claims to the extent
9 directly arising from or in CONSULTANT's negligent or wrongful acts or omissions in
10 connection with the performance under this Agreement.
11 5.7. Indeoendent Contractor. CONSULTANT, at all times while performing under
12 this Agreement, is and shall be acting as an independent contractor and not as an agent or
13 employee of CITY. CONSULTANT shall secure, at its expense, and be responsible for any and
14 all payment of wages, benefits and taxes including, but not limited to, Income Tax, Social
15 Security, State Disability Insurance Compensation, Unemployment Compensation, and other
16 payroll deductions for CONSULTANT and its officers, agents, and employees, and all business
17 licenses, if any are required, in connection with the Services to be performed hereunder. Neither
18 CONSULTANT nor its officers, agents and employees shall be entitled to receive any benefits
19 which employees of CITY are entitled to receive and shall not be entitled to Workers'
20 Compensation insurance, unemployment compensation, medical insurance, life insurance, paid
21 :vacations, paid holidays, pension, profit sharing or Social Security on account of
22 CONSULTANT and its officers', agents' and employees' work for the CITY. This Agreement
23 does not create the relationship of agent, servant, employee partnership or joint venture between
24 the CITY and CONSULTANT.
25 5.8. Conflict of Interest Disclosure: CONSULTANT or its employees may be subject
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to the provisions of the California Political Reform Act of 1974 (the "Act"), which (1) requires
2 such persons to disclose financial interests that ,may be materially affected by the work
3 performed under this Agreement, and (2) prohibits such persons from making or participating in
4 making decisions that will have a foreseeable financial affect on such interest.
5 CONSULTANT shall conform to all requirements of the Act. Failure to do so
6 constitutes a material breach and is grounds for termination of the Agreement by CITY.
7 5.9. Resoonsibi1itv for Errors. CONSULTANT shall be responsible forits work and
8 results under this Agreement. CONSULTANT, when requested, shall furnish clarification
9 and/or explanation as may be required by the CITY's representative, regarding any services
10 rendered under this Agreement at no additional cost to CITY. In the event that an error or
11 omission attributable to CONSULTANT occurs, then CONSULTANT shall, at no cost to
12 CITY, provide all other CONSULTANT professional services necessary to rectify and correct
13 the matter to the sole satisfaction'Qf CITY and to participate in any meetings required with
14 regard to the correction. CONSULTANT will assume the information supplied by the CITY, (or
15 on its behalf by third parties) is accurate and complete. CONSULTANT's responsibilities (and
16 associated compensation) do not include independent verification of required information.
17 Problems with information quality and/or delays in providing such information may result in a
18 delay in the performance of the Services or an increase in fees.
19 5.10. Prohibited Emo10vrnent. CONSULTANT shall not employ any current
20 employee of CITY to perform the work under this Agreement while this Agreement is in effect.
21" 5.11. Costs. Each party shall bear its own costs and fees incurred in the preparation
22 and negotiation of this Agreement and in the performance of its obligations hereunder except as
23 expressly provided herein.
24 5.12. No Third Partv Beneficiarv Rights. This Agreement is entered into for the sole
25 benefit of CITY and CONSULTANT and no other parties are intended to be direct or incidental
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1 beneficiaries of this Agreement and no third party shall have any right in, under or to this
2 Agreement.
3 5.13. Headings Paragraphs and subparagraph headings contained in this Agreement
4 are included solely for convenience and are not intended to rnodify, explain or to be a full or
5 accurate description of the content thereof and shall not in any way affect the meaning or
6 interpretation of this Agreement.
7 5.14. Amendments. Only a writing executed by all of the parties hereto or their
8 respective successors and assigns may amend this Agreement.
9 5.15. Waiver. The delay or failure of either party at any time to require performance
10 or compliance by the other of any of its obligations or agreements shall in no way be deemed a
11 waiver of those rights to require such performance or compliance. No waiver of any provision
12 of this Agreement shall be effective unless in writing and signed by a duly authorized
13 representative of the party against whom enforcement of a waiver is sought. The waiver of any
14 right or remedy with respect to any occurrence or eyent shall not be deemed a waiver of any
15 right or remedy with respect to any other occwTence or event, nor shall any waiver constitute a
16 continuing waiver.
