HomeMy WebLinkAboutAdvanced Data Processing Rescue Ambulance Billing -2006 10 24
AGREEMENT BETWEEN
THE CITY OF WINTER SPRINGS
AND
ADVANCED DATA PROCESSING, INC.
FOR RESCUE AMBULANCE BILLING & RELATED PROFESSIONAL SERVICES.
THIS AGREEMENT, hereinafter "AGREEMENT', made and entered into this 24th day of
October, 2006 by and between CITY OF WINTER SPRINGS, a Florida Municipal
corporation, with principal offices located at 1126 East State Road 434, Winter Springs,
Florida hereinafter referred to as the "CITY", and Advanced Data Processing, Inc., a
Delaware Corporation with principal offices located at 500 NW 165th Street, Suite 104,
Miami, Florida 33169, hereinafter referred to as the "CONTRACTOR".
WITNESSETH:
WHEREAS, Seminole County, a political subdivision of the State of Florida wherein
CITY resides, entered into an agreement ("Seminole Agreement") with CONTRACTOR
dated August 28, 2006 and as amended; and
WHEREAS, Seminole County utilized the due diligence established by the County
seeking responses from qualified firms to provide medical billings, collections, and
accounts receivable professional services for Seminole County's EMS Fire Rescue
Division; and
WHEREAS, the CITY desires to "Piggyback" the Seminole County process and obtain
certain terms and conditions of the Seminole Agreement, and
WHEREAS, the parties hereto now wish to enter into an agreement, pursuant to which
the CONTRACTOR will render those professional services in connection with said
project as defined in CONTRACTOR'S Agreement and hereinafter provided;
NOW THEREFORE, the parties hereto agree as follows:
1. DEFINITION OF THE PROJECT. The objective of the project is to utilize the services
of the CONTRACTOR to provide the CITY with ambulance billing and related services.
2. SCOPE OF SERVICES. The CONTRACTOR shall perform and carry out the work as
defined in the Seminole Agreement heretofore referenced and attached hereto. All
payments shall be paid directly to CITY OF WINTER SPRINGS or via Locked-Box
facility as directed by the CITY.
3. TIME OF PERFORMANCE. This Agreement shall be effective for a five-year period
from September 1. 2006 through August 31, 2011, under the terms and conditions
contained herein unless otherwise terminated. This AGREEMENT shall renew
automatically for a period of one additional year at the end of the initial term and any
subsequent renewal term unless the AGREEMENT is terminated in accordance with
section "12. TERMINATION". All terms and conditions hereof shall remain in full force and
effect during any renewal term.
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4. COMPENSATION AND METHOD OF PAYMENT.
4.01 The CITY reserves the right to request changes in the services within the general
scope of the Agreement to be performed upon mutual agreement by the CITY and
CONTRACTOR that shall specify the change ordered and the adjustment of time and
compensation required therefore.
4.02 Any services added to the scope of this Agreement by a change order shall be
executed in compliance with all other applicable conditions of this Agreement. No claim
for additional compensation or extension of time shall be recognized unless contained in
the duly executed change order.
4.03 The CONTRACTOR shall be paid by the CITY a monthly amount representing fees
for the services provided computed as:
4.03(a) Seven and twenty-five one-hundredths percent (7.25%) of all monies
collected by CONTRACTOR, excluding amounts collected from Florida Medicaid, plus
4.03(b) Eleven dollars and Seventy-eight cents ($11.78) per Florida Medicaid
account, whether or not such account is ultimately paid by Florida Medicaid.
4.03(c) an amount of $85 per month for providing billed patient required HIPAA-
compliant Privacy Notice per Scope of Work (Exhibit A).
Contractor reserves the right to increase these fees if postage is increased by the United
States Postal Service, but only to cover additional postage costs.
4.04 The CITY shall issue a check for the amount invoiced, within thirty (30) days of
receipt and acceptance of an accurate invoice. CITY's obligations hereunder are
absolute and unconditional and not subject to set-off, delay, counterclaim, termination or
performance. Contractor will resolve any disputed amounts within 60 days from the date
CITY gives notification.
4.05 The CITY elects to open and maintain a lockbox, it shall bear all the cost
associated with such Lock-box services. CITY, should they elect to participate in any
credit card acceptance program, agrees to assume and be responsible for all costs
associated with such program. All other costs incurred by CONTRACTOR in the
performance of services as specified herein (including, but not limited to postage,
materials, communications and phone costs and other operating costs) shall be
assumed by the CONTRACTOR.
5. REPORTS. The CONTRACTOR shall provide the CITY with status reports as set
forth in the Seminole Agreement and other reports as mutually agreed. The
CONTRACTOR shall also provide changes to such reports and ad hoc report requests
on a reasonable basis and as mutually agreed. CONTRACTOR reserves the right to
charge an additional fee for any programming cost associated with ad hoc reports that
would require more than a reasonable amount of time to accomplish.
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6. DATA TO BE FURNISHED BY CITY. The CITY will make available to the.
CONTRACTOR, for use in performance of services under this Agreement, all available
reports, studies or any other materials in its possession that may be useful to the
CONTRACTOR. All material furnished by the CITY will not be disclosed to any party,
other than as required under the scope of the Agreement, without the CITY's prior
written approval.
7. INDEPENDENT CONTRACTORS. The CONTRACTOR is an independent contractor
and not an employee or agent of the CITY with the following exception:
To the extent necessary to fulfill its billing and collection efforts
under the Agreement, the CONTRACTOR is authorized to sign in an
administrative capacity for the CITY the following types of standard
forms and correspondences only: probate filings; letters to patients or
their representatives verifying that an account is paid in full; forms
verifying the tax-exempt status of the CITY; and insurance filings and
retated forms. The CONTRACTOR has no authority to sign any
document that imposes any additional liability on the CITY.
The CONTRACTOR shall retain full control over the employment, direction,
compensation and discharge of all persons assisting in the performance of service by
CONTRACTOR. The CONTRACTOR shall be fully responsible for all matters relating to
payment of employees, including compliance with Social Security, withholding tax and all
other laws and regulations governing such matters. The CONTRACTOR shall be
responsible for its own acts and those of its agents and employees during the term of
this Agreement.
8. INDEMNIFICATION. The CONTRACTOR shall indemnify and hold the CITY
harmless from any and all claims, losses and causes of action which may arise out of
the performance of this Agreement as a result of an act of negligence, of the
CONTRACTOR, its employees, agents, representatives, consultants, or its
SUBCONTRACTORS.
9. INSURANCE.
9.01 CONTRACTOR shall procure and maintain for the duration of the Agreement, the
following insurance coverage:
9.01 (a) Workers' Compensation Insurance in compliance with the applicable
state and federal laws
9.01 (b) General Liability insurance in an amount no less than $1,000,000 per
occurrence.
9.01(c) Coverage for business interruption, destruction of data processing
equipment and media, liabilities affecting accounts receivable, contracts and
independent contractors and, valuable documents in an amount no less than
$100,000 aggregate;
9.01 (d) Liability coverage for all vehicles whether owned, hired or used in the
amount of $500,000; and
9.02 The policies are to contain, or be endorsed to contain, the following provisions:
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9.02(a) General Liability and Automobile Liability Coverage (CITY is to be
named as Additional Insured).
1. The CITY, its officers, officials, employees and volunteers are to be
covered as additional insureds; liability arising out of activities performed
by or on behalf of the Contractor, including the insured general
supervision of the Contractor; products and completed operations of the
Contractor; premises owned, occupied or used by the Contractor; or
automobiles owned, leased, hired or borrowed by the Contractor. The
coverage shall contain no special limitations on the scope of protections
afforded the CITY, its officers, officials, employees or volunteers.
2. The Contractor's insurance coverage shall be primary insurance as
respects the CITY, it officers, officials, employees and volunteers. Any
insurance of self-insurance maintained by the CITY, its officers, officials,
employees or volunteers shall be in excess of the Contractor's insurance
and shall not contribute with it. Contractor hereby waives subrogation
rights for loss or damage against the CITY.
3. Any failure to comply with reporting provisions of the policies shall not
affect coverage provided to the CITY, its officers, officials, employees or
volunteers.
4. The Contractor's insurance shall apply separately to each insured
against whom a claim is made or suit is brought, except with respect to
the limits of the insurer's liability.
5. Companies issuing the insurance policy, or policies, shall have no
recourse against the CITY for payment of premiums or assessments for
any deductibles with are all at the sole responsibility and risk of
Contractor.
9.02(b) All Coverage
1. Each insurance policy required by this clause shall be endorsed to
state that coverage shall not be suspended, voided, canceled by either
party, reduced in coverage or in limits except after thirty (30) days prior
written notice by certified mail, return receipt requested, has been given
to the CITY.
Contractor shall furnish the CITY with certificates of insurance and with original
endorsements effecting coverage required by this clause. The certificates and
endorsements for each insurance policy are to be signed by a person authorized by that
insurer to bind coverage on its behalf. All certificates and endorsements are to be
received and approved by the CITY before work commences. The CITY reserves the
right to require complete, certified copies of all required insurance policies at any time.
