R– Recovery Audit Third-party Health Insurers Underpayment Services

Notice Type: Sources Sought Notice

Posted Date: 17-JAN-18

Office Address: Department of Veteran Affairs;PCAC-ST. LOUIS;11152 South Towne Square;Saint Louis MO 63123

Subject: R-- Recovery Audit Third-party Health Insurers Underpayment Services

Classification Code: R - Professional, administrative, and management support services

Solicitation Number: 36C77718Q9070

Contact: Contract Specialist: Angela PerryPhone: 314-894-6656 x65115 Email: [email protected] Contracting Officer: Linda Eley Phone: 314-894-6656 x65106 mailto:[email protected] [Contract Specialist]

Description: Department of Veterans Affairs

VA Corporate Franchise Data Center

Department of Veterans Affairs Corporate Franchise Data Center

Page 6 of 22DISCLAIMER

This RFI is issued solely for information and planning purposes only and does not constitute a solicitation. All information received in response to this RFI that is marked as proprietary will be handled accordingly. In accordance with FAR 15.201(e), responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. Responders are solely responsible for all expenses associated with responding to this RFI.

Agency: Department of Veterans Affairs

Office: Office of Community Care (OCC), Revenue Operations (Rev Ops) Consolidated Patient Account Center (CPAC)

Notice type: Post Date: 16 January 2018

Sources Sought

Response Date: 22 January 2018

Original Proposed Set-Aside: Full & Open

Classification Code: R704

NAICS Code: 541211

Synopsis: THIS IS NOT A SOLICITATION. This is a Request for Information (RFI) Sources Sought Notice issued in accordance with FAR 15.201(e) to conduct market research. This RFI is issued solely for information and planning purposes it does not constitute a Request for Quote (RFQ) or a promise to issue a RFQ in the future. This request for information does not commit the Government to contract for any supplies or services whatsoever. The Department of Veterans Affairs (VA) is not, at this time, seeking proposals and will not accept unsolicited costs incurred in response to this RFI; all costs associated with responding to this RFI will be solely at the interested vendor s expense. Not responding to this RFI does not preclude participation in any future RFQ, if any is issued. Any information submitted by respondents to this RFI is strictly voluntary. All submissions become Government property and will NOT be returned.

Contracting Office Address:

Department of Veterans Affairs (VA)

SAO Central

PCAC- St. Louis

11152 South Towne Square

St. Louis, MO 63123

Points of contact:

Angela Perry

Contract Specialist

314-894-6656 x65115

Objective: This RFI is for Recovery Audit services that review different claim types and provide services to pursue payment of underpaid collected closed TPP commercial health insurance claims that are due to the Department of Veterans Affairs (VA), Veterans Health Administration (VHA).

1. Specific Response Instructions: Please submit your RFI response in accordance with the following:

a. No more than 10 pages (excluding transmittal page). Include the name, email address and phone number of the appropriate representative of your company; The Government will not review information or attachments in excess of the 5 page limit.

b. Submit your response via email to [email protected].

c. Submit your response by 8:00 A.M. (CST), 22 January 2018.

d. Mark your response as Proprietary Information if the information is considered business sensitive.

e. Marketing Materials are not allowed as part of this RFI.

2. Information Requested: VA encourages responses from small businesses with an emphasis on SDVOSBs and VOSBs. In response to the RFI interested contractors shall submit the following information:

a. Company Information/Socio Economic Status

b. Provide the company size and POC information

c. VA has identified the appropriate North American Industry Classification System (NAICS) Code 541211, Offices of Certified Public Accountants, which has a size standard of $20.5 million for this RFI.

d. Indicate whether your company, subcontractors, teaming partners, joint ventures have a Federal Socio-Economic Status, e.g., Small Business, Service-Disabled Veteran Owned Small Business, Veteran Owned Small business, Women-Owned Small Business, Disadvantaged Small business (8A), and Hub Zone. If Service Disabled or Veteran Owned Small business, is your company and or partners registered in VA s VetBiz repository

Scope of Work: See attached sample Performance Work Statement (PWS).

Questions for Industry: A previous RFI (VA777-17-N-0164) was released in FY17 requesting information from industry to help define a potential requirement for Recovery Audit services. The PWS was revised to be more in line with industry standard based off of the responses received. At this time, the Government is only seeking to identify viable and interested companies that could perform recovery audit services in accordance with the attached PWS:

Review the PWS carefully including the scope of work and number of claims to be reviewed per year. Has your company provided this service within the last three (3) years at an enterprise level (with enterprise level consisting of receiving requirements from a large healthcare organization supporting 3 or more locations across CONUS) Provide in your response the contract number(s), date of award and completion, dollar value, a general statement regarding timeframe (within three (3) years), type (must be healthcare), number of claims processed (relative to the PWS) and a current Point Of contact for each contract with information to contact them. (Note: The government requires confirmation of capability and will not use resources to track down POCs) .

Is your company interested in performing these services and will your company be able to accommodate performance within the next six(6) months (provide labor, management, equipment, and other resources, etc.)

