HomeMy WebLinkAboutA012 - Resolution approving contract renewal with EMC Claims Solutions, LLC, of Des Moines, IA, to provide third-party administration of the City's Workers' Compensation and Municipal Fire and Police claimsITEM #:13
DATE:07-08-25
DEPT:HR
SUBJECT:CONTRACT AWARD FOR WORKERS' COMPENSATION AND MUNICIPAL
FIRE AND POLICE SYSTEM MEDICAL CLAIMS ADMINISTRATION
COUNCIL ACTION FORM
BACKGROUND:
The City contracts third-party administration services for workers’ compensation and Municipal
Fire and Police “411 System” injury medical claims. The City’s current contract with EMC for
these services is set to expire on July 31, 2025. EMC has provided a renewal contract for the
same services since at least 2009.
Services provided in this contract include workers’ compensation claims administration
for all City employees, medical bill review, self-insured loss fund management, and
pharmacy and medical expense consultation. Also included under this contract are the
performance of regulatory filings and maintenance of an online claims database
accessible to City staff. Additionally, the third-party administrator collects for medical
bill review and savings identified through that process. The fees, along with actual
claims expenses are charged to individual departments.
On May 12, 2025, a Request for Proposal (RFP) was posted to Ames Bids, the electronic
bidding site. A total of 16 potential bidders viewed the RFP. On June 5, 2025, two proposals
were received as follows:
Firm Score Rank
EMC Claims Solutions, Des
Moines, IA 985 1
SFM Risk Solutions,
Bloomington, MN 840 2
An evaluation team was formed by staff to review proposals. Proposals were evaluated based
on experience, qualifications of personnel, the firms' claim administration process, capability of
providing the requested services, and cost. After evaluating the proposals, staff
determined that the proposal from EMC Claims Solutions of Des Moines, IA is most
acceptable. EMC Claims Solutions has a local presence in the state of Iowa and is the
incumbent, making it easy to meet the City's timeline. EMC highlighted a strong team,
pinpointing a primary and back-up team along with a claims specialist with expertise in
the police and fire (411) claims process.
This annual contract has historically run from August 1 to July 31. However, the first term of
this contract shall be August 1, 2025 through June 30, 2026, at which time the four (4) optional
1-year extensions will each run on the fiscal year of July 1 through June 30.
The actual costs incurred under this contract vary depending on the number and nature of
claims. The expenses under the current agreement total $27,820 to date, while the claims
under the contract in the prior year totaled $27,810. The FY 2025/26 budget contains $55,000
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for these services.
ALTERNATIVES:
1. Approve the contract with EMC Risk Services, LLC, of Des Moines Iowa, to provide third-
party administration of the City’s workers’ compensation and municipal fire and police
“411 System” claims for August 1, 2025 through June 30, 2026.
2. Accept the proposal from SFM.
3. Reject all proposals and direct City staff to seek other claims administration alternatives.
CITY MANAGER'S RECOMMENDED ACTION:
EMC Risk Services, LLC, continues to be an effective provider of professionally
administered workers’ compensation claims and associated services. Its staff has been
responsive and sensitive to the needs of City employees in managing their injury and
disability claims. The online claims system makes cost and other data accessible to
City staff and provides a frequently utilized tool for analyzing injury types and safety
program effectiveness.
While EMC prices per claim are slightly higher, SFM has more ancillary fees that are not
subject to their maximum fee cap. (See Attachments). Therefore, it is the recommendation
of the City Manager that the City Council adopt Alternative No. 1, as described above.
ATTACHMENT(S):
EMC Cost Proposal.pdf
SFM Cost Proposal.pdf
2025-153 TPA Contract Signed by EMC.pdf
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717 Mulberry St. | Des Moines, IA 50309 | P.O. Box 9399 | Des Moines, IA 50306-9399 |P 515.345.4532 |P 800.741.5302 | F 866.504.6598 | www.emcins.com
Employers Mutual Casualty Company Illinois EMCASCO Insurance Company Union Insurance Company of Providence EMC Underwriters, LLC
EMCASCO Insurance Company Dakota Fire Insurance Company Hamilton Mutual Insurance Company EMC National Life Company (affiliate)
EMC Reinsurance Company EMC Property & Casualty Company EMC Risk Services, LLC
June 4, 2025
SERVICE FEE SCHEDULE 2025
Workers Compensation – City of Ames
Claim Fees
Claim Fees shall be effective as of the Effective Date, 8-1-25, for 11 months and annually thereafter on
7-1, or upon the agreed established date.
PRICING REVISIONS PER RENEWAL
City of Ames agrees to pay EMC Claims Solutions the following fees:
Workers Compensation Claims:
Incident Only $35 per report
Medical Only $260.00
Indemnity $1,142.00
Medical Case Management $115.00 /hour
$.56 /mile + reasonable expenses
Legal Nurse Review $128.00 /hour
Medical Bill Review and Pharmacy Benefit Management:
PPO Network Utilization and audit of all bills by nurses in our Medical Cost
Review Unit for optimal savings and network reductions on every medical bill.
Also, the Pharmacy Benefit Management network provides both savings and
clinical management of prescription drug costs for your injured workers.
Per bill fee 9.50
Bill Review 30% of savings
PPO 30% of savings - Capped at $10,000
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717 Mulberry St. | Des Moines, IA 50309 | P.O. Box 9399 | Des Moines, IA 50306-9399 |P 515.345.4532 |P 800.741.5302 | F 866.504.6598 | www.emcins.com
Employers Mutual Casualty Company Illinois EMCASCO Insurance Company Union Insurance Company of Providence EMC Underwriters, LLC
EMCASCO Insurance Company Dakota Fire Insurance Company Hamilton Mutual Insurance Company EMC National Life Company (affiliate)
EMC Reinsurance Company EMC Property & Casualty Company EMC Risk Services, LLC
Miscellaneous Fees:
On-line Claim Reporting/Administration (includes banking, accounting and fund management)
Annual Administration/Reporting: $5,200.00
Additional users: $ 300.00
Risk Improvement $ 220.00 /hour
Subrogation: 18% of recovery
OSHA 300 Reporting $2650 Annually
Approved on _____________ by:
EMC Claims Solutions
By: Barbara A. Sullivan, CPCU
President and Chief Operating Officer
EMC Claims Solutions
City of Ames, Iowa
By: _____________________________
_____________________________
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Costs
For SFM Risk Solutions
SFM Risk Solutions, Inc. Proposal to City of Ames
June 5, 2025
Proposed fees subject to a not to exceed amount of $60,000
SERVICES PY 8/1/2025 – 6/30/2026 PY 7/1/2026 – 6/30/2027 PY 7/1/2027 – 6/30/2028
Incident Only 0 0 0
Medical Only $200 $200 $208
Lost Time $1075 $1075 $1118
Account Management $5000 $5000 $5000
Texting Fees $250 annually $250 annually $250 annually
Bill Entry Fee $11 per bill $11 per bill $11 per bill
CMS Reporting per claim $16 per submission $16 per submission $16 per submission
Claim Regulatory Fees $3.00 per submission $3.00 per submission $3.00 per submission
RMIS/Report System
Access
$500 per user $500 per user $500 per user
Additional ancillary Fees not subject to the $60,000 maximum
Services Fee
Bill Review Re-Pricing 30% of savings
PPO & Pharmacy network 30% of savings
Non-litigated subrogation by recovery specialist
**client approval required**
15% of recovery
In-house physician review
**client approval required**
$150 per review
Nurse prescription drug review
**client approval required**
$100 per hour
Telephonic Nurse Case Management
client requested services
$110 per hour
Loss Prevention Services
client requested services
$150 per hour plus expenses
SFM Hotline Reporting
client requested services
$95 per report
IT Programming Fees**/Data Transfer Fees** $400 per hour
**Programming time for specialty reports requested by the client that require additional programming time by the
Information Services Department and does not include the pre-determined list of reports that SFM Risk Solutions
already supplies. Data transfer fees refers to work done to move data to another TPA or entity.
