HomeMy WebLinkAbout911488.tiff RESOLUTION
RE: APPROVE SERVICE AGREEMENT FOR WORKERS' COMPENSATION SELF-INSURANCE PROGRAM
WITH OCCUPATIONAL HEALTHCARE MANAGEMENT SERVICES, INC. , AND AUTHORIZE
CHAIRMAN TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado,
pursuant to Colorado statute and the Weld County Home Rule Charter, is vested
with the authority of administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Service Agreement for Workers'
Compensation Self-Insurance Program between Occupational Healthcare Management
Services, Inc. , and the County of Weld, effective January 1, 1992, with the
further terms and conditions being as stated in said agreement, and
WHEREAS, after review, the Board deems it advisable to approve said
agreement, a copy of which is attached hereto and incorporated herein by
reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Service Agreement for Workers' Compensation Self-
Insurance Program between Occupational Healthcare Management Services, Inc. , and
the County of Weld be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 23rd day of December, A.D. , 1991.
BOARD OF COUNTY COMMISSIONERS
ATTEST: .41 / / f u WELD COUNTY OLORADO
4 ^ / 761
Weld County Clerk to the Board
Gor ac , rman
By' 41(4,,,,6/1_7"72R/
r�Ll�
Deputy Ck toard i George Kenne y, Pro-Tem
APPROVED AS ORM: EXCUSED DATE OF SIGNING - (AYE)
Constance L. Harbert
O "&de-- L
County Attorney C. W. Kirby
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W. H. Webste
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OEM.S
OCCUPATIONAL
HEALTHCARE
MANAGEMENT
SERVICES
■
December 16, 1991
Mr. Don Warden
Weld County Colorado
915 10th Street
P.O. Box 758
Greeley, Colorado 80632
Re: Workers' Compensation Claims and Medical Case Management Administration
Contract
Dear Don:
Enclosed please find the OHMS workers' compensation service agreement for your self-
insured workers' compensation program, effective January 1, 1992.
I believe we have incorporated all of the changes that you had outlined in the draft.
Please review this contract and if its contents are satisfactory to you and to the county,
it is ready for your signature. If you could kindly return to us a copy of the contract and
the signature page, it would be appreciated. If we need to make any additional changes
prior to the execution of your signature, please let us know.
Yours very truly,
--?e..,-;-___„,„._ '-
v
Francis H. Boissoneau, CPCU, ARM
Director of Sales
700 Broadway,Suite 1132
Denver,Colorado 80273
(303)831-3059
A ROCKY MOUNTAIN HEALTH CARE CORPORATION SUBSIDIARY
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SERVICE AGREEMENT FOR
WORKERS' COMPENSATION SELF-INSURANCE PROGRAM
THIS AGREEMENT is entered into this first day of January 1992, by and between
Occupational Healthcare Management Services, Inc. ("OHMS"), and the County of Weld,
("Client").
WITNESSETH:
WHEREAS,Client proposes to self-insure its workers'compensation risks and desires
to have OHMS provide specific services in connection with such self-insurance program; and
WHEREAS, OHMS is willing to provide such services on the terms and conditions
hereinafter stated;
NOW, THEREFORE, the parties hereto agree as follows:
Section 1. Definitions. When used in this Agreement,the following terms shall have the
meanings set forth below.
1.1 "Claim." A request for workers' compensation benefits. A claim includes all
potential or actual worker's compensation liability of Client for the illness or injury of an
employee, including medical, disability and/or other benefits and shall be determined as one
of the following:
1.11 "Compensation Claim."
a. Lost time as defined statutorily, or
b. permanent physical impairment, or
c. fatality, or
d. denial of benefits.
1.12 "Medical Claim." Claims for medical benefits only.
1.2 "Compensable illness or injury." An illness or injury for which an employee
is entitled to benefits under the workers' compensation laws of the State of Colorado. A
determination of compensability is the determination that an employee has sustained an injury
or illness and is eligible to receive treatment or services that are compensable under the
workers' compensation laws of the State of Colorado.
1.3 "Employee." An employee or other person who is eligible to receive workers'
compensation benefits from Client.
1.4 "Network provider." A healthcare provider who has entered into a contract
with OHMS to provide medical services to employees.
1.5 "Network provider rate." The fee for medical services established by the
contract between OHMS and a network provider.
1.6 "Medical industrial fee schedule." The workers' compensation medical
services fee schedule, as the same may be amended from time to time, established by the
State of Colorado in accordance with C.R.S. §8-49-101(3) (Supp. 1988).