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10. OWNERSHIP OF DOCUMENTS. CONTRACTOR shall be required to work in
harmony with other consultants relative to providing information requested in a timely
manner and in the specified form. The CONTRACTOR agrees that any and all
documents, records, disks, and electronic data produced in the performance of this
Agreement shall be the sole property of the CITY, including all rights therein of whatever
kind except as may otherwise be provided hereinafter.
11. ATTACHMENTS. The following named attachments are made an integral part of this
Agreement:
A. Seminole Agreement, dated August 28, 2006 (Exhibit A attached hereto and
made a part hereof)
B. Business Associate Agreement (Exhibit B attached hereto and made a part
hereof)
12. TERMINATION. During the time of this agreement the CITY may terminate this
Agreement either for convenience or for default after first giving to CONTRACTOR thirty
(30) days written notice.
For cases of default, the CONTRACTOR shall be given opportunity to cure the default
within the thirty (30) day period following such written notice. In the event the acts
constituting default are a violation of law, CONTRACTOR shall be subject to immediate
termination of Agreement.
Upon termination for any cause, the CONTRACTOR shall submit an invoice(s) to the
CITY in an amount(s) representing fees for services actually performed or obligations
incurred to the date of effective termination for which the CONTRACTOR has not been
previously compensated. Upon payment of all sums found due, the CITY shall be under
no further obligation to the CONTRACTOR, financial or otherwise.
For purposes of this section, the notice period begins when the CONTRACTOR receives
written notice from the CITY.
13. UNCONTROLLABLE FORCES. Neither the CITY nor CONTRACTOR shall be
considered to be in default of this Agreement if delays in or failure of performance shall
be due to Uncontrollable Forces, the effect of which, by the exercise of reasonable
diligence, the non-performing party could not avoid. The term "Uncontrollable Forces"
shall mean any event which results in the prevention or delay of performance by a party
of its obligations under this Agreement and which is beyond the reasonable control of
the non-performing party. It includes, but is not limited to fire, flood, earthquakes, storms,
lightning, epidemic, war, riot, civil disturbance, sabotage, terrorism and governmental
actions.
Neither party shall, however, be excused from performance if non-performance is due to
forces that are preventable, removable, or remediable nor which the non-performing
party could have, with the exercise of reasonable diligence, prevented, removed, or
remedied with reasonable dispatch. The non-performing party shall, within a reasonable
time of being prevented or delayed from performance by an uncontrollable force, give
written notice to the other party describing the circumstances and uncontrollable forces
preventing continued performance of the obligations of this Agreement.
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14. JURISDICTION, VENUE and CHOICE OF LAW. All questions pertaining to the
validity and interpretations of this Agreement shall be determined in accordance with the
laws of the State of Florida. Any legal action by either party against the other concerning
this agreement shall be filed in Seminole County, Florida, which shall be deemed proper
jurisdiction and venue for the action.
15. ASSIGNMENT OF AGREEMENT. Except to a parent, subsidiary, or affiliate, the
CONTRACTOR shall not sell, transfer, assign or otherwise dispose of this Agreement or
any part thereof or work provided therein, or of its right, title or interest therein, unless
otherwise provided in the Agreement, without express prior consent by the CITY.
16. SOVEREIGN IMMUNITY. Notwithstanding any other provision set forth in this
Agreement, nothing contained in this Agreement shall be construed as a waiver of the
City's right to sovereign immunity under Section 768.28, Florida Statutes, or other
limitations imposed on the City's potential liability under state or federal law. As such,
the City shall not be liable under this Agreement for punitive damages or interest for the
period before judgment. Further, the City shall not be liable for any claim or judgment, or
portion thereof, to anyone person for more than one hundred thousand dollars
($100,000.00), or any claim or judgment, or portion thereof, which, when totaled with all
other claims or judgments paid by the State or its agencies and subdivisions arising out
of the same incident or occurrence, exceeds the sum of two hundred thousand dollars
($200,000.00). This paragraph shall survive termination of this Agreement.
17. NOTICES. All notices pertaining to this Agreement shall be delivered or mailed to
such party at their respective address as follows:
To the CITY:
City Manager
City of Winter Springs
1126 East State Road 434
Winter Springs, FL 32708-2799
407-327 -1800 (phone)
407-327-4753 (fax)
To the CONTRACTOR:
Brad Williams
Vice President, Finance
Advanced Data Processing, Inc.
500 NW 165 Street Road, Suite 104
Miami, Florida 33169
18. PIGGYBACK. CONTRACTOR hereby extends to CITY the terms and conditions of
the Seminole Agreement with the exception of Compensation and Payments which shall
be governed by this Agreement (due to difference in transport volumes of the City and
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Seminole County). Where any conflict exists between this Agreement and the Seminole
Agreement, this Agreement shall prevail.
19. REPESENTATION AND WARRANTY. CONTRACTOR represents that they have
experience and agrees to follow all Federal, State and Local Laws including, but not
limited to, Public Records Laws and those laws and statutes applicable to discrimination.
20. SERVERABILlTY. Should any part, term or provision of this Agreement be by the
courts decided to be illegal or in conflict with any law of the State of Florida, the validity
of the remaining portions or provisions shall not be affected thereby.
21. ENTIRE AGREEMENT. This Agreement contains the entire agreement between the
parties. The CONTRACTOR represents that in entering into this Agreement it has not
relied on any previous oral and/or implied representations, inducements or
understandings of any kind or nature.
[signature pages to follow]
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IN WITNESS OF THE FOREGOING, the CITY has caused this Agreement to be signed
by its City Manager, attested by the City Clerk with the corporate seal of the City of
Winter Springs, and the CONTRACTOR has executed this Agreement effective as of the
date set forth above.
CITY OF WINTER SPRINGS, FLORIDA
By: ,7i~0/'c~U?t!~
CITY MANAGER >
ATTEST:
----7
~-----
(SEAL)
CONTRACTOR:
Advanced Data Processing, Inc.
A De are or, tion
(CORPORATE SEAL)
STATE OF FLORIDA
MIAMI-DADE COUNTY
BEFORE ME, an officer duly authorized by law to administer oaths and take
acknowledgments, personally appeared Doug Shamon, as President of Advanced
Data Processing, Inc., a Delaware corporation, and acknowledged execution of the
foregoing Agreement for the use and purposes mentioned in it and that the instrument
is the act and deed of the Contractor.
IN WITNESS OF THE FORE~OING, I have set my hand and official seal at in
the State and County aforesaid on Oi , 2006.
Nota Public, State of Florida at Large
My.. 0 mission expires: 0 tr em bM" (I if) D f)
tf ~ ill 011 a \ ~ ~rvwvn
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Exhibit A: Seminole County Agreement
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6
SEMINOLE CbuN7Y
FLORIDA'S NA'IURAL CHOiCE"
LmER OF TRANSMIITAL
Purchasing & Contracts Diyision
1101 East First Street. Room 3208
Sanford, Florida 32771
Ph. 407/665-7115 Fx. 407/665-7956
TO: Advanced Data Processing, Inc DATE: August 28, 2006
500 N.W. 165th Street, Suite 102
Miami, FL 33169 RE:
RFP-0780-0SrrRJ
Agreement
--
DOCUMENT(S) ATTACHED:
o Work Order 0 Amendment 0 Other
o Agreement 0 RFP/PS Documents 0
THE ATTACHED DOCURMENT(S) ARE:
0 For your signature liS> For your records 0 For your review & comment
0 For your information 0 For your use
0 Returned for 0 As requested
additional signatures
COMMENTS:
cc: Finance/File SIGNED: TIm1JflC
Contracts Analyst
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10-.."
'!'HIS AGREEMENT is made and entered into this day of
Q........\..~\A.._'--')J:.2-, 20 C,J(v, by and between ADVANCED DATA PROCESSING,
\..)
INC., duly authorized to conduct business in the State of Florida, whose
BILLING SERVICES AGREEMENT (RFP-0780-06/TRJ)
EMERGENCY MEDICAL SERVICES TRANSPORT
c:J ~ v\C I
address is 500 N.W. 16Sth Street, Suite 102, Miami, Florida 33169,
.
hereinafter called the "CONTRACTOR", and SEMINOLE COUNTY, a political
subdivision of the State of Florida, whose address is Seminole County
Services Building, 1101 East First Street, Sanford, Florida 32771,
hereinafter called the "COUNTY".
WIT N E SSE T H:
WHEREAS, the COUNTY desires to retain the services of a competent
and qualified contractor to provide billing services for emergency
medical services transport in Seminole County; and
WHEREAS, the COUNTY has requested and received expressions of
interest for the retention of services of contractors; and
WHEREAS, CONTRACTOR is competent and qualified to furnish services
to the COUNTY and desires to provide its professional services according
to the terms and conditions stated herein,
NOW, 'l'HEREFORE, in consideration of the mutual understandings and
covenants set forth herein, COUNTY and CONTRACTOR agree as follows:
SEC'l'ION 1 .
