2005-039 Medical Claims Audit AgreementRESOLUTION 39-2005
A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF NORTH PALM
BEACH, FLORIDA, AUTHORIZING AND DIRECTING THE MAYOR AND VILLAGE
CLERK TO ENTER INTO A MEDICAL CLAIMS AUDIT AGREEMENT WITH SIVER
INSURANCE CONSULTANTS ATTACHED AS EXHIBIT "A", WHICH AGREEMENT
PROVIDES FOR SERVICES OF AN INSURANCE CONSULTANT TO MAKE A
CLAIMS AUDIT OF THE VILLAGE THIRD PARTY ADMINISTRATOR REVIEWING ALL
CLAIMS PROCESSED FOR MEDICAL, DENTAL, HOSPITALIZATION AND
PRESCRIPTION DRUGS; AND, PROVIDING FOR AN EFFECTIVE DATE.
BE IT RESOLVED BY THE VILLAGE COUNCIL OF NORTH PALM BEACH, FLORIDA:
Section 1. The Village Council of the Village of North Palm Beach, Florida, does hereby
approve the Medical Claims Audit Agreement attached as exhibit "A", which agreement
provides for services of an insurance consultant to make a Claims Audit of the Village Third
Party Administrator reviewing a sampling of all claims processed for medical, dental,
hospitalization and prescription drugs.
Section 2. The Mayor and Village Clerk are hereby authorized and directed to execute the
Medical Claims Audit Agreement as set forth in Exhibit "A" for and on behalf of the Village of
North Palm Beach.
Section 3. This resolution shall take effect immediately upon its adoption.
PASSED AND ADOPTED THIS 28th DAY OF APRIL, 2005.
ATTEST:
C i~%C C_
„~ VILLAGE CLERK
Exhibit "A"
•
MEDICAL CLAIMS AUDIT AGREEMENT
THIS MEDI~C~yA~L~~C~LAIMS AUDIT AGREEMENT is made and entered into this
o~~{L day of _ (~7_` , 2005, by and between VILLAGE OF NORTH PALM
BEACH, a municipal corporation, hereinafter referred to as "VILLAGE" and SIVER
INSURANCE CONSULTANTS, hereinafter referred to as "SIVER."
WITNESSETH:
WHEREAS, VILLAGE is desirous of securing services of an insurance consultant
to make a claims audit of the VILLAGE third party administrator reviewing a sampling of
all claims processed for medical, dental, hospitalization and prescription drugs; and
WHEREAS, SIVER is desirous of forming a medical claims audit of the
VILLAGE'S third party administrator upon the terms set forth in this Agreement and ~~
attached Exhibit "A."
NOW, THEREFORE, in consideration of the promises mutually exchanged in this
Agreement, for other good and valuable considerations, the receipt and sufficiency of
which is acknowledged, the parties agree as follows:
1. SIVER agrees to perform the Medical Claims Audit Agreement of the
VILLAGE's third party administrator in accordance with the terms set forth in this
Agreement and attached Exhibit "A"; provided, however that the terms of Exhibit "A" are
changed as follows:
A. The Medical Claims Audit shall consist of 400 claims, taken as a
random sampling of claims for the_ twelve-month period ending
January 31, 2005, and not the audit period from July 1, 2003,
through June 20, 2004, as set forth in Exhibit "A."
B. Travel costs of consultant shall not exceed the sum of FIVE
HUNDRED ($500.00) DOLLARS.
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C. Consultant agrees to deliver to VILLAGE a draft of the audit report
with one-hundred twenty (120) days after full execution of this
Agreement.
D. Should the initial audit sample reveal an error ratio inconsistent with
industry standards, the Village may, at its discretion, direct Siver to
expand the audit sample, subject to additional fees, based on the
hourly rates indicated in Siver's initial proposal.
2. Any conflicts between this Agreement and terms and provisions set forth
in Exhibit "A" shall be resolved in favor of the Agreement.
IN WITNESS WHEREOF, the parties have executed this Agreement on
the day and year first above written.
SIVER INSURANCE CONSULTANTS
VILLAGE OF NORTH PALM BEACH
By
Attest:
i~~%l ~
Village Clerk
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Exhibit "A"
• Village of North Palm Beach
Request for Proposal
For
Claims Audit of Third Party Plan Administrator
March 13, 2005
I. Introduction:
a. The Village of North Palm Beach (Village) is contracted with Employers Mutual
Inc. (EMI), Third Party Administrator (TPA) to administer employee benefits
including medical, dental, hospitalization and other benefits.
b. The Village offers both a PPO and an EPO Plan to the employees, and has
approximately 185 full-time employees and retirees covered for medical and
dental insurance; approximately 50% of the Plan participants have family
coverage.
II. Request for Proposal:
a. The Village is requesting proposals to audit medical, dental and hospital,
including prescription drug, claims processed by EMI for a one (1) year period
from 1 /31 /2004 through 1 /31 /2005.