Company Name with relevant information, NAICS code the work was performed under, business status (large, Small, SDVOSB, VOSB, 8A, etc.)

Office of Community Care (OCC), Revenue Operations (Rev Ops) Consolidated Patient Account Center (CPAC)

Performance Work Statement (PWS)

1. Title of Project: Recovery Audit Third-party Health Insurers Underpayment Services

2. Background: Public Laws (PL) 99-272, 101-508, and 102-579 granted Department of Veterans Affairs the authority to recover the reasonable cost of medical care from third-party health insurers (TPP) for services furnished to a Veteran for treatment of a non-service-connected condition. Title 38 USC Section 1729 and Title 38 CFR Part 17.101 and Part 17.106 is the authority that permits VA to seek reimbursement from TPPs for the cost of non-service-connected medical care furnished to eligible Veterans who have commercial insurance coverage. The money collected from TPPs is revenue used to offset VA imposed cost sharing for world class medical care provided to our nations Veterans.

The Department of Veterans Affairs (VA) Consolidated Patient Account Centers (CPACs) business processes ensure that VA collects revenue from commercial health insurance carriers for non-service connected care provided to insured Veterans. There are seven regional CPACs located nationwide that provide revenue cycle management to the 18 Veterans Integrated Service Network (VISNs) and their associated VAMCs. The seven (7) regional CPACs are located as follows:

Asheville, NC Mid-Atlantic CPAC (MACPAC)

Smyrna, TN Mid-South CPAC (MSCPAC)

Orlando, FL - Florida Caribbean CPAC (FCCPAC)

Middleton, WI North Central CPAC (NCCPAC)

Lebanon, PA North East CPAC (NECPAC)

Leavenworth, KS Central Plains CPAC (CPCPAC)

Las Vegas, NV- West CPAC (WCPAC)

OCC Revenue Operations CPAC is seeking services to actively review insurance carrier payments to determine appropriate collections and, if underpayments are identified, pursue the collection of the under paid amount.

3. Objectives: Review claim types identified and provide services to pursue payment of underpaid collected/closed TPP commercial health insurance claims due to the Department of Veterans Affairs (VA), Veterans Health Administration (VHA).

3.1. VA Financial Policy Volume XII Debt Management Chapter 5 provides the following reasons a third party claim would be considered in a collected/closed status:

3.1.1. Partial payment received and the payment received is the full amount expected from the insurance carrier.

3.1.2. Usual and customary payment received.

3.1.3. Payment applied to the veteran s deductible.

3.1.4. Treatment does not meet medical necessity (this claim should be resubmitted to Revenue Utilization Review (RUR) prior to any decrease to file appeal; if no appeal, it will be closed).

3.1.5 Procedure is not authorized (this claim should be resubmitted to RUR prior to any decrease to file appeal; if no appeal it will be closed).

3.1.6. Medicare Part A deductible paid to another provider.

3.2. VHA s revenue cycle includes the following high level steps. The scope of work for this project begins following Step 5:

Step 1: Enrolled Veteran with third party insurance is seen in a VA facility for a non- connected condition

Step 2: The encounter is coded and billed to the third party payer using industry standard claim forms/electronic submissions

Step 3: The third party payer receives and adjudicates the claim

Step 4: VA Accounts Management staff perform follow up activity until the claim is processed to completion and VA is in agreement with the payment determination

Step 5: VA Accounts Management staff decrease the outstanding balance to zero and mark the claim Collected/Closed.

Note: If VA s systems determine the claim to be paid at the negotiated rate, the claim may be decreased automatically. For example, VA expected the TPP to allow $100 for a service and the electronic EOB shows an allowable of $100 and a patient share of $10 with a payment of $90, VA will automatically decrease the claim to zero and close the claim.

4. Scope of Work: The Contractor shall provide an analysis of all collected/closed TPP commercial health insurance claims from the prior Fiscal Year (FY17) to determine feasibility of achieving additional collections for all seven (7) regional Consolidated Patient Account Centers (CPACs) and their associated Veterans Affairs Medical Centers (VAMCs).. The feasibility assessment report shall include all collected/closed TPP commercial health insurance claims closed between October 1, 2016 and September 30, 2017(See Task 6.3).Following completion of the Feasibility Assessment Report the Contractor shall perform recovery audit services to include all labor, supervision, and other resources required to provide recovery audit services of collected/closed TPP commercial health insurance claims. Services shall include identification and collection of any revenues due to the Department of Veterans Affairs from TPP commercial health insurance carriers. There will be a minimum of one (1) CPAC to receive recovery audit services. Contingent of the results of the feasibility assessment, there could be a potential performance of recovery audit services for seven (7) CPACs associated with Veterans Affairs Medical Centers (VAMCs). Claims to be audited will be created from billable health insurance and consist of all applicable non-Medicare coverage by which the VA reasonably expects to receive payment. This excludes benefit programs such as Medicare, Medicaid, Champ VA, Tricare, and Tricare for Life. This excludes all pharmacy claims as well as claims for Regional Counsel, tort cases or worker s compensation.

The contractor shall not auto-generate mass mailing or appeal requests.