Section 2. Obligations of OHMS. OHMS shall provide the following services under this
Agreement.
2.1 Claims Administration. OHMS shall provide the following Claims
Administration services for workers' compensation claims submitted to client:
2.11 Unless otherwise agreed,OHMS shall review all claim reports for illnesses
and injuries incurred or reported on or after the effective date of this Agreement and shall
process each such claim in accordance with applicable statutory and administrative
regulations. OHMS shall conduct an investigation of each reported claim, including the use
of independent investigators or medical or other experts,to the extent deemed necessary by
OHMS in connection with processing any claim. Costs of such investigators and/or experts
shall be borne by Client, and paid from the account established pursuant to Section 3 of this
Agreement. The final determination of compensability of any claim shall be the responsibility
of Client.
2.12 OHMS shall pay from the account established pursuant to Section 3 of
this Agreement medical and death benefits,temporary and permanent disability compensation
and other expenses for claims, but only if, in the judgment of OHMS, such payment would be
prudent for Client and the anticipated amount of any one payment does not exceed the
discretionary disbursement limit specified in Section 5 hereof. OHMS shall also pay on behalf
of Client such other benefits or expenses related to workers' compensation claims that are
expressly authorized by Client. OHMS shall furnish to Client on a monthly basis a check
register showing all checks issued on the account during the prior calendar month.
a. Medical bills submitted by network providers shall be paid by OHMS at
the lowest of the agreed network provider rate, the medical industrial fee schedule or billed
charges.
b. Medical bills submitted by non-network providers shall be paid by OHMS
at the lower of the medical industrial fee schedule or billed charges.
2.13 OHMS shall maintain a file for each claim which shall be available for
review by Client at any reasonable time.
2.14 OHMS shall notify any excess insurer of all compensable or disputed
claims with respect to which potential losses may exceed Client's retention and, if requested,
provide such insurers with necessary information in accordance with the excess insurers
agreement.
2.15 OHMS shall assist counsel selected by Client to defend litigated cases,
as requested by Client.
2.16 OHMS shall maintain a current estimate of the expected total cost of each
claim.
2.17 OHMS shall furnish to Client on a monthly basis a Claim Experience
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Report.
2.18 OHMS shall provide claim forms and other forms believed by OHMS to
be appropriate for the efficient operation of the self-insurance program.
2.2 Medical Management. OHMS shall provide the following Medical
Management Services in connection with claims:
2.21 Providers. OHMS shall maintain a network of healthcare providers within
the State of Colorado in sufficient numbers and in sufficient locations so as to provide
reasonably adequate medical facilities for employees with compensable injuries or illnesses.
Client agrees that the OHMS network as of January 1, 1992 meets the requirements of this
paragraph.
a. Subject to the provisions of this paragraph 2.21, the composition of the
OHMS network shall be within the sole discretion of OHMS. Neither this nor any other
provision of this Agreement shall be construed to require OHMS to include within its network
any particular type or specialty of healthcare provider or facility or to contract with a provider
and/or facility in any particular community.
b. OHMS retains the sole authority to negotiate network provider rates with
network providers. Client understands and agrees that such rates may vary among providers,
and are subject to change at any time. Nothing contained in this Agreement shall be
construed to require OHMS to obtain any specific discount from its network providers.
c. OHMS shall provide to Client at least quarterly an updated list of its
network providers.
2.22 Medical Management Services. OHMS shall review all cases involving
employees who have lost more than three (3) days of work as a result of a compensable
injury or illness to determine whether medical management services would be appropriate and
effective, and shall provide such medical management services, if any, as it deems
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appropriate in individual cases. Medical management services shall be used so as to return
the employee to his prior employment or employment appropriate with his disabilities as
quickly as possible, shall be provided through registered nurses, and shall consist of the
following:
a. The review of medical records and the evaluation of the appropriateness
of medical care;
b. The development of recommendations regarding case management,
which by way of illustration may include the following:
(i) how to obtain patient care that is lower in cost than but of
comparable quality to traditional care;
(ii) how to coordinate care among facility and other professional
providers;
(iii) if appropriate,the availability of vocational rehabilitation services;
and
(iv) the coordination of the employee's return to work utilizing modified
duty if appropriate.
c. Telephone or personal meetings with the Client,the medical provider and
the injured employee as appropriate to communicate medical management recommendations.
