HomeMy Public PortalAbout109-2016 - Fire-Medicount Management - Professional billing servicesPROFESSIONAL CONSULTING SERVICES AGREEMENT
THIS AGREEMENT made and entered into this 0 day of 2016, and referred to
as Contract No. 109-2016, by and between the City of Richmo , Indiana, a municipal corporation
acting by and through its Board of Public Works and Safety (hereinafter referred to as the "City")
and Medicount Management, Inc., 10361 Spartan Drive, Cincinnati, Ohio, 45215 (hereinafter
referred to as the "Contractor").
SECTION 1. STATEMENT AND SUBJECT OF WORK
City hereby retains Contractor to provide professional billing services in connection with City of
Richmond Fire Department Emergency Medical Services (EMS) and motor vehicle accident
responses. Contractor shall perform all services described on Contractor's quotation dated August
30, 2016. Said quote is attached hereto as "Exhibit A" consists of sixteen (16) pages, and is made a
part hereof. Contractor agrees to abide by the same.
Contractor additionally agrees to comply with any and all applicable state or federal privacy laws as
well as any applicable health information compliance requirements under HIPAA and/or HITECH.
Should any provisions, terms, or conditions contained in any of the documents attached hereto as
Exhibits, or in any of the documents incorporated by reference herein, conflict with any of the
provisions, terms, or conditions of this Agreement, this Agreement shall be controlling.
Contractor shall perform all work herein in a timely manner, conforming to all applicable
professional standards.
The Contractor shall furnish all labor, material, equipment, and services necessary for the proper
completion of all work specified.
No performance of services shall commence until the following has been met:
1. The City is in receipt of any required certificates of insurance;
2. The City is in receipt of any required affidavit signed by Contractor in
accordance with Indiana Code 22-5-1.7-11(a)(2); and
3. A purchase order has been issued by the Purchasing Department.
SECTION IL STATUS OF CONTRACTOR
Contractor shall be deemed to be an independent contractor and is not an employee or agent of the
City of Richmond. The Contractor shall provide, at its own expense, competent supervision of the
work.
Contract No. 109-2016
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SECTION 1II. COMPENSATION
Payment to Contractor will be paid out of the collections generated from the billing services
Contractor provides to City and Contractor shall not be paid on any account (per run conducted) it is
unable to collect on. City will pay a flat rate of six and one-half (6.5%) percent for EMS revenues
collected plus the cost of software that the City elects to use for EMS Patient Care Reporting. City
will pay a flat rate of ten (10%) percent for motor vehicle accident revenues collected. Collections
generated at the rates set forth above are priced on a per run basis. City will not pay any upfront fees
for licensing or use of software.
SECTION IV. TERM OF AGREEMENT
This Agreement shall be effective as of July 1, 2016, and shall continue in effect until June 31, 2019.
The City shall have three (3) annual options to renew this Agreement, upon the same terms and
conditions, for three (3) additional years.
Notwithstanding the term of this Agreement, City may terminate this Agreement in whole or in part,
for cause, at any time by giving at least five (5) working days written notice specifying the effective
date and the reasons for termination which shall include but not be limited to the following:
a. failure, for any reason of the Contractor to fulfill in a timely manner
its obligations under this Agreement;
b. submission of a report, other work product, or advice, whether oral or written, by the
Contractor to the City that is incorrect, incomplete, or does not meet reasonable
professional standards in any material respect;
c. ineffective or improper use of funds provided under this Agreement;
d. suspension or termination of the grant funding to the City under which this Agreement
is made; or
e. unavailability of sufficient funds to make payment on this Agreement.
In the event of such termination, the City shall be required to make payment for all work performed
prior to the date this Agreement is terminated, but shall be relieved of any other responsibility herein.
This Agreement may also be terminated, in whole or in part, by mutual Agreement of the parties by
setting forth the reasons for such termination, the effective date, and in the case of partial
termination, the portion to be terminated.
SECTION V. INDEMNIFICATION AND INSURANCE
Contractor agrees to obtain insurance and to indemnify the City for any damage or injury to person or
property or any other claims which may arise from the Contractor's conduct or performance of this
Agreement, either intentionally or negligently; provided, however, that nothing contained in this
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Agreement shall be construed as rendering the Contractor liable for acts of the City, its officers,
agents, or employees. Contractor shall as a prerequisite to this Agreement, purchase and thereafter
maintain such insurance as will protect it from the claims set forth below which may arise out of or
result from the Contractor's operations under this Agreement, whether such operations by the
Contractor or by any sub -contractors or by anyone directly or indirectly employed by any of them, or
by anyone for whose acts the Contractor may be held responsible.
Coverage Limits
A. Worker's Compensation & Statutory
Disability Requirements
B. Employer's Liability $100,000
C. Comprehensive General Liability
Section 1. Bodily Injury $1,000,000 each occurrence
$2,000,000 aggregate
Section 2. Property Damage $1,000,000 each occurrence
D. Comprehensive Auto Liability
Section 1. Bodily Injury $1,000,000 each person
$1,000,000 each occurrence
Section 2. Property Damage $1,000,000 each occurrence
E. Comprehensive Umbrella Liability $1,000,000 each occurrence
$2,000,000 each aggregate
F. Malpractice/Errors & Omissions Insurance $1,000,000 each occurrence
$1,000,000 each aggregate
SECTION VI. COMPLIANCE WITH WORKER'S COMPENSATION LAW
Contractor shall comply with all provisions of the Indiana Worker's Compensation law, and shall,
before commencing work under this Agreement, provide the City a certificate of insurance, or a
certificate from the industrial board showing that the Contractor has complied with Indiana Code
Sections 22-3-2-5, 22-3-5-1 and 22-3-5-2. If Contractor is an out of state employer and therefore
subject to another state's worker's compensation law, Contractor may choose to comply with all
provisions of its home state's worker's compensation law and provide the City proof of such
compliance in lieu of complying with the provisions of the Indiana Worker's Compensation Law.