SERVICES.
COUNTY does hereby retain CONTRACTOR to
furnish professional services and perform those tasks as further
described in the Scope of Services attached hereto and incorporated
herein as Exhibit "AU.
SECTION 2.
AUTHORIZATION FOR SERVICES.
Authorization for
performance of professional services by the CONTRACTOR under this
Agreement shall be in the form of written Notice to
1
Proc~ed i'Cltffi~EDncbpy
MARYANNE MORSE
CLERK Of CIRCUIT COURT
SEMINOLE COUNTY, flORIDA
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BY ~.Y It ,
n&'DIITV ClFRK
executed by the COUNTY.
, l
SECTION 3. COMPENSATION AND PAYMENT.
( a)
The COUNTY agrees
to compensate CONTRACTOR for the
professional services called for under this Agreement as follows:
Compensation shall be an incentive fee (percentage of collected amount
of 6.25%. Monthly contingency of all monies collected in the previous
month (excluding Medicaid accounts) plus a $7.50 flat fee per account
-
for collecting of all Medicaid accounts, taking into consideration that
Florida Statutes prohibit charging on the basis of receivables for
billing of Medicaid accounts.
(b) Payments shall be made to the CONTRACTOR when requested as
work progresses for services furnished, but not more than once monthly.
CONTRACTOR may invoice amount due based on the total required services
actually performed and completed. Upon review and approval of
CONTRACTOR I S invoice, the COUNTY shall, within thirty (30) days of
receipt of the invoice, pay CONTRACTOR the approved amount.
SECTION 4. BILLING AND PA'YMENT.
(a) CONTRACTOR shall render to the COUNTY, at the close of each
calendar month, an itemized invoice, properly dated including, but not
limited to, the following information:
(1) The name and address of the CONTRACTOR;
(2) Contract Number;
(3) A complete and accurate record of services performed by
the CONTRACTOR for all services performed by the CONTRACTOR during that
month and for which the COUNTY is billed and the name of the individual
performing each service;
(4) A description of the services rendered in (3) above
with sufficient detail to identify the exact nature of the work
performed; and
')
'l
(5) Such other information as may be required by this
Agreement or requested by the COUNTY from time to time.
The original invoice shall be sent to:
Director of County Finance
Seminole County Board of County Commissioners
Post Office Box 8080
Sanford, Florida 32772
A duplicate copy of the invoice shall be sent to:
Public Safety Department / EMS Fire Rescue
150 Bush Loop, Suite 2-138
Sanford, FL 32773
(b) Payment shall be made after review and approval by COUNTY
within thirty (30) days of receipt of a proper invoice from the
CONTRACTOR.
SECTION 5. AUDIT OF RECORDS.
(a) COUNTY may perform or have performed an audit of the records
of CONTRACTOR after final payment to support final payment hereunder.
This audit would be performed at a time mutually agreeable to CONTRACTOR
and COUNTY subsequent to the close of the final fiscal period in which
the last work is performed.
Total compensation to CONTRACTOR may be
determined subsequent to an audit as provided for in subsection (b) and
of this subsection, and the total compensation so determined shall be
used to calculate final payment to CONTRACTOR.
Conduct of this audit
shall not delay final payment as required by Section 4(b).
(b) The CONTRACTOR agrees to maintain all books, documents,
papers, accounting records and other evidences pertaining to work
performed under this Agreement in such a manner as will readily conform
to the terms of this Agreement and to make such materials available at
CONTRACTOR'S office at all reasonable times during the Agreement period
and for five (5) years from the date of final payment under the contract
for audit or inspection as provided for in subsection (a) of this
Section.
\
(c) In the event any audit or inspection conducted 'after final
payment, but within the period provided in subsection (b) of this
Section reveals any overpayment by COUNTY under the terms of the
Agreement, CONTRACTOR shall refund such overpayment to COUNTY wi thin
thirty (30) days of notice by the COUNTY.
SECTION 6. RESPONSIBILITY OF CONTRACTOR.
(a) CONTRACTOR shall be responsible for the professional quality,
technical accuracy and the coordination of all reports and other
services furnished by CONTRACTOR under this Agreement. CONTRACTOR
shall, without additional compensation, correct or revise any errors or
deficiencies in his services.
(b) Neither the COUNTY'S review, approval or acceptance of, nor
payment for, any of the services required shall be construed to operate
as a waiver of any rights under this Agreement or of any cause of action
arising out of the performance of this Agreement and the CONTRACTOR
shall be and remain liable to the COUNTY in accordance with applicable
law for all damages to the COUNTY caused by the CONTRACTOR'S performance
of any of the services furnished under this Agreement.
SECTION 7. OWNERSHIP OF DOCUMENTS. All deliverable reference,.
data, survey data, plans and reports that result from the CONTRACTOR'S
services under this Agreement shall become the property of the COUNTY
after final payment for the specific service provided is made to
CONTRACTOR. No changes or revisions to the documents furnished by
CONTRACTOR shall be made by COUNTY or its agents without the written
approval of. CONTRACTOR.
SECTION 8. TERM. This Agreement shall take effect on November
20, 2006 and shall remain in effect for a period of three (3) years and,
at the option of the parties, may be renewed for two (2) additional one
(1) year periods.
"
SECTION 9.
(a) The
TERMINATION.
COUNTY may,
by
written
notice
to
the
CONTRACTOR,
terminate this Agreement, in whole or in part, at any time, either for
the COUNTY'S convenience or because of the failure of the CONTRACTOR to
fulfill CONTRACTOR'S Agreement obligations. Upon receipt of such
notice, the CONTRACTOR shall:
(1) immediately discontinue all services affected unless
the notice directs otherwise, and
(2) deliver to the COUNTY all plans, studies, reports,
estimates, sunnnaries, and such other information and materials as may
have been accumulated by the CONTRACTOR in performing this Agreement,
whether completed or in process.
(b) If the termination is for the convenience of the COUNTY, the
CONTRACTOR shall be paid compensation for services performed to the date
of termination. CONTRACTOR shall be paid no more than a percentage of
the Fixed Fee amount equivalent to the percentage of the completion of
work contemplated by the Agreement.
(c) If the termination is due to the failure of the CONTRACTOR to
fulfill his Agreement obligations, the COUNTY may take over the work and
prosecute the same to completion by Agreement or otherwise. In such
case, the CONTRACTOR shall be liable to the COUNTY for reasonable
additional costs occasioned to the COUNTY thereby. The CONTRACTOR shall
not be liable for such additional costs if the failure to perform the
Agreement arises out of causes beyond the control and without the fault
or negligence of the CONTRACTOR. Such causes may include, but are not
limited to, acts of God or of the public enemy, acts of the COUNTY in
either its sovereign or contractual capacity, fires, floods, epidemics,
quarantine restrictions, strikes, freight embargoes, and unusually
severe weather; but, in every case, the failure to perform must be
,
I
beyond the control and without the fault or negligence of the
CONTRACTOR.
(d) If, after notice of termination for failure to fulfill
Agreement obligations, it is determined that the CONTRACTOR had not so
failed, the termination shall be deemed to have been effected for the
convenience of the COUNTY. In such event, adjustment in the Agreement
price shall be made as provided in subsection (b) of this Section.
(e) The rights and remedies of the COUNTY provided in this clause
are in addi tion to any other rights and remedies provided by law or
under this Agreement.
SECTION 10. EQUAL OPPORTUNITY EMPLOYMENT. CONTRACTOR agrees that
it will not discriminate against any employee or applicant for
employment for work under this Agreement because of race, color,
religion, sex, age, national origin, or disability and will take steps
to ensure that applicants are employed, and employees are treated during
employment, without regard to race, color, religion, sex, age, national
origin or disability. This provision shall include, but not be limited
to, the following: employment, upgrading, demotion or transfer;
recruitment advertising; layoff or termination; rates of payor other
forms of compensation; and selection for training, including
apprenticeship.
SECTION 11. NO CONTINGENT FEES. CONTRACTOR warrants that it has
not employed or retained any company or persons, other than a bona fide
employee workir;tg solely for the CONTRACTOR, to solicitor secure this
Agreement and that CONTRACTOR has not paid or agreed to pay any persons,
company, corporation, individual or firm, other than a bona fide
employee working solely for CONTRACTOR, any fee, commission, percentage,
gift, or other consideration contingent upon or resulting from the award
or making of this Agreement. For the breach or violation of this
provision, COUNTY shall have the right to terminate the Agreement at. its
discretion, without liability and to deduct from the Agreement price, or
otherwise recover, the full amount of such fee, commission, percentage,
gift or consideration.
SECTION 12. ASSIGNMENT. This Agreement, or any interest herein,
shall not be assigned, transferred, or otherwise encumbered, under any
circumstances, by the parties hereto without prior written consent of
the opposite party and only by a document of equal dignity herewith.
