IN WITNESS WHEREOF, the parties hereto, by their duly authorized representatives, have affixed their hands. | |
COUNTY OF SAN MATEO | |
By: | |
Jerry Hill, President Board of Supervisors, San Mateo County | |
Date: | |
ATTEST: | |
By: | |
Clerk of Said Board | |
HEALTH ADVOCATES, LLC | |
Contractor’s Signature | |
Date: | |
Long Form Agreement/Business Associate v 1/09/06 |
EXHIBIT “A” | ||||||
In consideration of the payments set forth in Exhibit “B”, Contractor shall provide the following services: | ||||||
A. |
ELIGIBILITY SERVICES | |||||
1. |
Eligibility Fee: Medi-Cal, California Children Services (CCS), Medicare and Victims of Crime (VOC), Workers’ Compensation, Eligibility Services (Pre-Legal), Third Party Liability. | |||||
2. |
The following services are included: | |||||
a. |
Comprehensive Services, including hospital based and field eligibility support for the Medi-Cal, Social Security (SSI/SSD (SSA), California Children Services (CCS), CMSP, Genetically Handicapped Persons Program (GHPP), and Victims of Crime (VOC) programs, as well as Fair Hearings, SSA appeals and TAR/billing appeals. | |||||
b. |
Cost Recovery Services provided by ethnically diverse and experienced bilingual staff to screen and/or process applications for all eligible patients, including incompetent, deceased and homeless patients, and staff attorneys for Fair Hearings, SSI/SSD appeals, and other appeals. | |||||
c. |
Established Relationships with County Human Services Agency (HSA) and other County and State DSS offices for application, Medi-Cal and SSA disability evaluations and Fair Hearings. | |||||
d. |
Client Satisfaction and Communication. In addition to regularly scheduled meetings, Contractor will also provide customized management reports, graphs and charts which will be presented weekly, monthly, annually or on demand. Contractor will also maintain in-house software systems support staff to provide any additional report and/or systems for proper delivery of the contract requirements. | |||||
e. |
Client training as well as telephone consultation on all issues ranging from Medi-Cal to Third Party Liability will be conducted by Contractor’s attorneys and experienced managers. | |||||
f. |
Contractor will be proactive with SSA and HSA in representing patients in the application and/or appeal of their SSI/SSD cases and in obtaining Medi-Cal and Medicare eligibility. | |||||
g. |
Medi-Cal TAR and Billing and Appeals, if requested by County. Contractor’s process includes administrative appeals and legal action, with the approval of County. | |||||
h. |
Skiptracing Department. Contractor will utilizes search engines, public record databases and field investigators to locate patients once discharged from the hospital. | |||||
i. |
SMMC continued control of the referral process will include a review of all proposed procedures with SMMC staff who will retain the final approval on all procedures. Contractor will adjust its procedures to comply with SMMC guidelines/processes. | |||||
B. |
MEDI-CAL BILLING |
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Medi-Cal Billing (Pre-Legal). Once Medi-Cal eligibility is established, Contractor will assume responsibility for billing the appropriate fiscal intermediary for all services. This will include obtaining treatment authorization and billing both hospital (UB92) and professional (1500) charges. | ||||||
C. |
LEGAL SERVICES |
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Administrative Appeals, Legal Action, and/or Attorney Intervention. For TAR appeals, County agrees to provide Contractor with copies of all medical records. | ||||||
D. |
THIRD PARTY RECOVERY (TPR) SERVICES (WORKERS COMPENSATION, TPL, ETC |
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1. |
Third Party Liability and Worker’s Compensation (Pre-Legal) | |||||
2. |
The following services are included: | |||||
a. |
Correspondence Unit. At SMMC’s option and at no additional cost, Contractor will provide Full Time Employees (FTE’s) to process all attorney requests for business records received by SMMC. These FTE’s will be stationed on-site at SMMC. | |||||
b. |
Full Scope Identification of Patients with Potential TPC Cases. This includes all patient types including self-pay, Medi-Cal, managed care, etc., as well as all inpatient, outpatient, physician and clinic services. Contractor will also perform comprehensive investigation and review of all police and ambulance reports. Contractor will file lien for all cases authorized by law or court decisions, including contractual adjustments. | |||||
c. |
Comprehensive Lien Process. Contractor will file liens via certified mail with all parties, when required by California Statute. Contractor’s TPL process will also include a review of relevant provider contracts to ensure contract compliance as well as regular follow-up on all liened accounts supported and managed by the most sophisticated TPL collection system available. | |||||
d. |
Provide experienced settlement support. | |||||
e. |