SECTION VII. COMPLIANCE WITH INDIANA E-VERIFY PROGRAM REQUIREMENTS
Pursuant to Indiana Code 22-5-1.7, Contractor is required to enroll in and verify the work eligibility
status of all newly hired employees of the contractor through the Indiana E-Verify program.
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Contractor is not required to verify the work eligibility status of all newly hired employees of the
contractor through the Indiana E-Verify program if the Indiana E-Verify program no longer exists.
Prior to the performance of this Agreement, Contractor shall provide to the City its signed Affidavit
affirming that Contractor does not knowingly employ an unauthorized alien in accordance with IC
22-5-1.7-11 (a) (2). In the event Contractor violates IC 22-5-1.7 the Contractor shall be required to
remedy the violation not later than thirty (30) days after the City notifies the Contractor of the
violation. If Contractor fails to remedy the violation within the thirty (30) day period provided
above, the City shall consider the Contractor to be in breach of this Agreement and this Agreement
will be terminated. If the City determines that terminating this Agreement would be detrimental to
the public interest or public property, the City may allow this Agreement to remain in effect until the
City procures a new contractor. If this Agreement is terminated under this section, then pursuant to
IC 22-5-1.7-13 (c) the Contractor will remain liable to the City for actual damages.
SECTION VIII. IRAN INVESTMENT ACTIVITIES
Pursuant to Indiana Code (IC) 5-22-16.5, Contractor certifies that Contractor is not engaged in
investment activities in Iran. In the event City determines during the course of this Agreement that
this certification is no longer valid, City shall notify Contractor in writing of said determination and
shall give contractor ninety (90) days within which to respond to the written notice. In the event
Contractor fails to demonstrate to the City that the Contractor has ceased investment activities in Iran
within ninety (90) days after the written notice is given to the Contractor, the City may proceed with
any remedies it may have pursuant to IC 5-22-16.5. In the event the City determines during the
course of this Agreement that this certification is no longer valid and said determination is not
refuted by Contractor in the manner set forth in IC 5-22-16.5, the City reserves the right to consider
the Contractor to be in breach of this Agreement and terminate the agreement upon the expiration of
the ninety (90) day period set forth above.
SECTION IX. PROHIBITION AGAINST DISCRIMINATION
A. Pursuant to Indiana Code 22-9-1-10, Contractor, any sub -contractor, or any person acting on
behalf of Contractor or any sub -contractor shall not discriminate against any employee or
applicant for employment to be employed in the performance of this Agreement, with respect
to hire, tenure, terms, conditions or privileges of employment or any matter directly or
indirectly related to employment, because of race, religion, color, sex, disability, national
origin, or ancestry.
B. Pursuant to Indiana Code 5-16-6-1, the Contractor agrees:
That in the hiring of employees for the performance of work under this Agreement of
any subcontract hereunder, Contractor, any subcontractor, or any person acting on
behalf of Contractor or any sub -contractor, shall not discriminate by reason of race,
religion, color, sex, national origin or ancestry against any citizen of the State of
Indiana who is qualified and available to perform the work to which the employment
relates;
2. That Contractor, any sub -contractor, or any person action on behalf of Contractor or
any sub -contractor shall in no manner discriminate against or intimidate any
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employee hired for the performance of work under this Agreement on account of
race, religion, color, sex, national origin or ancestry;
3. That there may be deducted from the amount payable to Contractor by the City under
this Agreement, a penalty of five dollars ($5.00) for each person for each calendar
day during which such person was discriminated against or intimidated in violation of
the provisions of the Agreement; and
4. That this Agreement may be canceled or terminated by the City and all money due or
to become due hereunder may be forfeited, for a second or any subsequent violation
of the terms or conditions of this section of the Agreement.
C. Violation of the terms or conditions of this Agreement relating to discrimination or
intimidation shall be considered a material breach of this Agreement.
SECTION X. RELEASE OF LIABILITY
Contractor hereby agrees to release and hold harmless the City and all officers, employees, or agents
of the same from all liability for negligence which may arise in the course of Contractor's
performance of its obligations pursuant to this Agreement.
SECTION XI. MISCELLANEOUS
This Agreement is personal to the parties hereto and neither party may assign or delegate any of its
rights or obligations hereunder without the prior written consent of the other party. Any such
delegation or assignment, without the prior written consent of the other party, shall be null and void.
This Agreement shall be controlled by and interpreted according to Indiana law and shall be binding
upon the parties, their successors and assigns. This document constitutes the entire Agreement
between the parties, although it may be altered or amended in whole or in part at any time by filing
with the Agreement a written instrument setting forth such changes signed by both parties. By
executing this Agreement the parties agree that this document supersedes any previous discussion,
negotiation, or conversation relating to the subject matter contained herein.
This Agreement may be simultaneously executed in several counterparts, each of which shall be an
original and all of which shall constitute but one and the same instrument.
The parties hereto submit to jurisdiction of the courts of Wayne County, Indiana, and any suit arising
out of this Contract must be filed in said courts. The parties specifically agree that no arbitration or
mediation shall be required prior to the commencement of legal proceedings in said Courts. By
executing this Agreement, Contractor is estopped from bringing suit or any other action in any
alternative forum, venue, or in front of any other tribunal, court, or administrative body other than the
Circuit or Superior Courts of Wayne County, Indiana, regardless of any right Contractor may have to
bring such suit in front of other tribunals or in other venues.
Any person executing this Contract in a representative capacity hereby warrants that he/she has been
duly authorized by his or her principal to execute this Contract.
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In the event of any breach of this Agreement by Contractor, and in addition to any other damages or
remedies, Contractor shall be liable for all costs incurred by City in its efforts to enforce this
Agreement, including but not limited to, City's reasonable attorney's fees.
In the event that an ambiguity, question of intent, or a need for interpretation of this Agreement
arises, this Agreement shall be construed as if drafted jointly by the parties, and no presumption or
burden of proof shall arise favoring or disfavoring any party by virtue of the authorship of any of the
provisions of this Agreement.