SECTION 13. SUBCONTRACTORS. In the event CONTRACTOR, during the
course of the work under this Agreement, requires the services of any
subcontractors or other professional associates in connection with
service covered by this Agreement, CONTRACTOR must secure the prior
written approval of the COUNTY. If subcontractors or other professional
associates are required in connection with the services covered by this
Agreement, CONTRACTOR shall remain fully responsible for the services of
subcontractors or other professional associates.
SECTION 14. INDEMNIFICATION OF COUNTY. The CONTRACTOR agrees to
hold harmless, replace, and indemnify the COUNTY, its commissioners,
officers, employees, and agents against any and all claim, losses,
damages or lawsuits for damages, arising from the negligent, reckless,
or intentionally wrongful provision of services hereunder by the
CONTRACTOR, whether caused by the CONTRACTOR or otherwise.
SECTION 15. INSURANCE.
(a) General. The CONTRACTOR shall at the CONTRACTOR'S own cost,
procure the insurance required under this Section.
( 1 ) The CONTRACTOR shall furni sh the COUNTY wi th a
Certificate of Insurance signed by an authorized representative of the
insurer evidencing the insurance required by this Section (Professional
Liability, Workers' Compensation/Employer's Liability and Commercial
"
General Liability). The COUNTY, its officials, officers, and employees
shall be named additional insured under the Commercial General Liability
policy. The Certificate of Insurance shall provide that the COUNTY
shall be given not less than thirty (30) days written notice prior to
the cancellation or restriction of coverage. Until such time as the
insurance is no longer required to be maintained by the CONTRACTOR, the
CONTRACTOR shall provide the COUNTY with a renewal or replacement
Certificate of Insurance not less than thirty (30) days before
expiration or replacement of the insurance for which a previous
certificate has been provided.
(2) The Certificate shall contain a statement that it is
being provided in accordance with the Agreement and that the insurance
is in full compliance with the requirements of the Agreement. In lieu
of the statement on the Certificate, the CONTRACTOR shall, at the option
of the COUNTY submit a sworn, notarized statement from an authorized
representative of the insurer that the Certificate is being provided in
accordance with the Agreement and that the insurance is in full
compliance with the requirements of the Agreement. The Certificate
shall have this Agreement number clearly marked on its face.
(3) In addition to providing the Certificate of Ins~rance,
if required by the COUNTY, the CONTRACTOR shall, within thirty (30) days
after receipt of the request, provide the COUNTY with a certified copy
of each of the policies of insurance providing the coverage required by
this Section.
(4) Neither approval by the COUNTY or failure to disapprove
the insurance furnished by CONTRACTOR shall relieve the CONTRACTOR of
the CONTRACTOR'S full responsibility for performance of any obligation
including CONTRACTOR'S indemnification of COUNTY under this Agreement.
n
(b)
Insurance
Company
Requirements. Insurance companies
this Agreement must meet the following
providing the insurance under
requirements:
(1) Companies issuing policies other than Workers'
Compensation must be authorized to conduct business in the State of
Florida and prove same by maintaining Certificates of Authority issued
to the companies by the Department of Insurance of the State of Florida.
Policies for Workers' Compensation may be issued by companies authorized
as a group self-insurer by Section 440.57, Florida Statutes.
(2) In addition, such companies other than those authorized
by Section 440.57, Florida Statutes, shall have and maintain a Best's
Rating of "A" or better and a Financial Size Category of "VII" or better
according to A.M. Best Company.
(3) If, during the period which an insurance company is
providing the insurance coverage required by this Agreement, an
insurance company shall: 1) lose its Certificate of Authority, 2) no
longer comply with Section 440.57, Flor~da Statutes, or 3) fail to
maintain the requisite Best's Rating and Financial Size Category, the
CONTRACTOR shall, as soon as the CONTRACTOR has knowledge of any such
circumstance, immediately notify the COUNTY and immediately replace the
insurance coverage provided by the insurance company with a different
insurance company meeting the requirements of this Agreement. Until
such time as the CONTRACTOR has replaced the unacceptable insurer with
an insurer acceptable to the COUNTY the CONTRACTOR shall be deemed to be
in default of this Agreement.
(c) Specifications. Without limiting any of the other
obligations or liability of the CONTRACTOR, the CONTRACTOR shall, at the
CONTRACTOR'S sole expense, procure, maintain and keep in force amounts
and types of insurance conforming to the minimum requirements set forth.
,...
in this Section.
Except as otherwise specified in the Agreement, the
insurance shall become effective prior to the commencement of work by
the CONTRACTOR and shall be maintained in force until the Agreement
completion date.
The amounts and types of insurance shall conform to
the following minimum requirements.
(1) Workers' Compensation/Employer's Liability.
(A) CONTRACTOR'S insurance shall cover the CONTRACTOR
for liability which would be covered by the latest edition of the
standard Workers' Compensation Policy, as filed for use in Florida by
the National Council on Compensation Insurance, without restrictive
endorsements.
The CONTRACTOR will also be responsible for procuring
proper proof of coverage from its subcontractors of every tier for
liability which is a result of a Workers' Compensation injury to the
subcontractor's employees.
The minimum required limits to be provided
by both the CONTRACTOR and its subcontractors are outlined in subsection
(c) below.
In addition to coverage for the Florida Workers'
Compensation Act, where appropriate, coverage is to be included for the
United States Longshoremen and Harbor Workers' Compensation Act, Federal
Employers' Liability Act and any other applicable Federal or State law.
(B) Subject to the restrictions of coverage found in
the standard Workers' Compensation Policy, there shall be no maximum
limit on the amount of coverage for liability imposed by the Florida
Workers' Compensation Act, the United States Longshoremen's and Harbor
Workers' Compensation Act, or any other coverage customarily insured
under Part One of the standard Workers' Compensation Policy.
(C) The minimum amount of coverage under Part Two of
the standard Workers' Compensation Policy shall be:
$ 500,000.00
$1,000,000.00
$ 500,000.00
(Each Accident)
(Disease-Policy Limit)
(Disease-Each Employee)
(2) Commercial General Liability.
(A)
The CONTRACTOR I S insurance shall
cover
the
CONTRACTOR for those sources of liability which would be covered by the
latest edition of the standard Commercial General Liability Coverage
Form (ISO Form CG 00 01), as filed for use in the State of Florida by
the Insurance Services Office, without the attachment of restrictive
endorsements other than the elimination of Coverage C, Medical Payment
and the elimination of coverage for Fire Damage Legal Liability.
(B) The minimum limits to be maintained by the
CONTRACTOR (inclusive of any amounts provided by an Umbrella or Excess
policy) shall be as follows:
LIMITS
General Aggregate
$Three (3) Times the
Each Occurrence Limit
Personal & Advertising
Injury Limit
$500,000.00
Each Occurrence Limit
$500,000.00
(3) Professional Liability Insurance. The CONTRACTOR shall
carry limits of not less than FIVE HUNDRED THOUSAND AND NO/100 DOLLARS
($500,000.00) .
(d)
Coverage.
The insurance provided by CONTRACTOR pursuant to
this Agreement shall apply on a primary basis and any other insurance or
self-insurance maintained by the COUNTY or the COUNTY'S officials,
officers, or employees shall be excess of and not contributing with the
insurance provided by or on behalf of the CONTRACTOR.
(e)
Occurrence Basis.
The Workers' Compensation Policy and the
Commercial General Liability required by this Agreement shall be
provided on an occurrence rather than a claims-made basis. The
Professional Liability insurance policy must either be on an occurrence
basis, or, if a claims-made basis, the coverage must respond to all
claims reported within three (3) years following the period for which
coverage is required and which would have been covered had the coverage
been on an occurrence basis.
(f) Obligations. Compliance with the foregoing insurance
requirements shall not relieve the CONTRACTOR, its employees or agents
of liability from any obligation under a Section or any other portions
of this Agreement.
SECTION 16. ALTERNATIVE DISPUTE RESOLUTION.
(a) In the event of a dispute related to any performance or
payment obligation arising under this Agreement, the parties agree to
exhaust COUNTY protest procedures prior to filing suitor otherwise
pursuing legal remedies. COUNTY procedures for proper invoice and
payment disputes are set forth in Section 22.15, "Prompt Payment
Procedures," Seminole County Administrative Code.
(b) CONTRACTOR agrees that it will file no suitor otherwise
pursue legal remedies based on facts or evidentiary materials that were
not presented for consideration in the COUNTY protest procedures set
forth in subsection (a) above of which the CONTRACTOR had knowledge and
failed to present during the COUNTY protest procedures.
(c) In the event that COUNTY protest procedures are exhausted and
a suit is filed or legal remedies are otherwise pursued, the parties
shall exercise best efforts to resolve qisputes through voluntary
mediation. Mediator selection and the procedures to be employed in
voluntary mediation shall be mutually acceptable to the parties. Costs
of voluntary mediation shall be shared equally among the parties
participating in the mediation.