17 5.16. Severabi1itv. If any provision of this Agreement is determined by a court of
18 competent jurisdiction to be invalid or unenforceable for any reason, such determination shall
19 not affect the validity or enforceability of the remaining terms and provisions hereof or of the
20 offending provision in any other circumstance, and the remaining provisions of this Agreement
21 ihall remain in full force and effect.
22 5.17. Counteroarts: This Agreement may be executed in one or more counterparts,
23 each of which shall be deemed an original. All counterparts shall be construed together and
24 shall constitute one agreement.
25 5.18. Coroorate Authority. The persons executing this Agreement on behalf of the
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parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said
2 parties and that by doing so, the parties hereto are formally bound to the provisions of this
3 Agreement.
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10 IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the day
II and date first above shown.
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ATTEST:
CITY OF SAN BERNARDINO
Munici al Corporation and
Ch City
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J2~~. CLv~
Rachetclark, City Clerk
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fU7i~ / L;.u 6(1 Heme:.-.
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Approved as to form:
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JAMES F. PENMAN
City Attorney
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III. PROPO~%WCIFICATIONS
EXHIBIT 1
SERVICES TO BE PROVIDED
Following is a description of the required services for the Workers' Compensation Bill
Review Services, The following minimum services will be required of the vendor awarded
the bill review agreement:
SERVICES TO BE PROVIDED
. Provide state of the art bill review services for the City of San Bernardino;
. Review all bills in a timely matter for compliance with applicable fee schedules
and reduce accordingly, including those that fall outside of a fee schedule or
PPO network;
. Identify and reduce all duplicate billings;
. Deny charges for all items not required for injury described;
. Identify all unauthorized charges to insure billing does not exceed parameters of
injured workers' treatment plan;
. Provide an Explanation of Review ( EOR) for each bill reviewed
. Maintain contracts with effective PPO organizations ( including pharmacies),that
include providers in the City of San Bernardino area;
. Provide reports on a weekly, monthly and annual basis outlining bill review
activity savings and cost. Provide ad hoc reports as necessary;
. Handle all provider inquires regarding bill reductions;
. Provide Hospital Bill Audits and Reports.
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Lien On Me, Inc. is currently providing bill review services for City of San Bernardino. At this
time we are providing all that is required in this RFP F-10-20 for Workers' Compensation Bill
Review,
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Lien On Me, Inc, in this proposal will agree to continue to perform bill review services under
the Scope of Work, Proposal Specification RFP F-10-20 Workers' Compensation
requirements,
PROPOSAL CONTENT
. An overview of your companies' experience in providing bill review services for
Cities and other municipal clients;
Lien On Me, Inc, prides itself with providing bill review services to many of the cities
. here iJl Southern California. We currently provide bill review services to City of San
Bernardino, City of Long Beach, City of Glendale, City of Burbank, City of Santa
Ana, City of Newport Beach, City of Costa Mesa, City of Monterey Park, City of
Ventura, and City of Simi Valley. We also provide bill review services for school
districts, public transportation an private clients,
We thoroughly understand the needs of our cities and how important it is to contain
the public's costs. Whenever we have a dispute with a provider, or are in a middle
of negotiations, we remind them that this is the City's money and we need to keep
in mind what's the best interest of the public. That provider in most cases can be a
resident of that City and understands and appreciates our cost containment
methods,
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As a California based organization~&UPat~~ualified to deal with the ever changing .
dynamics of the California marketplace and in particular any issues that may impact
the City of San Bernardino.