IN WITNESS WHEREOF, the parties have executed this Agreement at Richmond, Indiana, as of the
day and year first written above, although signatures may be affixed on different dates.
"CITY"
THE CITY OF RICHMOND,
INDIANA by and through its
Board of Public Works and Safety
By:
Vicki Robinson, President
IM
Richard Foore, Member
oster, II,
Date:
APPROVED:
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Date: (0—
"CONTRACTOR"
MEDICOUNT MANAGEMENT
10361 Spartan Drive
Cincinnati, OH 45215
Printed: - 00 CP14 A , /1 cnyeamlla
Title: 61elcls/
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Date: 9-.j - %zpO/(o
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CLIENT SERVICES AGREEMENT
P P
This Agreement is made and entered into as of the day of July, 2016 by and between
Medicount Management, Inc. ("Medicount") and CITY OF RICHMOND, WAYNE COUNTY,
INDIANA ("EMS Agency").
WHEREAS, EMS Agency provides emergency medical services ("EMS Services"); and
WHEREAS, EMS Agency desires to retain Medicount to provide billing services for such EMS
Services according to the terms and conditions contained in this Agreement.
NOW, THEREFORE, it is agreed between the parties as follows:
1. Billing Services. Subject to the terms and conditions of this Agreement, EMS Agency
hereby appoints Medicount as its exclusive billing agent for EMS Services subject to the exceptions listed
below. As the billing agent, Medicount will provide all billing services on behalf of EMS Agency for the
EMS Services and will manage the accounts receivable for the EMS Services (collectively, the "Billing
Services"). Such Billing Services shall include those services described in Exhibit A attached hereto, as
the same may be modified from time to time.
a. Exceptions. EMS Agency will be the exclusive recipient of any revenue generated from
the following:
i. Medicaid Audits
ii. Private self billed non insurance contracts (i.e IU Health -Life Line
transports.
iii. Other mutually agreed to billing programs.
2. EMS Agency Obligations. EMS Agency will use Medicount as its exclusive billing agent
subject to Exceptions above (La). To facilitate the performance of the Billing Services, EMS Agency shall
cooperate with Medicount and will, at a minimum fulfill the obligations set forth in Exhibit B attached
hereto, as the same may be modified from time to time.
Compensation.
a. In exchange for the provision of the Billing Services, Medicount shall receive (i)
a base rate fee equal to 6.5% of the gross amount collected by Medicount and/or EMS Agency subject to
Exceptions above (1.a) for the EMS Services, (less refunds or "take -backs"), but not including any
deductions incurred by Medicount or EMS Agency for expenses and/or processing fees in collecting the
monies owed for the EMS Services, plus (ii) any additional fees set forth herein or in any exhibit or addenda
attached hereto (collectively, the "Medicount Compensation").
b. Medicount will continue to process the Motor Vehicle Accident at a rate of 10%
of the gross amount collected.
C. EMS Agency will also be responsible for any third party costs incurred by
Medicount in performing the Billing Services under this Agreement including, but not limited to (i) any
fees or charges assessed by governmental agencies or insurance agencies for required provider numbers,
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licensing, certification, and recertification applications; (ii) any dramatic increases in US Postal rates and/or
shipment rates; (iii) any ePCR billing software or hardware used by EMS Agency which is charged to or
paid by Medicount;(the "Third Party Costs"). Notwithstanding the foregoing, Medicount will provide to
EMS Agency with written notice of any known increases in any Third Party Costs at least thirty days (30)
days prior to such additional costs being assessed under this agreement. Such Third Party Costs shall be
invoiced by Medicount to EMS Agency monthly as the costs are incurred.
4. Collection of Funds.
a. Medicount will process all payments received by it from patients, third party payers or
other billed parties for EMS Services. Medicount will remit such funds to the EMS Agency according to
the terms and conditions of this Agreement. EMS Agency hereby acknowledges that it may, from time to
time, receive payments directly from insurance companies, billed parties and/or governmental agencies for
EMS Services. EMS Agency shall keep records as to all payments received and shall immediately forward
payments to Medicount for processing.
b. Medicare and Medicaid will remit all payments directly to the EMS Agency daily without
any deduction for costs or expenses. Unless EMS Agency has elected to use a lock box to facilitate its
receipt of payments, EMS Agency acknowledges that Medicount may receive all remaining funds for EMS
Services. Such funds will be remitted to EMS Agency monthly by no later than the 25' day of each calendar
month based upon funds received by Medicount or EMS Agency through the end of the preceding month.
Medicount will invoice the EMS Agency monthly for all costs or fees owed by the EMS Agency to
Medicount for the services, software or other fees due hereunder.
C. Credit Cards: EMS Agency authorizes Medicount to accept credit card payments
for the EMS Services. All credit card payments will be made directly to Medicount's credit card
depository account and shall be remitted to EMS Agency as set forth herein. The credit cards
accepted by Medicount include: MasterCard, Visa, Discover and American Express. No other
credit cards will be accepted by Medicount.
5. Reporting.
Medicount will provide EMS Agency with commercially reasonable access via the Internet to review
standard billing reports. Additional reports on an ad hoc basis will be provided to EMS Agency as requested
at no additional cost unless the reports requested are out of the normal course of the EMS billing business.
6. Securi1y.
a. The parties hereby acknowledge that certain of the information provided by EMS
Agency to Medicount may contain Protected Health Information "PHI" defined under the Health Insurance
Portability and Accountability Act ("HWAA") and the Health Information Technology for Clinical Health
Act (the "HITECH Act"). In providing the Billing Services, Medicount is acting as a Business Associate as
defined under HIPAA. Accordingly, Medicount shall be subject to and shall execute the Business Associate
Addendum attached hereto as Exhibit "C."
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b. EMS Agency acknowledges that it shall be responsible for the maintenance of all
PHI maintained and/or stored by EMS Agency. To the extent that Medicount provides any collection devices
to assist in the facilitation of the Billing Services hereunder, EMS Agency shall be responsible for all activity
of its users. EMS Agency shall immediately notify Medicount and use its best efforts to cease any of the
following events: (i) any unauthorized use of any password or account or a known or suspected breach of
security; (ii) any copying or distribution of any PHI; (iii) any use of false identity information to gain access
to any of the Billing Services; or (iv) any loss or theft of any hardware device on which a user has access to
PHI and/or any other information relevant to the Billing Services (collectively a "Security Breach Event").
