Agenda 03/13/2012 Item #11G3/13/2012 Item 11.G.
EXECUTIVE SUMMARY
Recommendation to waive competition and declare Naples Physician Hospital
Organization Inc. d /b /a Community Health Partners, Inc. a sole source for the provision
of integrated Health Advocacy, Disease Management, Workers' Compensation
Managed Care and Physician Hospital Network Services in an estimated amount of
$382,319.28 in calendar year 2012.
OBJECTIVE: To provide Health Advocacy, Disease Management, Physician Hospital Network and
Workers' Compensation Managed Care Services.
CONSIDERATIONS: The Board of Commissioners through its Risk Management Department
administers a partially self - funded Group Health Insurance Program (the Plan) for its employees and
their eligible dependents. The Plan is structured around a wellness based incentives model which is
designed to incentivize members to improve their overall health. In order to accomplish this objective,
the Plan integrates the physician /hospital network of over 800 providers, disease management
services, health advocacy services, and the associated information systems services provided locally
by Community Health Partners (CHP). Currently, the NCH Health System, the District School Board,
and the Board of Commissioners use this model and contract with CHP for these services. The Collier
County Sheriffs Office is in the process of pursuing a similar model but does contract with CHP for the
majority of these services. The contract with CHP will terminate on March 31, 2012.
The current wellness based incentives model was created from the ground up by three of the four
members of the Consortium (NCH, District School Board, and BCC) in partnership with CHP. The
model did not exist locally prior to 2009 and is not an "off the shelf' program. Staff has reviewed the
local market and determined that there is no other single vendor (other than CHP) that can provide all
of these services in an integrated manner. Staff asked the Board's contracted benefits /actuarial
consultant, Willis, Inc. to review the matter and provide an opinion as to whether CHP should be
considered a sole source for this service. Willis opined as follows.
"In our opinion it would not be possible to duplicate the current integrated structure that exists today by
stitching together groups of independent vendors or hiring a firm that purports to be integrated. In
addition, fragmentation of service delivery adds to structural costs, missed opportunities to mitigate
costs and other inefficiencies which would operate to the detriment of the County. The only alternate
would be if either NCH or HMA decided to create a separate PHO (Physician Hospital Organization) in
which case competitive bids might be appropriate. If this occurred, Community Health Partners would
not be the sole source for these services within a PHO platform." Douglas J. Ley, Senior Vice
President / Director, National Actuarial Practice and Human Capital Practice
It is important to note that neither NCH nor HMA have expressed a desire to create a separate PHO.
Staff concurs with this opinion. Further, as the implementation of Patient Protection and Affordable
Care Act (PPACA) is developed and finalized, it is imperative that County have the ability to integrate
its plan design with the health care provider resources available within the community to assure
compliance.
The provision of Workers' Compensation managed care services is also included in the current
contract. Similar to group health managed care services, the objective of the program is to manage the
delivery of care to injured employees in a prompt, efficient manner that comports with the County's
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3/13/2012 Item 11.G.
return to work and occupational health objectives. The CHP Workcare program has been a critical
partner, contributing to a premium reduction of 32% since FY 08.
CHP drafted an Agreement to continue to provide these services. Staff and the County Attorney have
reviewed the agreement. Staff is recommending that the Board waive competition per the Board's
Purchasing Policy V. B. based upon the opinion of the County's benefits and actuarial consultant and
approve the Agreement. The Agreement will commence April 1, 2012.
FISCAL IMPACT: The estimated cost of this Agreement is $382,319.28 in calendar year 2012 based
upon an average enrollment of 1,985 employees. The Agreement contains an initial term of 33 months
with the option to renew for two additional one year periods. The Agreement contains a 3% price
increase on January 1, 2013 and at renewal. The Agreement also contains a termination for
convenience provision with 90 days written notice should the competitive landscape change in the
interim. Funds are budgeted and available within Fund 517, Group Health and Life as well as Fund
518, Workers' Compensation Insurance for this purpose.
GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with this
item.
LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney's Office, requires
majority vote, and is legally sufficient for Board action. — CMG
RECOMMENDATION: That the Board waives competition and declares Naples Physician Hospital
Organization, Inc. d /b /a Community Health Partners, Inc. a sole source for the provision of integrated
Health Advocacy, Disease Management, Workers' Compensation Managed Care and Physician
Hospital Network Services and authorizes the Chairman to execute the Agreement.
PREPARED BY: Jeffrey A. Walker, CPCU, ARM, Director, Risk Management
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3/13/2012 Item 11.G.
COLLIER COUNTY
Board of County Commissioners
Item Number: 11.G.
Item Summary: Recommendation to waive competition and declare Naples Physician
Hospital Organization Inc. d /b /a Community Health Partners, Inc. a sole source for the provision
of integrated Health Advocacy, Disease Management, Workers' Compensation Managed Care
and Physician Hospital Network Services in an estimated amount of $382,319.28 in calendar
year 2012.
