IN WITNESS WHEREOF, the parties hereto, by their duly authorized representatives, have affixed their hands. | |
COUNTY OF SAN MATEO | |
By: | |
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 AssociateSMMC rev. 1/25/11 |
EXHIBIT A | ||||
In consideration of the payments set forth in Exhibit “B”, Contractor shall provide the following services: | ||||
A. |
ELIGIBILITY SERVICES | |||
1. |
Contractor shall undertake appropriate actions to secure determination of eligibility on behalf of San Mateo County Health Systems patients for the following programs: Medi-Cal, California Children Services (CCS), Medicare and Victims of Crime (VOC), Workers’ Compensation, Eligibility Services (Pre-Legal), and 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 Treatment Authorization Request (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 the County Board of Supervisors. | |||
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 (UB04) and professional (CMS1500) 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. Attorneys and experienced support staff 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 Director of Revenue Cycle Operations or designee on a routine monthly basis or on an as needed basis. | ||||
H. |
TERM AND TERMINATION |
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Notwithstanding the language in paragraph 4. Term and Termination. Page 2 of this Agreement, upon termination of this Agreement Contractor shall be authorized and required to retain and continue to perform all services contracted herein on all open Eligibility and other Third Party Recovery accounts until final disposition. If any accounts retained by Contractor are | ||||
approved, Contractor shall be entitled to its fee in accordance with Exhibit “B” of this Agreement. |
EXHIBIT B | |
In consideration of the services provided by Contractor in Exhibit “A”, County shall pay Contractor based on the following fee schedule: | |
All services set forth in this Agreement, including all legal services, are provided by Contractor on a contingency fee basis. | |
SERVICES FEES Inpatient account with pending application initiated and/or completed by SMMC for straight Medi-Cal Managed Care, Disability Evaluation Determination and CCS 10% of reimbursement Inpatient (Acute) account that was initiated and completed by HEALTH ADVOCATES for straight Medi-Cal, Managed Care, Disability Evaluation Determination and CCS 15% of reimbursement Inpatient (Psych) account that was initiated and completed by HEALTH ADVOCATES for straight Medi-Cal, Managed Care, Disability Evaluation Determination and CCS $1,700 fixed fee per approved account Outpatient accounts (Minimum account referral balance $2,500) 20% of reimbursement Inpatient (Acute) account Fair Hearings for straight Medi-Cal, Managed Care, Disability Evaluation Determination and CCS 22% of reimbursement Inpatient (Psych) account Fair Hearings for straight Medi-Cal, Managed Care, Disability Evaluation Determination and CCS $2,100 fixed fee per approved account Out of State Medicaid 15% of reimbursement Appeal of TAR denied days 22% of reimbursement Third Party Liability accounts (Auto Accident) 15% of reimbursement Probate hearings and conservatorship 22% of reimbursement Victims of Crime application 15% of reimbursement Worker’s Compensation appeals 15% of reimbursement HMO/PPO Insurance appeals, COBRA and other Health Reform Programs 15% of reimbursement Legal or attorney intervention 22% of reimbursement Courtesy Medi-Cal Acute or Long Term Care (LTC) application on non-self pay patients $750 | |
The term of this Agreement is May 1, 2011, to April 30, 2014. Total payments for services provided under this agreement will not exceed TWO MILLION NINE HUNDRED FIFTY-TWO THOUSAND DOLLARS ($2,952,000) and all payments shall be on a contingency fee basis only as set forth in this Exhibit B. Invoices will be approved by the Director of Revenue Cycle Operations and paid within 30 days of receipt of invoice. | |
Invoice Dispute Resolution – County agrees to review all invoices submitted by Contractor and submit all disputes via email within 30 days to Contractor at al@healthadvocates.com. Contractor is required to review and respond to all emails within 30 days of receipt. If Contractor response is not satisfactory to County, County shall notify Contractor via email and the parties shall meet in person or via conference call within 30 days to resolve all disputed invoices. |