If any Security Breach Event involves PHI and/or other personally identifiable information, EMS Agency
shall comply with all applicable notification requirements including, but not limited to the breach notification
requirements under the HITECH Act and/or any notification requirements. To the extent that any patient
requests and/or requires any identity theft protection in connection with the disclosure of any PHI or
personally identifiable information as the result of any Security Breach Event, EMS Agency shall be
responsible for any and all costs related to such protection.
C. Upon any termination of this Agreement, Medicount shall return to EMS Agency
all records pertaining to the Billing Services including, but not limited to, all patient information, monthly
summaries, quarterly summaries, insurance information, insurance provider numbers, and any other records
pertaining to the Billing Services. Such records shall be maintained are archived for the minimum period
establish by law.
7. Exclusionary Rule Warranty. EMS Agency hereby acknowledges that the Office of
Inspector General ("OIG") has developed the "Exclusionary Rule" which prohibits payment by Federal
health care programs for items or services furnished by persons who have been excluded from participation
in Federal health care programs. In connection with such Exclusionary Rule, OIG has developed a List of
Excluded Individuals/Entities ("LEIE") that provides information to the health care industry, patients and
the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid
and all other Federal health care programs. EMS Agency hereby represents and warrants that (a) it has
checked the LEIE to confirm that none of its employees and/or agents are included on such list or are
otherwise prohibited from participating in Federal health care programs; (b) it will check the LEIE every
six (6) months to confirm that none of its employees and/or agents have been added to such list or are
otherwise prohibited from participating in Federal health care programs; and (c) it will check the LEIE prior
to hiring any new employee to confirm that such candidate is not identified on such list or is otherwise
prohibited from participating in Federal health care programs.
8. Term. This Agreement shall commence upon the date first written above and shall continue
for a period of Three (3) years (the "Term Commencement Date"). Thereafter, this Agreement shall
automatically renew each year thereafter for three consecutive one year terms unless either party provides
written notice one hundred eighty (180) days prior to the then applicable renewal date that such party does
not desire to renew the contract for another term. This Agreement may also be terminated upon a material
breach by either party under this Agreement if such breaching party fails to cure such default within ten
(10) days of written notice of such default if such default is the non-payment of fees or sixty (60) days of
written notice of default for any other material default.
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9. Effect of Termination. Upon any termination of this Agreement or upon its expiration, the
parties hereby agree to the following terms and provisions:
a. Medicount may elect to continue to perform the Billing Services at the then -
current rates for a period of one hundred eighty (180) days after the effective date termination or expiration
(the "Wind Down Period") for all of EMS Agency's accounts receivable relating to the EMS Services
rendered prior to the termination date ("Existing Accounts Receivable").
b. EMS Agency expressly agrees to cooperate and assist Medicount with its
performance during the "Wind Down Period" and will timely report, or cause to be reported, all payments
received by EMS Agency related to the Existing Account Receivable.
C. Upon the expiration of the Wind Down Period, Medicount shall prepare a final
accounting of all monies received by it or EMS Agency for EMS Services and/or Existing Accounts
Receivable and shall invoice EMS Agency for any fees or monies due to Medicount..
d. Except for the foregoing or for such other matters as the parties may agree in
writing, Medicount shall have no further obligation to provide any Billing Services to EMS Agency. EMS
Agency may negotiate with Medicount for additional transitional services or for the provision of additional
data after the date of termination at EMS Agency's expense.
10. Intellectual Property Protection. EMS Agency hereby acknowledges that in connection with
this Agreement, EMS Agency may have access to certain business methods, software, and processes used
by Medicount in connection with the performance of the Billing Services hereunder (the "Proprietary
Information"). Such Proprietary Information is confidential to Medicount. EMS Agency hereby
acknowledges that Medicount owns all rights, title, and interest in such Proprietary Information. If EMS
Agency is ever held or deemed to be the owner of the Proprietary Information, EMS Agency hereby
irrevocably assigns to Medicount all such rights, title and interest and agrees to execute all documents
necessary to implement and confirm the intent of this Section. EMS Agency shall keep all Proprietary
Information confidential and further agrees not to use or disclose any Proprietary Information except as
permitted hereunder.
11. Limitation on Liability. Medicount shall defend, indemnify and hold EMS Agency
harmless from all claims arising out of or related to the performance of Medicount of its services
under this Agreement except to the extent such claims result from the negligence or unintentional
conduct of the EMS Agency.
12. Contractor Relationship. Medicount is acting as an independent contractor of EMS Agency
and it is not nor shall it act as, an employee of EMS Agency. Nothing in this Agreement shall be construed
to create any partnership between the parties.
13. Notice. Any notice given under this Agreement shall be in writing and delivered to the other
party by certified, registered or express mail, return receipt requested or by Federal Express to the address
set forth by each party's signature. Either Party may change the address to which notice or payment is to
be sent by written notice to the other.
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14. Miscellaneous.
a. Entire Agreement. This Agreement, including any exhibits, states the entire
agreement between the parties with respect to the subject matter hereof and supersedes any and all prior
written and verbal understanding of the parties with respect hereto. Any amendments or changes to this
Agreement must be in writing and executed by both parties hereto.
b. Governing Law. This Section shall be deemed governed by and construed in
accordance with the laws of the State of Indiana without reference to any conflict of law provisions. The
parties further agree that any dispute arising out of or related to this Agreement shall be resolved in the state
or federal courts located in Wayne County, Indiana and EMS Agency expressly consents to jurisdiction
therein.
C. Assignment. This Agreement may not be assigned by EMS Agency in whole or
in part without the express written consent of Medicount. Medicount may assign this Agreement to any
purchaser of the assets of Medicount.
d. Severability. Should any provision of this Agreement be held to be void, invalid,
or inoperative, the remaining provisions of this Agreement shall not be affected and shall be continued in
effect as though such provisions were deleted.