III. Scope of Audit:
a. Review 100% of the processed claims for medical, dental, hospitalization and
prescription drugs.
b. Search for an report electronically on over payment due to, but not limited to:
i. Reimbursement made for services not covered by the -Plan or outside
benefit limits.
ii. Claims paid for terminated employees or ineligible members.
iii. Duplicate claims and or payments.
iv. Erroneous, unbundled and up-coded claims.
v. Not taking proper discount under the PPO and EPO contract.
vi. Application of correct co-pay, co-insurance, deductibles and out of pocket
maximums.
vii. Any other reason not covered above.
c. Search for and report electronically on necessary coordination of insurance
coverage benefit payments with other carriers
d. Search for and report electronically on the proper and timely submission of claims
to the reinsurance carrier for reimbursement.
• e. Search for, prepare a schedule and provide a detail electronic listing. of specific
recoverable claim costs that the Village may pursue relating to or having been
caused by, although not limited to, the scope listed above.
• IV. Information requested from the Proposers:
In order to get a uniform review process and to obtain the maximum degree of
comparability, it is required that proposals be organized in the manner specified.
a. Title Page
i. Show the RFP subject, the name of the Proposer's firm, local address,
telephone number, name of the contact person and the date.
b. Table of Contents
i. Include a clear identification of the material by section and by page
number.
c. Letter of Transmittal
i. Limit to one or two pages.
ii. Briefly state the proposer's understanding of the work to be done, and to
make a positive commitment to perform the work within the time period.
iii. Give the names of the persons who will be authorized to make
representation for the proposer, their titles, addresses and telephone
numbers.
d. Profile of the Proposer
i. State whether the firm is local, national or international.
ii. Give the location of the office from which the work is to be done and the
number of partners, managers, supervisors, seniors, and other professional
staff employed at that office.
iii. Describe the range of activities performed by the local office such as
audit, accounting, tax service, or management services.
e. Summary of the Proposer's Qualifications (in addition to minimum qualifications)
i. Identify the partners, managers, and supervisors who will work on the
audit, including staff from other than the local office. Resumes for each
supervisory person to be assigned to the audit should be included. (The
resumes may be included in the appendix.)
•
• f. References '
i. Describe recent auditing experience similar to the type of audit requested
and provide the list of names, telephone numbers, and the contact person
of the municipalities for whom your office has performed the audit in the
last three (3) years.
g. Fee
i. All inclusive lump sum fee.
V. Proposal due date:
a. Responses to the Proposal should be e-mailed to:
Mark Bates, Village Manager
mbates(a~village=npb.org
501 U.S. Highway 1
North Palm Beach, FL 33408
b. Responses must be received by 2:00 PM on Tuesday, March 29, 2005.
VI. Scheduling: (tentative)
a. Advertising Request for Proposal -March 13, 2005
b. Due date for submitting proposal -March 29, 2005
c. Staff recommendation /Council Award -April 14, 2005
d. Completion of the contract -August 31, 2005
VII. Evaluation:
a. The Village Administration will evaluate and rank all proposals. The
Administration recommendation will be forwarded to the Village Council for final
consideration and approval.
VIII. Other information:
a. The Village will not be liable for any costs incurred in the preparation of the
proposals.
b. The submission of a proposal shall be prima facie evidence that the Proposer has
full knowledge of the scope, nature, quantity and quality of work to be performed,
the detailed requirements of the specifications, and the conditions under the work
is to be performed.
c. The Proposer shall furnish the Village such additional information as the Village
may reasonably require.
d. The Village will not be liable for any costs which were not included in the
proposal and subsequently contracted for costs.
e. The Village reserves the right to conduct personal interviews of any or all
Proposers prior to selection. The Village will not be liable for any costs incurred
by the Proposer in connection with such interview (i.e. travel, accommodations, etc.)
f. The Village reserves the right to reject any and all proposals, the right in its sole
discretion to accept the proposal which it considers most favorable to the
Village's interest, and the right to waive minor irregularities in the procedures.
The Village further reserves the right to reject all proposals and seek new
proposals when such procedures are reasonably in the best interest of the Village.
Proposers wishing additional information or clarification of information provided herein should
contact Mark Bates, Village Manager, 501 U.S. Highway 1, North Palm Beach, FL 33408,
telephone number (561) 841-3380.
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VILLAGE OF NORTH
PALM BEACH
PROPOSAL:
CLAIMS AUDIT OF
THIRD PARTY ADMINISTRATOR
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Provided by:
Siver Insurance Consultants
9400 Fourth Street North, Suite 119
St. Petersburg, FL 33 702
Toll Free (866) 967-4837
Contact: Brenda Sadler, Vice President
February 22, 2005
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B: TABLE OF CONTENTS
TAB
Title Page ........................................................................................................ A
Table of Contents .......
................................................................................... B
' Letter of Transmittal .................................................................................... C
Profile of the Proposer .................................................................................. D
Summary of the Proposer's Qualifications ................................................ E
References ...................................................................................................... F
Fee Schedule ..................................................................................................G
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C: LETTER OF TRANSMITTAL
The following characterizes our understanding of the scope of services to be performed and
outlines our typical audit process.