The contractor shall not use the threat of litigation or other aggressive tactics under this task order to elicit payment from TPP commercial health insurance carriers.

5. Applicable Documents:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA all existing and revised statutes)

Title 38 USC Section 1729 and Title 38 CFR Part 17.101 and Part 17.106

Federal Information Security Management Act (FISMA)

VA Financial Policy Volume XII, Chapter 5

6. Mandatory Tasks and Deliverables: The Contractor shall perform the mandatory tasks and provide the specific deliverables described below within the performance period stated in this Performance Work Statement (PWS). If, for any reason, any deliverable cannot be delivered on time according to the below schedule, the Contractor shall provide a written explanation to the Program Manager (PM)/Contracting Officer s Representative (COR) three days prior to deliverable due date. This written transmittal shall include a firm commitment of when the work shall be completed. This transmittal to the PM/COR shall cite the reasons for the delay and the impact on the overall project.

Task 6.1 Kick-Off Meeting

The Contractor and COR shall establish a bilaterally acceptable date (but not later than (NLT) 10 business days of award) for the kick-off meeting and shall provide a briefing in (MS Power Point format) to designated VA personnel two business days prior to Kickoff Meeting. The Contractor shall attend the technical and contract kick-off meeting. This meeting may be held remotely and attended virtually (i.e., Live Meeting, teleconference). At the kick-off, the Contractor shall present, for review and approval by the Government, the details of the intended approach, work plan, and project schedule to complete all tasks defined in this PWS.

The Contractor shall provide a meeting agenda at least two (2) business days prior to the meeting and meeting minutes shall be provided to all attendees within three (3) business days after conclusion of the meeting. The Contractor shall coordinate with the COR to invite the Contracting Officer, Contract Specialist, and any other necessary VA personnel.

Deliverables:

Contract Management Plan. One time. NLT 10 business days after award

Agenda NLT two (2) business days prior the kick-off meeting

Meeting Minutes NLT three (3) business days post kick-off meeting

Note: VA will review and approve Deliverable A within 10 calendar days of receipt. Deliverables B and C do not require review or approval.

Task 6.2: Project Plan: The Contractor shall provide a draft project management plan within two (2) weeks of the date of award. The Contractor shall schedule a conference call within two (2) weeks of the date of award to discuss the project plan. The specific focus will be to discuss the timeframes and tasks. Within one (1) week of this meeting the Contractor shall submit a formal project plan outlining resources and timeframe for completing the work outlined. The initial project plan will be for the base year of the contract. It is the responsibility of the Contractor to update the project plan as necessary and submit to the Government for additional approval. The initial project plan and subsequent updates must be approved by the VA prior to implementation.

The project plan shall include the following:

Insurance carrier communication plan At a minimum the communication plan shall include written and verbal methods the Contractor plans to utilize and sample communications

Contractor Organizational Chart At a minimum the organizational chart shall identify the names and titles of key personnel and the organizational structure to include the inclusion of any subcontractors in the organizational structure of this effort

The Contractor shall provide and maintain a detailed, product based, resource loaded, project management plan/schedule (PMP) compliant with Project Management Body of Knowledge (PMBOK) guidance in MS Project format. Contractor shall be responsible to maintain and revise the PMP and provide version controlled revisions (See below Deliverable A.)

The PMP shall also incorporate a Risk Management Plan/Risk Register together with a Quality Control Plan (QCP) incorporating QCP elements which are quantifiable and measurable in line with the quality assurance table (add the table to this document). The performance metrics for the QCP elements will monitored for performance utilizing a Quality Assurance Surveillance Plan (QASP)(See Section 7.2). The oversight provided for in the order and in the QASP will help to ensure that service levels reach and maintain the required levels throughout the contract term. Further, the QASP provides the COR with a proactive way to avoid unacceptable or deficient performance.. The QASP is a living document and may be updated by the Government as necessary. Initial QASP monitoring elements and acceptable quality level (AQL) are listed in the table below (See Section 7.2).

The contractor shall discuss the QCP and the QASP with the Customer to define what methodologies and metrics will be used to track contract performance and agreed to at the kickoff meeting and subsequently throughout performance, and be responsible for providing a briefing on the established QASP. It shall include Contractor roles, report on the methodologies to be implemented by the Contractor in the execution of the assigned Tasks/Deliverables, report the progress of key metrics and identification of any potential barriers. The initial brief shall be at the kick off meeting, and as necessary throughout contract performance, but reviewed at least annually.

Deliverables:

Project Management Plan and Execution. NLT 10 business days after the kick-off meeting updated as needed thereafter.

