A13-RFI-Industry Day-QArev.pdf

Question # Answer

1a) DOL will provide existing workflow documentation including, but not limited to standing operating procedures related to enrollment, authorization, bill processing, and payment requirements.

1b) The question is unclear. Customization will be contigent on the contractor's current technical offering, as well as laws and Department of Labor (DOL) regulations. All customization shall be completed prior to going live with full operations functionality no more than 365 days after the contract start date. The incoming contractor shall perform all required operations from the date of "go live".

2a) No, DOL will not adopt state workers' compensation guidelines.

2b) DOL will consider whether any state guidelines (e.g., those for scheduling, reporting, and payment) are applicable within federal guidelines and will attempt to align Office of Workers' Compensation Programs (OWCP) guidelines where possible.

2c) The incoming contractor shall provide training for all stakeholders; however, DOL may also conduct internal training.

2d) No, DOL has not made this identification. The incoming contractor is expected to provide expert advice to DOL during the development and implementation process, to assist DOL in making these determinations after award.

3a) DOL will accept all providers that are licensed for the state in which they provide service, do not appear on any List of Excluded Individuals and Entities (LEIE), and are willing to enroll with OWCP.

3b)The question is unclear. The incoming contractor shall provide all required functionality on day one of operations, including handling out-of-network (OON) provider requests and bills.

3c) No, the incoming contractor shall vet all currently enrolled providers (see 3a. above) prior to day one of operations.

Providers shall automatically be considered OON unless they belong to the incoming contractor's network.

4) DOL expects that technical proposals will include recommendations regarding best practices for encouraging provider participation, within the bounds of OWCP legal and regulatory constraints.

4a) No, DOL does not anticipate a quicker turnaround time for payments to in-network providers. However, DOL will consider suggestions on ways to prioritize in-network bill processing.

4b) No, the OWCP workers' compensation programs cannot steer claimants to specific providers.

5a) No, DOL will not make daily payments. The payments are made by Department of Treasury (Treasury) on a weekly basis for payment of medical services. OWCP will process invoices for payment of medical services at the fee schedule amount, within 15 days of OWCP receipt of a payable medical bill. Treasury will issue payment according to schedule, which is generally within one week of receiving the OWCP payment files. For contractor invoices of non-medical services and items

- OON administrative fees, other direct costs, optional service enhancement hours, and transition-out services, as utilized - Treasury will issue payment to the incoming contractor within 28 days of DOL receipt of a payable contractor invoice.

6a) See response to question 3a above.

7a) DOL expects the incoming contractor to fully manage the network status of providers. However, the criteria to disenroll a provider from OWCP will remain with DOL.

7b) See response to question 7a above.

7c) See response to question 7a above.

8) Section M of the solicitation will provide the Evaluation Factors for Award.

9) DOL analyzes the usage of Centers for Medicare & Medicaid Services (CMS) relative value units and state workers' compensation fee schedules to determine OWCP fee schedules for treatments. DOL expects that technical proposals will include recommendations on how to better align OWCP payment rates with state guidelines. See also the responses to questions 2b) and 2d) above.

10) This is not a question. See response to question 1a) above.

11) See response to question 5a) above.

Provider Network and Coverage:

12 What are the specific geographic coverage requirements for each program (FECA, Energy, Black Lung, Longshore)? Nationwide 13 Are there minimum provider-to-claimant ratios required for different specialties? No 14 What is the current number of claimants in each program? Currently, FECA - 160,000; Energy - 21,926; Black Lung - 26,694. Please note that these numbers can fluctuate.

15 What are the projected levels for the next 5-10 years? This question is unclear 16 Is there historical data on provider utilization rates? This question is unclear

Question

1) DOL OWCP (DOL) has several unique business processes due to its diverse claimant population that differs substantially from the commercial worker's compensation population.

a) What documentation does DOL intend to provide around DOL-specific business processes to assist the customization of a vendor's existing commercially of the shelf (COTS) systems, networks, solutions, and business processes?

b) Recognizing the extensive level of customization specific to meet all required DOL policies and rules, what is the DOL expectation/s to manage any needed system conversions?

2) DOL has indicated their desire to follow state edits and guidelines. However, state guidelines also include regulations and policies to address the direction of care, claim jurisdiction, case management, and compensability. The current draft SOO is unclear at what level state guidelines will be applied. We recommend DOL consider the following:

2c) Once DOL establishes all the requirements on a global and state-by-state basis then how will DOL train all stakeholders, including DOL staff (case manager, etc.), claimants, etc.?

2d) Has DOL identified all the applicable policies, regulations, and laws that will be impacted, and will that information be shared during the solicitation process?

4) What protocols does DOL envision establishing to ensure that participating providers continue to want to be a part of the program? For example:

4a) Will there be a quicker turnaround time in payments for those in-network providers as an incentive?

4b) Will DOL allow the vendor to steer claimants to network providers if they are within a certain geographic area of the claimant, even though the claimant is requesting an OON provider?