Available Reports: (this is not a comprehensive list, but basic reports requested by clients)
Loss Runs Paid in Year
Loss Spreadsheet Legal Costs
Invoices Settlements
Escrow invoices Permanent Total Disability
Check Registries (daily, weekly, monthly) Trending
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CONTRACT FOR
THIRD-
AND MUNICIPAL FIRE AND POLICE RETIREMENT SYSTEM
PROFESSIONAL SERVICES CONTRACT
FOR CITY OF AMES
THIS AGREEMENT, made and entered into effective the 1st day of August 2025, by and between
the CITY OF AMES, IOWA, a municipal corporation organized and existing pursuant to the laws of the State
of Iowa (hereinafter sometimes called "City") and EMC Risk Services, LLC (a Domestic Limited Liability
Company, organized and existing pursuant to the laws of the State of Iowa and hereinafter called
"Provider");
W I T N E S S E T H T H A T:
WHEREAS, the City of Ames has determined that certain services to be provided to the City of Ames
and its citizens by Provider, such services and facilities being hereinafter described and set out, should be
purchased in accordance with the terms of a written agreement as hereinafter set out;
NOW, THEREFORE, the parties hereto have agreed and do agree as follows:
I
PURPOSE
The purpose of this Agreement is to procure for the City of Ames certain services as hereinafter
described and set out; to establish the methods, procedures, terms and conditions governing payment by
the City of Ames for such services; and, to establish other duties, responsibilities, terms and conditions
mutually undertaken and agreed to by the parties hereto in consideration of the services to be performed
and monies paid.
II
SCOPE OF SERVICES
Provider shall provide the services set out in the City of Ames, Iowa, Scope of Services from Request
for Proposal #2025-153, and response Third-Compensation and
Municipal Fire and Police Retirement System, attached hereto as Exhibit A.
The City, without invalidating the Agreement, may direct changes in the services within the general
scope of the Agreement, with the authorized payment maximum being adjusted accordingly. Any change in
the scope of service by the provider shall be done by written agreement signed by both parties. The added
cost or cost reduction to the City resulting from a change in the Agreement shall be determined by mutual
acceptance of a lump sum properly itemized and supported by sufficient data to permit evaluation, or by
unit prices stated in the Agreement or subsequently agreed upon.
It shall be the responsibility of the provider, before proceeding with any change in scope, to verify
that the change has been properly authorized on behalf of the City. No additional charges or any other
change in the Agreement will be allowed unless previously authorized in writing by the City, with the
applicable compensation method and maximum authorized additional sum stated.
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III
METHOD OF PAYMENT
A.Payments shall be made by the City of Ames in accordance with Exhibit B Service Fee
Schedule, as applicable, attached hereto and incorporated herein.
B.The maximum total amount payable by the City of Ames under this Agreement is $55,000
and no greater amount shall be paid without written amendment.
C.Payment will be made upon completion of the services and acceptance by the City of Ames.
Provider shall submit an invoice upon completion of the services. The invoice shall include an itemization of
the services for which payment is claimed. Invoices referencing the assigned purchase order number shall
be emailed to accountspayables@cityofames.og.
D.In the event that this Agreement is terminated for any reason other than a breach by the
City, Provider shall refund to the City any unused pre-paid Administration fees, pro-rated through the date
of termination.
IV
FINANCIAL ACCOUNTING AND ADMINISTRATION
A.All claims for payment shall be supported by properly executed payrolls, time records,
invoices, contracts, vouchers, or other documentation, evidencing in proper detail the nature and propriety
of the charges. All checks, payrolls, invoices, contracts, vouchers, orders, or other accounting documents
pertaining in whole or in part to this Agreement shall be clearly identified as such and readily accessible for
examination and audit by the City or its authorized representative.
B.All records shall be maintained in accordance with procedures and requirements
established by the City Finance Director, and the City Finance Director may, prior to any payment under this
Agreement, conduct a pre- audit of record keeping and financial accounting procedures of the Provider for
the purpose of determining changes and modifications necessary with respect to accounting for charges
made hereunder. All records and documents required by this Agreement shall be maintained for a period
of three (3) years following final payment by the City.
C.At such time and in such form as the City may require, there shall be furnished to the City
such statements, records, reports, data, and information as the City may require with respect to the
payments made or claimed under this Agreement.
D.At any time during normal business hours, and as often as the City may deem necessary,
there shall be made available to the City for examination all records with respect to all matters covered by
this Agreement and Provider will permit the City to audit, examine, and make excerpts or transcripts from
such records, and to make audits of all contracts, invoices, materials, payrolls, records of personnel,
conditions of employment, and other data relating to all matters covered by this Agreement.
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V
INSURANCE
A.The provider shall maintain insurance coverage in scope and amounts acceptable to the
Risk Manager.
B.Any failure to comply with reporting provisions of the policies shall not affect coverage
provided to the City of Ames, its officials, employees, or volunteers.
C.Provider shall furnish the City with certificates of insurance and with original endorsements
effecting coverage required by this clause. The certificates and endorsements for each insurance policy are
to be signed by a person authorized by that insurer to bind coverage on its behalf. The certificates and
endorsements are to be on standard insurance company forms or forms provided by the City and are to be
received and approved by the City before services commences. The City reserves the right to require
complete, certified copies of all required insurance policies, at any time.
D.Provider shall include all sub-Firms as insured under its policies. All coverages for sub- Firms
shall be subject to all of the requirements stated herein.
E.To the fullest extent permitted by law the Provider shall indemnify and hold harmless the
City of Ames, their agents, and employees from and against all claims, damages, losses, and expenses,
including, but not limited to fees arising out of or resulting from the performance of the services,
provided that any such claim, damage, loss, or expense (1) is attributable to bodily injury, sickness, disease,
or death, or to injury to or destruction of tangible property (other than the services itself) including the loss
of use resulting therefrom; and (2) is caused in whole or in part by any negligent act or omission of the
Provider, any Sub-Firm, anyone directly or indirectly employed by any of them or any one for whose acts,
any of them may be liable.
F.
negligence alleged to be caused by the sole negligence of employees of the City of Ames.
VI
PROPRIETARY RIGHTS AND CONFIDENTIAL INFORMATION
Provider agrees to hold in trust and confidence any confidential and/or proprietary information or
data relating to City business and shall not disseminate or disclose such confidential information to any
individual or employees or sub-Firms performing services hereunder (who shall be
under a duty of confidentiality), and any other individuals specifically permitted in each instance by the City.
VII TERMINATION
The City of Ames may terminate this Agreement without penalty to the City at any time by giving
written notice to the Provider at least fifteen (15) days before the effective date of such termination. In any
case where the Provider fails in whole or in part to substantially perform its obligations or has delivered
nonconforming services, the City shall provide a Cure notice. If after notice the Provider continues to be in
default, the City may terminate this agreement immediately. The City shall only be obligated to compensate
the Provider for compliant services performed prior to notice of termination.
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VIII
INDEPENDENT CONTRACTOR STATUS
Provider agrees that the relationship between Provider and the City is that of an independent
contractor for employment tax purposes. The Provider shall be solely responsible for all taxes relating to
payments under this agreement, including those of employees.
IX
LAWS
This contract is governed by the law of the State of Iowa with venue in the appropriate state and/or
federal courts for Story County, Iowa
X
ASSIGNMENT
This Agreement may not be assigned or transferred by the Provider without the prior written
consent of the City.