Lien On Me, Inc. provides and will continue to provide a broad spectrum of medical bill
review services to the City of San Bernardino. Our services are as follows:
· Fee schedule review and reductions
· Usual and customary review, reduction and negotiation
. PPO/MPN re-pricing
. Guaranteed turn-around time
· Provider inquiry response and resolution
· Fee reduction defense services
. Integration with utilization review services
. Integration with Pharmacy Benefit Management services
· Integration with existing customized ancillary programs
. Hospital Inpatient review, reduction and negotiation as applicable
· Outpatient surgical review, reduction and negotiation as applicable
. EDI interface
. Courier Service
· Examiner Toolbox (web-based portal)
. Minimum of 3 professional references;
Ms. Carolyn Richard
Workers' Compensation Administrator
City of Santa Ana
20 Civic Center Plaza, 4th Floor
Santa Ana, CA 92702
(714) 647-6912
Mr. Michael Alio
Risk Manager
City of Long Beach
333 W. Ocean Blvd., 10th Floor
Long Beach, CA 90802
(562) 570-6754
Mr. Thomas M. Malooly
Risk Manager
613 East Broadway, Room 100
Glendale, CA 91206
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(818) 548-2151
Mr. Jonathan Chang
WC Administrator
City of Burbank
301 East Olive Avenue, Suite 320
Burbank, CA 91510
(818) 238-5012
Mr. AI Gorski
Risk Manager
Orange County Transportation Authority
Orange, CA 92863
(714) 560-5817
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Client since 1998 for Bill Review
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Client since 2009 for Bill Review
and Lien Defense
Client since 2005 for Bill Review
and Lien Defense
Client since 2005 for Bill Review
and Lien Defense
Client since 2005 for Bill Review
and Lien Defense
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Bill review and cost savings PPc3op~ql~~'bphy;
Lien On Me, Inc. takes pride in all the services we provide. We started a Bill Review
department in 1994 when we recognized some of the same abuse in bill review as we
saw on the lien side, Our philosophy became "if we appropriately review a bill and the
provider is paid correctly, the result will be less disputes," A welcome return in an
already adversarial system. .
We implemented workflows to assure bills are reviewed timely, we follow the correct
Sate mandated fee schedules, utilize current Preferred Provider Organizations (PPOs)
and negotiate aggressively. Our efforts also reduced the calls to the claims
departments as well as the number of liens filed.
Lien On Me, Inc, continuously monitors your savings derived from both bill review and
provided by our PPO partners. This ensures our clients receive the best possible
outcomes. We thoroughly understand the needs of our clients and the importance of
containing their medical costs, When we have to address provider disputes or .
negotiate, we do so with our clients' best interests. Your dollar is our dollar. Over the
years Lien On Me, Inc. has accumulated and set up a proprietary data system that also
helped in our efforts to aggressively negotiate bills.
We have established relationships with leading PPO Networks across the U.S. and
offer our clients access to a variety of PPO networks based on geographic coverage
and patient requirements. Lien On Me, Inc.'s automated system identifies all PPO
discounts as the provider's bill is processed. This helps to gain additional savings by
enforcing the terms of the applicable contracts, usually with discounts below fee
schedule. Proper application of PPO contracts combined with the superior
performance of the Lien On Me, Inc. review consistently results in the highest savings
to our clients. A thorough analysis of your bill history will allow us to recommend
network partners than can produC'e surprising results. Lien On Me, Inc. builds this step
into our service implementation plan to insure success with your bill review process.
· Medical bill review software utilized and tile software provider;
Lien On Me, Inc. owns its own Bill Review Service company. We do currently lease
our backend review engine software that is a fully automated nationwide web based.
The system provides cutting edge technology that allows us to generate accurate
reviews with maximum savings. The system fully integrates with claim management
and managed care systems. Integration allows users to access bill review history and
make notes or comments if appropriate. Our software also includes the National Drug
Code (NDC) database through Medi-Span, which identifies the wholesale cost of
drugs. This standard of reduction has been found reasonable at the WCAB and is
universally accepted by pharmacy providers.
Our medical bill review software is updated weekly with fee schedule changes. Our
, clients are not charged for system upgrades or enhancements required by changes in
the California fee schedule. Data can be sorted in nearly any desired format. The
ability to sort data quickly allows us to generate reports for client management needs.
The system also allows us to exchange production claim, vendor, and payment
information via EDI with the California Workers' Compensation Information System
(WCIS).
Lien On Me, Inc. has also developed its own proprietary bill review management
reporting system, which we ca II "DDAS". The DDAS system incorporates the
customer's data from the bill Jeview engine. It offers our customers web-based access
to their Explanations of Reviews (EaRs), as well as allowing them to drill down on
any key billing factors from Social Security Numbers, ICD9 Codes, CPT codes, specific
medial providers, claims, etc. While initially viewed as a web page, the data may be
converted to an Excel worksheet and exported to the customer's workstation for
detailed analysis as needed,
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The DDAS system allows our cust6flM1.s2tt?be able to directly access key economic.
data to analyze the details of a claim, a medical practice, or emerging economic and/or
medical trends.