Proposed Services
Siver proposes to conduct a Claim Audit for the Village of North Palm Beach to include the items
reflected in Section III (Scope of Services) of the Request for Proposal (RFP) issued on January 28,
2005. Upon completion of our review, a detailed written report will be provided, outlining the audit
findings, including Siver's recommendations to cure any discrepancies indicated during the course of
the audit and our assessment of any financial penalties applicable, consistent with any contracts or
agreements in place during the stipulated audit period.
While the RFP indicates a 100% review of all claim r ce
s p o ssed for medical, dental, hospitalization,
and prescription drugs, it is recommended that an initial audit of approximately 400 claims (for the
audit period of July 1, 2003, through June 20, 2004) be conducted, with the Village of North Palm
Beach having the option to increase the size of the audit sample, should the initial audit reveal
significant discrepancies. The suggested audit sample of 400 claims represents approximately 5% of
the medical, dental and prescription claims processed during the audit period, based on figures
obtained from the Third Party Administrator. A 5% audit is consistent with industry standards.
The on site audit schedule will be determined by mutual agreement with the Village of North Palm
Beach, Siver, and Employers Mutual, Inc. It is anticipated that four to five days will be required to
perform the on site portion of the audit process.
Explanation of Typical Audit Parameters
1. Overall Accuracy -The percentage of claims processed correctly in every aspect, including;
coding, procedures, financial accuracy, eligibility, and turnaround time. If a claim payment
has any error on it, financial, procedural, or otherwise, it is counted as one inaccurate claim.
Multiple errors on the same claim will count as one inaccurate claim.
2. Financial Accuracy -The total sum of absolute dollars of all underpayments and all
overpayments divided by the total dollars of claims paid.
3. Turnaround Time - Number of working days elapsed between the date the claim is received
by the claims paying vendor and the date the claim is either processed for payment, processed
for denial, or pended for further information/documentation.
Optional Audit Services (not included in basic quote)
1. Eli ibility Updates- Number of working days elapsed between the date the record is received
by the claims paying vendor and the date the eligibility is updated.
~ 2. System Change Requests- Number of working days elapsed between the date the client
requests an update (i.e., fee schedule revision) and the date the revision is updated in the
claims system.
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Siver's Typical Audit Process
Phase 1
k The audit will be conducted primarily at the TPA office, on a date to be determined. A letter
F authorizing Siver to obtain data on behalf of the client should be issued as soon as possible.
Prior to the dates of the on site audit, Siver will confirm the audit schedule and request the
required materials from the TPA. A detailed paid claim report for the period to be audited is
required, along with copies of any system codes and copies of plan documents.
From the detailed claim report, we randomly select the claims to be audited and request the TPA
have those claims and all related documentation available for review at the time of our on site
visit. In this case, random claim selections will. be made from the medical, dental, and
prescription plans. We recommend an initial audit of 400 claims, with the client having the
ability to expand the audit, should significant discrepancies be found in the initial review.
Phase 2
This phase includes the examination and recalculation of the claims that were selected for audit.
As each claim is audited, results are recorded. Spreadsheets, showing data collected for each
claim, will be included as a portion of the final audit report, with identifying data redacted in
compliance with HIPAA privacy guidelines.
Phase 3
This phase includes a brief exit interview with Siver and the TPA to share preliminary audit
findings and discuss the procedure Siver will follow in communicating audit results to the Client.
The TPA will be provided a preliminary draft spreadsheet of our findings, prior to submission of
the final report to the Client. The TPA is typically given up to two (2) weeks to challenge any of
the initial audit findings. A written response is required from the TPA if there are any challenges
to our report. Siver will review any challenges and make report revisions, if appropriate.
Phase 4
A report will be provided to the Client to include any suggested penalties or monies due as a
result of our audit findings, in accordance with any existing performance standards. In the
absence of a performance agreement, recommendations for improving services (if indicated) will
be presented. These recommendations would include a suggested date for completion of any
necessary training, system changes, etc. It would be our hope that the TPA would sign an
agreement to complete required enhancements within 30 days or lest of the final report.
Firm/Staff Details
! Brenda Sadler, the assigned auditor, has more than 20 years of auditing experience. Ms. Sadler has
conducted audits of numerous third party administrators and insurance carriers. A listing of those
I• firms and a copy of her curriculum vitae is provided under Tab E. Brenda Sadler, Vice President,
and George Erickson, Executive Vice President, are authorized to make representations for Siver and
may be reached, toll free, at (866) 967-4837. Our office is located at 9400 Fourth Street North, Suite
119, St. Petersburg, Florida, 33702. Additional details pertaining to Siver are located in Tab D.
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D: PROFILE OF THE PROPOSER
• Siver Insurance Consultants (Siver) is an independent employee benefits, risk management, and
insurance consulting firm located in St. Petersburg, Florida, in business since 1970. Siver is entirely
owned by its officers and employees. We are independently owned and not related to, or affiliated
with any other organization.
We do not sell insurance. We do not receive, directly or indirectly, any commissions, contingent
commissions, or overrides. All of our income is directly derived from the fees we charge our clients.