Task 6.3: Feasibility Assessment Report - Period of performance is thirty (30) days from issuance of the task order

6.3.1 Initial Assessment: The Contractor shall evaluate CPAC FY16 Fiscal Year collected/closed TPP commercial health insurance claims and conduct an analysis on the feasibility of additional collections. The Contractor shall develop an analysis report that identifies categories of claims that are deemed to be actionable based on a variety of factors to include, at a minimum, the third party insurance carrier, type of service, non-VA care, VA care, and an explanation of underpayment reason and supporting documentation for non-payment provided by the third party commercial health insurance carrier. The report shall include recommendations for types of claims to be forwarded to the Contractor for Task 6.3 CPAC Recovery audit Process. The report shall also include the estimated amount of additional recovery identified during the initial assessment including the basis for additional recovery with all additional recoveries available to review by account ID, TPP, CPAC, VISN, VAMC and VA closed month. The Contractor shall review the report with VA to determine the appropriate collected/closed claims that will be included in the monthly file sent to the Contractor by VA to perform the recovery audit tasks. VA has thirty (30) days to review and accept the results of the Feasibility Assessment Report. Upon acceptance, VA will only send those claims that match the criteria agreed to in the initial assessment report for the Recovery Audit Process. The government will provide the contractor a task order to begin performance of task 6.4, Recovery audit Services for each location.

Deliverable 6.3:

Feasibility Assessment Report. Due 30 business days after assigned.

Note: VA will review and approve Deliverable A within 30 calendar days.

6.4 CPAC Recovery Audit Services North Central CPAC: Period of performance is 12 months from execution of task order:

Utilizing criteria identified in the initial feasibility assessment report, the Contractor shall perform recovery audit services of collected/closed TPP commercial health insurance claims at North Central Consolidated Patient Account Center (NCCPAC) located in Middleton, WI.

Twice monthly a VA POC will provide to the Contractor a listing of claims determined to be reviewed by the Contractor as part of the recovery effort. Claims appropriate for review will have the following characteristics:

Any collected/closed claims that meet the criteria agreed to as part of the initial assessment

Excludes; all pharmacy, Medicare, Medicaid, ChampVA, Tricare, Tricare for Life claims, Regional Counsel claims, tort cases and worker s compensation

Includes;

Inpatient hospital

Outpatient hospital

Professional

Prior to submitting any correspondence to third party payers, the Contractor will provide copies of correspondence templates to VA for review and approval. VA will review and approve correspondence templates within 14 calendar days of receipt. (Deliverable A)

The Contractor shall perform the following tasks as part of the CPAC Recovery Audit Process:

Review collected/closed claims report and identification of claims subject to potential underpayment

Review electronic remittance advice information or scanned paper explanation of benefits (EOBs) through VA systems

Receive extracts and provide secure data transfer capabilities to receive and transmit extracts of sensitive information in accordance with FISMA from both VA and external sources

Receive access to the VHA VistA system for the purpose of documenting actions taken to pursue additional collections in VistA (TPJI) following CPAC established standard operating procedures.

Appropriate comments should be made to each account in VistA each time a recovery effort or contact is initiated. VA will provide access to Accounts Management guidebooks and Standard Operating Procedures to ensure appropriate comments are documented in VistA. VA will provide a virtual training session on documenting VistA comments once the Contractor staff has secured access to VA systems, including VistA

Prepare and submit documents in support of the claim recovery

Support the claim through the appeals process

Participate in conference calls with VA, third party payers and other stakeholders involved in recovery of collections as necessary to support claim recovery

Maintain quality customer service and provide accurate and timely responses to the Government and insurance carriers. This includes responding to written, telephonic and electronic inquires within the appropriate timeframes.

The following table identifies the amount type of denial by volume and dollar amount for each CPAC.

Table 1 CPAC Denial Data FY 2016

Table 2 Claim Compliant Payment Percentage FY 2016

The contractor shall provide VA with a monthly report of the payments (Deliverable B) generated from the accounts. VA will be paid by the payer in the normal course of business. The contractor shall generate and submit the monthly report to the designated VA representatives. Payments Report will be utilized by the COR as support for reimbursement. The contractor will be paid monthly within 30 days of validation of payment report with payment from the TPP. The monthly report should include: the VAMC Station Number, VAMC Name, VAMC Address, VA Bill Number, Veteran Name, Address, Date of Birth, Social Security Number, TPP Name, TPP Address, Date of Service, Total Billed Charges, Total Allowed Amount, Total Paid Amount, Total Patient Responsibility, Denial Code, Denial Amount, and Date Paid.

The contractor shall provide a monthly activities report (Deliverable C) containing; but not limited to, percentages recovered, denial analysis, and status of accounts. The report shall be submitted in both detail and summary in a format that is easy to review and comprehend results and trends. Report shall also contain details of recovery efforts for each claim, including date of contact, type of contact, and results of each contact. The report shall specify appeal information to include; a listing of appeals by date of appeal, current status (open or closed) and appeal outcomes. Report shall be submitted to the designated VA representative. The monthly activities report along with Payments Report will be utilized by the COR as support for reimbursement.

Utilizing a Government provided template the Contractor shall maintain and report monthly, a record of any health record information (Protected Health Information or PHI) printed and provided to insurance carriers in the course of the recovery audit Deliverable D).