Medical cost containment and medical bill review isn't just about the newest
technology. The key factor to a manager is how well that technology translates
data into knowledge so that it can be used to enhance your decision-making
abilities. That's where Lien On Me, Inc. differs from all others, when we use our
leased and proprietary software in conjunction with a management team that is
dedicated to helping our customer maximize all their management resources.
Sample of DDAS On-Line Screen Shot is available upon request
. Bill review work flow from receipt of bill through Explanation of Review (EOR)
and recommended payment; .
a Bills received in mailroom, date stamped and forward to MBR Manager
a MBR Manager examines each bill and distributes accordingly.
a Bills are re-priced and audited to Fee Schedule.
a Bills without Fee Schedule reductions are to be forwarded to Sr. MBR Auditor for
negotiation.
a First Quality Assurance conducted on each bill audited/re-priced on-line.
a External PPO applied to each bill and Quality Assurance Conducted for any missed
PPO reduction.
a EORs are printed and matched with hardcopy bills.
a Second Quality Assurance conducted.
a Bills with allowance of $10,000.00 or more andllor 30% savings to MBR Manager
for Third Quality Assurance. .',
a Post EORs to permanent history.
a Forward Payment File via EDI to client/administrator or issuance of payment to
Providers. ,
a Send hardcopy Bills and EORs via post office to Client.
Bill Review Workflow is available upon request
. Experience and training of bill review staff;
Bill Review Professionals:
Continuous recruiting, hiring and training of experienced medical bill review
professionals are conducted by our Human Resource professionals.
Bill review professionals are recruited for positions based on State of California Code
. of Regulations for bill review certification. We have held to these types of standards
long before these regulations were promulgated. These regulations ensure bill review
companies are no longer able to utilize clerical staff to perform the tasks of medical
bill audits as has been common practice in the past. Our practice of utilizing
experienced and technical reviewers has allowed us to exceed the standards set forth
by the California Code of Regulations. We believe on-going training and education is
vital to our success and, therefore, the following experience has always been required
of potential new hires:
Lien On Me, Inc. Managers: Associates degree, national certification or
equivalent in business required. Minimum five (5) years experience in medical
bill review. Have thorough knowledge and understanding of state fee
schedules and labor codes. Demonstrate excellent customer service and
communication skills. Have demonstrated past experience in management or
supervision. Possesses good computer and analytical skills.
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Lien On Me, Inc. Hearing Rg~ge~~htatives: Associates degree preferred..
Minimum five (5) years experience in workers' compensation. Claims and/or
Hearing experience at the WCAB. Excellent customer service and
communication skills. Knowledge of the OMFS, American Medical Association
and American Academy of Orthopedic Surgeons guidelines for professional
fees, and the National Correct Coding Initiative edits from Medicare for
outpatient surgical fees.
Lien On Me, Inc. Expert Witness: Coding certification or business equivalent
required. Minimum five (5) years experience in workers' compensation.
Thorough knowledge of the OMFS. Comprehension of the American Medical
Association and the American Academy of Orthopedic Surgeons guidelines for
professional bills, and the National Correct Coding Initiative edits from Medicare
for outpatient surgical fees.
Lien On Me, Inc. Auditors: High School diploma required. Designation as
required by California Code of Regulations, Coding certification or business
equivalent required. Five (5) years experience in medical bill review. Have
consistently met 99.5% accuracy as a LaM Reviewer. Thoroughly understand
state fee schedules.
Lien On Me, Inc. Reviewers: High School diploma required. Coding
certification, designation or business equivalent required, Excellent data entry
skills. Three years (3) experience in bill review. Thoroughly understand state
fee schedules.
Our professionals are required to complete continuing education classes that are
conducted live, online and internally, to maintain and upgrade their skills related to
coding, new legislation and fee scf1edule changes. Our medical bill reviewers are
certified biennially with the Insurance Commissioner of the State of California pursuant
to California Insurance Code Section 11761 and California Code of Regulations, Title
10, Section 2592.04 and 259.07.