SECTION 17. REPRESENTATIVE OF COUNTY AND CONTRACTOR.
(a) It is recognized that questions in the day-to-day conduct of
performance pursuant to this Agreement will arise. The COUNTY, upon
request by CONTRACTOR, shall designate in writing and shall advise
CONTRACTOR in writing of one (1) or more COUNTY employees to whom all
corrununications pertaining to the day-to-day conduct of the Agreement
shall be addressed. The designated representative shall have the
authority to transmit instructions, receive information and interpret
and define the COUNTY I S policy and decisions pertinent to the work
covered by this Agreement.
(b) CONTRACTOR shall, at all times during the normal work week,
designate or appoint one or more representatives of CONTRACTOR who are
authorized to act on behalf of CONTRACTOR regarding all matters
involving the conduct of the performance pursuant to this Agreement and
shall keep COUNTY continually advised of such designation.
SECTION 18. ALL PRIOR AGREEMENTS SUPERSEDED. This document
incorporates and includes all prior negotiations, correspondence,
conversations, agreements or understandings applicable to the matters
contained herein and the parties agree that there are not commitments,
agreements or understandings concerning the SUbject matter of this
Agreement that are not contained or referred to in this document.
Accordingly, it is agreed that no deviation from the terms hereof shall
be predicated upon any prior representations or agreements, whether oral
or written.
SECTION 19. MODIFICATIONS, AMENDMENTS OR ALTERATIONS. No
modification, amendment or alteration in the terms or conditions
contained herein shall be effective unless contained in a written
document executed with the same formality and of equal dignity herewith.
SECTION 20. INDEPENDENT CONTRACTOR. It is agreed that nothing
herein contained is intended or should be construed as in any manner
creating or establishing a relationship of copartners between the
parties, or as constituting the CONTRACTOR including its officers,
1 "2
employees, and agents, the agent, representative, or employee of, the
COUNTY for any purpose, or in any manner, whatsoever. The CONTRACTOR is
to be and shall remain an independent contractor with respect to all
services performed under this Agreement.
SECTION 21. EMPLOYEE STATUS. Persons employed by the CONTRACTOR
in the performance of services and functions pursuant to this Agreement
shall have no claim to pension, workers' compensation, unemployment com-
pensation, civil service or other employee rights or privileges granted
to the COUNTY'S officers and employees either by operation of law or by
the COUNTY.
SECTION 22. SERVICES NOT PROVIDED FOR. No claim for services
furnished by the CONTRACTOR not specifically provided for herein shall
be honored by the COUNTY.
SECTION 23. PUBLIC RECORDS LAW. CONTRACTOR acknowledges COUNTY'S
obligations under Article I, Section 24, Florida Constitution and
Chapter 119, Florida Statutes, to release public records to members of
the public upon request. CONTRACTOR acknowledges that COUNTY is
required to comply with Article 1, Section 24, Florida Constitution and
Chapter 119, Florida Statutes, in the handling of the materials created
under this Agreement and that said statute controls over the terms of
this Agreement.
SECTION 24. NOTICES. Whenever ei ther party desires to gi ve
notice unto the other, it must be given by written notice, sent by
certified United States mail, with return receipt requested, addressed
to the party for whom it is intended at the place last specified and the
place for giving of notice shall remain such until it shall have been
changed by written notice in compliance with the provisions of this
Section. For the present, the parties designate the following as the
respective places for giving of notice, to wit:
For COUNTY:
Public Safety Department / EMS Fire Rescue
150 Bush Loop, Suite 2-138
Sanford, FL 32773
For CONTRACTOR:
Advanced Data Processing, Inc.
500 N.W. 165~ Street, Suite 102
Miami, FL 33169
SECTION 25. RIGHTS AT LAW RETAINED. The rights and remedies of
the COUNTY, provided for under this Agreement, are in addition to any
other rights and remedies provided by law.
SECTION 26.
COMPLIANCE WITH LAWS AND REGULATIONS.
In providing
all services pursuant to this Agreement, the CONTRACTOR shall abide by
all statutes, ordinances, rules, and regulations pertaining to, or
regulating the provisions of, such services, including those now in
effect and hereafter adopted.
Any violation of said statutes,
ordinances, rules, or regulations shall constitute a material breach of
this Agreement, and shall entitle the COUNTY to terminate this Agreement
immediately upon delivery of written notice of termination to the
CONTRACTOR.
SECTION 27. CONFLICT OF INTEREST.
(a) The CONTRACTOR agrees that it will not engage in any action
that would create a conflict of interest in the performance of its
obligations pursuant to this Agreement with the COUNTY or which would
violate or cause others to violate the provisions of Part III, Chapter
112, Florida Statutes, relating to ethics in government.
(b) The CONTRACTOR hereby certifies that no officer, agent or
employee of the COUNTY has any material interest (as defined in Section
112.312(15), Florida Statutes, as over 5%) either directly or indirect-
ly,in the business of the CONTRACTOR to be conducted here, and that no
such person shall have any such interest at any time during the term of
1 r:;
thi s Agreement.
(c) Pursuant to Section 216.347, Florida Statutes, the CONTRACTOR
hereby agrees that monies received from the COUNTY pursuant to this
Agreement will not be used for the purpose of lobbying the Legislature
or any other State or Federal agency.
IN WITNESS WHEREOF, the parties hereto have made and executed this
Agreement for the purposes stated herein.
ATTEST:
&odaL~
Secretary
(cote SEAL)
ADVANCED DATA PROCESSING, INC.
~(-
By:11J. . ~ /0 -
WILLIAM J DEZ~re6ide:.l'lt EVP
Da te: 'JL J ne___ :J.Cl I ;)OCl{a
BOARD OF COUNTY COMMISSIONERS
SIDfiN~ECO~~
By/?~
; .
CARLTON HENLEY, ChaJ.rrnan
Date:
g-dd~(P
For'the use and reliance
of Seminole County only.
Approved
legal s
and
As authorized for execution by
the Board~county commissio,n ers
at their .1 A-J r 3 , 20~,
regular mee J.ng.
Co y A
AC/lpk
5/23/06
rfp-0780
Attachments:
Exhibit UA" - Scope of Services
Exhibit UB" - Rate Schedule
~ r
AMBULANCE BILLING SERVICES FOR THE SEMINOLE COUNTY
EMS/FIRE/RESCUE DIVISION
SCOPE OF SERVICES
2006
Seminole County, Florida (County) desires to enter into a contract with an experienced
and qUCllifi~d ,firm (Agency) to:
1. Provide billing services for Emergency Medical Services transport, as
required on a case by case basis, with an emphasis on an accelerated
turnaround between services provided and payments received. The monthly
invoice shouldshow gross collections, patient refunds, Medicaid collections,
net collections, M~dicaid transports, Privacy Notice Mailing fee arid Agency'
invoice amount. \ ,
2. Provide reasonably necessary trainillg to appropriate County
EMS/Fire/Rescue personnel regarding the gathering of necessary
informatio/'] and proper completion of run tickets. The A.gehcy will work with
the County's Collection Company for delinquent accounts.
'3.
Provide prqmpt submission of Medic;are, Medicaid, and insu,raDc;e c1a(ms
within ten (10) qusiness days aft~r receiving the completed patient billing
information, which shall be -the Agency's notice to commence th,e
bil/ing/collection'service: Ability to re,ceive the County's tr~nsport records file
digitally. The receipt of the digital transport records will meet with the
County's file layout criteria. (Reference Attachment B).. SecoDdary
insurance provider 'claims shall b,e submitted within ten (10) business ,days'
aft~r ~~e primary ins!-,rance provicjer h?s paid, this process shqiJld .alsq
include Me~,iC(are 'secondary. ~gency shall folloW-Up promptly on rejected
a~~ inactive cIailTls and establish payer remittance accounts and procedure.s,
. If there.is no response from insuran<;:e companies within 45'd~ys clainis will
be .res~brriitted. ' " ,
[-
\4.
Reconcile t~e number of transpprts collecte9 with those transl1litted t9 the
Agency. The Agency shall contact ~MS/Fire/Rescue within twenty-four (24)
hours of receipt to rep,ort any 'discrepancies.
5. Agency shall provide a designat~d liaison f~r patient/payer ~oncerns.
6. Prpvide aU cl,Jstomer-related inquiry services and prepare,additional.third
party cl?imsbased on this information exchange. p'rovide a'tol.l:"free
telephone r)!lmber and secure web site address for c'ustomeraccess.
7. Implement a collection system involving a minimum of six (6) invoices, which
l/:Iillin9lud~ an initial' statement to all transported patie8ts. Establish a fo1l00-
up campaign or up to twenty-four (24) telephone atterTlpts' to' :colleCt all priv'ate
pay accounts' with Qutstpriding balances, 'including required cq~payments ,and
deductibl~s assessed by"Medicare, Medicaid, HMO's or private insurance.,
Records of terephon~ calls and contacts sh~1I be main~ain'ed and 'ayalIaqle to
the County via on-line access to the Agency's database. Any payment on an
aCCOl:Jnt shall reset this cycle. Returned mail accounts are exempt from the
above-required subsequent mailings. The County reseNes the right to
approve the invoice format. The invoice will contain a stafement in Spanish
to call the toll-free telephone number for assistance.