The contractor shall conduct monthly conference call meetings with VA to discuss performance issues. Frequency of meeting can be adjusted as necessary. The Contractor shall be responsible for setting up the conference calls, preparing an agenda(Deliverable E), documenting minutes (Deliverable F)of the meeting and preparing any other supporting materials as needed. Additional conference calls may be held to discuss individual items and/or issues. The agenda of the reviews shall include:

Monthly performance assessment data and trend analysis

Issues and concerns of both parties

Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

Recommendations for improved efficiency and/or effectiveness

Issues arising from the performance monitoring processes

The contractor shall provide any newly identified and/or supplementary insurance information identified during the audit/recovery process to VA in a report for each appropriate CPAC, delivered through secure e-mail. (Deliverable G) The report identifying other insurance must always include the following data elements:

Full Name, including First Name, Middle Initial, Last Name, Suffix (if any)

Date of Birth (DOB)

Social Security Number (SSN)

Insurance Identification Number

Insurance Name

Insurance Address

Insurance Phone Number

Group Name

Group Number

Plan Type

Effective Date

Termination Date

Coverage Limitations

Deliverables:

Correspondence Templates NLT 10 business days prior to Contractor use

Monthly report of payments NLT five (5) business days after month end

Monthly activities report NLT five (5) business days after month end

Monthly PHI report NLT five (5) business days after the month end

Monthly Conference call agenda NLT two (2) business days prior to the meeting

Monthly conference call minutes NLT three (3) business days after the meeting

Monthly insurance identification report NLT five (5) business days after month end

Note: VA will review and approve Deliverables A-D and G within 10 calendar days. Deliverable E and F do not require review or approval.

6.5 Optional Task: Recovery Audit Services Central Plains CPAC- Period of performance is 12 months from execution of task order:

The contractor shall provide services identified in Task 6.4 CPAC Recovery audit Services for the Central Plains CPAC, Leavenworth, KS. Table one (1) provides claim denial and compliant payment information for each CPAC.

The Contractor shall have thirty (30) days after the optional task is issued via task order to begin performance.

Deliverables:

Monthly report of payments NLT five (5) business days after month end

Monthly activities report NLT five (5) business days after month end

Monthly PHI report NLT five (5) business days after the month end

Monthly Conference call agenda NLT two (2) business days prior to the meeting

Monthly conference call minutes NLT three (3) business days after the meeting

Monthly insurance identification report NLT five (5) business days after month end

Note: VA will review and approve Deliverables A-C and F within 10 calendar days. Deliverable D and E do not require review or approval.

6.6 Optional Task: CPAC Recovery Audit Services Florida Caribbean CPAC- Period of performance is 12 months from execution of task order:

The contractor shall provide all services identified in Task 6.4 CPAC Recovery audit Services for the Florida Caribbean CPAC, Orlando, FL. Table one (1) provides claim denial and compliant payment information for each CPAC.

Deliverables:

Monthly report of payments NLT five (5) business days after month end

Monthly activities report NLT five (5) business days after month end

Monthly PHI report NLT five (5) business days after the month end

Monthly Conference call agenda NLT two (2) business days prior to the meeting

Monthly conference call minutes NLT three (3) business days after the meeting

Monthly insurance identification report NLT five (5) business days after month end

Note: VA will review and approve Deliverables A-C and F within 10 calendar days. Deliverable D and E do not require review or approval.

6.7 Optional Task: CPAC Recovery Audit Services Mid-Atlantic-CPAC Period of performance is 12 months from execution of task order:

The contractor shall provide all services identified in Task 6.4 CPAC Recovery audit Services for the Mid-Atlantic CPAC, Asheville, NC. Table one (1) provides claim denial and compliant payment information for each CPAC.

Deliverables:

Monthly report of payments NLT five (5) business days after month end

Monthly activities report NLT five (5) business days after month end

Monthly PHI report NLT five (5) business days after the month end

Monthly Conference call agenda NLT two (2) business days prior to the meeting

Monthly conference call minutes NLT three (3) business days after the meeting

Monthly insurance identification report NLT five (5) business days after month end

Note: VA will review and approve Deliverables A-C and F within 10 calendar days. Deliverable D and E do not require review or approval.

6.8 Optional Task: CPAC Recovery Audit Services Mid-South CPAC- Period of performance is 12 months from execution of task order:

The contractor shall provide all services identified in Task 6.4 CPAC Recovery audit Services for the Mid-South CPAC, Smyrna, TN. Table one (1) provides claim denial and compliant payment information for each CPAC.

Deliverables:

Monthly report of payments NLT five (5) business days after month end

Monthly activities report NLT five (5) business days after month end

Monthly PHI report NLT five (5) business days after the month end

Monthly Conference call agenda NLT two (2) business days prior to the meeting

Monthly conference call minutes NLT three (3) business days after the meeting

Monthly insurance identification report NLT five (5) business days after month end

Note: VA will review and approve Deliverables A-C and F within 10 calendar days. Deliverable D and E do not require review or approval.

6.9 Optional Task: CPAC Recovery Audit Services North-East CPAC- Period of performance is 12 months from execution of task order:

The contractor shall provide all services identified in Task 6.4 CPAC Recovery audit Services for the North-East CPAC, Lebanon, PA. Table one (1) provides claim denial and compliant payment information for each CPAC.

