HomeMy WebLinkAboutAurora Health Care service agreement 1.1.2010 SERVICE AGREEMENT
THIS AGREEMENT ( "Agreement ") is made and effective this 1st day of January 2010,
by and between THE CITY OF OSHKOSH ( "Employer ") and AURORA HEALTH CARE,
INC., a Wisconsin corporation ( "AHC ").
WITNESSETH:
WHEREAS, AHC has established a network of health care providers through affiliation
agreements or other contractual relationships with various providers; and
WHEREAS, AHC arranges for the provision of health care services by such network
providers to certain individuals;
WHEREAS, Employer is desirous of having AHC arrange for the provision of health
care services by the network providers to Employer's employees and other persons who are
covered by Employer's medical plan; and
WHEREAS, Employer understands that there are health care providers participating in
the network who are not owned or employed by AHC or an affiliate of AHC, and understands
that these non -AHC providers have been selected to ensure that AHC can offer all necessary and
appropriate health care services to individuals covered by Employer's medical plan; further,
Employer desires to provide individuals covered by Employer's medical plan with access to
these non -AHC providers, and desires that these non -AHC providers be included in the AHC
network of providers.
NOW, THEREFORE, AHC and Employer hereby agree as follows:
1. Definitions. The terms used in this Agreement are defined as follows:
1.1. Actual Charges: shall mean the amount of each Provider's normal billed charges
as determined by the Provider for Covered Services.
1.2. AHC Network: shall mean the network of Providers, including AHC Providers
that AHC has established to provide Covered Services to Participants.
1.3. AHC Providers: shall mean physicians, hospitals and any other provider of health
care or other allied or related products or services who are owned or employed by
AHC or an affiliate of AHC.
1.4. Participants: shall mean all employees of Employer, retirees of Employer, their
respective dependents, and any other persons who are entitled to have their health
care for Covered Services paid for under the Plan, subject to the terms and
conditions of the Plan (including those persons eligible under COBRA) within the
Service Area.
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1.5. Clean Claim: shall mean a claim for services rendered submitted to Payor on the
industry standard claim form applicable for the type of service rendered, which
includes all information and sufficient detail reasonably necessary for Payor to
adjudicate the claim without further information.
1.6. Coordination of Benefits: shall mean the process by which payment for health
care benefits rendered to a Participant is sought from another insurer, service plan,
or government or other third party payor who has primary responsibility for the
cost of that Participant's health care.
1.7. Covered Services: shall mean the health care services that are medically
necessary and are reimbursable under the terms of the Plan.
1.8. Employer: shall mean The City of Oshkosh and its affiliates.
1.9. Medically Necessary: means those health care services or supplies which, under
the provisions of this Agreement, are determined to be one or more of the
following: a) appropriate and necessary for the symptoms, diagnosis or treatment
of the medical condition; b) provided for the diagnosis or direct care and
treatment of medical condition; c) within standards of appropriate medical
practice within the organized medical community; d) not primarily for the
convenience of the Participant or the Provider; and e) an appropriate and efficient
level of service or supplies which can be safely provided to the Participant. The
decision as to whether a service or supply is Medically Necessary for the purposes
of payment rests with Payor, as the case may be.
1.10. Payor: shall mean Employer's third party administrator which has an obligation
to process payments, on Employer's behalf, for Covered Services provided to a
Participant pursuant to the Plan, and to oversee all required elements of Plan
administration.
1.11. Plan: shall mean the health care benefit plan established by Employer for
Participants covered by and in compliance with this Agreement.
1.12. Provider: shall mean physicians, hospitals and any other provider of health care
or other allied or related products or services who have entered into an agreement
with AHC to provide Covered Services to Participants or are an AHC Provider.
1.13. Service Area: represents the following counties within the State of Wisconsin:
Brown, Dodge, Door, Fond du Lac, Kenosha, Kewaunee, Manitowoc, Marinette,
Milwaukee, Oconto, Outagamie, Ozaukee, Racine, Shawano, Sheboygan,
Walworth, Washington, Waukesha, Waupaca, Waushara and Winnebago.