XI
AFFIRMATIVE ACTION
Provider shall place on file with the City a statement of nondiscrimination policy in the form of a
completed Assurance of Compliance with the City of Ames, Iowa, Affirmative Action Program satisfactory to
the Affirmative Action Officer of the City
XII
NOTICE
All notices under this Agreement shall be in writing. Notices shall be deemed to have been given: (i)
upon hand delivery or (ii) if sent by Regular Mail, within seventy-two (72) hours after the notice has been
deposited in the United States Post Office, postage paid. Notices shall be sent to the other party at the
addresses set forth below. Either party may change its address by giving notice in writing thereof to the
other parties.
City of Ames: Provider:
Bill Walton, Risk Manager
Human Resources
515 Clark Avenue, PO Box 811
Ames, IA 50010
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XIII
DURATION
This Agreement shall be in full force and effect from and after August 1, 2025 until June 30, 2026, or,
until terminated by the City of Ames, Iowa.
IN WITNESS WHEREOF the parties hereto have, by their authorized representatives, set their hand and seal
as of the date first above written.
CITY OF AMES, IOWA
By: By:
John Haila, Mayor
Attest By: _______
Renee Hall, City Clerk Printed Name and Title
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Technical Response and Scope of Services
Overview
EMC Claims Solutions (ECS) is a multiline third party administer (TPA) equipped to handle
claims for the City of Ames. We would like to meet and discuss our best practices for claims
handling, audit standards, team members and our philosophy to provide the best service,
management and results. We are driven to be unsurpassed in the industry at cutting claim
costs and managing losses.
As soon as awarded the contract we will establish expectations and begin our work. We will
establish a tier structure in our system according to your financial reporting needs and develop
your structure of authorization and funding. Training on our claims system will be provided.
We will establish and document claims handling expectations during the transition and
implementation phase. Communication on an ongoing basis is key to ensure we are providing
the level of service that meets the needs of City of Ames. We know a dedicated client manager
is critical to the success of a great relationship. Lori McMurray Enger will be assigned to the
City of Ames.
We will work to make the transition as smooth as possible. Specific tasks include, but are not
limited to:
Bring our team to meet the City of Ames team
o Discuss expectations and document in claims handling instructions
o Discuss operations and review the types of claims received by the City of Ames
Integration of historic claim data
Tier structure and specific coding requirement setup
Medicare reporting TPA transfer of RRE submission agent
Contact current open claims parties alerting of TPA change
Setup and initial contact of open claims
Coordination between ECS and the City of Ames financial staff to setup billing and
reconciliation processes
For the City of Ames, we would propose a three-member team to handle the claims for w
compensation. A primary adjuster who would handle a majority of the claims, as well as a back-
up adjuster to assist with overflow and out of office situations and a chapter 411 claims
specialist. There would be one claims supervisor for each line of business for the City of Ames.
All claims are handled from the Des Moines, Iowa office. All team members, including the client
manager, reside in the Des Moines office and are available for on-site visits and phone
conferences.
The yearly average claim volume of both adjusters referenced will average from 100-125 open
claims at any one time.
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Executive Summary
Our Mission
Deliver quality financial protection and effective claim management to the clients and agents we
serve.
Our Business
laims handling
General Liability and Auto claims handling
Coordinating Risk Improvement Services
Medical Bill Review and Medical Case Management
Difference Maker
What sets EMC Claims Solutions
by our team members. We believe each client is unique and we treat them that way, which is
why our services are built around our clients.
Our Delivery
Client dedicated claims handlers
Prompt response to questions and an action plan for each loss
Customized billing and reporting
Strong relationships with Business Partners to mitigate losses
Commitment to service based on Client expectations and culture
Our Guiding Beliefs
Service
Honesty and Integrity
Teamwork
Continuous Improvement
How Will We Accomplish our Goals
Respond to customers in a positive manner
Provide the right products and services
Take initiative to deliver successful outcomes
Make financially responsible decisions
We Stand in our Clients Shoes
Develop lasting relationships
Offer new products and services
Continuously fine tune the process
Deliver excellent products and services
Adapt to your specific business needs and culture
Empathetic and creative suggestions to resolve difficult claims
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Exceeding Your Expectations
Quarterly, Biannually or Annual File Reviews
o These provide an opportunity for us to receive direct feedback from our
customers on how we are doing and how we can improve
o This face to face or virtual meeting allows us to be on a close business
relationship with our clients
Facility Tours
o Together with our clients, adjusters would like to participate in facility tours
o T
Attending seminars with clients offers additional education opportunities. This
creates a collaborative effort to ensure we understand the most up-to-date
information in a constantly changing industry.
The Right Products and Services
Clients have direct access to the claims file system and are directly involved with
claims
Developing loss analysis tools which meet individual client needs. Our claims
system allows for specific detailed loss runs
Providing a link between clients and EMC Claims Solutions
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The ECS Team
The ECS team consists of four workers compensation teams and one general liability/auto
team. Each team consists of 4-5 experienced adjusters and a supervisor knowledgeable in their
respective lines of business.
Workers Compensation Team
(4) Assistant Managers
(3) Claims Specialist
(5) Senior Claims Adjusters
(8) Claims Adjusters
(4) Claims Representatives
(1) Claims Assistant
General Liability/Auto Team
(1) Assistant Manager
(3) Claims Specialists
(2) Claims Adjusters
Support and Finance Team
(1) Assistant Manager
(4) Claim Support Associates
Leadership
(4) President, Claims Director, Client Services Management Consultant and Financials Services
and Systems Operations Manager
We are fully equipped and highly experienced in providing claims management services. We
will provide fully trained and experienced claim handlers who are well versed in Iowa workers
compensation laws. The caseload for the senior adjuster staff is approximately 100 claims.
The caseload for those with fewer indemnity claims and more medical only claims will be
approximately 125 claims per handler. Assistant Managers do not carry a caseload. We
handled approximately 2,215 claims over the last two years for other municipalities. ECS
average turnover rate is 7% over the past three years.
Licensing is not required for adjusters in Iowa; however, we support continuing education and
participation in any available legal and administrative training by the State of Iowa
Compensation Division.
ECS conducts quarterly claim file audits of every team member to identify by claim type any
areas for the supervisor to coach the team member. The results of these audits are tied to each
score at the end of each year. Our most recent
quarterly audit yielded a team average score of 94.7%. The 12-month team average score is
94.6%.
Our adjusting staff has access to internal legal counsel and private defense counsel. We will
work with the City of Ames legal staff to collaborate and achieve results.
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Administrative Services
We utilize the Filehandler Claims System designed by JW Software. It is a software system
specifically designed for claims handling in the TPA environment. ECS can store all your
s records, photos, videos, etc. and create reports to address any specific
need.
The City will receive a sign-on and password to be able to access all files in 24/7 real time from
any internet connected computer. Our system is easy to use and operate. Our goal is to be
flexible and responsive. Training on the Filehandler system will be provided within 30 days of
the program inception.
Claim handlers and the client manager will be available for risk management meetings, as
needed.
All new claims and correspondence may be emailed to ECS at ClaimsSolutions@EMCIns.com.
We will set up the claims in a tier structure to reflect your organization and generate reports in
the way best suited to provide the data requested. All data is stored on a secure network and is
backed up daily to a separate secure server location.
All federal, state and local filing requirements are managed by either the adjuster or claims
administrative team. The Filehandler claims system allows for Electronic Data Interchange
as well as Medicare
RRE reporting capabilities.
The City of Ames will have access to notes and all claim information, including financial
summaries and payment detail. The City will be able to request the design of any ad hoc
reports. Data points in the system can be translated into reporting capabilities tailored to the
Reports from Filehandler are available in PDF, Word and Excel formats.
The files will be retained in a manner agreeable to the established protocol of the City. All files
are owned by the City, and the City shall have the right to copy any and all claim files, or any
documents related to any claim. ECS shall retain and store closed claim files for such period as
required by the record retention policies or such other time as the City and ECS may mutually
agree. Until the obligation to retain and store claim files ends, ECS shall either return or destroy
closed claim files as directed by the City.