IN WITNESS WHEREOF, the parties executed this Agreement as of the date first set forth above.
EMS AGENCY:
CITY OF RICHMOND
MEDICOUNT MANAGEMENT, INC.
�Xl-l1-81T PAGE --OF
By: By:
Print Name:
Title: 4
Print Name: Joseph A. Newcomb
Print Title: President
Date: o Date:
Address: Address: 10361 Spartan Drive
Cincinnati, OH 45215
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EXHIBIT "A"
BILLING SERVICES TO BE PROVIDED BY MEDICOUNT
Responsibilities of Medicount.
a. Medicount will assist EMS Agency, as necessary, to complete and submit
credentialing applications to Medicare, Medicaid and any third party payer for group and/or individual
provider numbers when required for billing purposes.
b. Medicount will review the billing policies of EMS Agency and assist with the
development of insurance billing policies and procedures in accordance with insurance regulations and
standards and otherwise advise EMS Agency of any material changes in third party rules and regulations.
C. Medicount will, if required, develop and maintain electronic data interfaces
directly with EMS Agency's hospital service sites (to the extent permitted by such sites) to collect patient
demographic data. EMS Agency will use its best efforts to cooperate with and otherwise assist Medicount
in the development and maintenance of such interfaces including, but not limited to communicating directly
with hospital information system staff, administration, and other staff members to authorize and otherwise
enable the system.
d. Medicount will provide basic training to EMS Agency for management personnel.
Additional follow up training may be provided by Medicount from time to time as mutually agreed by
Medicount and EMS Agency.
e. Medicount will process all patient encounter information submitted by EMS
Agency in a timely manner and will code for diagnosis using CPT-4, HCPCS, and ICD-9 and ICD-10 CM
coding schemes. Medicount will then bill for all EMS Services within the guidelines established by EMS
Agency and the insurance or third party payer to whom the claim is being submitted.
f. Medicount will use its commercially reasonable efforts to accurately enter all
procedural and demographic data necessary for patient and third party billing into its billing system;
provided, however, that EMS Agency shall remain responsible for providing accurate and complete
information to Medicount.
g. Medicount will submit claims using the most effective means available for each
payer. Electronic claims will be used to the extent they are available and when mandated.
h. Medicount will communicate with patients and third party payers on a regular
monthly cycle according to EMS Agency guidelines. Up to three attempts will be made to communicate
with patients where inadequate information exists to bill for the EMS Services. Medicount may use an
automatic dialing system to obtain missing insurance information and other relevant information
needed to process the billing claim for the EMS Agency. Medicount shall exercise its sole discretion
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as to the form and substance of any the automatic dialing system dialogue and any other statements and/or
demand letters.
i. Medicount will provide toll free phone lines and customer staff to respond to
patient inquiries and otherwise assist patients with co -payments, insurance claims and other related matters.
j. Medicount will correspond with third party payers to resolve any coding
misinterpretations or other concerns that may arise in the processing and settlement of a claim and otherwise
remain current on payer's standards for claim information requirements.
k. Medicount will process all payments from insurance carriers, billed parties, and
governmental agencies.
1. Medicount will provide advice to Client during the term of this Agreement on
topics such as how to establish public awareness programs about the billing process, establishing rates,
payer participation, and other topics as mutually agreed.
M. Medicount will undergo a SSAE 16 Audit annually and provide the results to EMS
Agency upon request.
n. Medicount will conduct all billing in accordance with applicable federal and state
laws, rules and regulations, insurance regulations and standards and EMS Agency's policy.
2. Amendment of Exhibit. This Exhibit A may be amended by the parties from time to time
upon mutual written agreement.
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EXHIBIT "B"
RESPONSIBILITIES OF EMS AGENCY
Responsibilities of EMS Aaency.
a. EMS Agency will identify one administrative and one clinical representative to whom
Medicount may address all matters related to the Billing Services under this Agreement. Such
representatives will have the power to bind EMS Agency and will timely respond to questions and/or
additional document requests of Medicount.
b. EMS Agency will establish and enforce written billing policies and procedures for the
Billing Services that will serve as the foundation of a Compliance Program for the Billing Services. These
billing policies and procedures will be developed and amended, as needed, in concert with Medicount's
compliance staff and compliance plan.
c. EMS Agency will provide Medicount with all billing information related to the EMS
Services in a format acceptable to Medicount and will ensure that all billing information and other
information related to the EMS Services is accurate, current, and complete, and otherwise complies with
all applicable federal and state laws and regulations.
d. EMS Agency will provide Medicount will all information and otherwise complete and
obtain signatures on all documents, charts, or other information needed to enable Medicount to properly
submit claims on behalf of EMS Agency. EMS Agency hereby represents and warrants that it will obtain,
at a minimum, the following required information and forms and further confirms that Medicount may rely
upon the existence of patient signatures or other authorizations thereon where applicable:
i. Patient's complete name, address, phone number, social security number (if
available), date of birth, and gender;
ii. Information pertaining to the EMS run including, but not limited to the nature of
the call, location, zip code of incident location., squad assessment, treatment and
narrative, crew member identifiers and level of training, receiving hospital and
transport mileage;
iii. Insurance information including Patient's primary and secondary insurance,
payer(s)' address(es), group, and guarantor identification number, and primary
insured's name, social security number, relationship to patient, address, date of
birth, and gender;
iv. Assignment of Benefits Form (AOB);
v. Medical information releases;
vi. Advance Beneficiary Notice of Non -coverage (ABN);
vii. Physician's Certification Statement (PCS); and
viii. Physician signatures on medical charts or other medical documents.
e. EMS Agency providers will use their best efforts to identify the diagnosis or medical
condition that supports the medical necessity of a patient's services, if one exists. Medicount shall not be
8 Revised 08/30/2016
responsible for claim denials, partial payments or payment reductions resulting from EMS Services that are
not deemed to be "medically necessary" by third party payers.