"
Copy of Certification of Medical Bill Reviewers and Resumes of current bill
reviewers on the City of San Bernardino. account are available upon request.
. Average and corporate standard turn around time for bills;
Lien On Me, Inc. turnaround time is (5) business days from receipt of the medical bill.
Rush reviews can also be done on the same day before 3:00 p.m. referred via
facsimile, at no additional charge. We are currently averaging 2 business day
turnaround.
. We take great pride in consistently delivering service as promised.
The average turnaround time of our bills has consistently been under 5 business
day(s). In 2009 our averages were:
. 1 st quarter, average turnaround time - 3.0 days
. 2nd quarter, average turnaround time - 2.9 days
. 3'd quarter, average turnaround time - 2.1 days
. 4th quarter, average turnaround time - 2.2 days
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. Fee options and how fees are caf8lP..~:
$6.00 per bill: Each bill we review that isn't a hospital, negotiations, usual and customary
or pharmacy bill will cost the City $6.00 per bill,
$4.00 per bill for full pays and pharmacy bills: Every bill that comes in our bill review
department that states full pay which is the amount that the provider is asking for in full
then it would cost the City $4.00 per bill. For every pharmacy bill we will charge the City
$4,00 per bill.
5% of savin as for inpatient/outpatient hospital bills means we charge the City 5% of
the bill review savings. Savings is the difference between the provider charge and the
recommended allowance.
23% for PPO Savinas (except Blue Cross which is 26% of savinasl means that we
charge 23% of savings that the PPO discount allows. For example if the bill charge was
$1,000 and fee schedule reduced it to $500 and the PPO network discount reduced it an
additional $100 than we charge the City 23% of the additional $100 savings. For the blue
Cross PPO it would be 26% of savings of the additional $100 savings.
20% for PPA (Neaotiations and Usual & Customarvl means any bill that falls out of the
OMFS (CA Fee Schedule) can be subject to Usual & Customary review or negotiations.
When this occurs we than charge 20% of the savings we capture which is the difference
between the provider charge and the recommended allowance.
$0.40 per bill for WCIS State Reportina means we charge every bill that we report to the
State of California $0.40 in addition to the review charge above. For example if it was a
regular provider bill then we would charge $6 for the review and an additional $0.40 for the
State reporting which would total $6.40 per bill.
. Average level of savings for bill review; "
Lien On Me, Inc. gross savings for all our clients was 60% in 2009. Lien On Me, Inc.
always strives to do better.
. In the absence of a fee schedule, how are rate reductions negotiated;
If a bill doesn't fall under the OMFS and no PPO discounts are available, Lien On Me,
Inc. is able to provide the City of San Bernardino an aggressive negotiation.
When a provider's charges are not bound by fee schedule, Lien On Me, Inc. follows the
guidelines established in the en bane decisions of Kunz and Tapia. We first utilize a
. proprietary database to determine U&C for the provider's charges. The amount is then
compared to other providers within the same geographic area, PPO providers,
Medicare, etc. An average is determined and Lien On Me, Inc. finalizes the U&C
review. We have found that the courts follow this well proven approach.
Lien On Me, Inc. can also negotiate any bills that fall outside OMFS or any Network
savings. This process will involve a direct negotiation with the provider to gain their
agreement on a reduced payment. The above U&C review will first be completed.
Once the U&C review is done then the Lien On Me, Inc. bill review expert proceeds
with negotiating with the prol(ider. Our senior level bill review analysts complete a
thorough and technical review which has helped Lien On Me, Inc. get the best possible
savings for all our clients. All such successful negotiations will include a sign
agreement with the provider stating the terms of the payment and that is results in a full
and final payment.
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.
Computer systems and the abilifYllBiit6rface with City of San Bernardino and
utilization review vendor computer systems. Also, the ability to generate
reports documenting bill review activity, cost savings for the City;
Lien On Me, Inc. is currently the bill review vendor for the City of San Bernardino, We
are already interfaced with the City and receiving utilization review vendor's
information. We can integrate with your current utilization review vendor's computer
system if the City is interested. Lien On Me, Inc. is also generating reports
documenting bill review activity and cost savings for the City on a monthly basis. The
current reports we are providing are:
INVOICE MANAGEMENT REPORT:
The Invoice Management Report is a monthly, quarterly or annual report that
contains a summary of the number of bills reviewed by type (Inpatientl .'