5) MPNs maintain several contracts with providers that have varying requirements around the timeliness of bill payments and receipt of monies for approved bills.

5a)What will DOL’s process be to work with the MPN to get these funds transferred in a timely manner that enables the MPN to maintain its compliance with its provider contracts? For example, will DOL transfer money to the MPN daily to pay bills?

6) Workers’ Compensation Medical Provider Networks maintain PPO contracts for discounts as well as perform credentialing verification grievance management process, and quality programs with their providers.

6a) Does DOL intend to follow these same guidelines when approving out-of-network providers?

7) MPNs establish guidelines on how non-compliant providers are handled, educated, or removed from the program. For example, some employers choose to have providers removed from the pool of available providers until allegations are confirmed while other employers remove them after they are confirmed. Given DOL’s desire for the MPN to fully manage in-network providers, does DOL intend to:

8) When the solicitation is released, we recommend it includes full transparency into the evaluation factors that will be applied to each section. For example, how will mailroom services be evaluated against MPN?

9) 6.1.2.1 The Contractor shall use state industry guidelines/edits based on place of service for FECA program’s bill processing and an exception-based process for approving beyond the state edits/guidelines. Related to Performance Objective 5.1.7 Bill Resolution/ Edits and Audits [we] Sedgwick currently [manage] and provides workers compensation services in 53 jurisdictions including federal OWCP/FECA . We administer state specific edits, fee schedules and procedures as part of our core business. With that said, can the government please provide additional detail on how they envision the OWCP fee schedule, edits and protocols would interact with state edits and protocols? Once we have some additional information, [we] Sedgwick can share our industry expertise and the possibilities to execute.

10) 5.1.6.2 The Contractor shall coordinate benefits with federal, state, and commercial insurance carriers and process carrier reimbursements. Coordinating benefits may include the sharing of claimant eligibility files using specific data templates and processing unique bill forms for payment.

[We] Sedgwick [understand] the requirements set forth in 5.1.6.2 around coordination of benefits and brings significant experience in delivering on this task. As stated in the SOW, this process, including modeling operational requirements and driving/measuring efficacy relies on historical and current data. The following data elements should be provided to offers to assist in evaluating coordination of benefits operationalizing, recouping, and reporting:

11) 5.1.9.5 The Contractor shall process PPO and non-PPO bills, which includes keying/scanning/digitizing and transmitting the bills and medical reports. The Contractor shall pay all providers directly, separately requesting from OWCP the full amount of the medical services paid, and the aggregate transaction fees described below, and produce a bill history report by individual claim.

It is stated that the Contractor shall pay the providers. There will be, or is the potential for, a gap between the Contractor payments to providers and the government reimbursing the Contractor for such funds.

Can the government please provide more detail in regard to the timeframe and mechanism that will be in-place to reimburse and/or fund the Contractor payments to the providers?

17 Are there specific provider types or specialties that are particularly important to include? No 18 What are the current network adequacy standards, if any? there are no current standards 19 Are there any specialty areas or types of providers that need particular focus in network development? Refer to response to question 17 above 20 Are there any geographic regions or particular states where the programs have shortages of available providers? Yes

21 What percentage of Medicare do each of the fee schedules equate to for codes valued by CMS?

There are large variations in fee differences between OWCP and CMS. The percent differences depend on the category or specialty of medical services and devices under consideration such as Evaluation and Management, Medicine, Surgery, Pathology & Labs, Radiology, and Durable Medical Services, etc.

Typically, OWCP rates for comparable non-surgical procedure codes such as CPT Codes 70000-79999, 80000-89999, 99202- 99499, and HCPCS Codes G0008-G9978 are 56% - 68% higher than CMS rates for the same codes. OWCP rates for comparable surgical procedures such as CPT 10000-69999 are 94% higher than CMS rates for the same procedures. For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), OWCP fees are 25% higher than CMS fees for the devices and supplies.

22 What specific return-to-work programs are to be implemented as part of this program or that providers need to be notified of? FECA is the only program with Return-to-Work policies. Specifics to be discussed at contract award.

Volume and Scale:

23 What are the current and projected annual volumes for:

23a)

- Medical bills processed Government has previously provided sample historical data under prior request for information that vendors may analyze as a bench mark. The original data is located at https://www.dol.gov/rfi .additional data will be provided at time of solicitation 23b) - Authorization requests See response to 23a above 23c) - Provider enrollments See response to 23a above 23d) - Claimant inquiries See response to 23a above

24 Provider inquiries 24a) - How do these volumes break down by program? See response to 23a above 24b) - What is the current backlog of unprocessed bills, if any? See response to 23a above 24c) - What are the current call volumes and types of inquiries received? See response to 23a above

Bill Processing:

25 Are there any program-specific bill processing requirements that differ from standard industry practices? Yes

26 Can you provide more details on the financial reconciliation process between the contractor and OWCP?

This question is not clear. The Government is unable to respond without further clarification of what is meant by “financial reconciliation process”.

What is the expected timeline for reimbursement of out-of-network provider payments?

