The State’s Response to:
Questions Received
For
Request for Proposal
Notice to Prospective Bidders
RFP No. RFP06052012Third Party Administrator for Workers’ Compensation Claims Administration
Services
1. What are the two sources of claim systems from SCIF?
There are two systems that were developed in house.
2. Are the claims paperless?
Yes and no. Claims prior to 2010 are not completely paperless.
3. Does SCIF currently provide the Bill Review and UR services in house?
Yes. SCIF utilizes Comppartners and Anthem Blue Cross for more complicated
cases.
4. Do you know what system they use for cost containment?
Mitchell is the program used for cost containment.
5. What percentage (approx.) do you think caseloads are over-inflated?
198 files were audited and within three weeks 25 files were closed. Our
assumption is that this is due to staffing changes and the use of two different
claim systems.
6. Do you have other vendor panels that must be used? Legal, investigation, etc.
No.
7. How many user and logins will you need?
3 logins at most.
8. Submission needs to be stapled only?
Yes.
9. Are you looking for TPA to take on any closed physical files for storage? If so
how many?
At this time, no.
10. How many adjustors are in a dedicated unit handling the claims?
There are 30 dedicated claims adjustors.
11. What is volume of bills, UR, Nurse Case Management? Monthly, yearly?
This information is unavailable.
12. Do you use a Medical Provider Network?
No.
13. Is there a pharmacy program?
Express Scripts
14. Please provide loss data in Excel format.
Please see attachment titled “Loss Data in Excel Format”
15. Please provide a breakdown of reported claims by medical only and indemnity.
Please see page 7 and 8 of the RFP.
16. Please provide a breakdown of the open pending inventory by medical only,
indemnity, and future medical.
Please see attachment titled “Breakdown of MO, IN and FM”.
17. We note that the claims reporting from the departments (CalWorks, CalFresh,
and IHSS) are inconsistent year over year. What drives the variability in the
reporting from the departments? Does the Department anticipate an increase or
decrease in reporting volume over the contract term?
CalWorks- In 2009 and 2010, California dramatically increased the number of
welfare recipients participating in subsidized employment via funds made
available through the federal American Recovery and Reinvestment Act
"stimulus" package, which accounts for the large spike in claims. The stimulus
funds are no longer available and therefore the number of welfare recipients
participating in subsidized employment is dramatically decreased. The claims are
estimated to stabilize over the next 6 to 12 months.
For CalFresh, the increase in the number of reported claims was due to an
increased number of participants in the Employment and Training (E&T) program
namely under workfare, work experience and self-initiated workfare
activities. The CalFresh Branch does not anticipate an increase in the reporting
volume for the upcoming year.
18. Has there been a change in the number of employees for IHSS, CALWorks, or
CalFresh? Does the Department anticipate any future changes?
IHSS- Overall the number of IHSS providers has remained constant (range
between 360,000 – 365,000 providers). We do not expect a significant increase
or decrease of IHSS providers in the program.
CalFresh-The estimates for eligible participants during FFY 2007 through 2009
were smaller. For FFY 2010/2011 the participant numbers increased
dramatically due to an increased number of participants in work-like
activities. The CalFresh Branch does not anticipate any increases in the
program.
19. In the RFP document, the Department requests bill review services charged on a
flat rate per bill basis to the applicable claim file and utilization review services
charged on an unlimited treatment request per referral to the applicable claims
file. However, the cost proposal indicates that costs “based on a per unit basis, or
other basis, will be considered non-conforming and may disqualify the bid.” How
would the Department like us to present managed care pricing?
This cost is not to be included in the bid because it is an allocated cost.
20. Please provide a copy of the current claims administration and managed care
contracts.
Please see attachments titled “Agreement and Amendments”.
21. Please provide bill review volumes for CY 2011 and YTD 2012 to include total
bills, pharmacy bills, total charges, bill review reductions, and total paid.
Not all of this information was available. Please see attachment titled “Bill Review
Data”
22. What is the volume of utilization review activity?
6,473 referrals through May 31, 2012.
23. How many nurse case management referrals are there?
This information is not available.
24. Please provide current managed care pricing (Bill review, utilization review, and
nurse case management).
This is included in the flat fee for claims administration fees.
25. Does the Department of Social Services currently have a Medical Provider
Network? If so, please provide a list of providers within the network.
No.
26. Which vendor currently performs managed care services for the Department of
Social Services (bill review, utilization review, and nurse case management)?
Comppartners and Anthem Blue Cross
27. Is the Department’s current TPA utilizing a DVBE vendor? If so, which vendor(s)
and what services are they providing?
No.
28. Which fees should we include when calculating the “bid price” on which to base
the required 3% DVBE participation?
Any fee attributed to a DVBE providing a Commercially Useful Function (CUF)
within the RFP will count towards the 3% participation. The 3% amount is based
on the total cost proposal as presented in Attachment I.
29. Can the Department confirm which types of services and fees will be considered
for DVBE participation?
a. Allocated Loss Adjustment Expense (ALAE) as it applies to this contract
(for example: investigation, legal defense, nurse case management)
b. Fees normally paid to York
c. Other York expenses (for example: office supplies, rent, etc.)
Any CUF specific to this RFP’s Scope of Work performed by a DVBE will count
towards your DVBE goal. ALAE would be considered a CUF. However, rent
typically is not considered a CUF.
30. Breakdown of new loss information for each of the entity covered in this RFP: IN,
MO. (You gave us total dollars and total claims but not broken down for each
year)
Please see attachment titled “Loss Data”
31. What are the counties affiliated with the program?
All of California’s 58 counties are affiliated.
32. Do you have a location preference for the claims to be handled? One
location? Multiple locations? Northern Cal or So Cal?
As long as the location is in California, we will leave this up to the bidder’s
discretion.
33. % of claims involving a co-defendant? Does the TPA have the authority to file a
joinder or does the State have to approve it first?
We are unable to provide the percentage of claims involving a co-defendant. The
TPA has the authority to file a joinder.
34. What portion of CDSS claims is subrogated?
There are currently 4 open subrogation claims.
35. Does the State use specific ISO reporting code or will you be using the TPA
Reporting Code?
The TPA reporting code.
36. Do you have an MPN? If not, do you have an established list of primary care
providers?
There is no MPN or an established list of primary care providers.
37. Please clarify 15.a and b – penalties. Do they mean TPA is responsible for
penalties incurred as a result of TPA errors and TPA delays or all? 15.a/b
appears to make it a TPA penalty regardless of who is at fault.
TPA is responsible for the penalty only as a result of TPA error or delay.
38. What is CDSS record retention policy?
(a.) All claim files shall be maintained at least until the latest of the following
dates:
(1) five years from the date of injury;
(2) one year from the date compensation was last provided;
(3) all compensation due or which may be due has been paid;
(4) if an audit has been conducted within the time specified in (a)(1), until the
findings of an audit of the file have become final.
(b) Open and closed claim files may be maintained in whole or in part in an
electronic or other non-paper storage medium.
39. What is your settlement philosophy?
Each claim is handled on its own merit. Many of the care providers are family
members to the recipients; therefore, STIP settlements are more common than
C&Rs.
40. How many Field case management assignments are made for each group each
year?
This information is not tracked.