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Claims Administration Work Compensation
At ECS we understand Iowa e specialize in claims for police
officers and firefighters who are entitled to pension fund benefits created by the Iowa Code
chapters 410 and 411. We will verify the injury meets the requirements for acceptance under
the chapter and the bill has not been processed under another medical payer plan. We will
contact the injured worker to determine the extent of the injury and the relatedness to the work
activity so we can anticipate the extent of the cost to the City. We will maintain contact and
investigate medical treatment as necessary throughout the life of the claim.
Claims handling services include a three-point contact within 24 hours of receipt. ECS will
determine the cause and compensability of the incident and explain benefits or liability to the
injured worker or party. We handle the gathering of all information and advice our clients of the
best path to resolution in each specific case. Our handling includes all the required filings,
including Medicare Section 111 reporting, if needed.
We will create Special Handling Instructions with the City of Ames which would outline the
required actions for varying types of claims with ongoing communication and direction as
requested by the City of Ames and/or as situations change on the claim. Claims handling
services include contact within 24 hours of receipt. We will investigate the cause of the incident
and deny or pursue a settlement. We will handle the gathering of all information and advise the
City of Ames of the best path to resolution in each specific case. We will contact a lost time
injured worker a minimum of one contact weekly until they have returned to work.
We will assist the City of Ames by providing suggestions on the process for computing
indemnity payments for lost time claims as required by City of Ames policy and labor contracts
and how best to coordinate timely payments with the City of Ames risk manager. We pride
ourselves on our flexibility to meet the needs required to best serve the internal processes
within the City of Ames.
All authorized medical bills associated with an approved claim comply with the medical fee
schedule (UCR) and/or discounted fee arrangements negotiated by or on behalf of the City of
Ames. EMC Claims Solutions utilizes the Medical Care Review department of the parent EMC
Insurance Companies to process bills through the Mitchell International Medical Bill Review
platform. Savings are passed along to the client.
We are considered an approved vendor by many excess carriers and shall provide timely
notification to the City of Ames excess insurers and the City of Ames risk manager of all claims
or losses meeting the excess carrier reporting criteria with all necessary information about the
status of such claims or losses as determined or required by such insurers. Excess carrier
reimbursement requests are managed by our financial staff and are completed quarterly. We
report to the excess carrier when called for by the policy and in conjunction with requirements.
Typically, this is when the incurred amount hits 50% of the retention, or when certain types of
injury occur. Focus would be on open communication with the excess carrier.
Our claims best practices dictate our processes of investigation, file assignments and three-
point contacts. Recorded statements are required of complex claims or when needed, and
transcription needs are completed in house.
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Claims Best Practices Guidelines
These guidelines shall serve to provide positive recommendations for the timely investigation of
losses and evaluation of fact patterns, as well as careful attention to statutory and regulatory
regulations. The material is by no means exhaustive and shall not be replaced by the initiative,
ingenuity or imagination of the handler or client. Each claim is unique and must be dealt
with on an individual basis within the confines of its merit. The guidelines are intended to
provide consistency and reduce variation in the claims service provided to our clients and
customers. The guidelines will be included in the auditing function and will serve to provide a
superior claim product that includes flexibility, attention to detail and aggressive management
for cost control. Our intent is to continuously measure return to work outcomes and analyze
results to provide our client the benefit of proactive management in claim handling by our
experienced staff of claims adjusters.
Coverage
Coverage is provided by ______________ for $__________ Self Insured Retention
Confirm coverage for the date of loss and policy contract period
Identify State and be advised of proper statutory filings and jurisdictional conditions
Identify coverage discrepancies and conduct additional investigation as relevant
Review Coverage/Jurisdictional issues with Supervisor/Manager and/or Client
Investigation
The prompt and complete collection of the facts and circumstances surrounding each injury with
a goal to construct the best possible basis for closure and settlement of the claim, using sound
judgment and experience as to what each investigation might require.
ECS will complete compensability investigation within one week of the initial claim assignment.
We will contact the City of Ames with additional time requests or if any suspicion of fraud and
report any potential findings.
We will work with you to determine which claims you would like indexed. Costs for indexing are
passed through without a mark-up.
EMC Claims Solutions will partner with investigators and surveillance companies when
warranted on a claim. We will work directly with you prior to requesting services from a partner.
ECS will also work with EMC SIV unit depending on the level of severity of fraud,
misrepresentation or abuse.
Three Point Contact
Contact with the Supervisor, Employee and Medical provider is required within 24 hours of
receipt of the claim. All contacts and attempts to contact are to be documented in the claim
handling file with meaningful comments to include verification of the facts, dates and witnesses
along with whether or not the injury was preventable.
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Contact Point One Supervisor - Employer Interview
Obtain information about cause of injury (preventable or not)
Obtain internal records where available
Discuss and identify modified or light duty work opportunities
Identify potential witnesses and obtain statements as needed
Identify Subrogation Potential
Identify Medicare Potential and report accordingly
Contact Point Two Injured Employee - Employee Interview
Obtain recorded statement if a back or shoulder injury
Obtain recorded statement if:
o Controverted facts
o Cumulative/Repetitive Trauma
o Pre-existing conditions or Impairments
o Subrogation Potential
o Lost time not accommodated by light duty
Obtain list of past medical providers and secure medical authorizations as
necessary
Explain benefits and answer questions as needed
Follow-up contact as needed after medical appointments and to discuss RTW
Contact Point Three Medical Provider - Health Care Provider
Request medical records as per jurisdiction
Establish injury, diagnosis, treatment plan, next scheduled appointment,
physical restrictions and verify lost time if any
Confirm causal connection
Research pre-existing conditions
Follow-up after each appointment to obtain records and monitor treatment
plan
Send requests for medical opinions and clarification to physician as needed
Subrogation
Develop theory of liability based on first contacts
Contact responsible parties to protect liens
Continue investigation and settle or recover losses paid
EDI Reporting
Identify the waiting period has been exceed for jurisdiction and benefits are owed
Approach appropriate EDI filing system and update as necessary
Evaluation
Consistency and quality in claim handling is imperative to determine if sufficient information
exists and has been collected to document the loss and create an action strategy. This includes
consistent documentation of the investigation, the reserving process, vendor choices, and
ongoing evaluation of the information at hand.
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Documentation
Maintain diaries on each file for follow-up and action planning
Document all conversations and interpretation of medical records
Document payment of related, reasonable medical expense
Document factors upon with the reserves are based along with a settlement strategy and
action plans which may include timelines, negotiations, verification of benefits paid, and
evaluation of exposure
Document reserve changes and Special Funds Request
Reserving
Use online reserve worksheet to be updated as necessary with new information
collected
Set reserves per category of anticipated medical treatment and diagnostics
Evaluate for extent of lost time and potential permanent impairment and set reserves
accordingly
Use best reasonable judgment as to the total cost of the claim, reflecting the quantity
and quality of the information currently available
Notify Client of any new reserve set or increased over $10,000
Notify Client of significant changes in the course of medical treatment
Diary for ongoing reporting to excess carrier when incurred reaches 50% of SIR
Supervision
ECS assistant managers are responsible for the staff oversight of the
team members and their claims. They oversee the handling of all aspects of the claims
assigned to the unit including reserving, communication, documentation, evaluation, negotiation
and settlement. They will ensure all claims are eligible or ineligible for payment, conform to
quality and production standards.
The assistant manager will confirm the claim processing is consistent with policies, procedures
and claim handling guidelines. They will analyze and assign claims. They complete regular
quality audits of their work, records results and counsels team members to bring work to
or above standards. They will review reports and monitor the Filehandler system to ensure
adherence to corporate and regulatory standards. Besides reviews of the claim files quarterly
audits are conducts on five files for each adjuster. These proprietary audits are reviewed with
the team member and used for annual performance appraisals.