Meeting Date: 3/13/2012
Prepared By
Name: WalkerJeff
Title: Director - Risk Management,Risk Management
2/15/2012 11:09:43 AM
Submitted by
Title: Director - Risk Management,Risk Management
Name: WalkerJeff
2/15/2012 11:09:44 AM
Approved By
Name: pochopinpat
Title: Administrative Assistant,Facilities Management
Date: 2/27/2012 2:58:31 PM
Name: WoodLyn
Title: Contracts Specialist,Purchasing & General Services
Date: 2/28/2012 8:52:54 AM
Name: MarkiewiczJoanne
Title: Manager - Purchasing Acquisition,Purchasing & Gene
Date: 2/28/2012 2:31:07 PM
Name: WardKelsey
Title: Manager - Contracts Administration,Purchasing & Ge
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Date: 2/28/2012 2:49:18 PM
Name: GreeneColleen
Title: Assistant County Attorney,County Attorney
Date: 2/29/2012 9:47:22 AM
Name: PriceLen
Title: Administrator, Administrative Services
Date: 3/1/2012 10:44:10 AM
Name: KlatzkowJeff
Title: County Attorney
Date: 3/2/2012 3:38:52 PM
Name: FinnEd
Title: Senior Budget Analyst, OMB
Date: 3/3/2012 4:13:59 PM
Name: OchsLeo
Title: County Manager
Date: 3/4/2012 8:00:10 PM
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3/13/2012 Item 11.G.
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3/13/2012 Item 11.G.
From: Ley, Douglas [ley_dj @willis.com]
Sent: Wednesday, September 28, 201111:37 AM
To: WalkerJeff
Cc: ToppeAlice; SweetSonja; Hollochedoel; Meredith, Mike; Wiesing, Sue
Subject: RE: CHP Contract
Jeff,
Individually each of the services referenced in your e-mail below could be purchased individually. For example,
there are a host of firms or insurance carriers that will offer access to a provider network, provide case
management and utilization review services.
However, the evolution of the delivery of a new medical model in Collier County is not based on the piecemeal
acquisition of the services referenced below. Rather the current model is based on an integrated partnership with
the local providers that focuses on health improvement and filling what we refer to as a care gap. Filling the care
gap was accomplished by the creation of a new position within the health care community known as the health
advocate. When the County began the journey to support efforts for employees and their dependents to become
more aware of their health status and take steps to maintain heath and address health issues, we realized there
was a fundamental and significant gap that existed in the delivery of healthcare.
Physicians are trained to find what is broken and fix it. They do not have the time, they are not trained and they
are not paid to make sure people understand their suggested treatment and follow through on it. The overall
declining health of America is ample evidence of the existence of the care gap. Initially the County briefly
considered hiring staff to help fill the care gap. However, the County is not directly in the health care business.
Further, due to confidentiality and head count concerns the County, did not believe it was appropriate hire the staff
to perform this function. Finally, based on the focus groups that Willis conducted, employees wanted advocates
to be local, knowledgeable of the health care environment, credentialed health care professionals and dedicated
to the County. Therefore, the decision was to look to the local provider community to hire health care
professionals to act as advocates dedicated to the County. These advocates would fill the care gap, work with
local providers and be held accountable to delivering measurable improvements in the health of employees and
dependents.
Could another organization do this? On a high -level yes, but not on the accountable and integrated fashion that is
currently in place for the County. The individuals are dedicated to the County and act as an extension of both the
County and the local physician hospital organization.
Most geographic markets in Florida have Physician Hospital Organizations (PHOs). For example, a PHO also
exists in Lee County called the Lee County physician hospital organization. This is very similar to Community
Health Partners the PHO in Collier County. However, it does not operate in Naples. A PHO is formed around a
hospital and a group of physicians the hospital works with to serve a local community. If there is more than one
hospital in a community there could be more than one PHO. This is not the case in Naples as all the hospitals
have agreed to work as one PHO. PHOs are, by their nature exclusive to the hospital that works with physicians
to create one. Therefore, although a single vendor or group of vendors may be able to provide the services the
Government enjoys today, they would not be integrated with and represent the local healthcare delivery system.
Such integration and provider support is vital to the success of the program.
Another thing to keep in mind is that the advocates are dedicated to the County and their costs are passed
directly through to the County by Community Health Partners. These individuals live in Collier County, are
taxpayers and contribute to the community. Therefore even if a different management firm were engaged, it would
not change the overall cost structure in any material way since these individuals are mostly self- directed and
Community Health Partners does not add material management fees to the transaction.
In our opinion it would not be possible to duplicate the current integrated structure that exists today by stitching
together groups of independent vendors or hiring a firm that purports to be integrated. In addition, fragmentation
of service delivery adds to structural costs, missed opportunities to mitigate costs and other inefficiencies which
would operate to the detriment of the County. The only alternate would be if either NCH or HMA decided to
create a separate PHO in which case competitive bids might be appropriate. If this occurred, Community Health
Partners would not be the sole source for these services within a PHO platform.
I hope this addresses your questions regarding this matter. Please feel free to call me if you need any further
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input or discussion.
Thanks,
Doug
Douglas J. Ley
Senior Vice President / Director
National Actuarial Practice and Human Capital Practice
Willis
2323 North Mayfair Road
Suite 600
Milwaukee, Wisconsin 53226
douglas.leva.willis.com
Office:
(414) 203 -5248
Cellular:
(414) 640 -2710
Toll Free:
(800) 558 -1536 ext 5248
Fax:
(414) 271 -2805
THE WILLIS CAUSE
We thoroughly understand our clients' needs and their industries.
We develop client solutions with the best markets, price and terms.
We relentlessly deliver quality client service.
• We get claims paid quickly.
...WITH INTEGRITY
Click here for more information about The Willis Cause.
The information in this e-mail is intended only for the confidential use of the individual or entity to which it is
addressed. It may contain information that is privileged, confidential, and exempt from disclosure under law. If
the reader of this message is not the intended recipient, you are hereby notified that you have received this
document in error and that any review dissemination, distribution or copying of this message is strictly prohibited.
If you have received this communication in error, please notify us immediately at the e-mail address listed above.
