Automated Edit Module Contractor (AEMC)
Added: Mar 12, 2010 10:25 am
The Centers for Medicare & Medicaid Services (CMS) intends to issue a solicitation to procure a Commercial-Off-The Shelf (COTS) and/or modified COTS automated editing software that auto-denies Medicare health care claims across all claims types such as claims issued by hospitals, physicians, skilled nursing facilities, labs, ambulance companies, and durable medical equipment (DME) suppliers. CMS is only interested in engaging new application(s) that will be used by CMS and/or its contractors for denying improper claims before they are paid by the Medicare program (i.e., could be installed on a "prepayment" basis). CMS is NOT interested in software that identifies claims for human review, software that requires a comparison to a medical record or software that could only operate on a "postpayment" basis.This pre-solicitation notice is hereby posted in accordance with FAR 5.2. CMS reserves the right and anticipates making multiple IDIQ contract awards. The Government anticipates issuing task order 0001 to each IDIQ contract awardee for the performance of a field test. The results of the field test will be submitted to the Governement and used as an evaluation factor for the award of task order number 0002. The Government anticipates issuing a competitive RFP to all IDIQ contract holders for task order 0002 and anticipates awarding only one task order.The solicitation will be issued in accordance with FAR Part 15. CMS plans to issue the solicitation as a full and open competition.CMS anticipates making multiple IDIQ awards. CMS intends to use a multi-step acquisition process for this procurement to test automated edit products for completeness and accuracy through two required tests. The first test is considered small scale and requires vendors to submit answers to CMS to be assessed. The top qualified Vendors under the small scale test that provide the best overall solution will be awarded an IDIQ Contract and issued Task Order 0001 to perform a larger field test.Under Task Order 0001, vendors will compete on the accuracy of their product(s) and technical capability to process millions of claims per day. CMS anticipates only making one award of the Automated Edit Module work under Task Order 0002. The IDIQ SOW includes all work awarded under this solicitation and anticipated future work such as implementation of Predictive Modeling for claims in a pre-pay mode.BACKGROUND: Medicare is a multifaceted program. The Medicare Fee-for-Service (FFS) program consists of a number of payment systems, with a network of contractors that process over 1.2 billion claims each year, submitted by more than 1 million health care providers such as hospitals, physicians, skilled nursing facilities, labs, ambulance companies, and durable medical equipment (DME) suppliers. These contractors, called "Medicare Administrative contractors (MAC)," process claims, make payments to health care providers in accordance with Medicare regulations, and are responsible for educating providers about how to submit accurately coded claims that meet Medicare's medical necessity guidelines.Despite actions to prevent or recoup improper payments, it is impractical to prevent all improper payments. A January 2008 report by the Office of Management and Budget (OMB) indicated that Medicare is among the top three Federal programs with improper payments, totaling an estimated $10.8 billion in 2007. Improper payments on claims can occur for the following reasons:Payments are made for services that do not meet Medicare's medical necessity criteria.Payments are made for services that are incorrectly coded. Other reasons, such as basing claim payments on outdated fee schedules, or the provider is paid twice because duplicate claims were submitted. Medicare pays a claim that should have been paid by a different health insurance company (called Medicare Secondary Payer (MSP) improper payments)There is growing concern that the Medicare Trust Funds may not be adequately protected against erroneous payment through current administrative procedures. Therefore, CMS is undertaking a project to determine if there are Commercial-Off-The Shelf (COTS) software products that can automatically (without requiring human intervention) identify Medicare FFS claims for which payment should be denied.CMS is interested in a product(s) that:a. Only flag claims that can be auto-denied (i.e., do not require human review and are supported by clear policy). The term "clear policy" means a statute, regulation, National Coverage Determination (NCD), coverage provision in an interpretive manual, Local Coverage Determinations, or Medicare Administrative Contractor (MAC) article that specifies the circumstances under which an item/service will always be considered non-covered, incorrectly coded, or improperly billed; b. Never flags a claim that requires human review; c. Never flags a claim where the denial is not supported by clear policy; d. Accurately communicates what action should be taken on the flagged claim (full denial, partial denial, etc). In the case of a downcode, the product must indicate the new code to which the claim should be downcoded; e. Has the ability to mark each flagged claim with a Medicare-defined reason code; f. Has the ability to handle large volumes of claims (e.g. approximately 4.5 million claims per business day). g. Can provide an audit trail on actions taken on claims (denied on a specified date, etc) and that this information is available to authorized users via an interactive web-based application. h. Can provide statistical/workload reports such as number (and dollar value) of claims received from CMS in a given month, number (and dollar value) of full denials made that month, auto-deny rate (number of claims denied out of number of claims received), auto-deny dollar rate (dollars auto-denied per dollar claim paid and that these reports and statistics are available to authorized users via an interactive web-based application. i. Has the ability to turn off one or more edits within 1 hour of notification. j. Can edit across all claim types. If the product can only edit certain claim types please provide details. k. Can be modified to fit existing architectures. Describe if the product is adaptable to integration into existing environments such as an Enterprise Data Center or must the product run outside of the CMS environment; and, l. Can accept an input file from the CMS Common Working File and can submit a response file to the CMS Common working File in a CMS specified format. The layout of the input file and response file will be provided at a later date. In summation, CMS is seeking a single contractor who can provide automated editing software system (i.e., review claims without human intervention) across all claim types tailored to Medicare fee-for-service rules and policies for the best value possible. Award of the contract resulting from this solicitation will be made to the offeror whose proposal and product best meets the government requirements. In order to meet government requirements CMS reserves the right to make a single award or multiple awards. In addition, CMS also reserves the right to amended or canceled the solicitation as necessary to meet CMS requirements.The anticipated award date of the IDIQ and Task Order 0001 is September 30, 2010. THIS IS NOT A REQUEST FOR PROPOSAL. The Government will not evaluate responses or accept phone calls in response to this notice.
RFP-CMS-2010-0023 Department of Health and Human Services Centers for Medicare and Medicaid Services
3/12/10, 10:25 AM