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2.23 Utilization Review. OHMS shall provide retrospective utilization review
for all employee inpatient hospital admissions to evaluate the appropriateness and level of
charges and utilization.
2.3 Loss Control. OHMS shall provide the following Loss Control Services, if
requested by Client:
2.31 Information and recommendations with respect to the following:
a. State and Federal Rules and Regulations
b. General Safety and Accident Prevention programs
c. Human actions/ergonomics
d. Accident reporting, investigation techniques, and procedures.
2.32 Loss Control Reports shall consist of findings and recommendations to
control, minimize and/or eliminate loss producing hazards and exposures. Loss Control
services will be contracted on an hourly or program basis as specifically requested by the
Client.
2.4 Administrative Compliance. OHMS shall furnish appropriate renewal
application forms and, if mutually agreeable to the parties,file all periodic reports and renewal
applications required by state administrative agencies to maintain the self-insurance workers'
compensation program.
2.5 Other Services As Requested By Client. OHMS shall provide the following
other services, if requested by Client:
2.51 Additional Reports. OHMS shall provide narrative or analytical reports of
major or litigated claims,or other types of reports as mutually agreed upon by OHMS and the
Client.
2.52 Additional Meetings. OHMS shall participate in and attend additional
meetings as mutually agreed upon by OHMS and the Client.
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2.53 Additional Services. OHMS shall provide additional services as mutually
agree upon by OHMS and the Client.
Section 3. Obligations of Client.
3.1 Client shall notify its employees that OHMS' network providers are Client's
designated providers for treatment of compensabie illnesses and injuries, and shall instruct
employees on the use of this network.
3.2 Client shall be solely responsible for determining the compensabiiity of any
illness or injury.
3.3 Client shall reimburse OHMS for any payments made on behalf of Client and
for allocated loss expenses. For this purpose allocated loss expenses shall mean all costs,
charges, or expenses of third parties incurred by OHMS, its agents or its employees which
are properly chargeable to a claim or loss including, without limitation, court costs, fees and
expenses of attorneys, investigators,vocational rehabilitation vendors,experts and witnesses,
and fees for obtaining diagrams, exhibits, reports, documents and photographs.
3.4 Default. Should there be insufficient funds to cover any Claims Amount Due
or the Client is otherwise in default, and should such default continue for 72 hours after oral
notice thereof is given to Client, OHMS shall have the right to assess Client a late penalty of
one-half of one percent per day of the deficient amount and to immediately suspend claims
processing. The Client shall remain liable for all amounts payable under this Agreement.
3.5 Client shall designate a person as the principal contact to authorize payment
by Client for such service or treatment as recommended by OHMS.
Section 4. Compensation.
4.1 Client shall pay to OHMS the following fees:
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01 ~ter ,
Option III
4.11 A claims administration fee based on an annual fee of $ 22,750 on a
projected annual claim volume of 202 medical claims and 17 lost time claims. This
base fee shall be payable in twelve (12) monthly installments in the amount of $ 1,896 due
and payable in advance on the first day of each month. If the claim volume exceeds 202
medical claims and/or 17 lost time claims, the additional claims will be billed at the rate of
$ 80 per medical claim and $ 385 per lost time claim.
4.12 A network access fee, which shall be 50% of the difference, if any,
between the medical industrial fee schedule for any service or treatment, or billed charges,
whichever is applicable, and the amount actually paid by Client for such service or treatment
as recommended by OHMS. A claim shall be entered on the OHMS computer system for the
purposes of paying the network access fee. Monthly, OHMS will issue a payment to OHMS
based on the actual usage of the network.
4.13 The monthly medical management fee shall be $ 65 per hour, $.35 per
mile and expenses at actual, due and payable within 30 days of billing.
4.14 Client shall pay to OHMS the sum of $ 65 per hour, $ .35 per mile
and expenses at actual for all Loss Control services provided by OHMS, at the Client's
request.
4.2 In addition to the fees set forth above, Client shall pay to OHMS:
4.21 A mutually agreed upon sum for additional reports as described in Section
2.51.
4.22 A mutually agreed upon sum for additional meetings as described in
Section 2.52.
4.23 A mutually agreed upon sum for additional services as described in
Section 2.53.
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4.3 All applicable sales tax, service and/or use or receipts taxes shall be the
responsibility of Client and shall be in addition to the fees set forth in this section.