In-House Attorney Support. Three (3) full-time attorneys will be exclusively dedicated to TPL issues, case processing, negotiations and legal intervention including SMMC authorized legal action(s) against attorneys and patients that ignore SMMC’s liens. | |||||
f. |
Full Statutory Compliance on Medi-Cal Liens includes the immediate processing of refunds to the Medi-Cal Program on behalf of SMMC and full compliance with Medi-Cal’s TPL requirements. | |||||
E. |
HMO AND PPO INSURANCE COLLECTION |
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HMO/PPO:Insurance/Managed Care Claims (Pre-Legal)/COBRA. Contractor will aggressively follow-up, appeal, arbitrate and/or litigate insurance denial appeals and underpayment recovery. | ||||||
F. |
CORRESPONDENCE UNIT | |||||
Contractor will provide employees to process and respond to all civil attorney correspondence and subpoena requests for Business Records. SMMC will provide Contractor with access to workspace, supplies, computers, printers, hospital stationary, and postage in order to complete this process. Contractor will provide all labor, supervision, wages, benefits, workers compensation, payroll taxes, etc for this task. | ||||||
G. |
RELATIONSHIP |
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Contractor agrees to meet with Patient Access Manager or designee on a weekly basis. | ||||||
EXHIBIT “B” | ||||||
In consideration of the services provided by Contractor in Exhibit “A”, County shall pay Contractor based on the following fee schedule: | ||||||
All cost recovery services, including all legal services, are provided by Contractor on a contingency fee basis. | ||||||
SERVICES |
FEES | |||||
A. |
ELIGIBILITY SERVICES | |||||
1. |
Eligibility Fee: Medi-Cal, California Children Services (CCS), Medicare and Victims of Crime (VOC), Third Party Liability, Workers’ Compensation, Eligibility Services (Pre-Legal). |
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Prior to Attorney intervention After Attorney intervention |
20% of all facility per diem amount recovered 25% of all facility per diem amount recovered | |||||
2. |
These fees include the following services as described in Exhbit A. |
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a. |
Comprehensive Services |
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b. |
Cost Recovery Services |
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c. |
Established Relationships |
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d. |
Client Satisfaction and Communication |
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e. |
Client Training |
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f. |
Innovative Solutions |
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g. |
Medi-Cal TAR and Billing and Appeals |
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h. |
Skiptracing Department |
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i. |
SMMC continued control |
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B. |
LEGAL SERVICES |
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Administrative Appeals, Legal Action, and/or Attorney Intervention. For TAR appeals, County agrees to provide Contractor with copies of all medical records. | ||||||
All sums recovered |
25% of all facility per diem amount recovered | |||||
C. |
THIRD PARTY RECOVERY (TPR) SERVICES (WORKERS COMPENSATION, TPL, ETC |
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1. |
Third Party Liability and Worker’s Compensation (Pre-Legal) | |||||
Prior to Attorney Intervention After Attorney Intervention |
20% of all sums recovered 25% of all sums recovered plus out-of pocket costs | |||||
2. |
These fees include the following services as described in Exhibit A: | |||||
a. |
Correspondence Unit |
No additional cost | ||||
b. |
Full Scope Identification of Patients with Potential TPC Cases |
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c. |
Comprehensive Lien Process |
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d. |
Settlement Support Unit |
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e. |
In-House Attorney Support |
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f. |
Full Statutory Compliance on Medi-Cal Liens |
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D. |
HMO AND PPO INSURANCE COLLECTION |
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Insurance/Managed Care Claims (Pre-Legal)/COBRA | ||||||
Prior to Attorney Intervention After Attorney Intervention |
15% of all facility per diem amount recovered 25% of all facility per diem amount recovered plus out-of pocket costs | |||||
E. |
CORRESPONDENCE UNIT |
No Cost to County | ||||
Contractor shall only retain all payments received from outside parties (attorneys, liability carriers, etc.) for providing the documents requested. |
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F. |
The term of this Agreement is May 1, 2006 to April 30, 2009. Total payments for services provided under this agreement will not exceed TWO MILLION TWO HUNDRED EIGHTY THOUSAND DOLLARS ($2,280,000). Invoices will be approved by the Patient Access Manager and paid within 30 days of receipt of invoice. |