Deliverables:

Monthly report of payments NLT five (5) business days after month end

Monthly activities report NLT five (5) business days after month end

Monthly PHI report NLT five (5) business days after the month end

Monthly Conference call agenda NLT two (2) business days prior to the meeting

Monthly conference call minutes NLT three (3) business days after the meeting

Monthly insurance identification report NLT five (5) business days after month end

Note: VA will review and approve Deliverables A-C and F within 10 calendar days. Deliverable D and E do not require review or approval.

6.10 Optional Task: CPAC Recovery Audit Services West CPAC- Period of performance is 12 months from execution of task order:

The contractor shall provide all services identified in Task 6.4 CPAC Recovery audit Services for the West CPAC, Las Vegas, NV. Attachment one (1) provides claim denial and compliant payment information for each CPAC.

Deliverables:

Monthly report of payments NLT five (5) business days after month end

Monthly activities report NLT five (5) business days after month end

Monthly PHI report NLT five (5) business days after the month end

Monthly Conference call agenda NLT two (2) business days prior to the meeting

Monthly conference call minutes NLT three (3) business days after the meeting

Monthly insurance identification report NLT five (5) business days after month end

Note: VA will review and approve Deliverables A-C and F within 10 calendar days. Deliverable D and E do not require review or approval.

Table 1, Mandatory Deliverable Table

Deliverable

Description

Quantity

Due Date

6.1. A

Contract Management Plan

1

NLT 10 business days after award

6.1. B

Kick Off Agenda

1

NLT 2 business days prior to meeting

6.1. C

Kick Off Meeting Minutes

1

NLT 3 business days post meeting

6.2A

Project Management Plan

1

NLT 10 business days after the kick-off meeting updated as needed thereafter

6.3. A

Initial Assessment Report Analysis of Feasibility

1

NLT 30 business days from assignment

6.4 A

Correspondence Templates

UNK

NLT 10 business days prior to contractor use

6.4 B, 6.5A, 6.6A, 6.7A, 6.8A, 6.9A, 6.10A

Monthly Report of Payments

12

NLT 5 business days after month end

6.4 C, 6.5B, 6.6B, 6.7B, 6.8B, 6.9B, 6.10B

Monthly Activities Reports

12

NLT 5 business days after month end

6.4 D, 6.5C, 6.6C, 6.7C, 6.8C, 6.9C, 6.10C

Monthly PHI Reports

12

NLT 5 business days after month end

6.4 E, 6.5D, 6.6D, 6.7D, 6.8D, 6.9D, 6.10D

Monthly Conference Call Agenda

12

NLT 2 business days prior to the meeting

6.4 F,6.5E, 6.6E, 6.7E, 6.8E, 6.9E, 6.10E

Monthly Conference Call Minutes

12

NLT 3 business days after the meeting

6.4 G, 6.5F, 6.6F, 6.7F, 6.8F, 6.9F, 6.10F

Monthly Insurance Identification Report

12

NLT 5 business days after month end

7. Quality Control: The Government will evaluate the quality of the administrative services provided, but retains no control over the services rendered.

7.1 Contractor s Quality Control Program: The Contractor shall develop and maintain an effective internal quality control program to ensure that services performed are in accordance with the PWS. The Contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. As a minimum requirement, the Contractor shall internally develop quality control procedures that address the areas identified below in the Government s Quality Assurance Surveillance Plan (QASP).

7.2 Performance Monitoring: Contractor s performance will be monitored through the use of a formal QASP. This plan will provide specific performance standards used for monitoring and measuring the Contractor s performance. The Contractor's performance shall be monitored through direct observation, validated user complaint(s), periodic sampling, progress or status meetings, and analysis of Contractor s reports.

The PM/COR will certify receipt of services and/or goods and recommends acceptance of the services/deliverables. This process will be used for approval of payment for the Contractor s invoices and will serve as the mechanism to document that the overall performance of the Contractor has been acceptable for the period of time covered by the invoice.

PERFORMANCE STANDARDS MATRIX TABLE

ID

Required

Service

Performance

Standards

Acceptable

Quality

Levels

Method

Of

Surveillance*

Incentive

1

Contract Management and Project Management Plans

Plans submitted no later than the required due dates

97%

Direct Observation, 100% Inspection

Progress Meetings

Positive PP ratings and option renewal

2

Assessment Feasibility Report Analysis of Feasibility

Report submitted no later than the required due date with required elements

97%

100% Inspection

Positive PP ratings and option renewal

3

Monthly Reports

Reports submitted no later than the required due dates

97%

Direct Observation, 100% Inspection, Progress Meetings

Positive PP ratings and option renewal

4

Contractor Personnel maintain VA system access (VistA)

No loss of VA system access during contract period

100%

Direct Observation

Positive PP ratings and option renewal

5

Maintain quality customer service and timely responses to government and insurance carriers

No more than 5 complaints during contract period

Less than 5 complaints per contract year

Direct Observation

Validated user/customer complaints

Positive PP ratings and option renewal

6

Timely documentation of monthly conference call meetings with VA

The contractor shall provide meeting agendas and minutes by the required due dates

97%

Direct Observation

100% Inspection

Positive PP ratings and option renewal

7

Contractor performs recovery audit review in accordance with contract requirements