Thank you
From: WalkerJeff jmailto :JeffWalkerCa>collier4ov.net1
Sent: Tuesday, September 20, 2011 10:16 AM
To: Ley, Douglas
Cc: ToppeAlice; SweetSonja; Hollocherloel
Subject: CHP Contract
Doug,
I have to make a recommendation to the BCC regarding the CHP Agreement. I need an opinion from you
regarding the ability of other vendors to duplicate, in its entirety, the services provided under the CHP
agreement. These services include:
• The provider network
• Case and Utilization Management
• Workers' Compensation Case Management
• Advocacy Services
Certainly these services can be unbundled, however, are you aware of any other firms that integrate these
services into a single package as does the current agreement? Also, do you feel in your opinion, the cost of these
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3/13/2012 Item 11.G.
services are competitive with these services if unbundled?
Thanks,
Jeff Walker
Under Florida Law, e -mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not
send electronic mail to this entity. Instead, contact this office by telephone or in writing.
For information pertaining to Willis' email confidentiality and
monitoring policy, usage restrictions, or for specific company
registration and regulatory status information, please visit
http: / /www.willis.com /email trailer.aspx
We are now able to offer our clients an encrypted email capability for
secure communication purposes. If you wish to take advantage of this
service or learn more about it, please let me know or contact your
Client Advocate for full details. - W67897
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3/13/2012 Item 11.G.
NAPLES PHYSICIAN HOSPITAL ORGANIZATION, INC. d /b /a
COMMUNITY HEALTH PARTNERS
MANAGED CARE SERVICE AGREEMENT #12 -5854
This MANAGED CARE SERVICE AGREEMENT (the "Agreement ") effective as of the
day of , 2012 , (the "Effective Date "), is entered into -by and between Naples Physician
Hospital Organization, Inc. d/b /a Community Health Partners ( "CHP ") and Collier County, Florida, a
political subdivision of the State of Florida ( "County ").
WITNESSETH:
WHEREAS, Community Health Partners has as its primary objective arranging for the delivery
or provision of certain Managed Care Services, Utilization Review Services, Case Management Services,
and Advocacy Services through a cost effective, coordinated, and integrated health care delivery system.
WHEREAS, the County has adopted a self - insured employee benefit plan for the provision of
Health Care Benefits, Managed Care Program and Utilization Review Program to Plan Members;
WHEREAS, the County, a self - insured employer, is ultimately responsible for payment of
Health Care Benefits, Managed Care Program, Utilization Review Program, Case Management Program,
and Advocacy Program in accordance with the terms and conditions of this Agreement; and
WHEREAS, the County desires to increase control over the cost of providing Health Care
Benefits to Plan Members and enters into this Managed Care Agreement to arrange for CHP, through
CHP Providers, to render Managed Care Program(s) to Plan Members in conjunction with County's
various Benefit Programs.
NOW, THEREFORE, for and in consideration of the mutual covenants contained in this
Agreement, the parties agree as follows:
ARTICLE I
DEFINITIONS
For purposes of this Agreement, the following terms shall have the meaning ascribed thereto:
1.1 Agreement. This Managed Care Agreement.
1.2 Benefit Program. The County's self insured employee benefit plans covered under this
Agreement, as amended from time to time.
1.3 Medical Emergency. The sudden onset of a medical condition manifesting itself by
acute symptoms of sufficient severity which, if not immediately diagnosed and treated, could reasonably
be expected to result in serious physical impairment to a bodily function, or serious and permanent
dysfunction of any body, organ or body part, or to cause other serious medical consequences which
include placing a Plan Member's health in permanent jeopardy.
1.4 CHP Hospital. Any hospital facility that has contracted as an independent contractor
with CHP to provide certain Health Benefit Plan to Plan Members.
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1.5 CHP Physician. A physician who has contracted as an independent contractor with
I
1.6 CHP Provider. A CHP Physician, CHP Hospital, and any licensed health care facility or
professional, who or which has entered into a written agreement with CHP.
1.7 Plan Benefits. Those inpatient and outpatient services that are ordered for Plan Members
by physicians and other licensed health care providers, covered under a Benefit Program.
1.8 Plan Member. Any person who has elected to receive health care benefits from or
through County's Benefit Program and who is eligible to receive Plan Benefits under the Utilization
Review, Managed Care or Advocacy portion of the Benefit Program included in this Agreement.
ARTICLE II
PROVISION OF SERVICES
2.1 UTILIZATION MANAGEMENT PROGRAM
Community Health Partner's Utilization Management Program shall use nationally recognized
guidelines to determine the appropriateness of medical services as well as the delivery setting and length
of stay for inpatient hospital and MR /CT services only. The appropriateness guidelines have been
developed to create practice pathways that integrate with procedures that require precertification.
Community Health Partners will be responsible for:
• Maintaining a local telephone line and an out of area toll free telephone line for enrollees of the
County's Benefit Plan to call for Precertification of defined procedures and medical services. This
may include non - emergent inpatient hospital confinements, outpatient hospital services, surgeries,
diagnosis testing and/or medical procedures.
• Providing Utilization Management service that will be available during standard business days,
Monday through Friday 8:00 am through 5:00 pm EST. Voice mail messaging will be available
during non - business hours /days, and calls will be returned on the next business day.
• Responding to Utilization Management requests for the medical services within twenty-four (24)
hours of the request verbally when all necessary medical information and eligibility status is
provided. Written confirmation of the decision will be mailed within the next business day of the
decision.
• Providing retrospective process of emergent admissions.
• Performing concurrent review and assist with discharge planning.
• Providing Precertification forms.
• Assisting County to determine the medical services and procedures that are to be included in the
Utilization Management Program.
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3/13/2012 Item 11.G.
