HomeMy WebLinkAboutRENEWAL OF AGREEMENT WITH CORVEL, ACTING AS THIRD PARTY ADMINISTRATOR, TO PROVIDE WORKER COMPENSATION CLAIMS ADMINISTRATION SERVICES TO AUGUSTA, GEORGIA AMENDMENT#3
This Amendment #3 is entered into and made effective as of this 15th day of May, 2018 (the "Effective
Date") by and between CorVel Enterprise Comp, Inc. ("CorVel") and Augusta Georgia Consolidated
Government("Customer").
Whereas, CorVel and Customer entered into the TPA Services Agreement with an Effective Date of
February 1, 2015, as amended(the "Agreement")pursuant to which CorVel agreed to provide Customer
with certain third party claims administration and bundled managed care services.
Now therefore, in consideration of the mutual promises and covenants contained herein,the parties agree
to acknowledge to the Services and Fees below, which are not currently stipulated in the Agreement, and
to amend Agreement as set forth herein:
• Amend Exhibit B("Fees")of the Agreement whereby effective January 1,2018 the services
described hereunder in Exhibit A to this Amendment shall be included with fees as follows:
Case Management:
Vocational Rehabilitation $150.00 per hour
Medicare Set Asides
Life Care Planning $200.00 per hour
Medicare Conditional Payments $200.00 per hour
Catastrophic Case Management $200.00 per hour
All other terms and conditions of the Agreement shall remain in full force and effect.
IN WITNESS WHEREOF, CorVel and Customer have caused this Amendment to be executed by the
persons authorized to act in their respective names.
AUGUSTA GEORGIA CONSOLIDATED CORVEL ENTERPRISE COMP,INC.
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Augusta Georgia Consolidated Government Amendment 3 . M Pricing)to TPA Services Agreement 5-1-18
EXHIBIT A
SCHEDULE 2
Case Management Services
Terms and Conditions
1. DESCRIPTION OF SERVICES
(a) Case management services are provided to manage a claimant's case in order to identify the most
appropriate rehabilitative treatment and/or most cost-effective health care alternatives ("Case
Management Services"). Case managers may confer with the adjuster, attending physician, other
medical providers, employer(s), attorney(s),the patient and the patient's family.
(b) In certain states if requested by Customer, Case Management Services may include vocational
rehabilitation services.
2. DELIVERY OF SERVICES
(a) CorVel shall provide Case Management Services to Customer upon receipt by CorVel of specific
requests from Customer as mutually agreed by both parties under the special handling instructions.
(b) Telephonic Case Management: Telephonic case management ("TCM") includes a four-point
contact with claimant,employer,claims professional and provider.CorVel case managers("CMs")
do the following: (i) facilitate communication among all appropriate parties regarding the
diagnosis, prognosis and treatment plan provided by claimant's treating physician, (ii) channel or
direct claimant to a PPO Network provider as appropriate, (iii) monitor and facilitate treatment
planning, (iv) coordinate early return to work, and (v) subsequently provide periodic assessments
of treatment and return to work plans.CMs may recommend additional services or coordinate claim
closure, as appropriate.
(c) Medical/Field Case Management: CorVel's medical/field case management("MCM") personnel
perform field based case management services as directed by the employer and/or Authorized TPA
which may include on-site contact with claimant, employer, and provider, as well as telephonic
communication with the claims professional. MCM's provide the CM services set forth in Section
A above.
(d) Vocational Case Management: Vocational case management services may include the following:
(i) coordinating return to work, (ii) providing job analysis, (iii) assisting with job placement, (iv)
providing expert testimony, (v) assisting with job development, (vi) providing job analysis of
essential and non-essential duties for employers under the American's With Disabilities Act, (vii)
providing vocational testimony, (viii) providing advice regarding job seeking skills, and (ix)
providing transferable skills analysis.
(e) Utilization Review:
(i) CorVel's utilization management program reviews proposed inpatient hospital admissions and
ambulatory care to determine the appropriateness, frequency, length of stay, and setting for
such proposed treatment. In addition,CorVel can monitor and assess the appropriate utilization
of treatment for all orthopedic and soft tissue injuries requiring ambulatory diagnostics and
treatment.
(ii) CorVel nurses make recommendations to the claims adjuster based on nationally accepted
medical guidelines,including Optimed Managed Care System,a clinical protocol software;the
American College of Occupational and Environmental Medicine (ACOEM) Occupational
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties.
Augusta Georgia Consolidated Government Amendment 3(CM Pricing)to TPA Services Agreement 5-1-18
Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and
Functional Recovery in Workers; other nationally accepted treatment practice guidelines, as
well as any state mandated treatment guidelines.
(iii)Any nurse recommendations for limitation or denial of care based on lack of medical necessity
are reviewed by a CorVel Physician Advisor. The Physician Advisor makes a final
recommendation to the claims adjuster to approve or deny. If a final recommendation is made
to deny treatment, the treating physician is notified in writing of the decision and the appeals
process.