Outpatient, Pharmacy Med-Iegal). The report includes additional payment, full
pay and negotiation recommendations. The summary also breaks down billed
charges (fee schedule/usual & customary savings, duplicates, PPO savings
and recommended allowances). All fees related to fee schedule, usual and
customary, negotiations and PPO/MPN reductions are included. Total fees as
they relate to gross and net savings are outlined.
SAVINGS SUMMARY REPORT:
The Savings Summary Report describes the number of lines reviewed per bill
and includes PPO/MPN penetration and savings. The total charges reviewed
and savings generated from llll reviews is summarized.
"
SAVING SUMMARY BY PROVIDER:
The Saving Summary by Provider is typically generated monthly on specific
providers. It provides demographic inforrTlation on the claimant as well as
specific information related to each charge. Typical information found in this
report is the injured worker name, dates of service, date reviewed, claim
number, provider name, billed charges, reductions and allowances.
BILL REVIEW MANAGEMENT REPORT:
The Bill Review Management Report provides a summary of the total number
of bills reviewed, provider charges, gross savings, provider recommended
allowances and the percentage of gross savings as it relates to fees.
SUMMARY:
In addition to those reports provided routinely on a monthly basis, Lien On Me,
Inc. can provide management reports at any time for any interval requested.
This can be done either on a "by request" basis or on any predetermined
schedule to meet your requirements.
If requested, we also provide our clients our on-line "DDAS" system that allows
you to view your data on-line and export it into Microsoft Excel worksheets for
individualized analysis.
Our system is capable of creating ad hoc reports by date range as well as
numerous other selection criteria. Many of our clients have specific requirements,
which we have formatted into spreadsheets for customized reporting. We can
work with the City to provide an ad hoc report as needed.
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Sample Management Reports .ihOJ )\-O#'oc Reports are available upon
request.
. PPO networks offered and the average below fee schedule reductions;
Lien On Me, Inc. maintains relationships with PPOs through a combination of lease
access and direct contracts.
The number of PPOs available to our clients is increased on a continual basis, and we
consistently evaluate which ones are the best for each individual client. We recognize
our clients need for specialized networks to achieve their individual cost containment
goals. A variety of PPOs have been integrated into the system. Many are small
regional and serve a special purpose for the particular client accessing the network.
Our ability to customized and integrate various PPOs upon request is a significant
advantage to our clients. .
First HealthlFocus NCC
Blue Cross PPO Next
Healthsmartllnterplan Claris Pointe
Prime Health TN Healthcare
Tree Rivers AZ Foundation
Inteorated Health Plan
Corvel
Provider directories are available upon request.
Lien On Me, Inc. currently avera\les an additional 4.8% savings from our PPO
networks after fee schedule is applied.
. PPO fee options and how fees are calculated;
'.
23% for PPO Savinas (except Blue Cross which is 26% of savinas): The fees are
calculated 23% of savings that the PPO discount allows. For example if the bill charge
was $1,000 and fee schedule reduced it to $500 and the PPO network discount
reduced it an additional $100 then we charge the City of San Bernardino 23% of the
additional $100 savings. For the Blue Cross PPO it would be 26% of savings.
. Pharmacy PPO services and average savings;
Lien On Me, Inc. is getting an average of 15% of savings from the Pharmacy PPOs we
apply.
Lien On Me, Inc. does recommend the City of San Bernardino a pharmacy benefit
.
program to increase your pharmacy savings.
Lien On Me, Inc. uses Express Scripts for the pharmacy benefit program.
Express Scripts corporate philosophy is rooted in the belief that managing their
partners' medical costs is of the critical importance. Express Scripts accomplishes this
by taking an active role in both identifying and resolving drug therapy issues and
helping their clients reduce overall healthcare costs by improving the quality of patient
care, enhancing therapeutic outcomes, and reducing inappropriate pharmaceutical
expenditures. This philosophy combined with more than 20 years experience has
helped Express Scripts become a leading national provider of workers' compensation
services to nearly three quarters of a million patients annually. Express Scripts
Pharmacy Benefit Management program is unparalleled in the industry today.