All income we receive as the result of, or in connection with, our services to a client will appear on
our invoice to that client. We adhere to a strict code of ethics. We do not accept gifts, trips, prizes,
or anything else of any value from vendors. In short, we serve only our clients.
Siver's staff is highly qualified, including individuals with advanced degrees (including law and
insurance), and has the skills and knowledge necessary to provide the services requested. Siver staff
members have had substantial firsthand experience in providing a broad range of consulting services
to numerous, and widely divergent clients.
Following is an organizational chart reflecting our permanent staff. Siver also engages the
specialized services of a number of adjunct consultants who work with us on an as needed basis.
Those individuals are not reflected in this exhibit.
-.Jun Marshall
President
Brenda Sadler
Vice Resdent
Gc~ge Enckson
Execiuive Vice Presidcrrt
Kathy Gordon Karby Doak Stephanie Barnhill
Senior Consulaant Seniof Goosultant Senior Consultant '
Kon,York ~ Kay Killeen Laurie Ma~ewski
Tochaical Psststant'. `Administrative Assistant AccriirtSant
Jetutifer Ford
As sistanirl.ibrari an
We offer expertise in the following areas:,
Litigation Support/Expert Witness
Employee Benefits
Disk Management
f'~uditing Services
Life, Health, & Disability Insurance
Property & Casualty Insurance
Managed Care
Title Insurance
r
SIVER GOVERNMENTAL CLIENTS (Current and Previously Served):
~ CITIES
ltamonte Springs, FL
popka, FL
Bartow, FL
Charlotte, NC
Clearwater, FL
Coconut Creek, FL
Coral Gables, FL
Dania Beach, FL
Daytona Beach, FL
Deerfield Beach, FL
Delray Beach, FL
Fort Myers, FL
Fort Pierce, FL
Gainesvil]e, FL
Gulfport, FL
Holly Hill, FL
Hollywood, FL
Homestead, FL
I Jacksonville, FL
Key West, FL
Lakeland, FL
Largo, FL
Maitland, FL
Melbourne, FL
Miami Beach, FL
New Smyrna Beach, FL
Orlando, FL
Palm Bay, FL
Palmetto, FL
Pensacola, FL
Pinellas Park, FL
Richmond, VA
Rockledge, FL
Safety Harbor, FL
St. Augustine, FL
St. Petersburg, FL
St. Pete Beach, FL
Sanford, FL
Sanibel, FL
Sarasota, FL
Sebastian, FL
Tarpon Springs, FL
West Palm Beach, FL
Winter Haven, FL
COUNTIES & STATES
Alachua County, FL
Brevard County, FL
Broward County, FL
Charlotte County, FL
Collier County, FL
Desoto County, FL
Henrico County, VA
Hernando County, FL
Highlands County, FL
Hillsborough County, FL
Imperial Polk County, FL
Indian River County, FL
Lake County, FL
Lake County, Clerk of the
Circuit Court
Lee County, FL
Manatee County, FL
Martin County, FL
Mecklenburg County, NC
Orange County, FL
Putnam County, FL
St. Johns County, FL
St. Lucie County, FL
Sarasota County, FL
Seminole County, FL
State of Florida
DISTRICTS & AUTHORITIES
Alachua County Library District
Housing Authority of Avon Park
Broward County Airport Authority
Broward County Sheriffs Office
Clearwater Housing Authority
Council of Governments
Florida Department of Labor and
Employment Security
Florida Department of
Transportation
For[ Pierce Utilities Authority
Gainesville Housing Authority
Hillsborough County Aviation
Authority '
Jacksonville Electric Authority
Jacksonville Port Authority
Jacksonville Transportation
Authority
City of Key West Utility Board
Manatee County Housing
Authority
Naples Airport Authority
New Smyrna Beach Utilities
Commission
North Naples Fire Control and
Rescue District
Orlando Utilities Commission
Greater Orlando Aviation
Authority
Palm Beach County Sheriffs
Office
Palm Harbor Special Fire Control
District
St. John's River Power Park
Project
Sarasota-Manatee Airport
Authority
South Florida Conservancy
District
South Florida Water Management
District
South Trail Fire Protection and
Rescue Service District ,
Space Coast Labor Management
Health Coalition
Sumter County Sheriff s Office
Tampa Housing Authority
Tampa Port Authority
EDUCATION
Broward County School
Board
Charlotte County School
Board, FL
Charlotte County Board of
Public Education, NC
Duval County Schoo] Board
Eckerd College
Florida Community College
Florida Community College
of Jacksonville
Henrico County School
Board, VA
Hillsborough County School
Board
Lake County School Board
Manatee County School
Board
Mecklenburg County School
Board, NC
Miami-Dade Community
College
Miami-Dade County Public
Schools
School Board of Palm Beach
County
Pinellas County School Board
Polk County School Board
Putnam County School Board
School Board of Sarasota
County
School Board of Seminole
County
Shorecrest Preparatory School
St. John's Junior College
St. Petersburg Junior College
The Vanguard School
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AGRICULTURE
erican Agronomics
oration
Golden Gem Growers,
Inc.
vrassland Development
Corporation
Hollins Corporation
CN of Delaware, Inc.
f The Powell Group
Pursley, Inc.