2. AHC Responsibilities.
2.1. Provider Responsibilities. AHC agrees that each Provider shall agree to:
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2.1.1. Provide Covered Services to Participants at the payment rates set forth in
Exhibit A attached hereto and incorporated herein;
2.1.2. Accept the rates or charges set forth in Exhibit A applicable to such
Provider as payment in full for the Covered Services provided to
Participants, and not bill the Participants for any amount, except for: (i)
copayments and deductibles permitted under the Plan, such copayments
and deductibles constituting a part of and not in addition to the rates and
Actual Charges set forth in Exhibit A (it being understood that any
applicable copayments and deductibles shall be billed and collected by the
Provider); (ii) charges for the provision of services which are not Covered
Services; (iii) charges which may exceed benefit limits for a particular
service under the Plan; and (iv) charges for services which are determined
by Employer or its designee not to be medically necessary or otherwise are
not preauthorized due to Participants choice or preference and as a result
are not payable under the Plan;
2.1.3. Provide and maintain, at its expense, the facilities, equipment, and
professional and other personnel necessary to provide Covered Services to
Participants in the same manner and with the same quality as it provides
health care services to other patients;
2.1.4. Provide the organizational and administrative capabilities to carry out its
duties hereunder;
2.1.5. Maintain all governmental approvals, licenses, certifications and consents,
as applicable, necessary to provide Covered Services, operate in
compliance with all State and Federal laws, and maintain certification
under Title XVIII and XIX of the U.S. Social Security Act;
2.1.6. Cooperate with Employer in responding promptly to any complaint of a
Participant concerning the provision of Covered Services;
2.1.7. Obtain and maintain professional liability insurance in amounts sufficient
to qualify for participation in the State of Wisconsin Patients
Compensation Fund, and maintain comprehensive general liability
insurance in a reasonable amount as determined by each Provider
consistent with industry standards; and
2.1.8. Maintain credentials pursuant to this Agreement and the AHC
credentialing policy at all times. AHC shall perform credentialing of all
Providers pursuant to NCQA or similar industry standards, at no expense
or cost to Employer. AHC shall provide Payor an EDI file of all
credentialed Providers on a monthly basis.
2.2. Administrative Responsibilities. AHC shall provide the following administrative
services:
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2.2.1. Care Management. AHC shall provide care management services to
Participants in accordance with AHC's Care Management Program set
forth in Exhibit B attached hereto and incorporated herein, as such
Program may be revised by AHC from time to time. Employer
acknowledges and agrees that AHC may make exceptions with respect to
reviewing and approving Covered Services at non - network providers on a
case -by -case basis. AHC shall use best efforts to negotiate a discount with
such non - network provider. Employer shall be financially liable for the
resultant cost of any such Covered Services so approved and or authorized
by AHC.
2.2.2. Provider Directories. AHC shall provide Employer in lieu of hard copies
a listing of Providers on a secure website easily accessible by City of
Oshkosh employees.
2.2.3. AHC Services. In addition to providing Employer with access to the
AHC Network, AHC shall also provide Employer with access to related
products and services. Employer shall remit a monthly fee for such
related products and services as mutually agreed upon.
2.2.4. Utilization Reports. Upon Payor's submission of claims data to AHC,
AHC shall provide Employer with semi - annual utilization reports. In no
event shall such claims data submitted by Payor include any data
regarding the Actual Charges of Providers other than AHC Providers.
2.2.5. Operational Meetings. AHC agrees to meet semi - annually, or as needed
with proper notice, with Employer, consultant and /or Payor to ensure the
operational effectiveness of this Agreement in all areas.
2.2.6. Designate a Contact Person. AHC shall designate one person as the
contact person for purposes of this Agreement. Such contact person shall
be the Growth and Market Development Consultant as the representative
of AHC with whom Employer shall consult in all matters relating to the
terms of this Agreement.
2.2.7. Communication Materials. AHC shall assist with the design and
creation of Participant educational materials relating specifically to the
implementation of the Plan and annual enrollment campaigns. AHC may
also prepare and distribute to Providers summary materials setting forth a
list of payors /employers with then - current contracts with AHC, the rates
agreed to by each payor /employer, the duration of the contracts with AHC,
and such other information deemed appropriate by AHC.
2.2.8. AHC Network Composition and Utilization of AHC Providers. AHC
shall use all ommerc� ll bla efforts to v aiuiiv��.aa�a reasonable w
aivi�o provide a comprehensive
network of Providers to Employer such that there are no material service
types excluded from the AHC Network. AHC may in its sole discretion
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001.1404121
contract with non -AHC Providers to fulfill specific needs. The parties
agree that all Providers shall be available to render Covered Services to
Participants_ Specifically with respect to pharmaceutical services,
Employer shall utilize a Pharmacy Benefits Manager ( "PBM ") that
includes Aurora Pharmacies as participating providers.
3. Employer Responsibilities.
3.1. Plan Requirements. Employer shall have the following offering of the AHC
Network to Participants:
Employer will offer the AHC Network, offering the AHC service area as a
preferred provider organization ( "PPO "). Employer shall provide financial
incentives to encourage AHC utilization ( "in network "), including greater
deductibles and a twenty percent (20 %) differential in coinsurance for a
Participant's use of a non -AHC provider ( "out of network ").
3.2. Required Inclusion of Aurora Care Management Activities and Other AHC
Services. Employer agrees that it shall utilize all of the AHC Care Management
programs as described in Exhibit B and agrees not to contract with or otherwise
utilize any similar non -AHC programs.
3.3. Participant Eligibility. Employer shall ensure that AHC shall be provided with
accurate Participant eligibility information, at no cost, on a monthly basis in a
mutually agreed upon format. Payor shall respond directly to Providers with
respect to Participant eligibility inquiries.