Assistant managers also, review and analyze processes, procedures, and workflows to identify
opportunities for process improvement and efficiency. They also manage personnel
administration including employee evaluations and salary administration.
Vendors
Use only client approved vendors
Manage and monitor Medical Case Management to ensure effective results
outside vendors
Use MCR for medical bill review
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Litigation/Resolution
EMC Claims Solutions will expect to work with the firm and the client to achieve the best result
for the client in an efficient and cost effective manner. A sound legal defense shall be
developed in a timely matter and with a strategic plan for resolution. Alternate dispute
resolution is encouraged where applicable and is to be discussed with client and claim handler
prior to scheduling. A settlement range discussion will be documented in the report from
defense counsel and updated as developments occur and facts are revealed.
Adjuster Expectations in Litigation
Claims brief and Supervisor Review upon receipt of Petition
Notify Client and refer to appropriate Defense counsel
Change file status to Litigated and forward file copies to counsel
Offers, demands and negotiations clearly documented and communicated to Client.
Request settlement and/or reserve authority after coordination with Client and
defense counsel
Determine if additional reporting to Excess Carrier is needed and diary accordingly
Monitor litigation process and strategy
Reporting
Submit Large Loss Report when incurred reaches 50% of SIR
Maintain client requirements for reporting
o All ratings and PPD payments
o Any Industrial Disability
o All Settlement Discussions
o All Denials
o Hearings or Mediations
Maintain and update EDI reporting as required by the Jurisdiction
Report Medicare Eligibility as applicable
Ongoing reporting to Medicare as mandated
Maintain other statutory or regulatory reporting as needed
Prepare monthly, quarterly, annual and subrogation reports as requested by the City
of Ames
Attend claim review discussions as requested by the City of Ames
Provide assistance in preparation of the annual self-insurance renewal filings as
requested by the City of Ames
Meet with the City of Ames Human Resource Department quarterly and provide an
executive summary reviewing the program and its cost
Medical Management
It is our practice to monitor the treatment programs recommended by physicians or specialists
by reviewing all reports prepared by treating or examining physicians and by maintaining such
contact as may be appropriate or at the request of the City of Ames to monitor any change of a
injured worker
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Our adjusters shall also recommend any courses of medical management which will expedite
recovery and return to work of employees and will implement recommendations as approved by
the City of Ames. Medical treatment is coordinated by our adjuster and monitored by the
Claims Supervisor for all claims by setting appointments and authorizing necessary physician
referrals and treatments.
Our adjusters complete a review of all medical restrictions placed on the employee and will
consult with the risk manager regarding transitional duty capability if the City of Ames has
identified appropriate transitional work. We will review return-to-work documentation from the
treating physician and notify the risk manager of the date of return. Any concerns regarding the
ability of the employee to perform the essential functions of their job based on the City of Ames
job description should be communicated immediately to the risk manager.
ECS offers the following services to our clients in addition to our claims handling services.
Services can be provided by the Medical Management Department within our parent, EMC
Insurance Companies (EMC). ECS also utilizes outside vendors to obtain the most cost
effective pricing.
Medical Claims Review (MCR)
MCR provides medical bill review services for ECS. EMC bill review services comply with all
state mandates. EMC has received the necessary certifications from the appropriate states.
State fee schedule pricing procedure codes are compared to state fee schedules and
reduced accordingly. Many providers bill more than required for treatment of
occupational injuries
Usual and customary pricing
Correct CPT coding
Unbundling of charges Providers many times will separate procedures into smaller
units to maximize their billing. -
provide a lower cost than individual procedures
Duplicate services The system tracks procedures and dates of service and
automatically removes duplicate billings
Up coding Provides often use a code for a treatment which will pay them more for the
service. MCR is capable of re-coding and reducing the fee
Turnaround time on our bill review system is monitored, not only from the date MCR receives a
bill, but also from the date a branch receives a bill to be certain ERS is in compliance with state
regulations with specific timelines for payment of medical bills.
System links exist between EC
payments are for compensable claims
All medical provider payment disputes are handled by the MCR Unit.
Key submissions include, w compensation State reporting, NCCI/URE reporting,
Medicare & Medicaid reporting, and Excess Carrier reporting. Our claims handling instructions
21
developed for City of Ames would address quality control measures, review, cost control, City
of Ames staff involvement and the general resource management.
Pharmacy Benefit Management (PBM) Program
injured workers within 3-5 days of
notification
When the injured worker uses the card, the pharmacy will bill the PBM
The PBM pays the pharmacy
The PBM bills ECS and provides a record for each claim file
To initiate the program, the referral must be made through the PBM directly, either by
ECS or the employer
Advantages to using the program
o Savings are contracted between PBM and pharmacies
o The injured worker does not pay up front to fill prescriptions
o ECS and the PBM have designated staff to handle questions or problems
Medical Review
Medical review with a chronological timeline includes a brief summary as described above but
will also include a chronological summary of the medical records. When a file is lengthy or has
complex medical issues, we will do a chronology of the pertinent medical records. This gives
us a clear picture of the treatment, testing, statement of complaints, the consistency of the
injured worker and the ongoing status of the medical condition.
By documenting the information included on the bills in the chronological summary we can
confirm documentation of a service provided, we can also determine if there are pertinent
medical records not available in the file and we can determine if services unrelated to the
claimed injury are included on the bill.
Medical and Legal Report
This report is very similar to the above medical review with chronological summary. The
records with page numbers added will be organized and place in notebooks. The chronological
summary will include notations of these corresponding page numbers. This review can be
forwarded to our defense attorney.
The medical/legal review not only decreases legal costs but also provides the attorney with
access to a medical resource person. In addition to the medical records and bills, we ask the
specific demands are provided and/or issues of the case. This will assist us in providing a
more concise report directed towards the specific needs of our defense counsel.
Depending on the needs of the defense counsel we will:
Compile a notebook with records sorted by providers
Provide a summary of medical costs by provider
Create a timeline (chronology) of the medical records
Provide a summary which includes a list of medical records not available which may be
pertinent, point out discrepancies or questionable review findings
Provide medical research related to the claimed injury/illness
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List prescribed medications with a brief description
The Medical Claims Consulting Staff are available to discuss the file medical issues with the
defense attorney, to answer any questions, to discuss medical issues found in the medical
research provided and/or to assist with compiling questions for deposition, etc.
Utilization Management
Utilization Management ensures appropriate, effective, quality health care services. Reviewers
screen criteria to each case to assist in the evaluation of setting and the quality of care for the
injured person.
Medical Case Managers
Medical Case Managers covering the State of Iowa all have received the Certified Case
They are experienced in case
management, nursing, and managed care. For case management outside of Iowa, ECS
utilizes approved case management vendors. A Rehab Case Coordinator is available for
Vocation Case Management and Life Care Planning.
National Durable Medical Equipment
National durable medical equipment providers supply equipment for injured workers. Through
these vendors ECS will obtain prompt service and cost containment for all types of equipment
and other services:
Medical Equipment and supplies
Electrotherapy Equipment
Specialty Items
Orthotics and Prosthetics
Health Care Services and Ancillary Services
Transportation
Translation & Interpretation
Medical Diagnostic Imaging and Physical Therapy
Medical diagnostic imaging and physical therapy companies provide scheduling diagnostic
tests and physical therapy for adjusters with the following benefits:
Nationwide networks of imaging facilities and physical therapy providers
Guaranteed scheduling time for injured workers is within 1-5 days of the referral
Guaranteed written results to the adjuster in 1-2 days after the procedure
Reduced administrative costs on claims
Preferred Physician Program
A designated preferred physician program is -
claims. The Designated Physician Program shows an employer how to organize their
response to an initial work injury/illness situation, as well as how to efficiently and quickly
communicate needed information to ECS. The employer procedures prepare the claim for
ECS handling based on immediate action and accurate information.