Quality Grassing &
~3ervices, Inc.
COMMUNITY
ASSOCIATIONS
X000 Island Blvd.
Condominium Assoc.
?600 Island Blvd.
Condominium Assoc.
X800 Island Blvd.
Condominium Assoc.
3000 Island Blvd.
:Condominium Assoc.
4000 Island Blvd.
Condominium Assoc.
17000 Island Blvd.
Condominium Assoc.
Boca Grande Club
fhe Charter Club
~lub Longboat Beach & T
Mediterranean Village
ivlaster Association
~5cean Reef Club
Pirates Cove
Condominium Assoc.
!;Fort Royal Club
Jn Top of The World
Owners Property
~~Ianagement
Zeef Resort
condominium
Association
Cowers of Quayside No.
', Condominium Assoc.
Nilliams Island Property
Owners Association, Inc.
Nhispering Waters
condominium Assoc.,
nc
'elican Cove
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SIVER NON-GOVERNMENTAL-CLIENTS (Current and Previously Served):
CONTRACTOR/DEVELOPER
All State Homes
Lee Arnold & Associates, Inc.
Barron Collier Corporation
Bay Plaza Cos.
Baymont Engineering Company
Burnup & Sims, Inc.
Coastal Steel Construction Co.
DDI, Inc.
Eastern Environmental Services, Inc
F & S Frame & Trim, Inc.
Florida Progress Corporation
Hallmark Development Corp.
Krauss Company
North Florida Concrete
Paragon Group, Inc.
Parsons Brinckerhoff Construction
Services, Inc.
Arthur Rutenburg Homes
Shimberg Enterprises, Inc.
Southeast Capital Corporation
Wadsworth Development Company
P. Wallenberg Development Co., Inc.
Wellington Real Estate
J. H. Williams Oil Company
FINANCIAL
INSTITUTIONS
Bay Financial Savings Bank
Centerbanc Savings
Chrysler Capital Corporation
Community Bank
First National Bank of
Okaloosa
FMI Financial Corporation
Hendry County Bank
Heritage Federal Savings &
Loan Association
Home Builders Insurance
Services, Inc.
Landmark Union Trust Bank
of St. Petersburg
McNulty Banking Company
Mutual Fire Policyholders
Committee
National Bank of Lee County
New Hampshire Insurance
Group (AINetwork)
Park Banks of Florida, Inc.
Pioneer Savings Bank
R.J. Financial Corporation
Rockwood Programs, Inc.
Southeast Capita] Consulting
SouthTrust Bank
Suncoast Schools Federal
Credit Union
T.R. Jones & Company
HEALTH CARE (Cont'd)
Indian River County Hospital
Authority
Indian River Memorial
Hospital
Manatee Memorial Hospital
Mease Health Care
Mease Hospital
Mease Manor, Inc.
Memorial Regional
Rehabilitation Center
Memorial Medical Center of
Jacksonville
Memorial Hospital of
Jacksonville
Metropolitan Genera] Hospital
H. Lee Moffitt Cancer Center
& Research Institute
Morton F. Plant Hospital
Mount Sinai Medical Center
Pathology Associates
S.A. Insurance, Ltd.
St. Anthony's Health Care
Center, Inc.
St. Anthony's Hospital
St~ Francis Hospital
St. Joseph's Hospital
St. Luke's Hospital
Association
St. Mary's Hospital
Shands Teaching Hospital &
Clinic
South Broward Hospital
District
South Florida Baptist Hospital
STRAIGHT, Inc.
Suncoast Hospital
Suncoast Osteopathic Hospital
SunHealth Care Plans - Gu]f
Coast, Inc.
Tallahassee Memorial
Regional Medical Center
Unipsych
University Community Hospital,
HEALTH CARE
All Children's Health System
Allegany Health Systems
AMI/Florida Region
Anesthesia Professional
Association
Bay Area Renal Stone Center
Bay Medical Clinic, Inc.
Bayfront Medical Center
Cedars Medical Center
Dun & Bradstreet Plan
Services, Inc. '
Duval County Beaches Public
Hospital Board
FirstHealth of the Carolinas
Heritage Hospital (formerly
Centro Asturiano Hospital)
Highlands County Hospital
District
Inc.
University Medical Center
Venice Hospital
Vision Care Network
Winchester Gardens
Winter Haven Hospital
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SIVER NON=GOVERt'~1MENTAL CLIENTS (Current~and Previously Served, Continued):
V UFA CTURING
ce Plasma
..ems, Inc.
American District
Telegraph Company
Diamond Products
Company
Hughes Manufacturing,
lnc.
Precisionaire, Inc.
Saddle Creek
Corporation
atant Corporation
Thompson & Co., Inc.
Tiffany Furnitwe
Industries, Inc.
Tri-Chem, Inc.
Tropical Garment
VOT-FOR-PROFIT
Clearwater PACT, Inc.