3.4. Plan Information. Employer shall provide AHC with a copy of Employer's
Plan(s) to assist AHC in performing any included care management activities.
Employer shall coordinate with AHC's Medical Management team to ensure that
the schedule of benefits set forth in the Plan(s) is consistent with AHC's Care
Management objectives as set forth in Exhibit B.
Payor shall be solely responsible for administering the Plan, including but not
limited to identifying participating Providers for Participants and other
participating Providers pursuant to the EDI files transmitted to Payor as set forth
in Section 2.1.8 above.
3.5. Claims Information. Employer shall ensure that Payor shall comply with AHC
data specifications, and shall provide claims and other data, at no cost, to AHC on
a monthly basis; provided, however, that in no event shall Employer or Payor
submit information to AHC regarding the Actual Charges of non -AHC Providers.
The parties agree that they will review all data and medical cost history annually,
employing sound actuarial assumptions, to compare the Plan's experience and
determine performance of the Plan. Payor shall w ork with Providers directly to
resolve any claims related inquiries.
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3.6. Identification Cards. Employer or Payor shall furnish an identification card to all
eligible Participants, and such card is to be presented upon each instance of
Covered Services being rendered to Participants by Providers. Employer shall
ensure that Payor shall comply with the AHC identification card specifications
that require the AHC logo to be prominently displayed on the front of the card.
3.7. Designate a Contact Person. Employer shall designate one person as the contact
person for purposes of this Agreement. Such contact person shall be the
representative of Employer with whom AHC shall consult in all matters relating
to the terms of this Agreement.
3.8. Identification of Providers. Employer or Payor shall distribute employer
approved_educational materials prepared by AHC or Employer to all Participants,
at Employer's sole expense.
3.9. AHC Network Composition. In no event shall Employer supplement or add
health care providers to the Plan(s) utilizing the AHC Network by directly or
indirectly contracting, renting or otherwise including any provider who is not a
"Provider" hereunder, without the express prior written consent of AHC. The
foregoing shall not preclude Employer from obtaining Covered Services on a
case -by -case basis from providers who are not "Providers" hereunder in the event
such Covered Services are not available from a Provider subject to Section 2.2.8.
4. Payment for Covered Services.
4.1. Claims. Each Provider shall submit claims based on Actual Charges to Payor for
payment for Covered Services rendered to Participants on the industry standard
claims forms applicable for the service rendered and provide any reasonable
information on a timely basis to Payor for such claims to be Clean Claims.
4.2. Payment by Payor. Employer shall ensure that Payor pays each Provider directly
at the rates set forth in Exhibit A within thirty (30) days of receipt by Payor of
Provider's Clean Claims for Covered Services rendered pursuant to this
Agreement.
4.3. Overpayments. In the event of an overpayment to a Provider, Payor shall recoup
the amount of the overpayment within sixty (60) days of receipt by Provider of
the following information: Participant's name and identification number, service
provided, date service provided, claim number upon which erroneous charge
appears, specification and documentation of the error, and the erroneous amount.
Employer agrees that recoupment or any other adjustment of an overpayment
from Payor must be requested by Payor within one (1) year of the date of service
with respect to outpatient services and within one (1) year of the date of discharge
with respect to inpatient services
4.4. Coordination of Benefits. In the event the Participant has another insurance
policy protecting the Participant against the cost of Covered Services provided
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under the Plan, and such insurance policy and the Plan provide for the
Coordination of Benefits, the order of payment shall be determined as follows:
4.4.1. In the event Employer is the primary payor for Covered Services, Provider
shall be reimbursed by Payor as provided in this Agreement without
regard to any payments made by any other payor.
4.4.2. In the event Employer is the secondary payor for Covered Services, Payor
shall pay to Provider only those amounts which, when added to amounts
received by Provider from other payors, is equal to the reimbursement
payable pursuant to Exhibit A.
4.5. Acknowledgment. Employer acknowledges that AHC is not a payor, an insurer
or guarantor of payment, nor a provider of Covered Services.
4.6. Claims Audits. AHC shall provide access to AHC Providers' records in order for
Employer to audit high cost claims (i.e., claims over $50,000), provided that any
such audits shall be conducted in accordance with the AHC audit policy attached
hereto as Exhibit I. AHC shall provide a claims liaison to answer minor questions
from Employer or Payor regarding claims; however, in the event such questions,
in the sole discretion of AHC, become material, Employer and/or Payor will be
required to follow the AHC claims audit policy as described in Exhibit C. In the
event Payor denies claims for lack of information, Provider shall collect any
monies owed from the responsible party.
4.7. Claim Coding. AHC conforms to nationally recognized coding standards
mandated by Medicare including the Correct Coding Initiative ( "CCI "). AHC
also, with respect to owned and operated providers, has installed the CodeCorrect
software to its physician billing system to ensure compliance with Medicare and
CCI. AHC is knowledgeable that many third party payors utilize proprietary
software to adjust claims for "improper" coding. In the event Payor utilizes such
software and makes adjustments to claims above and beyond the Medicare and
CCI requirements, any such adjustments that are not reversed shall become
Participant liability.