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to do when an injury occurs.
hours after the work injury by:
Providing initial employee reporting procedures for a work injury or illness
Collecting accurate information regarding the injury/illness
Providing employees with prompt organized medical care
Getting employers to report the initial injury to ECS Claims Adjusters in a timely and
well-documented manner
It is important to designate medical facilities based on quality and convenience to the employer
and the employees.
Controlling costs of medical claims is prefaced by good documentation and organized
procedures at the first report of injury
The Designated Physician program is one of the many ways in which ECS is helping
Medical Claims Consulting
The medical claims consulting team consists of nurses possessing degrees and the Licensed
Nurse Consultant (LNCC) designation with the ability to help with w compensation
claims.
On Call Nurse
An injured employee or their immediate supervisor can contact a nurse any time day or night.
The employee speaks directly with a specially trained nurse who assesses the injury and
recommends the best course of action for the injured worker. This proven process resolves
many cases simply with first aid, avoiding unnecessary costs and time away from work.
Medical Review
A medical review includes a brief summary of the medical reports, answers to specific
questions, it may include recommendations, an explanation of the medical problem and it may
point out discrepancies in the file, prior conditions and their relationship to the claimed injury.
The contents of the review will vary according to specific needs for the claim file and according
to the findings on review.
Loss Fund
We can set up a payment system in several ways, but we suggest we analyze the payment
frequency to determine the amount of an imprest fund. An escrow imprest amount is
determined based on historical payment information for the City. The escrow imprest is pre-
funded and reimbursed on a weekly or monthly basis, whichever fits your business needs best.
Escrow imprest amount is recalculated bi-annually to ensure funds held are sufficient based on
claim activity. Large payments are prefunded outside of the monthly escrow cash flow. Escrow
balances are held in a checking account specifically held for TPA escrow funds. Your account
would be reconciled on a monthly basis and all 1099 reporting and unclaimed property reporting
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is managed by ECS. We can monitor and maintain the fund, which would be replenished at a
pre-agreed upon schedule as payments are made.
ECS may also access a bank account, if requested by the City of Ames, maintained by your
organization to withdraw funds on a weekly or monthly basis to make benefit payments or
settlement payments. We first provide a payment register statement to the authorized party
showing the exact dollar amount to be requested from the account on the weekday of their
preference and what amount is needed to replenish the account.
Supporting documentation including, but not limited to, a payment register and financial register,
Additional reports outside our
standard system generated reports can be requested as needed. Loss allocation is developed
into the tier structure so that all claim payments can be allocated back to the designated fund.
Monthly reconciliations are completed and sent to the City of Ames and include, but are not
limited to, beginning and ending balances, check register and a fund review summary. Any loss
allocation reporting can be discussed and tailored to meet the reporting needs of the City of
Ames and your internal accounting practices.
Balance billing is not practiced at EMC Claims Solutions and is not allowed in Iowa.
Loss Reports
ECS offers a large selection of reports tailored to your business needs which are available for
you to run, scheduled to you at prescribed times, or upon demand. Our goal is to be flexible
and responsive; we will set up the claims software in a tier system to reflect the structure of your
organization and report in the fashion best suited to provide whatever data you request. All
data is stored on a secure network and is backed up daily to a separate server location.
Any claim entered into the Filehandler system is available to query with either a Filehandler
report
either via our standard Filehandler reports or via Ad Hoc reporting.
reporting capability, which means
determine financial picture as of that day or any timeframe.
The City of Ames tier structure will be setup to allow for separation of w compensation
losses and Municipal Fire Police Retirement System losses. Furthermore, the tier structure will
allow for allocation to department and loss fund coding.
EC This custom
dashboard is an effective tool to be used when analyzing risk and the costs associated with
each injury within each department or tier level. This customized dashboard is delivered when
signing on to the Filehandler system.
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1
REQUEST FOR PROPOSAL NO. 2025-153
THIRD-
AND MUNICIPAL FIRE AND POLICE RETIREMENT SYSTEM
SCOPE OF SERVICES
1. OBJECTIVE
The City of Ames (City), Iowa, is requesting proposals to provide Compensation
Third-
Compensation Program and the Municipal Fire and Police Disability and Injury Program. The
Firm will provide all specified adjusting services for claims as well as all other required
services, such as administrative, managed care, web-based claims/loss statistical information
(RMIS) and banking/loss fund reconciliation.
2. BACKGROUND & OVERVIEW
2.1 The City is a full-service City employing approximately 600 full-time equivalent
employees. These employees provide a varied range of services to the residents and
visitors of the City. Employees range in classifications including professional, technical,
administrative support, maintenance/repair, and public safety services. The City
presently has a contract with a local clinic to provide occupational medical services for
initial and follow-up care, including physical therapy. Exhibit A includes a historical
May 1, 2015 until May 8,
2025.
2.2 -Party Administration
2.2.1 On-the-job injuries are an inherent
injuries do occur, the Third-Party Administrator (TPA) will treat City employees
with respect and professionalism when providing the required services. The TPA
representatives will introduce themselves to the City employees during the
initial communication after a claim has been received and shall provide clear
information concerning the content, purpose, and schedule of future contacts
to be made with that employee. The TPA representatives must make every
reasonable effort to explain pertinent rights, regulations, and responsibilities to
ultimate goal is to return the injured employee to work as soon as possible.
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2
2.2.2 The City has been self-more than
20 years and has been utilizing a TPA since at least 2010.
2.3 Municipal Fire and Police Retirement System of Iowa (411)
2.3.1 The disability benefit program includes both non-job related and job-related
disabilities. The program does not provide for partial disability or for a rated
disability.
2.3.2 The provisions also provide for Temporary Disability Assistance. If a firefighter
or a police officer has a medical condition which has, or is anticipated to last, for
longer than sixty days (Temporary Disability), the retirement System is to be
notified. Members receive full pay and allowances for a job-related temporary
disability and will be paid for the City outside of the self-insured workers
compensation program. The City is responsible for lifetime medical payments
for injuries that result in permanent disability under the program.
3. GENERAL
The basic scope of services is summarized as follows. The Firm will:
3.1 Provide Third-ensation and
Municipal Fire and Police Retirement System, including but not limited to claims
administration, medical management, loss fund management, temporary disability
Compensation costs, and related services.
3.2 Be responsible for complying with all State and Federal rules, regulations, and laws
relating to and required for compliance as a Third-Party Administrator for Self-Insured
Plans/Employers such as the City of Ames, Iowa. This includes, but is not limited to:
3.2.1 Iowa Code 85
3.2.2 Iowa Code 86.11 and 86.12
3.2.3 Iowa Code 86.13
3.2.4 Iowa Code 87.11
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3
3.2.5 Iowa Administrative Rule 879 sub-rules 3.1(1) and 3.1(2)
3.2.6 Federal Privacy Acts (HIPPA)
3.2.7 Iowa Code 411.15
3.3 The Firm shall have a web-based claims administration system and shall provide the City
with access to said system for file review, email communications, or other purposes at
no additional cost to the City.
3.4 Term of Contract
3.4.1 The current contract is in place through July 31, 2025. Services resulting from
this Request for Proposal shall commence on August 1, 2025, and shall continue
for eleven (11) months, through June 30, 2026, the end of the fiscal year.
3.4.2 The contract may be renewed for up to four subsequent one-year periods, from
July 1-June 30, provided all of the following occur:
3.4.2.1 The Firm will provide the City with written notice of any proposed price
adjustment for the subsequent year at least ninety (90) days prior to
the anniversary date of the contract
3.4.2.2 The City will provide the Firm with a written agreement to renew the
contract, with prices adjusted as mutually agreed, at least thirty (30)
days prior to the anniversary date of the contract.