8. Agency shall utilize the approved hospital medical record identifier number
(MRI#) to contact the hospital in retrieving patient information that was not
available during transport. It will be the responsibility of the agency to
contact the receiving facility for additional insurance information.
9. Agency will provide skip tracing through a nationally recognized change of
address system, example would be Accurint or similar agency. A credit
information resource will be used to determine returned mail corrections and
Agency will resubmit statement to patient with corrected address.
10. Attempt to collect all balances due for seNices rendered as well as attempt
to assess patient's ability to repay the debt, and if necessary, extend time
payments, all subjec~ tQ such policy guidelines as the County may establish.
11. Process requests for refunds through County on a monthly basis and provide
EMS/Fire/Rescue Division With documentation of eaGh refulld processed.
r-.
12. Provide ~o EMS/Fire/Rescue Division all unpaid invoices alol1g with the
complet~ processing history once collection effort~ are exhausted. Shquld
th!? agre~ment be terminated for any r~ason, the Agency shall turn over all
existing information in its pos,session concerning existing unpaid accounts.
Such information shall be transmitted by an electronic medium r,easonably
acceptable to EMS/Fire/Rescue.
13. Th,e Agency shall provide sufficient bi,-lingualpersonnel to process all
billinglrun tickets in ,a timely, efficient and effective manner and shall respond
pr<;:>mptly to the County al!d patients on reque'sts for information or records.,
'14. Agency will be HIPAA compliant with all their federal standards and will
prbvic;fe their policy upon request. The Agency will be willing t,o sign the
,HIPAA Business AS,sociate Agreement (Reference Attachment C)
rega'rding the us'e of any confidel)tial records of care ,or treatment of patients
,:~olely for the purpose of processing and collecting claims a'nd shafl not
. release any such information in any legal action, business dispute or
competitive bidding :process other than disputes with the Coun'ty over billing
services. '
15. Any procedL!res described:in t~is scope of seNices represents a IT)inimum
effort required by the Agency and shall not limit the Agency's use of its
ptoprfet~ry acco~nts receivable and billing and collections systems, including
modi~ca~ions ~s 'required ,by major provider groups, or ,its usual and
customary practj~es. The, successful collection rate will be calculated on a
m~nthly basis and reflect the percentage bas.ed upon what is billed versus
whC!t is actually collected before any other action is taken on the account, not
including any reduction or write-off for uncollectible Medicare or Medicaid
payments. The Agency will use its "best efforts" to ensure that the annual
collection rate does not fall below an annual 65% minimum. If the annual
collection rate falls below 65%, the County will require the Agency to provide
justification or corrective action. .
16. The following monthly reports shall be prepared by the Agency and submitted
to the County (Reference Attachm~nt A):
Reports:
· Transport Charges & Collections
· Billing & Collection Summary
o Ambulance Payment
· Ambulance New Patient Billing
· Ambulance Unit Report
· Collection by Financial.pass
· Report of Accounts Receivable
· Ambulance Billing Adjustments - Write Offs - Reversals
· .Accounts "Receivable for Collections
· Audit R~port of Accounts Changed
· Insurance Denial
· Revenue p'er Transport Report
· .Revenue Report .
r
17. The County requires on-line read-only and printable access to the Agency's
patient billing database, which will include the ability to select by account
number or by last name Index. The database access will include the
. following patient information:
· I.ncident location afld unit JD
· Patient contact information
· Date of ~ervice
· Trahs'p~rt mile~ge
· . Tr~nsport rate & mileage charge
· .Number of mai!ings' .
· . Pat(ent message screen with dates and descriptions of mailings,
comml..!nication with pati~nt, insur~nce company, a~orneys, etc.
· Pc3yment screen shoWing adjustments, payment type, payer name, check
number, dafe received, amount of payment and balaj1cedue
18. ..In the. ca~e of any untimely claims r~fusal of payment from an insurance
company for which the Agency is responsible, the amount of the transport .
charge. will be credited to the patient's account and deducted from the
calculation of the County's mi;>nthly invoice.
19. In case of a catastrophic event a toll-free telephone number will be avaiJable
for patient access within 24 hours. The Agency will provide the County with
a copy of the .Agency's Disaster Plan.
20.
Agency will attend at least one meeting annually with the County at a
mutually agreed upon specified location.
Agency will be responsible for tracking the Medicare and Medicaid renewal
dates and application .forms for the County.
21.
Seminole County EMS/Fire/Rescue Division
RFP Billing Summary
For the fiscal year October 2004 - September 2005, the transport net charges were @
$3,700,000 and net revenue was @ $2,700,000 with an additional $70,000 in revenue
from coliection accounts.
The billing collection rate for that fiscal- year was 72%.
The demographics of the 2004/2005 fiscal. year collections were:
· 40% lnsurance. .
.. 47% Medicare
· 7% Medicaid
· 6% Se.lf Pay
t---
The current fee schedule for our EMS transports range from $287 to $493, dependi~g
on th~ level of seryice with an ad~itional$6.05 per loaded mile. .
· BL$ - Emergency $287.31
· ALS 1 - Emergency $341.18
· ALS2 $493.81
ATTACHMENT A
Brief description of monthly reports to be prepared and submitted:
,1. Transport Charges & Collections:
Report should include the mO,n,thly transport gross charges, adjustments, net
charges, receipts (based on transport date), net balance, gross % of collections, net
% qf colle.ctions arid the % of paying patients. This should include a line of all the
data from ,the first billing month and year to the present. Totals should be on each
column.
2. Billing & Collection Summary:
Report should show by month/year total gross Qilling, ,adjustments, collections by
month, collections to-date. Totals should be on each column.
r
3. Ambula,n,te Payment Report:
. 'Report should list patient number, patient na'me, address, check nl,Jrnber, check
amount, payment type (self-pay, Insurance, MEldicare, Medicaid), payer'if other than
patient. It shp'uld subtotal.for each transport deposit pate, with the batch number and
totalamountof d~po~it. Tpt~ls for check amount coiurrin and each of the payment
types broken out separatl?ly and adjustments.
4. Ambulance New Pati,entBil/ing Rep~rt:
, Report sh~uld include the foil owing data for new patien,ts transported duri~g th~t ' ,
month. 'Patient number, pati~nt nalJ1e, incident date, base amount, rnileage 'amount,
total ,billed and leVel of service. Totals on' number of new accounts, base amdLin(
miieaQe ~mciul"!t an~tofaE"',by"ea(ih "evel of service':" _' , .,,' " '. " '. , .
'5. Al1!bulance Unit 'Report:
R~poii shqLildinclude~'rnbuJance unit numbE;!r with its number of Ga.lls i:jnd gross
,bili:ed for that month. -Total 'on number ,of p~lIs' and.:g'ross 'billed. ,"' ,
6. Collection by Fi,n.ancial Class Repo,rt:
,Report should show by m.onth/year and each payment type (Self Pay,lnsUri311ce,'
Medicare, 'Meqicaid). It should Include amount billed, amount collected, % collected,
number of accounts arid gross billed for each month. Totals for, each payment tyPE?
: and.%colfeCted.. .
7. Report of Accounts Receivable:
"
Report should show by year to date, the gross amount billed, less removed
accounts, less payments, less adjustments, less reversals and the accounts
receivable balance. These figures are shown by dollar amount and number of
accounts.
8. Ambulance Billing Adjustments / Write Offs / Reversals Report:
Report should include pt;ltient number, patient name, incident date, adjustment
amount and adjustment type. Total of adjustment amount and number of
adjustments should also be on this report.
9. A~counts Receivable for ~ollections Repo~:
This report should show patient number, patient name, patient addres,s, zip code,
incident date, amount billed, amount paid, adjustments, balance. Totals by gross
billed, 'less payments, less adjustments,' balan'ce of accounts receivable.
10. Audit Report of Changed Accounts:
Report should show account number, account name, leyel of service change, date
Changed, from base amount, to base amount.
11. Insurance Denial Report:
r
Report should show account number, account na,me, incideht d?te, inqident amount,
insurance c.arrier, condition code, reason for denial.
12. Revenue per Transport Report:
~eport should show the total dollar amount of payments received for a transport
mo'nth divided by the number of transports for a month and listed by month and
~~ ' .
13". Revenue Report:
. \. ... ..
Report should sh()w by month/year gross charges, adjustments, net chc;lrges,
' receipts (based on deposit d?te), %'collected.
..
l.