5. Term and Termination.
5.1. Term. The term of this Agreement shall be for a period of five (5) years commencing as
of January 1, 2010 and shall automatically renew for additional one (1) year terms
thereafter, unless terminated earlier as provided herein.
5.2. Termination. This Agreement may be terminated in any of the following events:
5.2.1. Either party may terminate this Agreement, with or without cause, upon
written notice to the other party not less than ninety (90) days prior to the
end of the then - current term of this Agreement.
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5.2.2. In the event either party provides written notice at any time to the other
party of a material breach of a provision of this Agreement (which notice
shall specify the breach), and such breach is not cured to the reasonable
satisfaction of the non - breaching party within thirty (30) days after written
notice is given to the breaching party, then the non - breaching party shall
have the right to terminate this Agreement upon ten (10) days prior written
notice to the breaching party, which notice shall specify the failure to cure
the breach. If the breaching party, prior to expiration of the thirty (30) day
period, has either cured the breach to the reasonable satisfaction of the
non - breaching party or taken all reasonable steps necessary to affect a
cure, this Agreement shall remain in effect, and the non- breaching party
shall be limited to specific performance as its exclusive remedy.
5.3. Continuation of Obligations. Upon termination of this Agreement as provided
above:
5.3.1. AHC agrees that each Provider shall continue to provide such Covered
Services as are customarily provided to inpatients of such Provider to any
Participant who was admitted to such Provider prior to termination of this
Agreement, and who remains an inpatient after said termination. Payor
shall pay for all such inpatient services rendered to Participants by
Providers subsequent to termination of this Agreement until the
Participant is discharged in accordance with the rates as set forth in
Exhibit A in effect on the date of termination;
5.3.2. Each Provider may continue to provide such Covered Services as are
customarily provided to outpatients of such Provider to any Participant
who was an outpatient of such Provider prior to termination of this
Agreement, and who continues to require outpatient care after said
termination. Payor shall pay for all such outpatient services rendered to
Participants by Providers subsequent to termination of this Agreement in
accordance with such Provider's Actual Charges; and
5.3.3. Employer agrees to notify its Participants of the effective date of
termination of this Agreement not less than thirty (30) days prior to such
effective date. A copy of said notice shall also be delivered to AHC not
less than thirty (30) days prior to the effective date of termination. Failure
to provide such notification to AHC shall cause Employer to be liable for
all services provided by Providers to Participants, pursuant to this
Agreement, between the effective date of said termination and the period
ending thirty (30) days after the delivery of said notification to AHC.
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6. Precertification and Preauthorization.
AHC agrees that each Provider shall cooperate with the prenotification requirements of
Employer under the Plan applicable to Participants. Once the provisions of the Plan are
met and a Covered Service is provided, if payment is denied for alleged error or defect in
meeting the provisions of the Plan, or if a Participant fails to identify himself or herself as
a Participant by presenting an identification card, Provider may bill Participant for
services rendered. In the event payment is denied retroactively or payment is withheld as
described herein, the terms of Section 2.1.2 shall apply.
7. Confidentiality and Advertising.
7.1. Patient Records. AHC and Employer shall comply (and shall require their
respective agents to comply) at all times with all applicable state and federal laws
and regulations concerning the confidentiality of patient records.
7.2. Advertising. AHC and Employer agree that neither party shall advertise or
publicly disclose the existence of this Agreement or advertise using the name of
the other party as a contracting entity, except as permitted herein, without the
prior written approval of the other party.
7.3. Confidentiality. Unless otherwise provided herein, in no event shall Employer
disclose any of the terms or conditions of this Agreement. The foregoing shall
not prohibit Employer from disclosing terms of this Agreement to Payor for the
administration of this Agreement.
8. Relationship Between the Parties.
The relationship of the parties hereto is that of independent contractors. Nothing
contained herein is intended or shall be construed to create the relationship of
employer /employee or of a joint venture. Neither of the parties hereto, not any of their
respective employees, shall be construed to be the agent, employee or representative of
the other.
9. Indemnification.
9.1. By Employer. Employer agrees to defend, indemnify and hold AHC and each
Provider, and their respective officers, directors, employees and agents, harmless
from and against any cost, damage, expense or settlement costs arising from any
claim, suit or proceeding, whether proven or not, relating to the failure of
Employer or its agents, including but not limited to Payor, to fulfill any of its or
their obligations under this Agreement or the negligent or wrongful performance
of any such obligations.
9.2. By AHC: AHC agrees to defend, indemnify and hold Employer, and its officers,
directors, employees, and agents, harmless from and against any cost, damage,
expense or settlement costs arising from any claim, suit or proceeding, whether
proven or not, relating to the failure of AHC or its agents to fulfill any of its or
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their obligations under this Agreement or the negligent or wrongful performance
of any such obligations.