4.4 On or before the 20th day of the month, OHMS shall submit to Client an
invoice for all fees payable under this section. Such invoice shall reflect the basis for the
calculation of the fees due. Client shall pay OHMS the amount invoiced on or before the last
day of the month in which the invoice is received. Checks shall be sent to O.H.M.S.,
Department 227, Denver, Colorado 80291-0227.
Section 5. Discretionary Authority Limit. The limit on any single discretionary payment
by OHMS in connection with a claim, or for allocated loss expenses,as the case may be, shall
be $ 5,000 . It is agreed that OHMS shall have full authority and control in all matters
pertaining to the payment, processing, investigation and administration of claims or losses
within the limit established by this paragraph. Failure of OHMS to settle a claim or loss within
such limit, however, shall not subject OHMS to liability to any party in the event an adverse
judgment is entered by any court or such claim is settled in an amount in excess of such limit.
Section 6. Audits and Data.
6.1 OHMS shall allow Client full access to all claims data, including paper
documents, microfilm, and microfiche relating to employee claims.
6.2 OHMS shall promptly respond to reasonable requests for data and assistance
in sampling surveys.
6.3 As to all original books, manuals, films, or any other patentable or
copyrightable material developed with contract funds provided by Client under this Agreement,
Client shall have a non-exclusive, irrevocable, royalty-free license to reproduce, translate, or
otherwise use and to authorize other healthcare facilities to publish and use such material.
Such license shall not extend to the use of reproduction in any form or fashion of the names
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"Blue Cross and Blue Shield", or "Blue Cross and Blue Shield of Colorado", or the marks
associated therewith.
6.4 OHMS shall take all steps necessary to safeguard any data, files, reports or
other information from loss, destruction or erasure. Liability for any costs or expenses of
replacing data,or damage resulting from the loss of such data shall be born by OHMS unless
at the time of loss, such data was in the exclusive custody of Client.
Section 7. Term of Agreement and Cancellation.
7.1 The initial term of this Agreement shall be for one year ending on December
31, 1992. If not canceled in accordance with this paragraph,this Agreement shall be renewed
automatically for successive twelve-month periods thereafter. However,this Agreement shall
not be so renewed unless the amount of the compensation to be paid to OHMS in any
renewal year shall have been agreed upon by the parties hereto not later than sixty (60) days
prior to the end of the preceding contract year. Notice of any request for increased fees or
material changes in services shall be given by the requesting party to the other at least ninety
(90) days prior to the end of the preceding contract year.
7.2 If either party defaults in the performance of its obligations under this
Agreement, then the non-defaulting party shall give the defaulting party 45 days'prior written
notice to cure the default. If the default is not cured within the 45-day period to the
satisfaction of the non-defaulting party,then such party shall give the defaulting party 45 days'
prior written notice of termination of this Agreement, and this Agreement shall terminate at the
end of the calendar month in which the 45-day notice requirement expires, or at the end of
any subsequent calendar month as specified in the notice.
7.3 This Agreement may be canceled by either party at the end of any contract
year, provided that written notice of such cancellation is received by the other party not later
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than ninety (90) days prior to the end of such year. However, OHMS may terminate the
Agreement at any time should Client fail to provide the funds required by Section 3 of this
Agreement.
7.4 If requested by Client,after termination of this Agreement OHMS will continue
to handle claims reported or incurred during the term of this Agreement for a period of 12
months, provided that Client shall continue to make adequate funds available for the payment
of such claims and any allocated loss expenses. The additional fee for this service shall be
negotiated and agreed upon prior to the effective date of termination.
7.5 Upon termination of this Agreement, Client shall be entitled, if it so requests,
to have returned the files OHMS has maintained for claims or losses (but not including any
computer hardware, software or other proprietary information of OHMS); provided, however,
that OHMS or its agents, employees or attorneys shall continue to be entitled to inspect such
files and make copies or extracts therefrom either before or after returning same. If Client
does not request these files, they will be retained or destroyed at OHMS's option and Client
shall have no recourse against OHMS for failure to retain them.
7.6 In the event that this Agreement is terminated Client shall notify its employees
within ten (10) days that this Agreement is to be or has been terminated.
Section S. Service Marks. OHMS and Client agree that neither will use the names,
symbols, trademarks or service marks of the other party without its prior written consent.