• Providing analysis and reports of the Utilization Management Program. Standard reporting of
authorizations and Denials by CPT codes.
• Providing Precertification information to the County's claim administrator via email or fax. CHP will
coordinate with claim administrator the assignment of authorization numbers.
• Following CHP Grievance Procedure process that does not include medical services excluded by the
benefit plan.
• Providing Nurse and Physician review as necessary.
• Providing Pharmacy over rides for PPI's only and Pharmacy utilization reports.
• Providing basic Case Management.
• Providing basic Benefit Verification and Eligibility Information.
• Precertification process will not include any medical services requested or begun prior to the effective
date of this Agreement. CHP will not handle overlap Precertification processing.
The County will be responsible for:
• Providing written notification to their Benefit Plan enrollees of the Utilization Management Program
and the requirements of this program.
• Providing up to date enrollment eligibility information to CHP online.
• Assisting CEP with the integration of the Utilization Management Program with the County's claim
administrator.
• Distributing the Precertification forms as necessary to enrollees.
2.2 LARGE CASE MANAGEMENT
Community Health Partners will be responsible for:
• Case managing catastrophic chronic and acute illness.
• Case managing transplants, inclusive of negotiating rates, all authorizations, working with in -house
case management with discharge planning, i.e. home health, DME, Rehab services, etc.
• .The CHP Case Manager will use claims data to determine which members can most benefit from the
program. Members will be selected by high cost and high complexity diagnoses. Need for out -of-
network services will also be a factor.
•
The CHP Case Manager will attempt to negotiate rates for all services not available within the CHP
network, or the employer's national network. This service will be provided only with the written
approval of the employer's reinsurer when applicable.
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Determining inappropriate Emergency Room utilization of members that have had (3) or more
emergency room visits per calendar year. The 1CD -9 codes will be reviewed, and members with
inappropriate ER use will be contacted by the case manager. The case manager will encourage the
member to establish with a participating Primary Care Physician.
County will be responsible for:
• Encouraging their enrollees to participate in the Large Case Management Program.
• Assisting with the notification to employees about the Large Case Management Program.
• Providing Preventative Benefits to help identify potential health problems early.
• FaciIitating the production of monthly claims data files to the Large Case Management program.
2.3 MANDATORY CASE MANAGEMENT
Community Health Partners (CHP) will be responsible for:
• Monitoring a Covered individual's emerging risk, a condition or diagnosis that may be potentially
significant by utilizing several different methods such as Verisk Medical Intelligence, Notification
request, Pharmacy and TPA reports.
• CFIP Registered Nurse Case Managers communicating on a weekly basis until less intensity is needed
as determined by the Case Manager or the Covered Person is dis- enrolled from program.
• Communicating with individuals in the form of letters, phone calls, face to face meeting or encrypted
email.
2.4 SMARTCHOICE PROGRAM (Disease Management)
The SmartChoice Disease Management portion of the program will be used on a case by case as
needed basis for those employees seeking Gastric Bypass Surgery. Each employee will need to actively
enroll in SmartChoice and comply with an Active Participation Agreement for a period of one (1) year
prior to the surgery.
Reimbursement for this program will be calculated based on the number of individuals enrolled.
Community Health Partners will be responsible for:
• Providing telephonic entry assessment to determine eligibility for Smartchoice program.
Providing Disease Management for the following diagnoses: Coronary Vascular Disease, Asthma,
Diabetes and Life Style Management for those individuals seeking gastric surgery for weight loss
only.
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• Discharging members from the SmartChoice Disease Management program when they are in
compliance with the Active Participation Agreement and have completed one (1) year in the
program.
• Providing anonymous cost savings report to the County.
County will be responsible for:
• Encouraging their enrollees to participate in the Smartchoice Program.
• Assisting with the notification to employees about the Smartchoice Program.
• Providing claims data to the Smartchoice program as described below.
2.5 HEALTH ADVOCACY PROGRAM
Community Health Partners Health Advocates collaborate with the members of Collier County
Government to promote personal wellness goals and encourage their overall health status. They provide
support and guidance as members complete their preventative screenings for the "Invest in Your Health"
program. All CHP Health Advocates are Certified Health Coaches, have a background in Nursing or
Exercise physiology, and are skilled in motivational interviewing. They meet confidentially with
members to discuss personal results from labs /biometrics and the health risk questionnaire. The Health
Advocates assist members enrolling in all educational wellness requirements including Tobacco
Cessation, Pre - diabetes, Diabetes and Heart Smart. They also identify and initiate referrals to Case
Management, Dietary Counseling, Exercise programs, and Behavioral Health Services. Health Advocates
focus on prevention, wellness, and personal accountability. This dynamic partnership encourages
members to minimize those personal health risk factors that can lead to chronic medical illnesses.
Community Health Partners will be responsible for:
• Providing three (3) Community Health Partners employees dedicated to the Collier County
Government Health Advocacy Program. Employees will consist of
o Two (2) Health Advocates (Job Description Exhibit 2)
• One (1) Health Coordinator
• Each employee will work a minimum of forty (40) hours per week. Local travel will be
required.
• Health Advocacy staff working with Collier County Government Wellness Program Manager to
collaborate on the start up, implementation, and day to day management of the Health Advocacy
Program.
• Providing all applicable and necessary office equipment required for the employees including but
not limited to:
• Furniture
• Technology — computer, internet access, copier and fax machines
• Miscellaneous office supplies (paper, pens, notepads, etc.)
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• Securing and maintaining a three (3) year agreement with WellSource to provide Collier County
Government employees with access to the WellSource Personal Wellness Profile and Health
Activity Tracker program.