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Express Scripts ensures negotiate3~~c~fi~ts and special pricing is passed on to
customers regardless of the proximity of the network provider.
Express Scripts is committed to providing the highest quality products and service.
Detailed below are key features that distinguish Express Scripts from the competition:
Express Scripts's Proprietary Auto Authorization Process: Express Scripts's
proprietary auto authorization process replaces the traditional, manual process of
adjudicating pharmacy claims that require prior authorization. A key advantage of
Express Scripts's proprietary auto-authorization process is that the pharmacy does not
need to contact Express Scripts for authorization, Express Scripts will automatically
send the pharmacy an electronic message instructing them that Express Scripts is in
the process of determining if the medication is authorized. The goal is to assist in
managing the authorization process without losing control of the fill at the pharmacy
level to a third party biller.
.
In-house Clinical Pharmacist Expertise: Express Scripts's program was developed
by their in-house Department of Clinical Services team, staffed by PharmDs and
licensed Pharmacists. Years of experience allow their team to effectively manage their
pharmacy program and provide the following components found in no other PBM in our
industry:
Injury Specific Formulary: Using NCCI or ICD-9 codes, Express Scripts is able to
offer a customized formulary specific to individual injury classifications, matching the
medications to the actual injury.
. PDRx - An individualized, retrospective Pharmacist Drug Review (PDRx)
delivers a formal written report, focusing on specific drug therapy problems to
be resolved and desired outcomes to be achieved,
. Consult Rx - Express Scripts in-house pharmacy Help Desk! Staffed by their
licensed clinical pharmacist, Express Scripts provides you easy access for
consultation for your claims staff and claimants.
Focused Penetration Efforts: Express Scripts believes that a program that is able to
increase network pharmacy utilization is more valuable than a program that simply
reduces pharmacy reimbursement for medications. For this reason, Express Scripts
has implemented several proactive processe's to ensure your penetration into the
network is maximized:
. Express Scripts provides fully customized identification material to aid in the
proper channeling of claims at the point of sale.
. By leveraging IVR technology, Express Scripts assists in claimant
communication in order to better relay program benefits. Express Scripts
allows claimants have the ability to identify their network pharmacy of choice.
Express Scripts then proactively communicates directly with the pharmacy to
provide billing information, ensuring the billing of prescriptions through the
. Express Scripts network.
. Express Scripts's open communication with network partners assist in the
channeling of out-of-network bills to assist in full penetration efforts.
Web Based Reporting: Express Scripts's comprehensive on-line reporting and
productivity tool allows claim managers, supervisors and adjusters immediate access
to customized reporting formats that track financial savings, utilization management,
clinical management, patient activity, as well as monitor authorizations and view
claimant history. Express Scripts has the capability to report on trends, company
wide, as well as for a specific. patient. Client management and adjusters can utilize this
data to make educated and appropriate decisions for their claimants.
Third Party Billing I Doctor Dispensing: Express Scripts has developed the most
comprehensive and effective process for handling out of network bills in the industry.
This process minimizes paper, maximizes clinical cost savings and elevates network
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penetration. This is accomplishec?t~~8ug~7a distinct but synergistic product offering of
Third Party Biller Connectivity. In addition, Express Scripts is establishing a program to
capture prescriptions dispensed by physicians,
One Stop Shop and Dedicated Service: A single phone call to our 800 number
streamlines the order process for the adjuster/nur;:;e case manager and provides our
client with vendor management and guaranteed savings. Referrals can also be
processed on the web at www.express-scripts.com Express Scripts contacts the
claimant and provider to verify claimant demographics and appointment at least 24-
hours prior to all service. Our proactive approach increases accuracy and promptness
reducing discrepancies. Express Scripts provides status reports, fax or email
confirmation for all service orders. Express Scripts's hours of operation are Monday
thru Friday, 8:00 a,m, to 10:00 p.m, EST, after hours and weekend emergencies are
accommodated by several on-call Express Scripts associates, including a clinical
pharmacist. Our on-call associates are specially trained to handle emergency
situations. Additionally, Express Scripts will assign a local and home office
representative to their clients.