Section 9. Trade Secrets. The parties agree that during the term of this Agreement
each will receive trade secrets and confidential information from the other, including without
limitation, information relating to their respective business practices,fees,personnel,provider,
customer or consumer lists, marketing research developments, marketing data and statistics
and production and data processing methods. During the term of this Agreement and
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thereafter, each party agrees not to disclose such confidential or trade secret information
either directly or indirectly to any other person, firm or organization except as is reasonably
necessary for the performance of its duties under this Agreement.
Section 10. Confidentiality. OHMS agrees that information from medical records of
employees shall be kept confidential and shall not be disclosed without the written consent
of the employee, except that disclosure may be made to a provider, the employee or his/her
representative,the employer or its representative,the Division of Labor,and as otherwise may
reasonably be necessary for the performance of this agreement.
Section 11. Indemnification. Client shall indemnify and hold OHMS harmless against
any and all claims, demands and expenses of all kinds made against or incurred by OHMS,
resulting from or arising out of any business dispute with a Claimant/Employee, or the
negligence or misconduct of Client or any agent, employee or representative of the Client.
Client shall indemnify and hold OHMS harmless against any and all claims, demands, and
expenses of all kinds made against or incurred by OHMS, resulting from the negligence or
misconduct of Client's previous claims administrator(s) or any agent, employee or
representative of Client's previous claims administrator(s).
OHMS shall indemnify and hold Client free and harmless against any and all claims,
demands and expenses of all kinds made against or incurred by Client resulting from or
arising out of the negligence or misconduct of OHMS or any agent, employee or
representative of OHMS in the performance or omission of any act or responsibility assumed
by OHMS pursuant to this Agreement.
Section 12. Notices. Notice required to be given under this Agreement to OHMS shall
be sent by mail or hand delivered to 700 Broadway, Denver, Colorado 80273, Attention:
President and Chief Operating Officer. Notice required to be given under this Agreement to
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Client shall be sent by mail or hand delivered to Weld County, 915 10th Street, Greeley,
Colorado 80634, Attention: Don Warden .
Notice mailed to the Client or broker/consultant shall be deemed effective notice by
OHMS to each employee.
Section 13. Successors. This Agreement shall be binding upon and shall inure to
the benefit of all assigns, transferees and successors in interest of any kind of the parties
hereto; provided, however, that this Agreement may not be assigned without prior written
consent.
Section 14. Entire Agreement and Modification or Amendment. This Agreement
represents the entire and exclusive statement of the agreement of the parties, and, except as
otherwise provided herein, may be modified or amended only by a written statement signed
by both parties.
Section 15. Headings. Headings used in this Agreement are for convenience of
reference only and shall not be considered in any interpretation of this Agreement.
Section 16. Governing Laws. This Agreement is made and delivered in the State of
Colorado, and will be interpreted and enforced so as to remain in compliance with Colorado
statutes and regulations. Should any provision of this Agreement in any way contravene the
laws of the State of Colorado or of the United States of America, such provision shall not be
deemed a part of the Agreement. However, the Agreement shall otherwise be enforceable.
Section 17. Enforcement of the Agreement. Failure of either party to enforce any of
the provisions of this Agreement shall not constitute a waiver of rights for that or subsequent
breaches.
Section 18.Subcontracts. OHMS may subcontract any or all of its obligations hereunder
to a third party, with approval of Client. No such subcontract shall relieve OHMS of its
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obligations to Client under this Agreement.
Section 19. Relationship of Parties. The relationship of the parties to this
Agreement is that of independent contractors.
Section 20. Disputes. If a dispute or grievance between the parties arises with respect
to the obligations of the parties under this Agreement or as a result of this Agreement, and
such dispute or grievance cannot be resolved in an informal fashion, the parties shall submit
their dispute to arbitration in accordance with the rules for arbitration of commercial matters
of the American Arbitration Association. The parties agree that such arbitration shall be held
in Denver, Colorado. The decision of the arbitrator shall be final and binding upon the parties,
and may be enforced by any court having jurisdiction thereof. Each party shall bear its own
costs and shall share equally in the American Arbitration Association's administrative fee as
well as the arbitrator's fee, if any, unless otherwise assessed by the arbitrator. Any legal
action must be brought in Denver, Colorado.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement this
,h ki" day of (),r e Jaen_ , 19 ell
OCCUPATIONAL HEALTHCARE MANAGEMENT SERVICES
By:
WELD COUN , CiOLORADO/
Attest: (] //Af
eld Cou ty r to a Board f
(.1/
By: _ ) 4 , ( 7.4. (t _
Deputy Clerkito the Board
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY O DO
By: _
acy, Chum
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