3.4.2.3 The City will provide the Firm with a written agreement for the renewal
of the contract, at least thirty (30) days prior to the anniversary date of
the contract.
3.5 Owner
3.5.1 The Owner is identified as the City of Ames, Iowa.
3.5.2
Manager.
3.6 All reports currently provided to the City are required from the Firm; refer to Section 6.
The cost of reports shall be included in the fee structure and not considered an
additional cost; the City of Ames will not pay any additional charges for reports.
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3.7 All files shall remain the property of the City during and subsequent to the expiration of
any contract or agreement and shall be returned to the City. Failure to comply shall
constitute a breach of contract and be subject to damages and reimbursement for the
cost of reconstruction of information.
3.8 Documents and furnished reports shall be provided in format acceptable to the City.
4. QUALITY REQUIREMENTS
4.1 personnel and management providing services under this contract shall be
knowledgeable, trained, and certified or credentialed in their respective areas of
expertise. The City reserves the right to conduct investigations as may be deemed
necessary to ensure that competent personnel will be utilized in the performance of the
work.
4.2 -effective
-insured loss
payments is to ensure the claims administrator hires and retains the appropriately
qualified staff and assigns caseloads to ensure that all requests are handled in a timely
and efficient manner.
4.3 The claims administrator shall have a full-service claims operation. The claims
administrator shall be familiar with City of Ames policies and procedures and area
medical providers to ensure efficient claims handling and to demonstrate value and
respect for City employees.
5. GENERAL REQUIREMENTS
5.1 The City expects its Third-Party Administration Firm to treat City employees with respect
and consideration when providing the required services. The TPA will introduce
themselves and provide clear information concerning the content, purpose and
schedule of future contracts to be made with the employees. The Firm must make every
reasonable effort to explain pertinent rights, regulations, and responsibilities to the
5.2 Other than the filing of applications for self-insurance, the successful firm, at the option
of the City, shall be required to:
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5
5.2.1 Provide services on all claims occurring during the contract period and until six
months after the termination of the contract, including renewals, extensions, or
replacements thereof.
5.2.2 Provide all legally required reports for the contract period rendered and assist
in assigning ratings to City job groups.
5.3 All claims data is the property of the City, and any data and media will be provided to
the City upon request or upon termination of this agreement.
6. CLAIMS ADMINISTRATION
The Firm shall be responsible for the following tasks:
6.1
6.1.1 Perform all of the administrative services required and shall control the
disposition of all claims in accordance with applicable statutory and
administrative notification requirements of the Iowa Code and the Iowa
and procedures.
6.1.2 Review all notices of injury received from the City prior to the assignment to an
adjuster approved by the City.
6.1.3
with applicable Workers' Compensation Law. The decision to deny a claim must
first be discussed with and approved by the City.
6.1.4 Investigate each reported claim to the extent deemed necessary or at the
request of the City.
6.1.5 Contact the injured worker within 24 hours of notice of injury. There shall also
be periodic contact thereafter as deemed necessary for the type of claim filed.
For example, a lost time claim would require a minimum of one contact weekly
until the claimant has returned to work.
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6.1.6 Subject to prior approval from the City of subcontractor selection, the Firm shall
arrange for independent investigators, experts or other professionals when such
action is necessary to properly process cases, assist in determining the status of
disabled claimants, assist in preparation of litigated cases, or at the request of
the City.
6.1.7 Payment will be made by the claims administrator from the loss fund as an
allocated expense.
6.1.8 Assure, prior to payment, that all authorized medical bills associated with an
approved claim comply with the medical fee schedule and/or discounted fee
arrangements negotiated by or on behalf of the City.
6.1.9 Assist and support legal counsel selected or retained by the City in the
preparation and defense of litigated cases and negotiations of settlements and
provide periodic analytical or narrative reports of litigated cases to the City.
Under no condition will a claim be settled without the express approval of the
City.
6.1.10 Assist in arranging for rehabilitation or retraining of claimants in appropriate
cases, as requested by the City.
6.1.11
Manager of all claims or losses meeting the excess carrier reporting criteria with
all necessary information about the status of such claims or losses as determined
or required by such insurers.
6.1.12 Pursue all possibilities of subrogation.
6.2 Claims Administration for Municipal Fire and Police Retirement System
6.2.1 Record the injury, review the incident, and provide recommendations regarding
whether the injury is work-related.
6.2.2 Make medical payments. The City is responsible for lifetime medical costs for
claimants that receive a medical disability.
6.2.3 Track medical payments.
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6.2.4 Record the specific cause of the disability and monitor payment for the
appropriate treatment.
6.3 Administrative Services
The Firm shall perform the following administrative services:
6.3.1 Prepare all required Federal, State, and local filings.
6.3.2 Submit all required Federal, State, and local filings.
6.3.3 Perform loss management including but not limited to monitoring and reporting
fund balance used to pay claims
6.3.4 Prepare and provide loss runs and other management reports as required
herein.
6.3.5 Prepare and file, on behalf of the City, with the appropriate State agency, all
-insurer.
6.3.6 Prepare, maintain, and file all records and reports as may be required by all legal
authorities including, but not limited to, Federal, State, and local.
6.3.7 Prepare, maintain, and file statistical data, records, or reports as required by
6.3.8
compensation rating bureaus, including all data required for promulgation of the
6.3.9 Prepare and file any other reports as required by the City and State relating to
claims experience and payments.
6.3.10 Submit quarterly requests to the excess carrier for all payments above each
checks will be forwarded to the City and the amount recovered will be entered
information system.
6.3.11 Maintain a file for each claim or loss including but not limited to medical reports,
legal reports, cost data, and estimates of future liability on an individual claim
basis which shall be available for review by the City or its authorized agents.
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6.3.12
City.
6.4 Medical Management
6.4.1 Monitor treatment programs recommended by physicians or specialists by
reviewing all reports prepared by treating or examining physicians, and by
maintaining such contact as may be appropriate or at the request of the City to
monitor any change of a claima
their ability to work.
6.4.2 Recommend any courses of medical management which will expedite recovery
and return to work of employees, and implement recommendations as
approved by the City.
6.4.3 Assign City approved/selected nurse case managers on a case-by-case basis after
Provider has the authorization to assign a nurse case manager for the initial visit
pending contact and approval for continued use of a nurse case manager.
6.4.4 Coordinate the medical treatment of all claims by setting appointments and
authorizing necessary physician referrals and treatments.
6.4.4.1 Review all medical restrictions placed on the employee and consult with
Transitional Duty Team has identified appropriate transitional work.
6.4.4.2 Review return-to-work documentation from the treating physician and
notify the Risk Manager of the date of return. Any concerns regarding
the ability of the employee to perform the essential functions of their job
based on the City of Ames job description should be communicated
immediately to the Risk Manager.
6.5 Loss Fund Management
6.5.1 All claims, expenses and legal payments will be made by the Firm on checks
drawn on a separate account set up by the City and funded monthly by the City
in a manner agreed to by both parties. It is understood that all funds in this
account are City funds and are to be returned to the City upon request or at
termination of this contract.
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6.5.2 The Firm is responsible for the monthly reconciliation of this account and shall
provide bank statements to the City monthly.
6.5.3 The monthly reconciliation statement submitted by the Firm to the City will
include the following:
6.5.3.1 Balance at inception of statement period.
6.5.3.2 Total disbursements which cleared, by date and claimant/payee.
6.5.3.3 Balance at close of statement period.
6.5.3.4 A list of all payments issued and outstanding.
6.5.4 Penalties required due to late payments or adjuster mishandling are to be paid
by the Firm unless caused by late reporting from the City.