10. Maintenance of Records.
AHC agrees that each Provider shall maintain records of the Covered Services provided
to Participants pursuant to this Agreement for a period of at least (7) years from the date
of the Covered Service. Employer shall obtain and provide to AHC and Providers, as
necessary, all patient consents and releases from Participants prior to Employer
requesting to review any such records. To the extent required by state or federal law,
AHC agrees that each Provider shall permit designated state and federal officers access to
all such records upon request. AHC and Employer agree, to the extent permitted by law,
to coordinate the exchange of all information necessary to the administration of this
Agreement. Copies of records or information contained therein shall be release free of
charge for claim adjudication or determination of medical necessity purposes, provided
such requests are made to Providers business office or utilization management
department respectively. In the event Employer or Payor attempts to obtain copies of or
information from such records directly from Providers medical records department,
Provider shall be reimbursed by requesting party at Provider's usual charge.
11. Severability.
If any provision of this Agreement shall be held or declared to be invalid, illegal or
unenforceable under any law applicable thereto, such provision shall be deemed deleted
from this Agreement without impairing or prejudicing the validity, legality and
enforceability of the remaining provisions hereof.
12. Notice.
Any notice or approval required or permitted under this Agreement shall be given in
writing and shall be sent by courier or mail, postage prepaid, to the address specified
below or to any other address that may be designated by prior notice. Any notice or
approval sent by courier shall be deemed received one (1) day after the date of posting.
Any notice or approval sent by mail shall be deemed to have been received three (3) days
following deposit in the U.S. Mail:
To AHC at:
Aurora Health Care, Inc.
3000 W. Montana St.
Box 343910
Milwaukee, WI 53234 -3910
Attn: Senior Vice President & Chief Financial Officer
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001.1404121.
To Employer at:
City of Oshkosh
PO Box 1130
215 Church Ave.
Oshkosh, WI 54903
Attention: City Manager
13. Assignment; Amendment.
This Agreement may not be assigned by either party without the prior written consent of
the other party hereto. This Agreement may be amended only in a writing signed by the
parties hereto.
14. Governing Law.
This Agreement and all exhibits hereto shall be governed by and construed in accordance
with the laws of the State of Wisconsin and applicable federal laws. The venue for any
dispute or proceeding hereunder shall be in the Wisconsin Circuit Court for Winnebago
County.
15. Entire Agreement.
This Agreement sets forth the entire understanding between Employer and AHC with
respect to the matters covered herein. No prior agreement or understanding not
specifically mentioned herein shall have any effect upon this Agreement.
16. Waiver.
The waiver or failure of any party to enforce any provision hereof shall not preclude or
waive the right of such party from later seeking enforcement of such provision or be
deemed a waiver of any subsequent breach of the same or any other provision.
17. Construction of Headings.
The captions or headings of this Agreement are for convenience only and in no way
affect the construction or effect of any of the terms, covenants and conditions hereof.
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001.1404121.
EXHIBIT A
PAYMENT RATES
EXHIBIT A
PAYMENT RATES
Employer shall pay Providers as follows:
A. Employer shall pay to each Provider an amount equal to such Provider's
Actual Charges less the discounts outlined below:
Discounts: 35% - All AHC Providers
10% - Children's Hospital & Children's Medical Group
All non -AHC Provider will make available to Employer the
best discount contracted between AHC and the non -AHC Provider;
generally in the range of 15% to 30 %. (The following are for
illustrative purposes only)
15% - All Hospital Based Providers (Radiology,
Emergency Room, Anesthesiology) except
Pathology, which are at 30 %.
15% Radiologists: Milwaukee Radiology, Great Lakes
Radiology, Kettle Moraine Imaging and Radiology
Associates of the Fox Valley.
Emergency Room: ERMED, EMPEC, Emergency
Physician of West Allis, Midwest Emergency
Associates.
Anesthesiology: Anesthesiology Associates,
Summit Anesthesiology, Milwaukee Anesthesia
Consultants, Kirsten Simanonok MD, Mary Rashel
CRNA, Dorothy Carl CRNA, Susanna Lindsey
CRNA and Southeastern Wisconsin
Anesthesiology.
30% - All other AHC Contracted Providers with the
exception of the following providers:( Dr.'s Kim
and Kagen, allergists in Oshkosh Wisconsin at
10 %).
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B. In the event Employer offers transplant services as part of its Plan,
Employer shall pay St. Luke's Medical Center(as they are the only AHC
Provider at which transplant services are provided under this agreement)
for transplant services at AHC's then - current Global Transplant
reimbursement rates (including physician services) which AHC offers to
commercial payors.
EXHIBIT B
AURORA CARE MANAGEMENT PROGRAM
Set forth below is a general summary of the Aurora Health Care, Inc. Care Management
Program. AHC has the right to revise, amend or modify the Care Management Program from
time to time, in any manner deemed necessary or desirable by AHC.