The Contractor s determination that an underpayment did or did not occur on the claim. The completeness and accuracy of underpayment analysis

95%

Direct Observation, Periodic Sampling

Positive PP Ratings and option renewal

8

VistA TPJI comments document recovery effort and support contractor payment

Vista Comments shall be completed in accordance with VA Standard Operating Procedures

95% Accuracy

Random Sampling

Periodic Sampling

Positive PP ratings and option renewal

8.0 Financial Management of Collected Funds

8.1 General: Collections from TPP commercial health insurance carriers will be sent directly to the VA.

VA will record collections into Vista and make payments to the contractor based upon the collections received without the need for contractor invoicing. Contractor will maintain a database, compatible with the VA, for establishment of debts and reconciliation purposes.

Recovery audit cases that are reviewed and found to have received a refund request from a TPP commercial health insurance carrier within eighteen (18) months of the paid date and is validated by VA will be deducted from future payments to the Contractor.

8.2 Payment to the Contractor: Task 6.3, Assessment Feasibility Report will be paid on a firm fixed price basis when the report is complete and accepted by the government. For all other tasks, Contractor will be paid monthly and at the agreed percentage only based on collected (recovered) funds VA receives from the TPP commercial health insurance carrier for services provided in support of section 6. The Contractor shall not be paid for uncollected amounts. Payment shall be made for recovery audit services at single (same) percentage contingency rate for all CPACs. Upon receipt of the payment, the VA will deposit these payments in accordance with VA policy and procedures and furnish payment to the contractor. Invoicing by the contractor is not necessary, with the exception of the initial feasibility assessment, Task 6.3A.

Payment to the contractor will cease 6 months after task order expiration for all cases submitted to VA for reimbursement.

9. Government-Furnished Equipment (GFE)/Government Furnished Information (GFI):

Most work can be done remotely from the Contractor location; however, one work cubicle with GFE will be provided for staff member(s) performing printing functions onsite at the Mid-Atlantic CPAC in Asheville, NC. Any other physical location access must be requested by the Contractor and will be approved by VA based on availability of the requested location.

10. Performance Details:

10.1 Period of Performance: The period of performance shall be five (5) years, 01 May 2018 through 30 April 2023. All work will be completed within five (5) years. All work for Tasks 6.4-6.10 will be completed within a 12 month period of performance (Task Period of Performance May Overlap):

Feasibility Assessment Report- 01 May 2018- 31 May 2018

Audit Recovery Services- 01 June 2018-30 April 2023

10.2. Place of Performance: Work shall be primarily performed at the Contractor s site. On-site office space for one contractor staff member shall be made available at the Mid-Atlantic CPAC located in Asheville, NC for the purpose of printing and mailing documents containing PHI/PII. Any other physical location access must be requested by the Contractor and will be approved by VA based on availability of the requested location. Contractor shall provide services during normal business hours from 8:00 A.M. to 4:30 P.M. local time, Monday through Friday, or as otherwise specified.

10.3 Observance of Government Holidays. There are 10 Federal holidays set by law (USC Title 5 Section 6103). Under current definitions, four are set by date:

New Year's Day January 1

Independence Day July 4

Veterans Day November 11

Christmas Day December 25

If any of the above falls on a Saturday, then Friday shall be observed as a holiday. Similarly, if one falls on a Sunday, then Monday shall be observed as a holiday. The other six holidays are set by a day of the week and month:

Martin Luther King's Birthday Third Monday in January

Washington's Birthday Third Monday in February

Memorial Day Last Monday in May

Labor Day First Monday in September

Columbus Day Second Monday in October

Thanksgiving Fourth Thursday in November

10.4. Type of Contract: The Government anticipates award of a firm fixed price (FFP) Indefinite Delivery Indefinite Quantity (IDIQ) contract. The contract will include a FFP CLIN for the Feasibility Assessment Report. As well, the contract will include a CLIN for Recovery Audit Services that will be firm fixed percentage (%) of recovered funds contract. This percentage fee will be determined at the time of award based off of the successful offeror s proposed fee (See 38 USC Section 1729).

10.5. Travel: Travel and per diem are not reimbursable under this contract.

11. Key Personnel. The contractor shall provide the appropriate level of labor mix that constitutes both professional and technical expertise in order to accomplish the work that is reflected within the body of this PWS. Certain skilled experience professional and/or technical personnel are essential for accomplishing the work to be performed. These Key Personnel professionals, or Key personnel , are the individuals whose resumes were submitted and marked by the vendor as Key Personnel. The Contracting Officer may notify the Contractor, to allow the contractor to cure any discrepancies or non-performance issues, within the specified number of days that shall be annotated within the body of the cure notice. The Contracting Officer reserves the right to request immediate removal of any Key Personnel for non-performance issues, for conflict of interest issues, or any other issues that are not in the best interests of the VA and the mission that the contract supports. The contractor shall be allowed to provide the government with suitable Key Personnel replacement, which then will be vetted amongst all of the VA approving officials connected to the contract.