• Creating and maintaining a website specifically for the Health Advocacy Program.
• Assisting with notification to members reminding them to utilize their Preventative Benefits and
call for free telephonic assessment to determine entry to Smartchoice Program under Advocacy
Program.
County will be responsible to:
• Provide to CHP reimbursement for services on a quarterly basis as established in Schedule 4.7
attached. CHP will conduct a bi- annual review of services /staff provided to the Health Advocacy
Program and adjustment of payment terms may be granted with mutual agreement by both
parties.
• Provide to CHP reimbursement for any travel related expenses of dedicated Health Advocacy
Program staff in accordance with Section 112.061, Florida Statutes.
• Provide to CHP monthly reimbursement for the hosting of the Health Advocacy Program website.
• Provide to CHP Health Advocate staff the following operational equipment:
• Office Space
• Telephone [Minimum of three (3)]
• Appropriate printed/promotional material related to the Health Advocacy Program.
2.6 WORKCARE PROGRAM
Community Health Partners will be responsible to:
• Provide County with a Tracking Report template, for printing of Tracking Report forms and
provide instruction on the use.
• Provide County or County's workers' compensation claim administrator with verification, either
verbal or written, of a beneficiary's work - related injury or illness within twenty -four (24) hours of
the beneficiary's evaluation and notification by a participating provider, provided that the
Participating Provider or County notify's WorkCare of the injury or illness.
• Provide County or County's workers' compensation claim administrator with completed Tracking
Reports within twenty -four (24) hours of receipt from Participating Provider.
• Provide Case Management services on call twenty -four (24) hours a day, seven (7) days a week.
• Provide County or County's workers' compensation claim administrator with progress and status
reports for rehabilitation services only, every two (2) weeks on beneficiaries receiving treatment
from rehabilitation participating providers, provided that the Participating Providers provide such
information.
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• Assist County with training its management personnel with respect to participating in the
WorkCare Program.
• Case Manager will authorize all non- emergent medical care and provide documentation of
authorizations.
• Notify employer or County when there is a question of compensability for a reported injury.
• Provide case management services by a registered nurse case manager for up to one (1) year from
date of injury or date of surgery. Refer to Exhibit 4.7 of the Agreement for cost to provide case
management after one (1) year.
• Provide pre - certification utilizing Interqual criteria for all tests, procedures and surgeries with
expected cost greater than one thousand dollars ($1000.00).
• Provide file reviews with case manager and County as necessary.
County will be responsible to:
• Use its best efforts to assure that employees utilize the WorkCare Program and protocols.
• Use best efforts to assure that management initiates Tracking Reports for employee injuries or
illnesses and sends Tracking Report with employee to treatment location.
• Use best efforts to assure that WorkCare is contacted within twenty -four (24) hours of beneficiary
injury or initial onset of illness.
• Participate in appropriate WorkCare Program training.
• Find modified duty positions for beneficiaries receiving treatment when appropriate.
• Upon request, provide Workcare within a reasonable period, information related to claims paid
under the employer's workers' compensation program.
• Verify the enrollment and eligibility status of workers who present to Workcare Case
Management Program.
2.7 Countv Representations and Warranties. For purposes of CEP Providers compliance with
Rule 4 -153, Florida Administrative Code, County represents and warrants that its Benefit Programs are
completely and fully self - insured, except for any reinsurance or similar form of stop -loss insurance.
2.8 Grievances. Any complaints received by County or its claims administrator with respect
to the provision of the Managed Care Program by CB? shall be forwarded to CEP and shall be submitted .
for resolution in accordance with CEP's patient grievance resolution procedures attached hereto as
Exhibit 1.
2.9 Force Maieure. Neither CEP, any CEP Provider, nor County shall be liable or deemed
to be in default for any delay or failure in performance under this Agreement or other interruption of
service or employment deemed resulting, directly or indirectly, from acts of nature, civil or military
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authority, acts of public enemy, war, accidents, fires, explosions, employee strikes or work interruptions,
earthquakes, floods, hurricane, failure of transportation or any similar or dissimilar cause beyond the
reasonable control of such party.
3.0 Managed Care and Utilization Review Requirements. The County shall provide CHP
copies of the Utilization Review and Managed Care requirements and other conditions to be followed by
CBP and Plan Members with respect to providing Managed Care Services under a particular Benefit
Program. To the extent of any conflict between the terms of this Agreement and such policies the Plan
Benefits shall govern if the Plan Benefits address the specific conflict and if not the terms of this
Agreement shall govern provided, however, that in no event shall this Agreement amend the Benefit
Program.
3.1 Review Board. The County and CHP shall actively participate in a review board and
work toward creating equitable methods to measure outcomes of the CB? Managed Care Programs and
utilization strategies that have an impact on medical costs.
3.2 Notification of Claims Payment Administrator. Upon execution of this Agreement,
the County shall provide CHP with written notification of its designated third party administrator, if any,
and shall thereafter provide CHP with written advance notice ninety (90) days prior to any changes.
3.3 Program Fees. The County shall choose the Managed Care Program(s) and pay CHP
the fees for each program chosen as listed on Schedule 4.7 as compensation for each Managed Care
Program CHP provides.
ARTICLE III
TERM AND TERMINATION
3.4 Term. The initial term of the Agreement shall be for thirty-three (33) months from April
1,_2012 to December 31, 2014 and may be renewed for two (2) additional one (1) year periods in writing;
upon consent of the parties, unless either party gives the other notice of it intention not to renew at least
ninety (90 ) days prior to the annual anniversary of the Effective Date after the initial term of this
Agreement.