f. EMS Agency will assist Medicount in resolving issues and/or otherwise facilitating the
exchange of information between Medicount and any hospitals, labs or other institutions necessary for the
submission of claims.
payers.
g. EMS Agency will timely provide any information requested by any patients or third party
h. When applicable, EMS Agency will timely issue refunds of overpayment to patients or
payers.
i. Prior to, or contemporaneously with this execution of this Agreement, EMS Agency will
provide to Medicount all required information to enable Medicount to establish payment processing with
Medicare, Medicaid, insurance companies and third party payers, including any provider numbers which
have been issued to EMS Agency, copies of EMS Agency's certifications, copies of any applicable driver's
licenses and licensed EMS vehicle titles, licensures from the State Department of Health, any provider
applications which have been completed or are currently in process by any provider and any other
information necessary for credentialing.
j. EMS Agency will assist Medicount with EMS Agency's Medicare and Medicaid
applications and revalidations when they occur and will promptly forward all correspondence from
Medicare, Medicaid, insurance companies, and/or other third party payers to Medicount. EMS Agency
will provide Medicount with timely advance notice of any new payment contracts, HMO or PPO
relationships or other contracts so that Medicount may accommodate changes as necessary. Subject to
Exceptions above (La in the Client Services Agreement)
k. EMS Agency will provide Medicount with copies of all payments received directly by
EMS Agency from any insurance carrier, patients or any third parties and submit a copy of the payment or
other correspondence on a daily basis, Subject to Exceptions above (La in the Client Services Agreement),
1. EMS Agency will pay the Medicount Compensation and any other fees detailed herein.
Subject to Exceptions above (La in the Client Services Agreement).
m. EMS Agency shall provide Medicount with at least thirty (30) days advance written notice
of any changes to any EMS Services and any applicable BLS, ALS, ALS2 and mileage rate changes;
Subject to Exceptions above (La in the Client Services Agreement). No rate change shall be applicable
until EMS Agency has received written notice from Medicount acknowledging the rate change
notice. Medicount shall not be responsible for any losses, delays in payment, or any lost revenue resulting
from EMS Agency's failure to follow these policies.
n. EMS Agency agrees to abide by Medicount established Patient Hardship Policy (Exhibit
D) if applicable.
2. Amendment of Exhibit. This Exhibit B may be amended by the parties from time to time
upon mutual written agreement.
EXHIBIT C
9 Revised 08/30/2016
Business Associate Addendum
This Addendum is effective on _day of 2016, and is made part of the
Agreement by and between CITY OF RICHMOND, WAYNE COUNTY, INDIANA ("EMS
Agency") and MEDICOUNT MANAGEMENT, INC. ("Business Associate").
1. Definitions. Capitalized terms not otherwise defined in the Agreement shall have
the meanings given to them in the Security, Breach Notification, and Enforcement Rules (the
"HIPAA Rules") as contained in Title 45, Parts 160 and 164 of the Code of Federal Regulations
("CFR') and are incorporated herein by reference.
2. Prohibition on Unauthorized Use or Disclosure of Protected Health Information.
Business Associate acknowledges that any PHI provided to Business Associate by EMS Agency
or any PHI created, maintained or transmitted by Business Associate or any authorized
subcontractor or agent in connection with providing services to, or on behalf of EMS Agency, shall
be subject to this Addendum. Business Associate shall not use or disclose any Protected Health
Information ("PHI") it receives, creates, maintains or transmits, except as permitted or required by
the Agreement or as otherwise required by law or authorized in writing by EMS Agency, and then
only if such use or disclosure would not violate the Privacy Rule if used or disclosed by EMS
Agency. Business Associate shall comply with: (a) the HIPAA Rules as if Business Associate
were a Covered Provider under such rules; (b) State laws, rules and regulations that apply to PHI
and that are not preempted by the HIPAA Rules or the Employee Retirement Income Security Act
of 1974 ("ERISA") as amended; and (c) EMS Agency's Health Information Privacy and Security
Policies and Procedures.
3. Use and Disclosure of Protected Health Information. Except as otherwise permitted
herein, Business Associate shall use and/or disclose PHI only to the extent necessary to satisfy
Business Associate's obligations under the Agreement or as required by law.
4. Business Associate's Operations. Business Associate also may use PHI it creates
or receives for or from EMS Agency to the extent necessary for Business Associate's proper
management and administration or to carry out Business Associate's legal responsibilities under
the Agreement and hereunder. Business Associate may disclose PHI as necessary for such
purposes only if:
(a) The disclosure is required by law; or
(b) Business Associate obtains reasonable assurance, evidenced by written contract,
from any person or organization to which Business Associate will disclose PHI that such person
or organization agrees to abide by the terms and conditions of this Addendum and specifically to:
10 Revised 08/30/2016
(i) Hold such PHI in confidence and use or further disclose it only for the
purpose for which Business Associate disclosed it to the person or organization or as required by
law; and
(ii) Notify Business Associate (who shall in turn promptly notify EMS Agency)
of any instance of which the person or organization becomes aware in which the confidentiality of
such PHI was breached.
5. Data Aggregation Services. Business Associate may use PHI to provide Data
Aggregation Services related to EMS Agency's emergency medical services. Notwithstanding the
foregoing, Business Associate hereby acknowledges that Business Associate may not sell any PHI
except as otherwise permitted under the HIPAA Rules.
6. PHI Safeguards. Business Associate shall develop, implement, maintain, and use
appropriate administrative, technical, and physical safeguards to prevent the improper use or
disclosure of any PHI received from or on behalf of EMS Agency.
7. Electronic Health Information Security and Integrity. Business Associate shall
develop, implement, maintain and use appropriate administrative, technical and physical security
measures and safeguards in compliance with the HIPAA Rules and other applicable laws and
regulations to preserve the integrity and confidentiality of all electronically maintained or
transmitted PHI Business Associates creates, maintains, transmits and/or receives from or on
behalf of EMS Agency pertaining to an Individual. Business Associate shall document and keep
these security measures current.
8. Subcontractors and Agents. Business Associate shall require each of its
subcontractors or agents to whom Business Associate may provide PHI or Health Information
received from or on behalf of EMS Agency or who otherwise create, receive, maintain, or transmit
PHI on behalf of Business Associate to agree to the same restrictions, conditions and requirements
to protect such PHI as are imposed on Business Associate by this Addendum.
9. Access to PHI by Individuals. Business Associate agrees to provide access, at the
request of EMS Agency and during normal business hours, to PHI in a Designated Record Set to
EMS Agency or, as directed by EMS Agency, to an Individual or an Individual's designee in order
to meet the requirements of Section 164.524 of the CFR provided that EMS Agency delivers to
Business Associate a written notice at least five (5) business days in advance of requesting such
access. Subject to such notice requirements, Business Associate shall permit an Individual or an
Individual's designee to inspect and copy PHI in Business Associate's custody or control that
pertains to such Individual. Business Associate shall establish procedures providing for such
access to the PHI maintained by Business Associate in Designated Record Sets in the time and
manner designated by EMS Agency to enable EMS Agency to fulfill its obligations under the
HIPAA Rules. Business Associate shall produce PHI in electronic format if an Individual requests
such PHI to be delivered in such format and the PHI is readily producible in such format.
1 I Revised 08/30/2016
10. Accounting to EMS Agency and to Government Agencies. Unless otherwise
protected or prohibited from discovery or disclosure by law, Business Associate shall make its
internal practices, books and records relating to the use and disclosure of PHI received from or on
behalf of EMS Agency or created, maintained, or transmitted by Business Associate available to
EMS Agency and to the Secretary or its designee for the purpose of providing an accounting of
disclosures to an Individual or the Individual's designee or determining Business Associate's
compliance with the HIPAA Rules. Business Associate shall have a reasonable time within which
to comply with request for such access and in no case shall access be required in less than five (5)
business days after Business Associate's receipt of such request unless otherwise designated by
the Secretary.
11. Accounting to Individuals. Business Associate agrees to maintain necessary and
sufficient documentation of disclosures of PHI as would be required for EMS Agency to respond
to a request by an Individual for an accounting of such disclosures in accordance with 45 CFR
Section 164.528. Upon the request of EMS Agency, Business Associate shall provide to EMS
Agency documentation made in accordance with this Agreement to permit EMS Agency to
respond to a request by an individual for an accounting of disclosures of PHI in accordance with
Title 45, Part 164, Section 164.528 of the HIPAA Rules. Business Associate shall have a
reasonable time within which to comply with such a request from EMS Agency and in no case
shall Business Associate be required to provide such documentation in less than five (5) business
days after Business Associate's receipt of such request. Except as provided for in this Agreement,
if Business Associate receives a request for access to PHI, an amendment of PHI, an accounting
of disclosure, or other similar requests directly from an Individual, Business Associate will redirect
the individual to the EMS Agency.
12. Correction of Health Information/ Restriction on Disclosure. Business Associate shall,
upon receipt of notice from EMS Agency, promptly amend or correct PHI received from or on
behalf of EMS Agency. Business Associate shall promptly identify and provide notice of the
amendment to all agents or subcontractors who create, maintain, or rely on the PHI that is the
subject of the amendment. Business Associate further agrees to comply with any restrictions on
the disclosure of an Individual's PHI subject to the applicable limits under the HIPAA Rules.
13. Minimum Necessary Determination. Business Associate shall use its professional
judgment to determine the minimum amount and type of PHI necessary to perform its obligations
under the Agreement. Business Associate represents that it will only request the minimum
necessary PHI to perform its obligations under the Agreement. Business Associate acknowledges
that EMS Agency will rely on its determination for compliance with the minimum necessary
standards under Title 45, Parts 160 and 164 of the CFR.
14. Reporting. Business Associate shall report to EMS Agency any use or disclosure
of PHI not provided for by the Agreement of which it becomes aware including breaches of
unsecured PHI and any security incident of which it becomes aware. Business Associate shall
12 Revised 08/30/2016
make the report to EMS Agency's Privacy Official not less than 24 hours after Business Associate
learns of such unauthorized use or disclosure or security incident. Business Associate's report
shall at least: (a) identify the nature of the unauthorized use or disclosure; (b) identify the PHI
used or disclosed; (c) identify who made the unauthorized use or received the unauthorized
disclosure; (d) identify what Business Associate has done or will do to mitigate any deleterious
effect of the unauthorized use or disclosure; (e) identify what corrective action Business Associate
has taken or shall take to prevent future similar unauthorized use or disclosure; and (f) provide
such other information, including a written report, as reasonably requested by EMS Agency's
Privacy Official.
15. Obligations of EMS Agency.
(a) EMS Agency shall notify Business Associate of any limitations in the privacy
practices of EMS Agency under 45 CFR Section 164.520, to the extent that such limitation may
affect Business Associate's use or disclosure of PHI.
(b) EMS Agency shall notify Business Associate of any changes in, or revocation of,
the permission by an Individual to use or disclose his or her PHI, to the extent that such changes
may affect Business Associate's use or disclosure of PHI;
(c) EMS Agency shall notify Business Associate of any restriction on the use or
disclosure of PHI that EMS Agency has agreed to, or is required to abide by, under 45 CFR Section
162.522, to the extent that such restriction may affect Business Associate's use or disclosure of
PHI.
16. Right to Terminate for Breach. Notwithstanding any other provision of the
Agreement, EMS Agency shall have the right to terminate the Agreement if it determines, in its
sole discretion, that Business Associate has violated a material term of this Addendum or any
provision of Title 45, Parts 160 and 164 of the CFR. EMS Agency may exercise this right by
providing written notice to Business Associate of termination, with such notice stating the
violation that provides the basis for the termination. Any such termination shall be effective
immediately or at such other date specified by EMS Agency in such notice.
17. Return or Destruction of Health Information. Upon termination, cancellation,
expiration or other conclusion of the Agreement, Business Associate, with respect to PHI receipt
from EMS Agency, or created, maintained or received by Business Associate on behalf of EMS
Agency, shall:
(a) Retain only that PHI which is necessary for Business Associate to continue its
proper management and administration or to carry out its legal responsibility.
(b) Return to EMS Agency, or, if agreed to by EMS Agency, destroy, the remaining
PHI that the Business Associate still maintains in any form;
13 Revised 08/30/2016
(c) Continue to use appropriate safeguards and comply with HIPAA regulations with
respect to electronic protected health information to prevent use or disclosure of the PHI other than
as provided for in this Section, for as long as Business Associate retains the PHI;
(d) Not use or disclose the PHI retained by Business Associate other than for the
purposes for which such PHI was retained and subject to the same conditions set out herein which
applied prior to termination;
(e) Return to EMS Agency the PHI retained by Business Associate when it is no longer
needed by Business Associate for its proper management and administration or to carry out its
legal responsibilities; and
(f) Transmit the PHI to another Business Associate of EMS Agency at termination as
requested by EMS Agency.
18. Continuing _Obli atg ions. Business Associate's obligation to protect PHI received
from or on behalf of EMS Agency shall be continuous and shall survive any termination,
cancellation, expiration or other conclusion of the Agreement.
19. Automatic Amendment. Upon the effective date of any amendment to the HIPAA
Rules, the Agreement shall automatically be amended such that the obligations imposed on
Business Associate as a Business Associate remain in compliance with such regulations.
IN WITNESS WHEREOF, each of the undersigned has caused this Addendum to be duly
executed in its name and on its behalf effective as of this date as indicated above.
EMS AGENCY:
CITY OF RICHMOND
By: a
Print Name:
a
Title: Q
Date:
BUSINESS ASSOCIATE
MEDICOUNT MANAGEMENT, INC.
oil W WOOL wvl
•`
Print Title: President
a Date:
EXHIBIT D
PATIENT HARDSHIP POLICY
14
Revised 08/30/2016
To establish a billing policy that allows waiving of ambulance transport fees based on established
Department of Health and Human Services Poverty Guidelines, and to abide by decisions made by the
United States Department of Health and Human Services, Centers for Medicare & Medicaid Services, and
the Office of Inspector General (OIG).
SCOPE:
This policy pertains to all individuals transported by clients of Medicount Management, Inc.
PROCEDURE:
1. Patients who are unable to pay their co -pays or deductibles, or who are uninsured and unable to
make payments, may request a financial hardship review of their transport fee. Patients, or their
designee, must complete an "EMS Hardship Waiver Form" (see attached). The form is available
on Medicount Management, Inc.'s website or can be requested by contacting a representative
Beth Horton at Medicount Management, Inc. at 513-612-3389.
2. Documentation needed for consideration of the request is to include:
a. W-2 Withholding Statements or unemployment check stubs for the past 90
days
b. Paycheck stubs for the past 90 days for all persons employed in the home
c. Income Tax Return (most recent; signed)
d. Any other information the patient submits as proof
Other circumstances that indicate financial hardship (Proof needs to be submitted for
consideration):
• Bankruptcy settlement
• Catastrophic situations (Death or disability in family; divorce)
3. The waiver application will be forwarded to the patient or patient's representative for review
and decision. Final resolution will be noted on the form and in the patient's account. Once
reviewed, a letter will be sent to the patient with the determination.
GUIDELINES:
1. If insurance information is provided, insurance must be billed out before waiver is approved or
denied.
2. All payment plans will be setup on a reoccurring credit card so that payments are automatically
deducted on a monthly basis from the patient's credit card.
3. A minimum $50 a month payment plan will be implemented when possible.
15 Revised 08/30/2016
4. If patient was approved for financial assistance at a medical facility and submits a copy of the
letter, the patient will be approved for the same amount as granted by the medical facility;
unless the EMS Agency (Client) has a collection policy where all patients unable to pay are sent
to the client for collection.
5. If the balance is $100 or less (approximately), based upon the patients economic circumstances
and guidelines, the balance will be written off.
6. If a patient does not have insurance, we will allow up to a 30% discount of the gross claim
amount as settlement in full of the claim.
Hardship approvals or denials will be based on the Fee Schedule below (excluding collection clients):
Maadnwm Annual kwmw Any wn for each Ad% Fee Percenuge Cate@► (except for 0% discount)
LW#W
Family Size
1
I =%
$11,770
I Um
$12,947
L Um
$14,124
Um
$15,301
WX
$16A78
is0%
$17,655
SUM
$18,832
im
$20,009
lum"
$71.186
2M
$22,363
200lG
$23,540
130UM
$23,541
2
$1S,930
$17,523
$19,116
$20,709
$22,302
$23,M
$25,488
$27,081
$28.674
$30,267
$31,860
$31,861
3
$20,090
$22,099
$24.108
$26,117
$29,126
$30,235
$32,144
$34,153
$36,162
$38,171
$40,180
$40,181
4
$24,250
$26,675
$29,100
$31,525
$33,950
S%,375
S38,800
$41,22S
$43,6S0
$46,075
$48,500
$48,501
5
$28,410
$31,251
$34,092
$36,933
$39.774
$42,615
$45,456
$48.297
551,138
$53,979 1
$56,820
$56,821
6
1$32,570
$35,827
$39,054
$42,341
$45,598
S48,855
$52,112
$55,369
$58,626
$61,893
$65,140
$65,141
7
$36,730
$40,403
$44,076
$47,749
$51,422
$55,095
$S8,768
$62,441
$66,114
$69,787
$73,460
$73,461
s
$40,890
$44,979
$49,068
$53,157
$57,246
$61,335
$65,424
$69,513
$73,602
$77,691
$81,780
$81,781
For each
add kmW
Person, add
$4,160
$4,576
$4,992
$5,408
$5,824
$6,240
$6,656
$7,072
$7,488
$7,904
$8,320
$8,320
*Based on 2015 Federal Poverty Guidelines (http://aspe.hhs.gov/poverty)
16
Revised 08/30/2016
a