Florida United Methodist
~hildren's Home
Joodwill Industries
3uncoast, Inc.
fohn Knox Village
OTHER ENTERPRISES
Affiliated of Florida, Inc.
Allied International Holdings
American Rental Dealers Inswance
The Beacon Group, LLC
Sam P. Broady, Inc. Communications
Church & Tower, Inc.
Russ Cline & Associates
Equity Associates
FCA Fruit & Vegetable (FFVA)
Insurance
Florida First Service Inswance
FFVA Mutual Inswance
Florida Lawyers Legal Inswance Corp.
Florida Power & Light
J.D. Garner & Associates, Inc.
Jim Garrison, Inc.
Hardrives Company
Hollins Corporation
Insurance Catastrophe Consultants, Inc.
Laney & Duke Warehouse Company
Lucas Ford Associates, Inc.
Morefar Marketing, Inc.
Michael Mullery, M.D.
PDG Environmental
Performance Feeders, Inc.
The Pierre Association, Inc.
Poe & Associates, Inc.
Universal Studios of Florida
Valjean Corporation
RECREATION/SPORTS
Biscayne Kennel Club
Boca Grande Club
Carlouel Yacht Club, Inc.
The Center Foundation, Inc.
Feather Sound Country Club
The Florida Aquarium
Florida Suncoast Dome
International Speedway Corp.
Major Bowl Association
NASCAR, Daytona Beach
Orange Bowl Committee
Port Royal Club
St. Petersbwg Grand Prix
St. Petersbwg Yacht Club
Tampa Yacht & Country Club
Venice Yacht Club
RETAIL/WHOLESALE
B & R Foods Holding, Inc.
Badcock Economy Furniture
Stores, Inc.
W. S. Badcock Corporation
Baymont Technologies, Inc.
Belco Electric, Inc.
Bishop's Welding Supply
BuyingBrain
Coral Cadillac
Cox Lumber Company
Davgar Restawants, Inc.
Dew Cadillac, Inc.
Diamond Motor Sports
Dick Devoe Buick-Cadillac,
Inc.
Dimmitt Cadillac, Inc.
Gate Petroleum
Gerhardt's, Inc.
Great Bay Distributors, Inc.
Grevgold Enterprises
Hav-a-Tampa Corporation
Hospitality Resowces, Inc.
Kane Furniture Company
Lerner Corporation
Logan Lumber Company
Jim Lynch Enterprises, Inc.
Manufactwed Housing
Products
Marlow-Werner Pontiac-
Buick-GMC
McNichols Co.
Mid-America Industries, Inc.
National Merchandise Co., Inc.
Oyster Bar of Clearwater
Parkway Food Service, Inc.
Pic N Save Drug Co., Inc.
Sacino & Sons, Inc.
Save On Seafood Company
Scotty's, Inc.
Thomas Restawant
Management
United Auto Parts
United Seafood Imports, Inc.
Wal-Mart Stores, Inc.
Winn-Dixie Stores, Inc.
Yesterday's Restawant
7,ier, Inc. dba Discount
t1niform
TRANSPORTATION
Emery Air Freight Corporation
Joule Yacht Transport, Inc.
People Express Airline, Inc.
Purolator Courier Corporation
Shaw Trucking Company
Sun State Marine, Inc.
TRUSTS & ASSOCIATIONS
American Association of Airport
Executives
American Dental Association
Automotive Warehouse
Distributors
Broward County Consolidated
Consortium
Federal Realty Investment Trust
Florida Associated General
Contractors Benefit Trust
Florida Association of Counties
Florida Association of Inswance
Agents
Florida Bar Association
Florida Comprehensive Health
Association
Florida Health Care Association
Florida Petroleum Marketers
Health
Florida Pest Control Association
Greater Tampa Association of
Realtors
Group Health Benefits
Pwchasing Consortium
Hillsborough County Pwchasing
Department
Idaho Cattleman's Association
National Association of
Building Service Contractors
Pinellas Classroom Teachers
Association
Prestressed Concrete Institute
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E: SUMMARY OF THE PROPOSER'S pUALIFICATIONS
Brenda Sadler, Vice President and Siver's practice leader for the Employee Benefits Division is the
primary individual assigned to this audit project. Ms. Sadler has over 20 year of auditing experience,
having audited multiple carriers and third party administrators. Ms. Sadler's background includes
several years experience in claims adjudication and claims auditing and also served as the manager
of a third party administrator in Atlanta, Georgia. Her knowledge of various claims adjudication
systems as well as her experience with both self-funded and fully insured programs provides Ms.
Sadler with the expertise to perform the requested services. Additionally, Ms. Sadler is frequently
called upon to interpret policy language as well as normal industry protocol. She personally
conducted each of the audits listed in our proposal response to the request for references, located
under Tab F. Ms. Sadler's curriculum vita is attached for your review, following this page.
Insurers and Third Party Administrators Audited by Ms Sadler
Insurers Third Pa Administrators
Aetna Administrative Services, Inc.
Blue Cross Blue Shield Anchor
CIGNA Anthem
Confederation Life Benefit Services, Inc.