At a minimum, the Contractor shall designate a Project Manager and Health Care Reimbursement Denials management subject matter expert with 7-10 years experience as key personnel. The Contractor may designate additional key personnel at its discretion.

It is an integral requirement of this contract that the contractor shall provide staff experienced in healthcare consulting including a comprehensive knowledge and understanding of common reimbursement methodologies and payment practices for Medicare and other third party payers. Key personnel demonstrating an understanding of the federal regulatory process as well as the VA charge methodology detailed in 38 CFR 17.101 is preferred.

If a Key Personnel employee/partner/subcontractor of the contractor is requested to be removed from the contract due to any detrimental reasons, the contractor shall have (3) business days to provide the government with a suitable replacement to be vetted. The reason for removal will be documented and replacement personnel shall be identified within (3) business days of the notification. Employment and staffing difficulties shall not be justification for failure to meet established schedules.

11.1 Substitution of Key Personnel. All Contractor requests for approval of substitutions hereunder shall be submitted in writing to the COR and the Contracting Officer at least (30) calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the Contracting Officer necessary to vet the proposed substitution. New personnel shall not commence work until all necessary security requirements have been fulfilled and resumes provided and accepted. The COR and the Contracting Officer will evaluate such requests and promptly notify the Contractor of approval or disapproval in writing.

11.2 Management and Oversight. The Contractor shall be responsible for managing and overseeing the activities of all the Contractor, subcontractor and/or partnership personnel and subcontractor personnel, used in performance of this effort. The Contractor s management responsibilities shall include all business activities necessary to ensure the accomplishment of timely and effective support performed in accordance with the requirements contained within this PWS.

11.3 Domain Knowledge.

The Contractor shall ensure that personnel assigned to this contract shall have the following domain knowledge of healthcare revenue, healthcare finance, risk management, quality management, and project and program management. Domain knowledge criteria are specified below: Personnel shall have an in depth knowledge of health care revenue cycle processes in addition to the following:

1. Specific knowledge of Project Management;

2. Expert knowledge of Project Management; Certified in Project Management Professional (PMP) from Project Management Institute

3. Expert knowledge of healthcare revenue cycle;

4. Specific knowledge healthcare billing and collections processes and TPP commercial health insurance carrier reimbursement methodologies

5. Expert knowledge of healthcare business analytics

12. Formal Acceptance or Rejection of Deliverables: The Government will review each deliverable within (10) business days and provide comments. The Contractor shall have (3) business days to incorporate the Government s comments and make appropriate revisions.

13. Changes to the PWS: Any changes to this PWS shall be authorized and approved only through written correspondence from the CO. A copy of each change will be kept in a contract folder, along with all other products of the contract. Costs incurred by the Contractor through the actions of parties other than the CO shall be borne by the Contractor.

14. Operations during Emergency Situations: Individual contingency operation plans shall be activated immediately after determining that an emergency has occurred, shall be operational within 12 hours of activation, and shall be sustainable until the emergency situation is resolved and normal conditions are restored or the contract is terminated, whichever comes first. In case of a life threatening emergency, the COR shall immediately make contact with the Contractor Task Manager to ascertain the status of any Contractor personnel who were located in Government controlled space affected by the emergency. When any disruption of normal, daily operations occur, the Contractor Task Manager shall promptly open an effective means of communication and verify:

Key points of contact (Government and Contractor)

Temporary work locations (alternate office spaces, telework, virtual offices, etc.)

Means of communication available under the circumstances (e.g. email, webmail, telephone, FAX, courier, etc.)

Essential work products expected to continue production by priority

The Contractor Task Manager, in coordination with the COR, shall make use of the resources and tools available to continue CPAC contracted functions to the maximum extent possible under emergency circumstances. The Contractor shall obtain approval from the COR and Contracting Officer prior to incurring costs over and above those allowed for under the terms of this contract. Regardless of contract type, and of work location, Contractors performing work in support of authorized tasks within the scope of their contract shall charge those hours accurately in accordance with the terms of this contract.

15. Confidentiality and Non-Disclosure: It is agreed that:

The preliminary and final deliverables, as well as all associated working papers and other material deemed relevant by VA that have been generated by the Contractor in the performance of this contract, are the exclusive property of the U.S. Government and shall be submitted upon request to the CO at the conclusion of the contract.

The CO will be the sole authorized official to release, verbally or in writing, any data, draft deliverables, final deliverables, or any other written or printed materials pertaining to this contract. No information shall be released by the Contractor. Any request for information relating to this contract presented to the Contractor shall be submitted to the CO for response.

Press releases, marketing material, or any other printed or electronic documentation related to this contract shall not be publicized without the written approval of the CO.

Non-Disclosure and Conflict of Interest: The Contractor and Contractor s staff may have access to Government-sensitive information and shall be required to sign non-disclosure and conflict of interest statements.

16. Business Associate Agreement: The contractor shall provide a fully executed Business Associate Agreement (BAA). Work may not begin until a fully executed BAA has been received and accepted (to be included in contract award).

Link/URL: https://www.fbo.gov/spg/VA/VAAAC/VAAAC/36C77718Q9070/listing.html