3.5 Termination With Cause. If either party materially breaches this Agreement (the
"Breaching Party") the other party (the "Non- Breaching Party") shall have the right to give the Breaching
Party written notice of the alleged breach and the Breaching Party shall have thirty (30) days following
receipt of such notice to cure the breach to the reasonable satisfaction of the Non - Breaching Party. If the
breach is not cured to the reasonable satisfaction of the Non - Breaching Party within the thirty (30) day
period the Non - Breaching Party shall have the right to immediately terminate this Agreement.
3.6 Obligations After Termination, Continuation of Care.
Termination of the Agreement shall not affect the rights, obligations and liabilities of the parties arising
out of transactions occurring prior to termination. Termination of this Agreement shall be without the
consent of or notice to any Plan Member or any other third party. Upon the termination of this
Agreement for any reason or cause, CET shall cooperate with County by taking reasonable and medically
appropriate measures to assure the assumption of Managed Care Services to Plan Members. CHP shall be
compensated for such services in accordance with the terms of this agreement. CHP shall furnish any
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information and take any action including, without limitation, continuing to provide Managed Care
Services, for up to thirty (30) days, as the County may reasonably request in order to effectuate an orderly
and systematic termination of CHI' duties and activities under this Agreement and the transfer of
obligations.
ARTICLE IV
GENERAL PROVISIONS
4.1 Relationship of Parties. The County and CHP acknowledge that CHP is an independent
contractor.
4.2 Recitals. Each of the recitals set forth above are true and correct and are incorporated
into and made part of this Agreement by reference.
4.3 Limitation of Assignment. This Agreement shall not be assigned by either party
without the prior express written consent of the other party.
4.4 Binding on Successors in Interest. To the extent permitted by this Agreement, the
provisions of and obligations arising under this Agreement shall extend to, be binding upon, and inure to
the benefit of the successors and assigns of CHP and the County.
4.5 Severability; Changes in Law. If any part of this Agreement is determined to be
invalid, illegal, inoperative or contrary to law or professional ethics, the part shall be reformed, if
possible, to conform to law and ethics; the remaining parts of this Agreement shall be fully effective and
operative to the extent reasonably possible. If any restriction contained in this Agreement is held by any
court to be unenforceable and unreasonable, a lesser restriction shall be enforced in its place and the
remaining restrictions shall be enforced independently of each other.
4.6 Conformance With Law. Each party agrees to carry out all activities undertaken by it
pursuant to this Agreement in conformance of all applicable federal, Florida and local laws, rules and
regulations.
4.7 Time of the Essence. Time shall be of the essence with respect to each and every term,
covenant, and condition of this Agreement.
4.8 Attornev Fees. In the event of any action, dispute, litigation or other proceeding relating
to or in connection with this Agreement, each party shall be responsible for their own fees, costs, and
expenses of counsel incurred in connection with that action, dispute, litigation or other proceeding.
4.9 Entire Agreement/Amendments. This Agreement supersedes all previous Managed
Care Service contracts and constitutes the entire agreement between the parties relating to the subject
matter of this Agreement. Oral statements or prior written materials not specifically incorporated in this
Agreement shall not be of any force and effect. In entering into and executing this Agreement, the parties
rely solely upon the representations and agreements contained in this Agreement. Except as otherwise
expressly provided in this Agreement to the contrary, no changes in or additions to this Agreement shall
be recognized unless and until made in writing and signed by an authorized officer or agent of CHP and
County.
4.10 Governing Law. This Agreement has been executed and delivered and shall be
construed and enforced in accordance with the laws of the State of Florida excluding and without
application of any choice of law principles except to the extent pre empted by federal law. Any action
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brought by the parties whether at law or in equity shall be commenced and maintained and venue shall
properly be in Collier County, Florida. The parties knowingly, intentionally and irrevocably waive any
claim that any suit, action or proceeding brought in Collier County, Florida has been brought in an
inconvenient forum. Each party further waives all rights to any trial by jury in all litigation relating to or
arising out of this Agreement.
4.11 Waiver of Breach. No provision of this Agreement shall be deemed waived unless
evidenced by a written document signed by an authorized officer or agent of CHP and the County. The
waiver by either party of a breach or violation of any provision of this Agreement shall not operate as, or
be construed to be, a waiver of any subsequent breach of the same or other provision of this Agreement
unless specifically provided for in the written instrument consenting to the waiver.
4.12 Paragraph and Other Headings. The section and other headings contained in this
Agreement are for reference purposes only and shall not affect in any way the meaning or interpretation
of this Agreement.
4.13 Gender and Number. When the context of this Agreement requires, the gender of all
words shall include the masculine, feminine, and neuter, and the number of all words shall include the
singular and plural.
4.14 Execution. This Agreement and any amendments may be executed in multiple originals,
each counterpart shall be deemed an original, but all counterparts together shall constitute one and the
same instrument.
4.15 Additional Assurances. The provisions of this Agreement are self - operative and do not
require further agreement by the parties; provided, however, at the request of either party, the other shall
execute, except as otherwise provided in this Agreement, any additional instruments and take any
additional acts as may be reasonably necessary to effectuate this Agreement.
4.16 Construction. This Agreement shall be construed without regard to any presumption or
other rule requiring construction against the party causing this Agreement to be drafted.
4.17 Authority. Each signatory to this Agreement represents and warrants that he possesses
all necessary capacity and authority to act for, sign, and bind the respective entity on whose behalf he is
signing.