I
i-
\
ATTACHMENT B
Fixed Lengt.h Billing Extract Format-Existing
Phase N/A D.ate 08/04/05
Author , Docwnent In Fixed Length Billing Vertlon 2
Extract Fonnat-
Existin/l.d6c
Introduction:
11lls document details the fixed longth billing extract format that '",,;}1 be u~lized to tran.smi~ incident
information electronically to ADPI. rfa field is not requireq, or not, IleedCd, 'the deSignated '1ocatio~
'for that ,field may,be l~ftbla,nk Numeric fomiats are right justified and alpha'fonmits are left justified.
Record 1 :,Patien t. ~surance: and Level of Service Information
431 c~~ters, 1 record per incident/account
-- -- - -- ---- "
- - -- - ,- .- - . - &- -- - . . '" \. . '. . ~
: ...... . .. "
"
-. '. -'
I': : ~~OD, ~ RCICOro Code, y A 1:' ; RccortI codc .'1
'. .:..
2-1.1' ACTNR Incident Number y N' 10 w~ ~,positjollS,arc lakoi for the
account inimbcr' and last 2
'posItions for#. ~{paticrilS
1241 ANAME Patient NlIlTIc N A 30 lohn Smith
~7..s1 'UNE2 Patient AddreSS N A 20 Filllt20 chazaclcr3
62-81 LINE Patient Addrc:s! N A 20 .. UtiliZe if more than 20 chanlctcrs
82-101. : LINE4 Patient Cilyand Slate 1'1 A 20 "City, Statc"
102-106 ZIPCD Pati ent l.iP Codc N N ,5
101-116 ?I3ONE Patient Phonc,lI N " A 10 No seplX'lllOrs
117-124, mATE lnpidcnt pate . y N 8 MMDDYYYY
17S-IJ~ ~r.r UnifNumbcr N A ,12 . "
.
'\37.144 VPOB Patient pce N A 8 MMDOYYYY .,
!<l5 " Y~EX,.': Pati~t Sex y A " 1 M~M~Ie.,:'
.- l' -l'analc '
146-154 SSNR' Patient Social See II ' N l'! 9 No s~ori ,
, 155--189,' IADOR lncidentA~! N A 35 .-
190 ',' " BLSI ALS Tran.sport Service Y A I' B - BLS
, Level' A'-ALS
T~1V(T,
A;" Ailplane
H ';'He!icoplcr
S - Standby/Event
191;195 HOSP# Dc:s~ation lD y A 5 i Receivc Wliquc dcsl1natiOll #$ froni
ADPl
196-215 HOSf NAME ~ation'Name N A 20
"
216 OXYFLG ~xygcn Used? y A 'I :'fIN. Default to N if not charging
foroltygen.
,. "
,
"
)
Fixed Length Billing Extract Format-Existing
Phase N/A 'Date 08/04/05
Author Document ID Fixed Length Billing Version 2
Extract Format-
Existinll,doc
217-221 MIMILE Total Mileage Y N 5,\ 9999.9
222.231 BPHONE Patient Business N A /0 No seplll1llors
Phonc
232.236 START Start Tune N A 5 runeon=c:. Example; 0121P.
or02S0A
237.241 STOP Stap Time N A 5 Examplc 0121P or 02S0A
242 HELlCOP A!r Transport? y A I YIN. Default 10 N ifnol providing
air traiuportscivices.
~43 SpECHDLG Special Handling? N A Th is is an open fi el d that can b.
utilized 10 mi:et client uniqu'e
needs; such as ALS/BLS
identifiers for TWT.
2#-255 MEDICARE Mcd,icarc ID N A 12 NO$Cp8llltolll
256-267 MEDICAID McdiC!'id ID N A 12 No SCPllt3tolll
268-287 INSNAMEI Patient IllSUral1ce # 1 N A 20
Name
288-302 INSII?I Patient'lnsul'llllCC # 1 N A IS No scpataiors
Polley /I
303-322 INSN~E2 F.atient Ins\ll'1lllcc #2 N A 20
) Namc
C- 323-337 INSID2 Patient Insurance #2 N A IS No sepllt3lors
Policy 1#
338 ~U1' Worlc. or AulD Y A W-Work
Related InjUl}' Flag A - Auto
N-None
339.34~ ' ~ICKUPZlP Piclc-up Zip Code Y N 5 '
344 'ALS+ Advanced Tl'llllSpOrt N A 1 2 . ALS2
Service Level ,S:"scr
345.349 MlLESBYND Mileage In Excess of N N 5.1 9999.9
FiatAppropriatc
Designation " '
350 '~S Resident YIN? Y ,A Y IN. Default 10 ,N if not billing
differently for residents vs. non.
residents.
m' AMBUL Paljenl Can Y A I' '(IN
Ambulate?
352 ALSASS ALS Assessment Y A YIN
Given? '
353 MUTAID ],futual Aid? y A I, y~; Default 10 no if not providing
,assisianc;c to other providers.
\
Fixed Length Billing Extract'Format-E;cisting
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354 SCODEI Spa:ial Code I N A I Thi.J b an,cp<n licld thatcin be
ub"liz.cd to mccl cliO)t lUIique
n=ls.
355 INTF Int=facility7 Y A I YIN
356 MODCD Pickup 'Modifier N A ] E" Residential, Domiciliary,
Custodial Facility
N.. Skilled NlU'Sing FlICility
H - Hospital
I ~ Sile ofTransport Between
Ambulance Transport (Airport or
Helicopter Pad)
po. Physician's Office
S - Scene of Accident or Acute
Event
R" Residence
D ,;, Diag~sti.c or Therapeutic Site
Other Than "P" or '11"
G" Hospital Based Dialysis
FBCllity
J - Non-:Hospital Based Dialysis
Facility
357 MODCD Destination Modifier N 1 E - !l-aj~tia), Domiciliary, . .
Cl,IStodia' Facility
N .. Ski!led"NlIl3irig Facility
H - HospilBl
1- Site of Transport Between
Ambulance Tran$port ~Airport or
H~ieopler Pad)
p.. PhySician's Office
" So. Scene or.A~cnt or Acute
Event
R .. Residencc
D - DiagnOstic or Thcnpeutic Site
, otJi~ Than "P" or ''R'" "
G ~ HllSJ'ital ~~ Dialysis
FaCility .
J.. Non-Hospltal Based Dialysis
Facility
X:- lntc:rmedialc Stop In j!.oute to
Hospiial Dciitiilatioil
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Phase N/A Date 08/04/05
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358.359 MODCD HCPCS Modifier N A" 2 GM-Gl'Oup~~
GW .. Scniice IlOt related to
hospice patienrs terminal condition
GY.. Not Medically Necessary .
QL-Death
360 Fcc I Fcc\? N A I Y IN. Each w.iII hav~ a consl8nt
and.unique S1!PPlemental fee tied to
it. Dc::fau!t to N.ifnol charging for
supplemental fee!.
36\ Fcc2 Fcc2? N A I ..
362 Fce3 Fce3? N A \ '..
:
363 F~ Fec4? ' N A 'I ..
364 FeeS FeeS? N A I ..
,365 Fee6 Fec6? N A \ ..
366-371 Fcc:Arnll Fee I DoUar Amount N N 6.2 9999.99
372:377 'FeeAmi2 Fcc 2 Dollat Amount' N N " 6.2 ..
378-.383 FceAmtJ Fec.3 Dollar Amount N N 6.2 ..
384-389 FeeAmt4 Fcc 4 Dollar AmOUllt" 'N N 6.2 ..
390.395 FccAmtS Fcc S Dollar AmOUllt 'N N 6.2 ..
396.40\ FeeAmt6 Fcc 6 Dollar AmOUnt N. N 6:2 ..
402- 4.16 PGrou~ I Patient JnsgRlla: #1 N A 15 No scp...to~
GioupID
417-431 PGroup2 Patient InsuriInce #2 N A 15 No separalol'3
GroUp ID
. ~e~ord 2: Impressions Information
. . . . ~
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2-11 ACJlo:IR lnciilent Number Y' t:I 10 ..
/2-291 ' IMPRES imPrcssiom N A 280
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Record 3: Interventions Information
29.1 chara~tcrs. ~ultiple records per incident/account possible_
~---::------. .-----------~- ------------_-:_- ---------.:._-- -------~-~-- ---
- . . .
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I' RECOD Record Code . Y A 1.' R.ecorti Code.- 3
2-11. ACTNR Incident Number y N 10
12-791 INTERV lntcrventiolU N A 280 lV, Meds, etc.
. .
Record 4: PCR N ar~ative
291 ch~~t~. ~~tiple re~rds per inci~ent/~ccoimt possible,.
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I .. RECOD " ~'~ ., y A I Record Code - 4 .,
..
2-11 ACTNR Incident Number y N '. 10 "
12-291 R'[NRPT RUI\ p.epOtt Text! Y A 280
NllIT8Iive
----~.------...----- ---- .. - ----~~--_....._-----
'Record 5: Char2e List
7 5 cIj.8r:aC~~': niuitiple recorclspet incidcnt/a~co1,1I1t possible, Only utilize if S\}bmitting itemized
ch,aigeo/suppl~en~ f~, . '. . ":.. , ....'..:.