A. General. Participants shall be responsible for obtaining all necessary precertification or
preauthorization required by Employer's Plan, although hospital Providers shall use
reasonable efforts to inform Employer or its designee of any inpatient admission of a
Participant within 24 hours or the next business day, whichever is later. Physician
Providers shall use reasonable efforts to act as gatekeepers and shall assist Participants
when applicable with any precertification or preauthorization requirements in accordance
with Employer's Plan. In no event shall AHC or Providers be liable to Participants or
Employer for the failure to precertify or preauthorize covered services
B. AHC's Medical Management Services (Episodic, Chronic and Catastrophic Disease
Management). The AHC Medical Management Team provides a different scope of
review activities depending upon the employer under contract, the product, and the
contractual relationship for delegated activities. The Medical Management Team works
with Employer and Participants to understand and appropriately manage their benefits
under Employer's Plan. The following is a brief description of the functions of the
Medical Management Team:
1. Certification for inpatient admissions /outpatient procedures: The Medical
Management Team screens and authorizes inpatient admissions and outpatient
procedures to ensure that the individual's condition/treatment warrants the
service, the individual is an eligible Participant, the planned services are covered,
and the most appropriate setting is used for the service. Options such as home
health care and outpatient services are utilized whenever medically appropriate.
2. Concurrent review: The Medical Management Team performs concurrent
review on certified inpatient admissions and as necessary for outpatient services.
This process verifies and documents the continued need for hospitalization /
outpatient services and ensures our prompt awareness of any potential need for
post - discharge alternative care services. We apply purchased guidelines where
appropriate to ensure timely and appropriate utilization of services.. Each
patient's care is reviewed. Physicians may be contacted on a periodic basis to
obtain additional information. Periodic treatment plan updates are necessary to
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assess the discharge planning needs of the member and to facilitate activities that
meet these needs.
3. Catastrophic case management: Nurse catastrophic case managers
telephonically plan, organize, and sequence activities with the patient, family, and
care providers along the continuum of care to enhance the quality of the outcome
of catastrophic illness or trauma. The process positively impacts the cost of care
through the effective and efficient use of the place of service, intensity of the
treatment modality, and duration of services.
4. Disease management: Aurora's pre- certification and case management are
integrated with our disease management programs. Aurora Medical Management
utilizes software tools (developed internally) that allow us to proactively identify,
filter, sort and prioritize those individuals who might benefit from case
management and/or disease management. Regardless of the type of intervention
needed or already in place, staff can electronically access the information
necessary to see who is involved and what's happening. This enables us to very
effectively work together to manage an individual's care. Some disease
management programs that we have in place include congestive heart failure,
diabetes, asthma, cholesterol, colorectal cancer screening, breast cancer screening
(mammography) and cervical cancer screening (pap smears).
C. Other AHC Services:
1. Plan Design Consultative Support: The Medical Management Team works with
Employer to advise and provide support regarding Plan design. This service is
based on extensive experience with various plans and current knowledge of
medical standards of care.
2. Teleservices (Wellness & Health Promotion, Episodic and Chronic Disease
Management): The Aurora Teleservices unit provides advanced telephone —
based patient risk assessment and management, and physician referral. This
program enhances Participant health education and assists Participants with
selecting appropriate health services. This program also provides early
identification of serious conditions which may avoid costs of delayed or
inappropriate care.
3. Aurora Call -A- Nurse: The Call -A -Nurse program is a demand management
center that is also used by preventative services, wellness management, case
management and care management programs to make outbound calls.
(a) Registered Nurses are currently available 24 hours a day, 7 days a week at
the Aurora Call -A -Nurse Unit. The trained Registered Nurses endeavor to
identify' needs and levels of urgency among callers. The registered Nurses also
have access to a translation line that allows them to assist Participants regardless
of the language spoken.
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(b) If desired, Participants can receive printed information regarding their
particular question or issue. This information explains in layman's terms what the
particular illness is, how it occurs, how it is diagnosed, how it is treated, how long
the effects will last and how the Participant can administer self care. This written
documentation serves to reinforce the verbal information given by the Registered
Nurse. Through employee mailings, AHC can also supply wallet cards and
refrigerator magnets, as well as instructions on the use of the Call -A -Nurse line.
4. Clinical Preventive Care Recommendations (Wellness & Health Promotion):
Aurora Care Management will monitor the recommendations and updates
developed by the United States Preventive Services Task Force and the CDC. We
will advise the Employer when there are changes so the Employer can choose
whether or not to update their plan benefits.
(a) Preventive guidelines serve as evidence -based recommendations regarding
the appropriateness and frequency of various screening and preventive
services for individuals and populations. They are proven interventions to
decrease the rate at which "well" Participants become diseased.