4.18 Notice. Any notice given pursuant or relating to this Agreement shall be given by United
States mail, postage prepaid, certified or registered mail, return receipt requested, hand delivery, or
overnight delivery, and delivered to the addressee at the following address unless otherwise changed in
accordance with the provisions of this Section:
To Community Health Partners: To Board of County Commissioners, Collier
851 5b Ave N Suite 201 County, Florida
Naples, Florida 34102 3311 Tamiami Trail East
Attention: Contracting Dept. Naples, FL 34112
Attention: Risk Management Department
4.19 Cumulative Remedies. Remedies provided for in this Agreement shall be in addition to
and not in lieu of any other remedies available to either party and shall not be deemed waivers or
substitutions for any action or remedy the parties may have under law or in equity.
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3/13/2012 Item 11.G.
4.20 Marketing and Promotion. The County and CEP each reserve the right to and control
of its name, symbols, trademarks, logos and service marks presently existing or established in the future.
The County agrees that CHP may use its name in any publication listing the names of managed care
programs and health benefit plans with which CHP contracts. Except as provided in this Section, the use
of any written promotional documents, publicity, media advertising, or any other materials for public
disclosure carrying the name, trademark, service mark, or a pictorial likeness of either party shall require
the prior written consent of the other party.
4.21 Confidentiality. The County and CHP shall take all reasonable precautions to maintain
the confidentiality of this Agreement and any related information provided to or discovered and shall not
disclose this Agreement, the terms thereof, or such other information to any party other than a party
directly involved in the transaction contemplated by this Agreement. Confidentiality is subject to Chapter
119, Florida Statutes, also known as the Public Records Law.
4.22 Coordination of Defense of Claims. The County and CHP shall promptly notify the
other of any claims or demands asserted by third parties that arise under or related to this Agreement. The
parties shall make all reasonable efforts, consistent with advice of counsel and the requirements of the
respective insurance policies and carriers, to coordinate and assist in the defense of all claims in which the
other party is either a named defendant or has a substantial possibility of being named. This Section shall
survive termination or expiration of this Agreement.
4.23 Comiihance with Laws and Reaulation. In the event any applicable federal, state, or
local law or any regulation, order or policy issued under such law is changed (or any judicial
interpretation thereof is developed or changed) in a way which will have a material adverse effect on the
practical realization of the benefits anticipated by one or both parties to this Agreement, the adversely
affected party shall notify the other party in writing of such change and the effect of the change. The
parties shall enter into good faith negotiations to modify this Agreement to compensate for such change.
If an agreement is not reached within thirty (30) days of such written notice; the Agreement may be
terminated by either party.
4.24 Insurance. CHP shall provide insurance to County as follows:
A. Commercial General Liability: Coverage shall have minimum limits of $300,000 Per Occurrence,
$2,000,000 aggregate for Bodily Injury Liability and Property Damage Liability. This shall include
Premises and Operations; Independent Contractors; Products and Completed Operations and Contractual
Liability.
B. Workers' Compensation: Insurance covering all employees meeting Statutory Limits in compliance
with the applicable state and federal laws.
C. Professional Liability: Shall be maintained by CHP to ensure its legal liability for claims arising out
of the performance of professional services under this Agreement in the amount of $500,000.00.
Special Requirements: Collier County Government shall be listed as the Certificate Holder and included
as an Additional Insured on the Comprehensive General Liability Policy.
Current, valid insurance policies meeting the requirement herein identified shall be maintained by CEP
during the duration of this Agreement. Renewal certificates shall be sent to the County ten (10) days prior
to any expiration date.
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3/13/2012 Item 11.G.
CHP shall insure that all subContractors comply with the same insurance requirements that is required to
meet. The same CHP shall provide County with certificates of insurance meeting the required insurance
provisions.
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3/13/2012 Item 11.G.
IN WITNESS WHEREOF, the parties have caused. this Agreement to be duty executed as of the
Effective Date.
ATTEST:
Dwight E. Brock, Clerk of Courts
BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
By:
By: Print Name: Fred. W. Coyle
Dated:
Title: Chairman
Date:
NAPLES PHYSICIAN HOSPITAL ORGANIZATION, INC. d /b /a COMMUNITY HEALTH
PARTNERS
ATTEST:
By:
Corporate Secretary
H. David Greider, MD, Co- Chairman
Date:
Print Name
By:
Approved as to form and legal
sufficiency:
Deputy County Attorney
Scott R. Teach
Print Name
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Kevin Cooper, Co- Chairman
Date:
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SCHEDULE 4.7
PROGRAM FEES
3/13/2012 Item 11.G.
Board of County Commissioners, Collier County, Florida shall pay Community Health Partners monthly
the fees listed below for the Managed Care Programs that are indicated as purchased. The fee(s) shall be
paid upon receipt of a proper invoice and in accordance with Chapter 218, Florida Statutes, also known as
the "Local Government Prompt Payment Act." Fees to be disbursed to:
Community Health Partners
851 Fifth Avenue N. Suite 201
Naples, FL 34102
Utilization Management Fee:
CHP Utilization Review Management program with
Large Case Management /Care Coordination including Maternity
Management
$2.32 per employee per month*
* to increase by 3% annually beginning January 1, 2013, and an additional 3% each year thereafter
effective the first of the month of the new contract year.
SmartChoice (Disease Management Fee):
Six month program: $600.00 per person enrolled payable quarterly.
Health Advocacy Program Fees:
Year One:
Total amount due for period of April 1, 2012- December 30, 2012: $287,793.18
Year Two:
Total amount due for period of January 1, 2013- December 30, 2013: $395,236.08
* to increase by 3% annually beginning January 1, 2014, and an additional 3% each year
thereafter effective the first of the month of the new contract year.
WorkCare Program Fees:
CHP WorkCare Case Management program $2.65 per employee per month*
* to increase by 3% annually beginning January 1, 2013, and an additional 3% each year
thereafter effective the first of the month of the new contract year.