" . " .'.:: \ '. ';:';.. .: !." ~- .. .- '. . '. .~.' ..
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T\.'...,....,:..:.:...: }.'~cgD .ReCOrd aide .- y .. ." A. I:, :./ Record COde~ 5 ."
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Hi. ACTNR Incident Number y. .' '. N 10: , ..
.. ..
'12;~1 CHGCn Uniqu~ <;"hq..ID y A '. 10
.22 -71 CHqDESC Cberge.1xsaiplion y A 50
72 ~ 75 CHGQTY, Quantity Used y N 4
(
ATTACHMENT C
Seminole County
Business Associate Agreement
Between EMS/Fire/Rescue Division and Billing Agency
This Agreement between Seminole County ("EMS/Fire/Rescue Division") and
AgenGY ("Billing Agency") is eXE?cuted for the purpose of en'suring that Agency carries
out its obligations to Seminole County in compliance with the privacy and security
regulations pursl,J~mt to Public Law 104-191 of August 21. 1996, known as the Health
InslJrance Portability and Accountability Act of 1996, Subtitle F - Administrative
Simplification, Sections 261, et seq., as amended ("HIPAA"). ,
This Agreement encompasses Agency assurance to protect the confidentiality,
integrity, an,d security of any personally identifiable protected health information ,("PHI")
that"is coll~cted, processed or learned as a result of the ~ervic~~ provided to Seminole
County by Agency r,epresentatives, including any such informatiDn stored and '
transmitted eledrc:mic;ally, referred to as electronic protected health information ("e_
PHI"). '
Agency agree$ that it \yiI/:
1. Not ,use or further disclose PHI exceot as oermitted under this Aareement
or required bY'law;
(-
2. l.)se, appropriate s?f!?gl,Jards to prevent use or disclosure of PHI except as
,permitted by this Agreement; .
3. T.o mitigat~j to, the, extent practicable, any harmful effect thCjt is known to the
Agenc~iof a use "or disClosure of PHI by the Ag'ency in 'violation of th.is . '
Awe~me.nt.
4. Repo.rt to Serri.in.ole CQunty any use or disclosyre of PHI not provided for by this
Agr~'e,ment of which the Agency'becomes aware;,' ' , , - "'" :
5. E;ns'ure that'anyagents or subcontra~tors to whom the Agency provides PHI, or,
who 'have access to 'PH I, such as other consulting 'companies agr~eto, the same
res'Wctlons a,rid conditions -that apply to the Agency with res~eqt tq's~ch PHi;
6. Make, Ptfl available to Seminole County and to th~ in9ividual who has a right of .
access as required u!1derHIPAA within 30 days of the reqLJest by,Serninqfe
Co0'~tY' to the individual;
7. Incorporate any amendments to PHI w~ennotified to do so by Seminole County;
8. P~o.vide an accoun'ting of all uses or 9isclosures qf PHI made by the Agency as
re~uired under the HIPAA'privacy rule within 60 days; . . .'
9. Make it~ internal practices, books and records relating to the use a,nd disclosure
of PHI ayaiiable to the Secretary of the Department of Health an'd Hum~n
.
v .
~\)
Services for purposes of determining the Agency' and Seminole County
compliance with HIPAA; and
10: At the termination of this Agreement, return or destroy all PHI received from, or
created or received by the Agency on behalf of Seminole county, and jf return is
infeasible, the protections of this agreement will extend to such PHI.
The specific uses and disclosures of PHI that may be made by the Agency on behalf of
Seminole County include: '
1. The review of patient care information providing advice to Seminole County
conc~rning a particular ambulance incident;
2. The review of patient care information and o~her medical records and submission
of that information to carriers, insurers, and,other' payers with respect to the
Agency assisting Seminole County in an insurance or Medicare audit or other
similar action;
3. The review of patient care informa~ion with respect to providing Seminole
County with business and optional advice generally and 'in the course of
perform!ng ,compliance assessment activities by the Agency;
4, Uses required for the proper management of the Agency as a business
associate.
)
(
5.' Other uses or disclosures of PHI as permitted by HIPAA privacy rule.
, The Agency agrees 'to assume the following obligations regarding electronic Protected
Health Information (e-PHI):
1. The Agency agrees to implement administrative, physical 'and technical
safegl,jards that reasonably and appropriately proted the' c6nfidE;1ntiality, integrity
and availability of the e-PHrthat 11 creat~s, receives, ma'intains or transmits on
b,eha!f of Seminole CoLinty. '
2. Th,e Agency will ensure that any ,agent, including a subcontractor, to whom to Jt
p'roviqes e-PHI that w~s creat~d, re'ceived, maintained or tr~nsmitted on behalf
.of Seminole County agrees to implement rea?onable, andappro'priate safe~Iuards
to pidect the 'col'}fidentiality, security, arid infegrityof e-PHI.
3. Thf? Ag~ncy agrees t6 alert Seminole County of any security inciden~ (as defined
by the HIP,AA Security Rule ):which it become~ ,aware, and'the stE?ps ,if has takE?n
'to mi~igate any po\ential security c()mprom,ise that may have occurred, and
provide a ,report to Seminole County oJ ~ny loss of data or either 'information
system compromise asa result of the incident.
(
Notwithstanding any pther provisions of ,this Agreement, this Agreement may be
terminated by' Seminole Coun~y, in its sole qiscretion, if Seminole County determines
'that the Agehcy has violated a term or provision of this Agre~ment pertaining to
Ser:ninol~ County obligations under'the HIPAA priv,acy or s~curity rulE;1s, or if the ~gency
..,"J '"
)
engages in conduct which would, if committed by Seminole County, would result in a
violation of the HIPM privacy or security rules by Seminole County.
Agreed to this
day of
,2006.
Seminole County
EMS/Fire/Rescue Division
Agency
By:
By:
-Its:
Its:
Date:
Date:
I
, !
.
'{
1
Exhibit B
Business Associate Addendum
CONTRACTOR the "Business Associate" and CITY hereby add the following
additional language to the Agreement.
1. CONTRACTOR shall carry out its obligations under this Addendum in
compliance with the privacy regulations pursuant to Public Law 104-191 of
August 21,1996, known as the Health Insurance Portability and Accountability
Act of 1996, Subtitle F - Administrative Simplification, Sections 261, et seq., as
amended ("HIPAA"), to protect the privacy of any personally identifiable
protected health information ("PHI") that is collected, processed or learned as a
result of the Billing Services provided hereunder. In conformity therewith,
CONTRACTOR agrees that it will:
a. Not use or further disclose PHI except as permitted under this Addendum or
required by law;
b. Use appropriate safeguards to prevent use or disclosure of PHI except as
permitted by this Addendum;
c. To mitigate, to the extent practicable, any harmful effect that is known to
CONTRACTOR of a use or disclosure of PHI by CONTRACTOR in violation of
this Addendum.
d. Report to CITY any use or disclosure of PHI not provided for by this Addendum
of which CONTRACTOR becomes aware;
e. Ensure that any agents or subcontractors to whom CONTRACTOR provides PHI,
or who have access to PHI, agree to the same restrictions and conditions that
apply to CONTRACTOR with respect to such PHI;
f. Make PHI available to CITY and to the individual who has a right of access as
required under HIPAA within 30 days of the request by CITY regarding the
individual;
g. Incorporate any amendments to PHI when notified to do so by CITY;
h. Provide an accounting of all uses or disclosures of PHI made by CONTRACTOR
as required under the HIPAA privacy rule within sixty (60) days;
i. Make their internal practices, books and records relating to the use and
disclosure of PHI available to the Secretary of the Department of Health and
Human Services for purposes of determining CONTRACTOR's and CITY's
compliance with HIPAA; and
j. At the termination of the Agreement, return or destroy all PHI received from, or
created or received by CONTRACTOR on behalf of CITY, and if return is
infeasible, the protections of this Addendum will extend to such PHI.
Page 2 of 11
~
2. The specific uses and disclosures of PHI that may be made by CONTRACTOR
on behalf of CITY include:
a. The preparation of invoices to patients, carriers, insurers and others responsible
for payment or reimbursement of the services provided by CITY to its patients;
b. Preparation of reminder notices and documents pertaining to collections of
overdue accounts;
c. The submission of supporting documentation to carriers, insurers and other
payers to substantiate the health care services provided by CITY to its patients or
to appeal denials of payment for same.
d. Uses required for the proper management of CONTRACTOR as business
associate.
e. Other uses or disclosures of PHI as permitted by the HIPAA privacy rule.
3. Notwithstanding any other provisions of this Addendum, the Agreement may be
terminated by CITY if CONTRACTOR has violated a term or provision of this
Addendum pertaining to CONTRACTOR's material obligations under the HIPAA
privacy rule, or if CONTRACTOR engages in conduct which would, if committed
by CITY, result in a violation of the HIPAA privacy rule by CITY.
Page 3 of 11