.
Provider Relations Department: Express Scripts provides complete network
management ensuring contracted discounts, provider credentialing, licensure, proper
limits of liability and coverage for all vendor partners. Express Scripts uses a
proprietary program, PointRight, to grade and evaluate all vendors on an ongoing
basis.
Express Scripts's proven Cost Containment programs produce client savings of 20-
25% over state fee schedule. As the provider to the largest Worker's Compensation
carrier in the United States, Express Scripts has successfully delivered real dollar
savings, while maximizing penetration and controlling utilization. Express Scripts truly
provides a better choice!"
. Any distinguishing or unique qualifications that your company possesses or any
other information that documents your a~i1ity to provide quality bill review
services;
What distinguishes Lien On Me, Inc. from all other bill review companies are our Lien
Defense program, the claims background of our management staff, and our exemplary
customer service.
The Lien Defense program was the purpose for the creation of Lien On Me, Inc. Ms.
Hartin and Mr. Lents (Director of Lien Defense) came from the workers' compensation
claims arena giving them an intimate knowledge of what clients' needs were regarding
lien negotiation and litigation. By being able to coordinate Lien On Me, Inc. Medical Bill
Review with Lien Defense, the bill review expert witnesses are well prepared for any
hearings that may arise. Not only are they prepared for bill review issues but are also
. instructed in legal arguments. The Director of Lien Defense will also assist defense
counsel with coding questions and strategies to better prepare for lien litigation.
Our President, Tess Foley, has a long history of Workers' Compensation claims
handling and management. She understands and anticipates our clients' needs. Her
versatile skills, along with those of our multifaceted management staff, bring a much
valued service to all of our clients. Thus, we are able to provide a product that is helpful
in integrating your entire Workers' Compensation program.
Our exemplary customer service separates our Medical Bill Review from all
competitors. The executive management team recognizes satisfied customers are
essential to business success and the most important relationship we have is with our
customers. Because we are large enough to service national clients yet small enough
to customize our programs, we can tailor ourselves to the specific needs of each
individual client.
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It. .t t t d I' 2010"t227 t t. t . h..
IS our comml men 0 elver quall y cos con alnmen services ac levlng
maximum savings at a competitive cost to our customer.
It is our commitment to meet and exceed your service expectations. We recognize
that our contribution to the claims process is critical to your on-going success in this
dynamic and changing marketplace.
It is our commitment to be responsive when issues occur and reliable when it
comes to the rapid resolution of service issues.
It is our commitment to create a program for the City of San Bernardino that is
effective, efficient and easy.
.
.
.
Lien On Me, Inc. also has the capability of imaginglscanning documents in a format if
the City of San Bernardino requests. We have been on a paperless program since
2004 and are very familiar with the requirements of the Electronic Data Interface
process. Lien On Me, Inc. has many different types of imaging processes and can
work with the City for the most efficient workflow. The workflow that most of our.
existing clients use is included for your review,
. An Overview of your company's experience in providing bill review services for
cities and other clients
Lien On Me, Inc. has addressed this questions in the 1st bullet point of the
proposal answer
. Minimum of three professional references
Lien On Me, Inc. has addressed this questions in the 2nd bullet point of the
proposal answer
" ~
. Experience and training of bill review staff, including how continued education
requirements are met.
, '
Lien On Me, Inc. had addressed this question' in the 6th bullet point of the proposal
answer
. WCIS Reporting Procedures and Fees.
After completion of medical bill reviews and audits of all clients' provider bills, Lien On
Me, Inc. will generate a Medical Bill Review (MBR) Data File and forward to client via
Electronic Data Interface (EDI) for issuance of payments to providers per our
Explanation of Review (EaR) allowance. Client will then generate a Payment
Data/lnformation File and will send it via EDI to Lien On Me, Inc. to import into our
MBR software/system. A workers' Compensation Information System (WCIS) Data
File is then generated and is exported into the WCIS Database. Lien On Me, Inc.'s fee
, for filling MBR Data File for State Reporting to the WCIS is 0.40 cents per bill.
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