6.5.5 The Firm will reimburse the City for any penalties or fees generated due to the
errors of the Firm, including but not limited to interest and penalties assessed
for late benefit payments, overpayments, and bad faith claims.
6.6 Loss Data
6.6.1 The City will provide the Firm with historical claims data. This data shall not be
purged and shall be returned to the City upon termination or expiration of the
contract.
6.6.2 The Firm, at its expense, will ensure all claims and payment data is included in
their loss run by the 10th day of the month following the claim.
6.6.3 Claims data for all open and closed claims shall be transferred from the
database to the City database upon termination or expiration of the contract.
6.6.4 All notes recorded by the Firm will be included
transfer to a successive claims administrator.
6.7 Loss Reports
All loss reports are to be provided in electronic format by the Firm
Representative. Reports shall include data for all claims active during the current fiscal
year.
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6.7.1 Reports shall be separated for Workers Compensation losses and Municipal Fire
Police Retirement System losses.
6.7.2 Weekly Reports
the date the claim was submitted to the carrier.
6.7.3 Monthly Reports
6.7.3.1 A report of claims, alphabetically by last name shall include
Representative:
6.7.3.1.1. Claimant name.
6.7.3.1.2. Date of injury.
6.7.3.1.3. Status of claim.
6.7.3.1.4. Type of injury.
6.7.3.1.5. Type of claim.
6.7.3.1.6. Reserves (an estimate of future cost and total expected
costs.
6.7.3.1.7. The amount and type of each payment made during the
current period.
6.7.3.1.8. Total paid during the period for the claimant.
6.7.3.1.9. Grand total of all claims paid during the period.
6.7.3.2 A report of claims by City department number shall include the
Representative and including the above information plus a total
amount paid during the period for each department.
6.7.3.3 A monthly cumulative report by claimant by department shall include
Representative:
6.7.3.3.1. Claimant name.
6.7.3.3.2. Date of injury.
6.7.3.3.3. Status of injury.
6.7.3.3.4. Type of injury.
6.7.3.3.5. Type of claim.
6.7.3.3.6. Reserves.
6.7.3.3.7. Amount paid fiscal year-to-date for each claim.
6.7.3.3.8. Amount paid claim-to-date.
6.7.3.3.9. Total amount paid fiscal year-to-date by department.
6.7.3.3.10. Grand total amount paid fiscal year-to-date.
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6.7.3.4 Monthly check register indicating the date, amount, associated claim
reference, and payee.
6.7.3.5
attorney paid, description of work performed, reserves recommended,
and settlement date (if applicable).
6.7.3.6 OSHA 300 log.
6.7.3.7 Compensation claims that involve no payment or no medical
treatment. This data shall be reported and included in the database as
reporting purpose only (RPO), or first aid or no pay cases and should
be identified in the system in that way. Information is recorded in the
same manner as an active claim with the date of the incident, claimant
name, department, and type of injury.
6.7.3.8 Report on large loss claims ($20,000 plus).
6.8 Quarterly Loss Reports
Every 90 days, on a schedule as agreed, the Provider shall submit a full summary report
to the City on all claims of the following types:
6.8.1 Any claim in which an employee is not working full duty.
6.8.2 Claims in which settlement (washout) is recommended.
6.8.3 Annual Reports:
6.8.3.1 Cumulative report by type of claim (medical only, lost time) of coverage
for each fiscal year.
6.8.3.2 Summary report of claims paid by medical only, lost time, open claims,
reserves for each fiscal year.
6.8.3.3 For each fiscal year period and for each calendar year:
6.8.3.3.1. The total number of claims or losses by department and city
wide.
6.8.3.3.2. A summary of medical and indemnity payments by
department and city wide.
6.8.3.3.3. Estimated future costs and total costs by department and
city wide.
6.8.3.3.4. Number of open and closed claims by department and city
wide.
6.8.3.3.5. Detail of medical bill savings and charges.
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6.8.3.3.6. Any other data deemed necessary by the City to comply
Commission requirements.
6.9 Subrogation Reports
6.9.1 On a semi-annual basis, or as specifically requested by the City, a report shall be
provided of all claims for which the claims administrator has pursued (whether
successfully or not) subrogation, contribution or indemnity or recovery from
special or second injury funds on behalf of the insured. In addition to the data
specified in the Basic Report, as applicable, the report should include the
following:
6.9.1.1 Name of claimant.
6.9.1.2 Date of injury.
6.9.1.3 Type of injury.
6.9.1.4 Amount paid claim-to-date.
6.9.1.5 Name of party from whom recovery is sought.
6.9.1.6 Basis for recovery.
6.9.1.7 Amount recovered to date.
6.9.1.8 Estimated amount yet to be recovered.
7. COST OPTIONS AND METHODS
7.1 The successful fee shall include full consideration for such continuing obligations
and, except for as noted herein, no additional consideration shall be due for such
obligations which extend beyond the contract period.
7.1.1 Medical review bill shall be shown as a percentage of savings with a cap of
$10,000 per medical bill.
7.2 All charges related to the Work are to be included in the annual claims administration
fee.
7.3 Any costs associated with programming changes that are necessary to create a report
required by the City are the responsibility of the TPA.
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717 Mulberry St. | Des Moines, IA 50309 | P.O. Box 9399 | Des Moines, IA 50306-9399 |P 515.345.4532 |P 800.741.5302 | F 866.504.6598 | www.emcins.com
Employers Mutual Casualty Company Illinois EMCASCO Insurance Company Union Insurance Company of Providence EMC Underwriters, LLC
EMCASCO Insurance Company Dakota Fire Insurance Company Hamilton Mutual Insurance Company EMC National Life Company (affiliate)
EMC Reinsurance Company EMC Property & Casualty Company EMC Risk Services, LLC
June 4, 2025
SERVICE FEE SCHEDULE 2025
Workers Compensation City of Ames
Claim Fees
Claim Fees shall be effective as of the Effective Date, 8-1-25, for 11 months and annually thereafter on
7-1, or upon the agreed established date.
PRICING REVISIONS PER RENEWAL
City of Ames agrees to pay EMC Claims Solutions the following fees:
Workers Compensation Claims:
Incident Only $35 per report
Medical Only $260.00
Indemnity $1,142.00
Medical Case Management $115.00 /hour
$.56 /mile + reasonable expenses
Legal Nurse Review $128.00 /hour
Medical Bill Review and Pharmacy Benefit Management:
PPO Network Utilization and audit of all bills by nurses in our Medical Cost
Review Unit for optimal savings and network reductions on every medical bill.
Also, the Pharmacy Benefit Management network provides both savings and
clinical management of prescription drug costs for your injured workers.
Per bill fee 9.50
Bill Review 30% of savings
PPO 30% of savings - Capped at $10,000
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717 Mulberry St. | Des Moines, IA 50309 | P.O. Box 9399 | Des Moines, IA 50306-9399 |P 515.345.4532 |P 800.741.5302 | F 866.504.6598 | www.emcins.com
Employers Mutual Casualty Company Illinois EMCASCO Insurance Company Union Insurance Company of Providence EMC Underwriters, LLC
EMCASCO Insurance Company Dakota Fire Insurance Company Hamilton Mutual Insurance Company EMC National Life Company (affiliate)
EMC Reinsurance Company EMC Property & Casualty Company EMC Risk Services, LLC
Miscellaneous Fees:
On-line Claim Reporting/Administration (includes banking, accounting and fund management)
Annual Administration/Reporting: $5,200.00
Additional users: $ 300.00
Risk Improvement $ 220.00 /hour
Subrogation: 18% of recovery
OSHA 300 Reporting $2650 Annually
Approved on _____________ by:
EMC Claims Solutions
By: Barbara A. Sullivan, CPCU
President and Chief Operating Officer
EMC Claims Solutions
City of Ames, Iowa
By: _____________________________
_____________________________
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