SCHEDULE 8-A
Medicare Set-Aside Services
Terms and Conditions
DESCRIPTION OF OTHER SERVICES
a. Medicare Set-Asides: CorVel provides an extensive review of medical records and medical
bills,producing a comprehensive report and cost projection outlining future Medicare eligible
costs in anticipation of settling out future medical care on a Customer's employee or insured
individual. Costs are determined through CorVel's proprietary Bill Review system as well as
utilization of the online Red BookTM access for medication costs. Red BookTM is the
accepted authority by CMS for pricing on all medications.
b. Life Care Plans/Future Cost Projections: Life Care Plans/Future Cost Projections are a plan
for optimal utilization of health care dollars that document objective view of the future health
needs, services and related costs. It provides for comprehensive reports summarizing medical
treatment and care and outlining life time needs for a Customer's employee or injured
individual when they are catastrophically injured. Life Care Plans/Future Cost Projections
are also used both for litigious settlements as well as projecting reserves setting.
c. Medicare Conditional Payment Resolution: CorVel's service includes securing Medicare
Conditional Payment letters and disputing the Medicare Conditional Payments unrelated to
the claim. CorVel communicates directly with the Medicare contractors,the CRC
(Commercial Repayment Center)or BCRC(Benefits Coordination&Recovery Center)to
resolve the Medicare Conditional Payment debt.
II. DELIVERY OF SERVICES OF MEDICARE SET ASIDES
a. Customer/Carrier shall provide the CorVel Medicare Set-Aside Hub office with a copy of the
first report of injury, most recent two years of medical records and medical bills including
indemnity payout, all operative reports, IMEs/AMEs as well as orders rendered by the
workers' compensation judicial system. Appropriate releases for completion of request for
service will be forwarded either to the Customer or, at the Customer's request,directly to
counsel representing the injured worker to obtain the injured worker's signature.
b. Customer may submit a request for a Medicare Set-Aside via email,phone, fax,or
electronically via CorVel's CareMC website, if applicable.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties.
Augusta Georgia Consolidated Government Amendment 3(CM Pricing)to TPA Services Agreement 5-1-18
c. A certified Medicare Consultant("Consultant")will review the medical records and bill
summary, prepare a detailed summary of the records and a projection for future medical
expense which are Medicare eligible. If requested,the Consultant will also provide a
projection of those costs which are not Medicare eligible in order to provide the customer
with their total medical exposure.
d. The Consultant will return the completed Medicare Set-Aside report to the Customer within
fifteen(15)business days of receiving all relevant medical records and related information.
If a rated age is warranted,the Consultant will acquire same. If the Medicare status of injured
party is unknown or unclear, a request for Medicare status will be submitted to the Social
Security Administration. Once the Medicare status is known,the Coordination of Benefits
Contractor will be notified and conditional payments requested.
e. Upon Customer's request, CorVel Medicare Set-Aside Hub office will submit through the
web-portal all required documents to enable CMS to review and approve the proposal. Items
submitted include the Medicare Set-Aside report,the tentative settlement amount, along with
other required documentation,to the Centers for Medicare&Medicaid Services(CMS).
Upon receipt, CorVel Medicare Set-Aside Hub office will forward the CMS Determination
letter to the Customer. Final executed settlement documents(reflecting CMS recommended
Medicare Set-Aside amount)will be provided to CorVel Medicare Set-Aside Hub by the
Customer/counsel and then forwarded by CorVel to CMS through the web-portal.
f. Upon request from Customer, CorVel shall provide Customer quarterly activity report within
twenty(20)business days following the applicable quarter.
III. DELIVERY OF SERVICES OF LIFE CARE PLANS/FUTURE COST PROJECTIONS
a. Customer shall provide all available medical records and billing to CorVel Medicare Set-
Aside Hub office as well as any other pertinent records for initial review.
b. For a Life Care Plan, a visit to the residence of the Customer's employee or injured individual
with interview of claimant and family will be conducted after permission is acquired by the
Customer. The interview will include evaluation of the home setting, extensive information
gathering, and pictures of the various equipment and housing structures.
c. Letters will be sent to all treating physicians to obtain their opinions on future medical
treatments including medications and therapies for the claimant. The physician's opinions
will be included as recommendations within the Life Care Plan summaries.
d. Future cost projections are utilized to immediately set reserves for future medical needs
regarding catastrophic or major injuries. Home visits are not conducted for a future cost
projection.
e. Customer may submit a request for a life care plan or future cost projection via email,phone,
fax, or electronically via CorVel's CareMC website, if applicable.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties.
Augusta Georgia Consolidated Government Amendment 3(CM Pricing)to TPA Services Agreement 5-1-18