5. Health Risk Assessment — Total Health (Wellness & Health Promotion): The
purpose of the AHC Risk Assessment Program is to identify and quantify health
issues contributing to the risk that "well" individuals or "well" groups will
become "sick ". These programs provide consultation and education to groups and
individuals as deemed necessary fromt eh risk areas identified. AHC
recommends that all Participants be assessed for health risks. Participants will
provide information to Health Risk Assessment Professionals through a
standardized, confidential questionnaire. The Health Risk Assessment
Professionals will analyze the information and provide Participants with the
opportunity for consultation and education.
6. Occupational Health (Wellness & Health Promotion and Episodic Disease
Management): Aurora Occupational Health Services is the AHC provider of
occupational health services for Eastern Wisconsin employers and employees.
Services include treatment and management of work place injury and illness,
wellness and prevention programs, rehabilitation, and exams and screenings
required by federal and state regulations. Aurora Occupational Health Services
provides a comprehensive approach to reducing unnecessary health and safety
costs and offers three types of services: (a) Care and prevention of work related
injury and illness, (b) Direct Client Services, and (c) Occupational Health
Services /Consultation.
?. Employee Assistance Program (Wellness & Health Promotion): The AHC
Employee Assistance Program ( "EAP ") is a worksite program designed to
identify and resolve personal and family problems that may adversely affect a
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001.1404121.
individual's well -being or job performance. The EAP gives employees a
confidential resource to turn to, 24 hours a day. Standard services include:
Assessment and referral; 24 hour crisis intervention services; management
consultation; supervisory /union steward training, utilization reports; program
promotion; family connections, a referral source for child and elder care; financial
management consultation; legal consultation; quality improvement surveys;
educational and personal enrichment seminars; convenient locations; and
substance abuse professionals.
8. Managed Behavioral Health Services (Episodic and Chronic Disease
Management): To complement the Episodic Disease management program,
Aurora Behavioral Health Services provides a comprehensive provider network
and Care Management program to manage the behavioral health needs of the
Participants.
(a) Aurora Behavioral Health Services brings a managed care focus to the
field of behavioral health care. By integrating all programs and assigning
trained case managers to each patient, nonessential duplication of services
is avoided and close monitoring and coordinated care throughout each
stage of recovery is possible. Practice guidelines and clinical standards
are applied, resulting in generally consistent treatment.
(b) Aurora Behavioral Health Services provides a wide array of services to
ensure that individuals receive the least restrictive and most appropriate
level of care. These services include, but are not limited to, the following:
• Employee Assistance Programs
• Evaluation, Assessment and Referral Services
• Outpatient Programs
• Partial Hospital Programs
• Crisis Stabilization Programs
• Inpatient Hospital Services
• Aftercare Programs
• Family Programming
• Home Based Programs
• Residential Programs
• Other programs as needed to serve specific client groups.
(c) Access.
(�
Participants are provided a toll -free number to call when they have
questions about to behavioral health issues. The Care Management
Center is staffed with Masters level therapists and /or Registered
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001.1404121.
Nurses trained in behavioral health. The Care Management Center
assesses the severity of the call as emergent, urgent or routine.
Based upon specific assessment criteria, the caller is then directed
to the appropriate level of care or provided the information he /she
is seeking.
(2) If treatment is required, a care management specialist coordinates
services for each Participant and, if appropriate, communicates
information to family members, Employer, Employee Assistance
Program professionals, and/or to the Participant's primary care
physician.
(d) Outcome Monitoring.
(1) The Care Management Center specialists coordinate services for
patient populations with common problems, such as depression,
through the use of clinical protocols and pathways. By examining
defined populations with common symptoms and socio-
demographic needs, Aurora Behavioral Health Services is able to
offer programs that obtain measurable clinical outcomes for
patient - specific groups.
(2) The goal of the Aurora Behavioral Health Services Care
Management Center is to provide a coordinated approach to the
management of behavioral health services that is easily accessible
and provides the appropriate care when needed. Aurora Behavioral
Health Services Care Management Center strives to ensure that its
customers understand its services and to achieve measurable
outcomes that can be monitored and continually improved.
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001.1404121.
EXHIBIT C
RELATED PRODUCTS AND SERVICES
Included Fee
Network Access Yes No Fee
Occupational Health Yes Pursuant to RFP response rate
Care Management (as defined in Yes No Fee
Exhibit B)
CBCM Yes No Fee
Health Link Yes No Fee
Employee Communication Yes No Fee
Provider Directories Yes Actual cost paid to vendor for
printing
EAP Yes Pursuant to RFP response rate
from prior contract.
Behavioral Health Management Yes No Fee
Health Risk Assessments Yes No Fee
Self Care Book Yes No Fee
Aurora Experts Yes No Fee
Complementary Medicine Yes 30% discount on Chiropractic
Services services, 20% discount on
Massage Therapy services, 10%
discount on all other services
001.1404121.
EXHIBIT D
AURORA CLAIMS AUDIT POLICY
PURPOSE:
To provide a framework for conducting billing audits with insurance companies and /or third party
auditing firms engaged to verify the accuracy of the patient's bill.