D2 Verisk Predictive Modeling Software $.17 per employee per month
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3/13/2012 Item 11.G.
EXHIBIT 1
Community Health Partners
PRECERTIFICATION POLICY & PROCEDURE
Policy: Appeals
Levels and Types
Original Date: 4/19/01
Page: 1 of 2 Revised Date: 01/01/12
Reviewed: 01/01/12
Policy: The Utilization Management Department will provide a documented
process for an appeal. The Utilization Management Precertif cation
Department will accept additional information from the member,
attending physician or other ordering provider over the telephone or via
facsimile or other acceptable means.
There are two levels of the appeal process and two types.
The level is identified internal and external
The two types are standard and expedited.
An internal appeal requires an expert medical advisor within the
Community Health Partners network to review the additional information,
initial documentation provided and any plan language that may apply to
render his/her decision.
An external appeal requires an independent reviewer to review the
additional information, initial documentation and any plan language that
may apply to render the decision.
A standard appeal will have a determination within 30 calendar days.
An Expedited appeal will have a determination within 72 business hours.
A member or provider may appeal any non - certified services within six
months of the initial denial.
Community Health Partners will maintain all records, correspondence,
dates and minutes of any appeal process.
Procedure:
The Utilization Management Committee will provide direction
and oversight of the expedited appeal process and will function as the Peer
Review Level. Responsibilities include immediate or on -call peer review
activities related to initial adverse review decisions (first level) or review
consulting services.
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3/13/2012 Item 11.G.
Community Health Partners
PRECERTIFICATION POLICY & PROCEDURE
Policy: Appeals
Levels and Types
Original Date: 4/19/01
Page: 2 of 2 Revised Date: 01/01/12
Reviewed: 01/01/12
• A panel of consulting physicians will be designated, as necessary to the
Utilization Management Committee for specialty review support. The panel
physicians minimally are board eligible and will span several specialties.
However, all reviews conducted through specialty or consulting reviews will be
reported back to the Utilization Management Committee:
External reviews are handled differently with respective payors:
Those employers utilizing Allegiance as the TPA:
All documentation will be placed on a folder on the FTP site (Appeals)
and an email notification will be sent to Allegiance to notify them of the
appeal. Allegiance will utilize independent reviewers of their choice for
the decision.
Those employers utilizing First Services Administrators as the TPA:
Community Health Partners Utilization Management Department will
utilize one of three independent review organizations for the external
review; 1.) Medical Review Institute of America, 2.) Propeer or 3.)
Healthcare Alternatives (through Specialty Care Management)
Written certification notification will be provided to the member (patient),
attending physician or other ordering provider, and the facility rendering service
that meets the time frame, within one business day of the determination for an
expedited appeal.
The Utilization Management Committee will provide telephone notification to the
attending physician or other ordering provider of the appeal outcome, and provide
written notification that meets the time frame for the process, i.e. within one
business day.
The physician will have an unrestricted license in the United States.
Request should be submitted to:
Community Health Partners, Attention: Appeals Coordination, Utilization
Management. Identify the member and services to be reconsidered
Mail or Fax the appeal request to PO Box 9589, Naples, Fl. 34102 or Fax
to 239 -659 -7785.
APPROVED BY:
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DATE:
.Y
t (J2o)
EXHIBIT 2
Community
Health Partners -
PHYSICIAN HOSPITAL ORGANIZATION
Health Advocacy Program
Job Description
Job Title: RN. Health Advocate
Reports to: Chief Operating Officer of Community Health Partners
3/13/2012 Item 11. G.
Description: The Health Advocate Program integrates Utilization Management, Case Management, Clinical Preventive
Care(Wellness Services, Medication and Educational Programs. Nurse Advocates work closely with providers, community
resources and the members for the best health outcomes. A goal of the Health Advocates is to facilitate member learning of
wellness strategies, promoting the prevention of complications and empowering for individual responsibility.
Primary Responsibilities:
• Advocacy
• Responsible for overseeing members participation with PWP and Biometric screenings
• Responsible for collecting data and reviewing with members to identify qualifiers
• Assist members with the process to achieve goals needed to meet qualifiers
• ResponsiNe for overseeing quality of care being provided to members of the health plan.
• An understanding of the process of change in order to empower member personal health care.
• Provide educational materials, presentations and community resources.
• Assist with provider referrals for appropriate healthcare.
• Assist with the development of the healthcare plan in collaboration with the provider and member.
• Follow up with individual member progress and adjust the plan accordingly.
• Work collaboratively and efficiently to resolve provider issues.
Program Planning
• Participate in ongoing program development, marketing, and enhancement in order to meet the needs of the
members and the health plan.
• Maintain data, follow -up and make referrals and evaluations for specifically assigned program such as nutritional
counseling, smoking cessation and wellness programs
• Other duties as assigned.
Qualifications:
• Current R.N. license in the State ofFlorida, BSN preferred
• Valid Florida Drivers License.
• At least 3 years of case management and 3 years of clinical experience.
• Organizational skills.
• Excellent written and verbal communications skills.
• Ability to work independently and within a team setting.
• Problem solving skills.
• Proficient in Microsoft Excel, Word, Outlook, Windows and Internet Usage
Performance Standards:
• Must comply with all company policies and rules.
• Must complete all assignments on a timely basis and in a correct manner.
Equipment Used:
• Computers, software packages, printers, photocopiers, facsimile machines, telephones, etc.
Working Conditions:
• Office environment
• Wellness Center
• Worksites -
• Overtime may be required
• Local travel is required
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