Florida Healthcare Coo erative Florida First
Prudential Hunt
Trustmark Jenkins & Associates
Em loyers Mutual, Inc. Robey Barber
Talma e
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EDUCATION
BRENDA M. SADLER
Vice President & Senior Consultant
State of Florida Life Health and Variable Annuity License -Certified Employee Benefits Specialist
(CEBS) Recognition of Academic Achievement in Group Benefits through the University of
~? Pennsylvania -Completed full course of study through Health Insurance Association of America
(HIAA)
BUSINESS EXPERIENCE
Over 32 years' experience in the Health and Welfare Industry with a focus on managed care, client
development, underwriting, product analysis and rate negotiation -Heavy claims background,
including management of a Third Party Administrator (TPA) organization and over 20 years' claims
auditing experience
AREAS OF EXPERTISE
Underwriting skills and renewal evaluations -Plan design -Enrollment material development -
Policy & Procedure development -Claims audits -Network negotiations -Contract negotiations -
SPD design -Product analysis -COBRA & HIPAA Compliance-RFP Development- Proposal
Analysis
Prior Senior Management position with a major group insurance company -Committee member for
Member Education, Quality Improvement, NCQA, Risk Management, and Disease Management
Programs
PROFESSIONAL ACTIVITIES
Florida West Coast Employee Benefits Council (1996 & 1997) - 1997 FAHMO Event Committee -
Inroads Mentor (1996 & 1997) -National Association for Female Executives (NAPE) (1999-2001)
Current member of Leadership Tampa Alumni (Class of `97), -International Foundation of
Employee Benefit Plans (IFEBP) -Member, Society of Risk Management Consultants, -Business
Member of FERMA
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Brenda M. Sadler - (Continued) -
PARTIAL LIST OF CLIENTS PREVIOUSLY SERVED
• Charlotte Mecklenburg School System
• City of Dania Beach
• City of Fort Pierce
• City of Charlotte (NC)
• City. of Hollywood
• City of Miami Beach
• City of St. Petersburg
• City of Tampa
• City of Winter Haven
• Coca Cola Corporation
• DANKA
• Fiserv
• Flagler (The Breaker's)
• Florida Power Corporation & Florida Power & Light
• Fort Pierce Utilities Authority
• Fort Worth School District
• Hillsborough County Government
• Hillsborough County Indigent Health Care Plan
• Hillsborough County School District
• Lee County Sheriff's Office
• Logan Lumber Company
• Martin County School Board
• McNichols Company
• North Naples Fire Control & Rescue Unit
• Northern Telecom (Norte])
• Palm Harbor Special Fire District
• Perkins Restaurants
• Pic `N Pay Shoes
• Pinellas County School Board
• Polk County Schools
• Raymond James Financial
• Shriner's Hospital
• Staffing Concepts
• Tampa General Hospital
• Tech Data
• TECO
• Thompson & Company
• Times Publishing
• Tucson Electric Power
• University of Arkansas
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F: REFERENCES (client audits conducted within the last three years)
FORT PIERCE UTILITIES AUTHORITY
206 South Sixth Street
Fort Pierce, FL 34950
Mr. Doug Giel
Director of Human Resources
Tel.: (772) 466-1.600 ext. 3265
Fax.: (772) 429-2035
Email: dgiel e,fpua.com
Siver has conducted numerous audits for this client. Our most recent audit was performed the week
of February 7, 2005. This audit included review of medical, dental, and prescription drug claims for
the plan year 2004. The final results of this review of services provided by the Third Parry
Administrator, Employers Mutual, Inc. are pending client review.
HILLSBOROUGH COUNTY GOVERNMENT
601 E. Kennedy Blvd.
Tampa, FL 33602
Mr. Jack Kroll
Finance Services Manager
Tel.: (813) 272-5040
Fax: (813) 276-2865
Email: krolli(a,hillsboroughcounty.org
Ms. Lillie H. Joe
Contracts Manager
Tel: (813) 301-7341
Fax: (813) 276-2865
Email: Joel (a,hil lsborou~hcount~ rg
Siver has conducted three separate audits for this client. Siver was engaged by Hillsborough County
to conduct an independent review of the Claims Settlement Process developed and managed by the
County. The audit included an overview of the process utilized by the County to resolve payment of
unprocessed health claims incurred prior to February 15, 2002. The settlement process was
generated in response to network providers who complained that numerous claims had not been
processed by the administrator for the County's indigent health plan from October 1, 2000, through
February 15, 2002.
Siver Insurance Consultants (Siver) was subsequently ongaged by Hillsborough County to conduct
an independent review of the new claims administration services provided by Administrative
Services, Inc. (ASI) in conjunction with the County's Indigent Health Caze Plan. This audit included
an overview of the process utilized by ASI to adjudicate claims during the first half of calendar yeaz
2003. This audit was concluded in September of 2003 and a similar audit was conducted in
September of 2004, covering the period subsequent to the 2003 audit.