II. POLICY:
AURORA HEALTH CARE and it's affiliates will cooperate with insurance companies and third
party auditing firms which have been engaged by insurance companies and/or employers to verify
the accuracy of patient bills. It is our expectation that fair and equitable reports and resolution will
result from the audit.
III. PROCEDURE:
A. The following guidelines must be agreed to and followed by all parties:
1. All requests for audits must occur no later than one year after the final
billing date. To schedule an audit, a call should be made to the insurance audit
coordinator within the medical audit department at (414) 649 -7625. The request
should include the patient's name, account number and the dates of service.
AURORA HEALTH CARE does not recognize off -site (desk) audits.
2. Prior to any actual review of patient's medical record or initiation of a
medical audit the insurance company or third party auditing firm must sign the
AURORA HEALTH CARE audit policy agreement and pay all associated fees.
3. Prior to the actual review of a patient's health record, Medical Records
Department personnel will require individuals reviewing health records to show
proofs of identification/credentials as well as produce patient authorization. This
can be accomplished with a business card or a letter of introduction from the
employer on letterhead identifying the person as an employee, and in addition, a
valid driver's license. Review agencies that are not third party payors must obtain
a letter on the applicable insurance company letterhead identifying the review
agency as lc authorized agent and also sign an audit ag eelllerlt.
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001.1404121.
Subject: Third Party Claims Audit Policy
Page 2:
4. An Audit may be scheduled when 100% of the total insurance liability has been paid
5. The medical record does not serve as a duplicate patient bill or as the sole document to
support individual charges on the patient's hospital bill. The purpose of the medical
record is to document clinical data on diagnosis, treatment and outcomes. Ancillary
department daily charge records, departmental policies and protocols, individual service
charge tickets, and other sources of information both written and electronic are
evidence of services provided to the patient.
6. The Aurora Medical Auditor and the auditing firm will review the disputed charges and
unbilled items within 30 business days. After findings are agreed upon, it is expected
that both parties will process any credit /debit in a prompt manner.
7. There will be no attempt by the auditing firm to close an audit before the Aurora Medical
Auditor reviews the findings and an agreement has been reached.
8. It is not within the scope of a billing audit to assess the reasonableness of the medical
center's cost /charge relationship or, except in certain worker's compensation claims, the
medical necessity of services provided to the patient.
B. Violation of, or unwillingness to follow, these guidelines by the audit firm representative
and /or insurance company will result in denial of a request to perform an audit.
(The following page is the signature page.)
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001.1404121.
IN WITNESS WHEREOF, the parties hereto have caused their duly authorized
representatives to execute this Agreement as of the date and year first above written.
CITY OF OSHKOSH AURORA HEALTH CARE, INC.
�`' By: r �'L'��'� --'�
B y:
Name: Mark Rohloff Name: Robert M. Mueller
Title: City Manager Title: Vice President
Revenue Cycle and Payer
Contracting
Date: 3 3 �11 Date: ,R(.9,( (,�o ( �
� rq
By: _
Name: Pamela R. Ubrig
Title: Cit Clerk � ��
Dale: a�t 3/` J� t k
App ed as to Form
� R�As %' . Lorenso
City Attorney
12
001.1404121
Service Agreement Amendment One
The Service Agreement ( "Agreement ") between The City of Oshkosh ( "Employer") and Aurora
Health Care, Inc., a Wisconsin Corporation ( "AHC ") is hereby amended below. The Additional
Provisions ( "Additional Provisions ") outlined below are an addition to the current Service Agreement.
The Amended Provisions ( "Amended Provisions ") outlined below replace the initial Service Agreement
provisions effective January 1, 2010.
Additional provisions:
1. Definitions. The terms used in this Agreement are defined as follows:
1.14. Health Payment Systems, Inc. shall mean the network discount provider located at 735 North
Water Street, Suite 333, Milwaukee, WI 53202 -4106. The location of this organization is subject to
change without notice and shall not effect the terms of this Agreement.
2. AHC Responsibilities
2.1.9. AHC shall recognize Health Payment Systems, Inc.' ( "HPS ") and agrees that Employer can
contract with HPS, a network discount provider, to achieve increased discounts resulting in increased
savings to the Plan.
Amended Provisions:
5. Term and Termination
5.1. Term. The term of this Agreement shall be initially effective for a one year term, commencing on
January 1, 2010 and shall automatically renew for additional one (1) year terms thereafter, unless
terminated earlier as provided herein.
In Witness Whereof, the parties hereto have caused their duly authorized representatives to
execute this Agreement as of the date and year first written in the service agreement, the 1 day of
January 2010.
City of Oshkosh Aurora Health Care, Inc.
By: / 7C� /C�(/ J By:
Name: Mark Rohloff Name: Robert M. Mueller
Title: City Manager Title: Vice President
Revenue Cycle and Payer Contracting
Date: s/ 1 i / Date: