HomeMy WebLinkAbout2017-026 CONFIDENTIAL AND PROPRIETARY Client Indian River County
Amendment Numtxr P3+:171,0113626
AMENDMENT
This amendment (the "Amendment") amends the Scr%ices Agreement that became effective on May I. 2001 (the
"Agreement"),between Indian River County("Client")and PST Services, Inc ("PST'')and is effective the latest date
in the signature block bclo".
Tor good and valuable consideration,the receipt and sufficiency of which are hereby acknowledged.the parties agree
as follows:
I. The Agreement is amended by adding Schedule IA. (Scope of Services - Supplemental Payment Recovery
Assistance Services)attached hereto,to the Agreement.
2. This Amendment may be executed in multiple counterparts.each of"hich shall tx:deemed an original and all of
which together shall be deemed one and the same instrument.
3. Capitalized terms used herein and not otherwise defined have the same meaning as in the Agreement. In the
event anv term or condition of this Amendment is inconsistent"ith any term or condition ofthe Agreement.the
terms of this Amendment "ill control. Except as stated above, all terms of the Agreement shall remain in full
torte and of w. PST and Client represent and "arrant that they ha,c the full power and authority to enter into
this Amendment. that there are no restrictions or limitations on their ability to perlbrm under this Amendment.
and that the person executing this Amendment has the full power and authority to do so.
IN WITNESS WHEREOF. and in agreement hereto.the parties ha-,e executed this Amendment on the dates set forth
bolo".
Indian River County PST Services ne.
13y: - ��
.;s°• fay: 1
f rin 'me:Joseph E. F1esCher * PrintName: �r1 r 1 W, dbe
Tit Chairman �' ;Q�: Title: Je.Y11 r
Date: February 14, 2017 Date:
�'•gNRI iE
APPROVED
Attest: Jeffrey R. Smith, C rk of
Cour and Coit , ler
Ely:
f'nttrtt Adm nistratar eputy Cit,
APPROVED AS TO FORM
AND LE„ AL SUFFICIENP1'
B Ll n:7U=�1
WILLIAP K OEBRALAL
DEPUTY COUNTY ATTORNPv
wpr J-.,I
CONFIDENTIAL AND PROPRIETARY Client Indian Rivt!r County
Arnenditicrit Number P201710013626
SCHEDULE IA
SCOPE OF SERVICES-SUPPLEMENTAL PAYMENT RECOVERY ASSISTANCE SERVICES
The Terms and Conditions or the Agreement and this Schedule apply to all services rendered by PST under this
Schedule.
1. TERM
1.1 Initial Term ol'Schedule. The initial term or this Schedule is three years (the "Schedule Term-)
beginning December 1.2016(the-Commencement Date'*).
1.2 Automatic Renewal, This Schedule will automatically renew for one year terms unless (i) either
puny delivers to the other written notice of termination at least 90 days prior to the expiration of the
then-current term.or(ii)as otherwise set lbrth in the Agreement.
1.3 No Cause Termination. Either party may terminate this Schedule IA at any time and lbr any reason
or no reason upon 90 days prior written notice to the other party,
2 SCOPE OF SERVICES
2.1 S..pM. PST will provide supplemental payment assistant services as specified below based on
intormation provided by Client for professional ambulance services rendered by Client in
accordance with the terms of the Agreement and this Schedule.
2.2 Responsibilities Each party agrees to perform its respective responsibilities identified below in a
timely and diligent manner. Client acknowledges and agrees that PST's performance or the
Services described herein is dependent upon Client's performance of its responsibilities as set forth
in this SchLdulc.
2.2.1 PST Rg§nonsibi I i ties. As part of the PST's Supplemental Payment Assistance Services,
PST's responsibilities under this Schedule will include.
(a) Advising and assisting Client with enrolling in the rloridu Ambulance Supplemental
Payment Program:
(b) Assisting Client with enrolling in the Florida Ambulance Supplemental Payment
Program
(C) Managing the program applications and required cost reports lbr Client in accordance
with the ASPP:
(d) Managing the ASPP pre-Lost report submittal process for Client. which may also
include:
• Developing and submitting the Provider Approval materials to the Florida
Agency ror Health Cart: Administration ("Al-ICA-) agency on behalf of
Client:
• Developing and submitting the Cost Allocation Model and Report to ARCA
on behall'orClient for rekie%% as pan ol'thc ASPP;
• Changing and finalizing the Cost Allocation Model during AHCA's rc%ic"ol'
the Cost Allocation Model and Report. to meet AHCA*s requirements to
move forward with the cost report submittal.
(e) Assisting Client in developing cost models for LNIS transports for submission to
ASPP;
(i) Assisting Client with submitting other annual reports as my required by the ASPP;
(g) Ensuring that cost report preparer(s)engaged on behalf ol'Client by PST are ccrti fied
in accordance with all applicable rules.laws and regulations:and
(h) Ensuring that it utilizes separate stall for all billing and cost report preparation services
provided to Client.
2.2.2 Client Responsibilities. Client acknowledges and understands that inaccurate or false data
submissions, even advertent ones, can lead to a false claim charge or Medicaid program
exclusion. Therefore.Client agrees that it will use best ell'orts to:
,v;r 2 4 3
CONFIDENTIAL AND PROPRIETARY Chent Indian River County
Amendment Number P201 7 100 1 36 26
(a) Ensure the accuracy of all cost report data pro%ided by Client to PST and provide
written certification of the accuracy of such data to PST and all applicable
governmental agencies.
(b) Make its internal practices, books and records relating to all cost report data provided
to PST by Client available to PST to ensure the accuracy of all such data;
(c) Comply with PST policies and procedures for the documentation oral I cost report data
as established and provided to Client by PST from time to time;and
(d) Provide PST with the following as part of Client's request for Supplemental Payment:
• An organizational chart of Client's agency;
• An organizational chart of Client's ambulance department:
• Identification of the specific geographic service area covered by Client's
ambulance department:
• Copies of job descriptions for all staff employed within Client's ambulance
department and an estimated percentage of time spent working for Client's
ambulance department and for other departments of Client's agency,
• Primary contact person for Client's agency;and
• A signed letter documenting the governmental provider's voluntary
contribution of non-lederal tunds.
3 SERVICE FEES
3.1 For Supplemental Payment Recovery Assistance Services rendered under Section 2 in Schedule IA
directly above. Client will pay PST a service lee equal to 6.8%* of the Supplemental Payments
recovered by PST on behalf of Client during the previous month, in accordance with Section J of
the Agreement,entitled "Monthly Fees." Supplemental Payments shall include any payments from
Florida Medicaid to Client related to the Florida Ambulance Supplemental Payment Program.
*In the event that charging a percentage of'payments recovered for the services described
herein is determined to be out of compliance with lederal or state laves or regulations.either
party may amend this Amendment to set forth a different payment arrangement. The
parties acknowledge and agree that such amendment does not waive the obligation to pay
determined fees.
3? In addition to the 6.8%service lee due by Client to PST under this Schedule Client%kill pay PST a
one-time, upfront fee of$5.500.00 (*'Setup Fee") for completion of the pre-cost report submittal
requirements necessary for Client's participation in the Florida Ambulance Supplemental Payment
Program. The Setup Fee will be due upon Client's execution of this Agreement.
3.3 All service lees are exclusive of all lederal.state and local taxes. including sales taxes,assessed on
or due in respect of any Services performed by PST under this Agreement, for "hick taxes Client
shall be solely responsible. Client shall reimburse PST for all those costs and expenses of Client
paid by PST or any subsidiary or affiliate of PST on bchall'of Client in connection with the
provision of Services hereunder.
3.4 Client acknowledges and agrees that PST shall be entitled to receive service fees for Services
prokided by PST under this Agreement even alter expiration or earlier termination of this
Agreement provided that PST provided such services on or betore the date of expiration or
termination of this Agreement.
Heidi Bockus
Vice President-Surety AUG 0
4 2017
MMARSH Marsh USA Inc.
1301 5th Avenue
Suite 1900 4N 1]
Seattle,WA 98101-2682
206 214 3164 Fax 206 214 3485
heidi.bockus@marsh.com
www.marsh.com
April 13, 2017
David Schultz
Change HealthCare
3055 Lebanon Pike
Nashville, TN 37214
Subject: New Replacement Bond
Principal: Per-Se Technologies, Inc.
Obligee: Indian River County, FL
Bond Description: Performance Bond — Billing Services Contract
Bond Amount: $52,000
Bond No.: 0145071
Dear David:
I am sending you the above-referenced replacement bond which replaces Bond No. 6469321
issued through McKesson's surety program. The bond is based on the information I had in file.
Please have the original bond signed and attested on behalf of Per-Se Technologies prior to
sending to the County for filing and acceptance (Indian River County, 2525 St. Lucie Ave, Vero
Beach, FL 32960). The bond should be filed prior to May 1, 2017. The additional copy is for
your records.
Under separate cover you will be receiving our invoice for this transaction in the amount of$650
covering a one year term. Marsh will receive 30% of this amount from the surety company.
Your payment of this invoice constitutes your agreement of our compensation for this bond. As
always, I ask that you recheck the bond for accuracy before filing it with the obligee.
In the event that you do not accept and file the bond with the obligee, please return this original
document to Marsh so that we can notify the surety company that the bond was not accepted and
filed; otherwise, the surety company will process a premium billing for the bond.
If you have any questions, please feel free to contact me. Thank you for allowing Marsh to
service your surety needs.
OG 1/40
Sincerely,
1. •
ll01 0 9tld AUG 03 7.OiI
Hetds
Vice President— Surety 0
/Encl.
MARSH&McLENNAN
P.
This bon ' regl,acbs+�rlQ up rsedes Bond#6469321 issued through Safeco Insurance Company of America, dated 4/19/2007.
��UUbb Bond No.0145071
//tF107. PERFORMANCE BOND
KNOW ALL MEN BY THESE PRESENTS that Per-Se Technologies, Inc. Principal, hereinafter called Contractor,and Berkley
Insurance Company, as Surety, hereinafter called Surety, is held and firmly bound unto Indian River County, Florida, as
Obligee, hereinafter called Owner, in the amount of Fifty Two Thousand and No/100 Dollars($52,000.00),for the
payment whereof Contractor and Surety bind themselves,their heirs, executions, administrators, successors and assigns
jointly and severally,firmly by these presents.
WHEREAS,the Contractor has by written agreement date May 1, 2001, entered into a contract with Owner for
Billing Services in accordance with the specifications prepared by the Owner, hereinafter called the Contract.
NOW THEREFORE,THE CONDITION OF THIS OBLIGATION is such that if the Principal:
1. Faithfully performs the contract at the times and in the manner prescribed in the Contract; and
2. Promptly makes payments to all persons, including claimants as defined in Section 255.05 (1), Florida
Statutes, supplying labor, materials and equipment used directly or indirectly by the said Contractor,
Contractors, Sub-Contractor or Sub-Contractors in the prosecution of the work provided for in the Contract;
and
3. Settles all claims and demands incurred for the same and fully indemnifies and saves harmless the owner
from all losses, damages, expenses, costs and attorney's fees, including appellate proceedings,which Owner
suffers by reason of failure to do so and fully reimburses and repays the Owner all outlay and expenses
which the Owner may incur in making good any such defect; and
4. Performs the guarantee of all work and materials furnished under the contract for the time specified in the
Contract, then this obligation shall be null and void; otherwise it shall remain in full force and effect.
And provided that any alterations which may be made in the terms of the Contract or in the work to be done
under it, or giving by the Owner of any extension of time for the performance of the Contract, or any other
forbearance on the part of either the Owner or Principal to the other shall not in any way release the Principal
and Surety or Sureties, or either or any of them, their heirs, executors, administrators, successors or assigns for
their liability hereunder, notice to the Surety or Sureties, of any such alterations, execution or forbearance being
hereby waived.
SIGNED AND SEALED THIS 13th day of April , 2017.To become effective: May 1, 2017.
ATTEST: AS TO PRINCIPAL:
oLQy d . Per-Se Technologies, Inc.
TITLE: BY:v-- CSW"
TITLE: ct- 5\-C_ -
ATTEST: AS TO SURETY,
BY: 12)0-01/A1.46
TITLE: Witness TITLE: Heidi K. Bockus,Attor.Lev-in Fa:.t
COUNTERSIGNED BY: N/A Nonresident Lic:nse#P052668
This bond replaces and supersedes Bond#6469321 issued through Safeco Insurance Company of America, dated 4/19/2007.
Bond No.0145071
PERFORMANCE BOND
KNOW ALL MEN BY THESE PRESENTS that Per-Se Technologies, Inc. Principal, hereinafter called Contractor,and Berkley
Insurance Company, as Surety, hereinafter called Surety, is held and firmly bound unto Indian River County, Florida, as
Obligee, hereinafter called Owner, in the amount of Fifty Two Thousand and No/100 Dollars ($52,000.00), for the
payment whereof Contractor and Surety bind themselves, their heirs, executions, administrators, successors and assigns
jointly and severally, firmly by these presents.
WHEREAS, the Contractor has by written agreement date May 1, 2001, entered into a contract with Owner for
Billing Services in accordance with the specifications prepared by the Owner, hereinafter called the Contrac
RECEjp,tt%
NOW THEREFORE,THE CONDITION OF THIS OBLIGATION is such that if the Principal:
1. Faithfully performs the contract at the times and in the manner prescribed in the Contract; a t-
2. Promptly makes payments to all persons, including claimants as defined in Section 255.05 (1), Florida
Statutes, supplying labor, materials and equipment used directly or indirectly by the said Contractor,
Contractors, Sub-Contractor or Sub-Contractors in the prosecution of the work provided for in the Contract;
and
3. Settles all claims and demands incurred for the same and fully indemnifies and saves harmless the owner
from all losses, damages, expenses, costs and attorney's fees, including appellate proceedings,which Owner
suffers by reason of failure to do so and fully reimburses and repays the Owner all outlay and expenses
which the Owner may incur in making good any such defect; and
4. Performs the guarantee of all work and materials furnished under the contract for the time specified in the
Contract, then this obligation shall be null and void; otherwise it shall remain in full force and effect.
And provided that any alterations which may be made in the terms of the Contract or in the work to be done
under it, or giving by the Owner of any extension of time for the performance of the Contract, or any other
forbearance on the part of either the Owner or Principal to the other shall not in any way release the Principal
and Surety or Sureties, or either or any of them, their heirs, executors, administrators, successors or assigns for
their liability hereunder, notice to the Surety or Sureties, of any such alterations, execution or forbearance being
hereby waived.
SIGNED AND SEALED THIS 13th day of April , 2017.To become effective: May 1, 2017.
ATTEST: AS TO PRINCIPAL:
Per-Se Technologies, Inc.
TITLE: " • k'ne ^
55 BY: /` �
- C'C
TITLE: ct L
ATTEST: AS TO SURETY:
BY: —11Q . AAU7 _x�i(�
TITLE: Witness TITLE: Heidi K. Bockus,Attomev-in-Fa:a _
COUNTERSIGNED BY: N/A Nonresident License#P052668
No. BI-7876a
POWER OF ATTORNEY
BERKLEY INSURANCE COMPANY
WILMINGTON, DELAWARE
NOTICE: The warning found elsewhere in this Power of Attorney affects the validity thereof. Please review carefully.
KNOW ALL MEN BY THESE PRESENTS, that BERKLEY INSURANCE COMPANY (the "Company"), a corporation duly
organized and existing under the laws of the State of Delaware, having its principal office in Greenwich, CT, has made, constituted
and appointed, and does by these presents make, constitute and appoint: Heidi K. Bockus or Krista M. Lee of Marsh USA,Inc. of
Seattle, WA its true and lawful Attorney-in-Fact, to sign its name as surety only as delineated below and to execute, seal,
acknowledge and deliver any and all bonds and undertakings, with the exception of Financial Guaranty Insurance, providing that
no single obligation shall exceed Fifty Million and 00/100 U.S. Dollars(U.S.$50,000,000.00),to the same extent as if such bonds
had been duly executed and acknowledged by the regularly elected officers of the Company at its principal office in their own
• proper persons.
— = This Power of Attorney shall be construed and enforced in accordance with, and governed by, the laws of the State of Delaware,
- without giving effect to the principles of conflicts of laws thereof. This Power of Attorney is granted pursuant to the following
• resolutions which were duly and validly adopted at a meeting of the Board of Directors of the Company held on January 25,2010:
RESOLVED, that, with respect to the Surety business written by Berkley Surety Group, the Chairman of the Board, Chief
Executive Officer, President or any Vice President of the Company, in conjunction with the Secretary or any Assistant
Secretary are hereby authorized to execute powers of attorney authorizing and qualifying the attorney-in-fact named therein
• = to execute bonds, undertakings, recognizances, or other suretyship obligations on behalf of the Company, and to affix the
corporate seal of the Company to powers of attorney executed pursuant hereto; and said officers may remove any such
attorney-in-fact and revoke any power of attorney previously granted; and further
RESOLVED, that such power of attorney limits the acts of those named therein to the bonds, undertakings, recognizances,
= or other suretyship obligations specifically named therein, and they have no authority to bind the Company except in the
manner and to the extent therein stated; and further
RESOLVED, that such power of attorney revokes all previous powers issued on behalf of the attorney-in-fact named; and
- further
- - RESOLVED, that the signature of any authorized officer and the seal of the Company may be affixed by facsimile to any
- = power of attorney or certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or
other suretyship obligation of the Company; and such signature and seal when so used shall have the same force and effect as
- though manually affixed. The Company may continue to use for the purposes herein stated the facsimile signature of any
person or persons who shall have been such officer or officers of the Company, notwithstanding the fact that they may have
- ceased to be such at the time when such instruments shall be issued.
IN WITNESS WHEREOF, the Company has caused these presents to be signed and attested by its appropriate officers and its
corporate seal hereunto affixed this 22-day of / ,2013.
Attest: - Berkley Insurance Company
- (Seal) Byr By ,
Ira�S. Lede an J ffry' I .'_er
Senior Vice President& Secretary Se ' r rice ',resident
WARNING: THIS POWER INVALID IF NOT PRINTED ON BLUE"BERKLEY" SECURITY PAPER.
STATE OF CONNECTICUT)
) ss:
COUNTY OF FAIRFIELD )
- Sworn to before me, a Notary Public in the State of Connecticut, this?Z. day of TY , 20113, by Ira S. Lederman and
Jeffrey M. Halter who are sworn to me to be the Senior Vice President and Secret "and dle Senior Vice President,respectively, of
Berkley Insurance Company. --)2Z/ L-1-""17Z4. NOTAgyp UC
Notary Public, State of I• c- CONNECTICUT
SSION EXPIRES OCTOBER 31 2017
CERTIFICATE
1,the undersigned, Assistant Secretary of BERKLEY INSURANCE COMPANY, DO HEREBY C RTIFY that the foregoing is a
true, correct and complete copy of the original Power of Attorney; that said Power of Attorney has not been revoked or rescinded
=- and that the authority of the Attorney-in-Fact set forth therein, who executed the bond or undertaking to which this Power of
Attor.iey is attached, is in full force and effect as of this date.
Given under my hand and seal of the Company,this VI—day of 1 Q c,
(Seal) 4/)
An' 4 ' T a
ECF/` 'o. BI-7876a
POWER OF ATTORNEY <O
BE KLEY N, DELAWARE WOANCE ANY i(/G
ILMING 031,
121
NOTICE: The warning found elsewhere in this Power of Attorney affects the validity thereof. Pleas 449VA )ly.
KNOW ALL MEN BY THESE PRESENTS, that BERKLEY INSURANCE COMPANY (the "Company"), a corporation duly
organized and existing under the laws of the State of Delaware, having its principal office in Greenwich, CT, has made, constituted
and appointed, and does by these presents make,constitute and appoint: Heidi K Bockus or Krista M. Lee of Marsh USA, Inc. of
Seattle, WA its true and lawful Attorney-in-Fact, to sign its name as surety only as delineated below and to execute, seal,
acknowledge and deliver any and all bonds and undertakings, with the exception of Financial Guaranty Insurance, providing that
no single obligation shall exceed Fifty Million and 00/100 U.S. Dollars(U.S.$50,000,000.00),to the same extent as if such bonds
had been duly executed and acknowledged by the regularly elected officers of the Company at its principal office in their own
proper persons.
.2 70 This Power of Attorney shall be construed and enforced in accordance with, and governed by, the laws of the State of Delaware,
without giving effect to the principles of conflicts of laws thereof. This Power of Attorney is granted pursuant to the following
resolutions which were duly and validly adopted at a meeting of the Board of Directors of the Company held on January 25, 2010:
511 RESOLVED, that, with respect to the Surety business written by Berkley Surety Group, the Chairman of the Board, Chief
L i Executive Officer, President or any Vice President of the Company, in conjunction with the Secretary or any Assistant
> Secretary are hereby authorized to execute powers of attorney authorizing and qualifying the attorney-in-fact named therein
to execute bonds, undertakings, recognizances, or other suretyship obligations on behalf of the Company, and to affix the
corporate seal of the Company to powers of attorney executed pursuant hereto; and said officers may remove any such
c attorney-in-fact and revoke any power of attorney previously granted; and further
RESOLVED, that such power of attorney limits the acts of those named therein to the bonds, undertakings, recognizances,
or other suretyship obligations specifically named therein, and they have no authority to bind the Company except in the
c manner and to the extent therein stated; and further
y 8 RESOLVED, that such power of attorney revokes all previous powers issued on behalf of the attorney-in-fact named; and
= r further
ori RESOLVED, that the signature of any authorized officer and the seal of the Company may be affixed by facsimile to any
° power of attorney or certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or
other suretyship obligation of the Company; and such signature and seal when so used shall have the same force and effect as
though manually affixed. The Company may continue to use for the purposes herein stated the facsimile signature of any
person or persons who shall have been such officer or officers of the Company, notwithstanding the fact that they may have
ceased to be such at the time when such instruments shall be issued.
V IN WITNESS WHEREOF, the Company has caused these presents to be signed and attested by its appropriate officers and its
corporate seal hereunto affixed this Z2-day of / ,2013.
Attest: Berkley Insurance Company
F. (Seal) By By .
c • Ira-S.ILede an J ffr y� ) .'_er
o Senior Vice President& SecretarySets. r ice 'resident
t 2,
WARNING: THIS POWER INVALID IF NOT PRINTED ON BLUE"BERKLEY" SECURITY PAPER.
STATE OF CONNECTICUT)
-c o ) ss:
oN COUNTY OF FAIRFIELD )
��
Sworn to before me, a Notary Public in the State of Connecticut, this<� day of� v , 201/3, by Ira S. Lederman and
Jeffrey M.Halter who are sworn to me to be the Senior Vice President and Secret !and tl e Senior Vice 'resident, respectively, of
Berkley Insurance Company. �� REY
KA T,«.
/612"L--± i/Z4 , NOTARY PUBLIC
c
N'otary Public, State of II• r. INNEcricur
S�� OCTOBER 31,2017
—_ CERTIFICATE
t I,the undersigned, Assistant Secretary of BERKLEY INSURANCE COMPANY, DO HEREBY C RTIFY that the foregoing is a
true, correct and complete copy of the original Power of Attorney; that said Power of Attorney has not been revoked or rescinded
and that the authority of the Attorney-in-Fact set forth therein, who executed the bond or undertaking to which this Power of
Attorney is attached, is in full force and effect as of this date. .
Given under my hand and seal of the Company,this \3--day of .
(Seal)
An. 4. 'f a