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CITY OF-WINTER HAVEN
I 431 Third Street, NW
P. O. Box 2277
Winter Haven, FL 33883-2277
Ms. Michele Stayner
Community and Workforce Services Department Director
Tel.: (863) 291-5667
Fax: (863) 291-5623
Email: mstaynerna,mywinterhaven.com
At the request of the City of Winter Haven, Siver Insurance Consultants conducted an audit of the
I Claims Administrative Services provided to the City by Blue Cross Blue Shield of Florida. The
' scope of the audit project included a random review to confirm if claims from the first eight months
of 2003 were processed according to the City's benefit schedule. Additionally Siver's audit included
a targeted review of claims denied, to determine if covered services might have been excluded in
error or if claims were appropriately rejected for additional information. This audit was completed in
October of 2003.
CITY OF FORT PIERCE
100 North U.S. Highway One
P. O. Box 1480
Fort Pierce, FL 34954
Mr. George Bergalis
Director of Finance
Tel.: (772) 460-2200, ext. 332
Fax: (772) 489-2594
Does not utilize Email
Our most recent audit for this client was performed the week of February 7, 2005. This audit
included a review of medical, dental, and prescription drug claims for the plan year 2004. The final
results of this review of services provided by the Third Party Administrator, Employers Mutual, Inc.
are pending client review.
Siver has conducted numerous audits for this client, including an audit of the City's prior TPA,
conducted in 2002.
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LEE COUNTY SHERIFF'S OFFICEF; ~~
14750 Six Mile Cypress Parkway
Fort Meyers, FL 33912-4406
Mr. George Mitar
Legal Director
Tel.: (941) 980-9994
Fax: (941) 477-1040
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Siver Insurance Consultants (Siver) were engaged by the County of Lee Sheriff's Office to conduct
an independent audit of the Employee Benefit Plan administered by Hunt Insurance Group, Inc.
The audit, conducted in May of 2002, covered claims adjudicated by Hunt and incurred from June
2000 through the end of October 2001.
MARTIN COUNTY SCHOOL BOARD
500 East Ocean Blvd.
Stuart, FL 34994
Ms. Julie Sessa
Employee Benefits Risk Manager
Tel.: (772) 219-1200 x.30206
Fax: (772) 219-1226
Martin County School Board engaged Siver Insurance Consultants (Siver) in May of 2002, to
conduct an independent audit of the employer sponsored Employee Benefit Plan, administered by
CIGNA. The audit period included claims adjudicated by CIGNA for claims incurred from
November of 2000 through the end of October of 2001. This audit was completed in August of 2002.
COLLIER COUNTY SHERIFF'S OFFICE
3301 Tamiami Trail East, Building J
Naples, FL 34112
Ms. Carol Golightly
Assistant Finance Director
Tel.: (239) 793-9230
Fax: (239) 793-9405
At the request of Collier County Sheriff's Office, Siver Insurance Consultants conducted athree-
phase review of the Group Health Plan and the Claims Administration Services provided to the
Sheriff's Office by Hunt Insurance Group, Inc. (Hunt), a division of Hilb, Rogal & Hobbs (HRH).
The three-phase scope of the project included a series of Focus Group Interviews with employees; a
comparison of the Group Health Plan offered by the Sheriff's Office to other Florida Group Health
Plans; and an on-site claims audit at Hunt's offices to confirm if 2003 health claims were processed
according to the Sheriff's Office Plan parameters. The project was completed in July of 2004.
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G: FEES --
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IMPORTANT NOTE
While the Scope of Services indicates the audit was intended to include a review of 100% of the
processed claims for medical, dental, hospitalization, and prescription drug claims, it is our
experience that the typical audit consists of a sampling of paid claims, rather than a 100% review.
The sample is randomly selected from a listing of all processed claims to determine if any significant
discrepancies exist. In the absence of significant discrepancies, a full claims audit is usually
unnecessary and would prove to be cost prohibitive.
Based on the population indicated for this group, Siver recommends an initial sampling of 5% or
approximately 400 claims. Our selection process would cover claims throughout the 12 month claim
period requested and would include samples from each of the categories indicated (medical, dental,
hospitalization and prescriptions).
Should the initial sampling reveal an error ratio in excess of industry standards, Siver would contact
the Village of North Palm Beach to determine if an extended audit is desired.
With these comments in mind, Siver has offered a project estimate, based on review of an initial
sample consisting of 400 claims. Based on information obtained from Employer's Mutual Inc., 400
claims represents an audit sample of approximately 5% of the claims adjudicated during the audit
period indicated. A 5% audit is consistent with industry standards.
To the extent that a larger audit is desired, we have provided our fee for each additional 100 claims
to be reviewed. We are available to discuss our fee structure and will provide adjusted estimates
based on other parameters, if desired.
- Auditor Rate:
- Technical &,Administrative Support Rate:
- Travel & Business Expenses:
$150.00/Hour
$ 40.00/Hour
Pass Through Basis to Client
Estimated Cost
- First 400 Claims
- Each Additional 100 Claims Reviewed
- Travel & Business Expenses:
$ 7,500.00
$ 1,200.00 ,
Pass Through Basis to Client