DOL will not make daily payments. The payments are made by Department of Treasury (Treasury) on a weekly basis for payment of medical services. OWCP will process invoices for payment of medical services at the fee schedule amount, within 15 days of OWCP receipt of a payable medical bill. Treasury will issue payment according to schedule, which is generally within one week of receiving the OWCP payment files. For contractor invoices of non-medical services and items - OON administrative fees, other direct costs, optional service enhancement hours, and transition-out services, as utilized - Treasury will issue payment to the incoming contractor within 28 days of DOL receipt of a payable contractor invoice.

Transition and Implementation:

28 What is the expected timeline for transition from the current contractor? DOL expects that technical proposals will include recommendation for appropriate transition timeframes 29 Will there be a parallel run period? If so, for how long? Yes. TBD at contract award.

30 What data migration will be required from the current system? ALL 31 What is the format and quality of the data to be migrated? TBD at contract award.

32 What specific transition support will be provided by OWCP and/or the incumbent contractor? Requires discussion.

Technology Requirements and Integration:

33 Are there specific technology platforms or standards required? Yes. Specifics TBD at contract award.

What level of customization is expected for the COTS solution?

Customization will be contigent on the contractor's current technical offering, as well as laws and Department of Labor (DOL) regulations. All customization shall be completed prior to going live with full operations functionality no more than 365 days after the contract start date. The incoming contractor shall perform all required operations from the date of "go live".

35 What are the specific integration requirements with OWCP systems? Specifics TBD at contract award.

36 What are the data storage and retention requirements? Specifics TBD at contract award.

What are the disaster recovery and business continuity requirements?

The Government requires backup facilities established and maintained by the Contractor, at a location sufficiently distant from the primary facility to continue operations in the event of a regional disaster. A Contingency plan is one of the required deliverables.

38 Can you provide more details on the existing OWCP systems that will need to be integrated with? Specifics TBD discussed at contract award.

39 What are the specific data exchange formats and protocols required? h) Are there any legacy systems that require special consideration? Yes. Specifics TBD discussed at contract award.

Security and Compliance:

40 What specific security standards and certifications are required (beyond those mentioned like NIST 800-53)?

The contractor must ensure compliance with the Privacy Act and the DOL Cybersecurity Policy Portfolio (CPP). The contractor must evaluate their existing privacy-related policies and procedures to ensure that they comply with federal privacy-related policies--including the 1-hour notification timeframe for security incidents. Where the contractor’s policies and procedures do not comply, the contractor must revise them to ensure compliance at no additional cost to the Government. The contractor must ensure that all identified areas of noncompliance and related corrective actions have been fully documented.

The contractor must comply with the most recent federal and DOL information security guidelines, currently defined as:

· The Freedom of Information Act, as amended (5 USC §522), which provides for the disclosure of information maintained by Federal agencies to the public, while allowing limited protection for privacy.

· The Privacy Act of 1974, as amended (5 USC §522a), including the Computer Matching and Privacy Act of 1988 (Public Law 100-503)

· The Federal Information Security Modernization Act of 2014 (FISMA), 44 USC §3551 et seq.

· OMB Circular A-130, Management of Federal Information Resources, which provides instructions to Federal agencies on how to comply with the fair information practices and security requirements for operating automated information systems.

· OMB Memorandum M-17-12, Preparing for and Responding to a Breach of Personally Identifiable Information, https://www.whitehouse.gov/wp-content/uploads/legacy_drupal_files/omb/memoranda/2017/m-17-12_0.pdf

· FIPS PUB 199, Standards for Security Categorization of Federal Information and Information Systems at http://csrc.nist.gov/publications/fips/fips199/FIPS-PUB-199- final.pdf · FIPS PUB 200, Minimum Security Requirements for Federal Information Systems at https://csrc.nist.gov/pubs/fips/200/final

· NIST Special Publication (SP) 800-171, Protecting Controlled Unclassified Information in Nonfederal Systems and Organizations

· US DOL Cybersecurity Policy Portfolio (CPP) (DOL’s implementation of NIST SP 800-53). (Reference Attachment 25 - Cybersecurity Policy Portfolio)

· Department of Labor Manual Series (DLMS) – 7, Chapter 1100, DOL Safeguarding Sensitive Data Including Personally Identifiable Information (Reference Attachment 26 – DLMS 7, Chapter 1100) Prior to the deployment of the web portal, the contractor must provide a System Security Plan (SPP), Contingency/Disaster Recovery Plan, and an Incident Response Plan pertaining the information system(s) that will be used to provide services under this contract.

The Government must review the documents and make a risk-based decision before granting permission for deployment of the web portal. The contractor must repair any defects that are discovered during the review, specifically defects that arise from non- compliance with NIST 800-171 and/or the DOL CPP.

5.18.5 Security Incidents, Disclosure, Breach or Disaster The contractor must use a government-approved incident reporting form to notify the Government (via zzowcpsecurity@dol.gov) of all security incidents, disclosures, or breaches, disasters

41 Are there any program-specific compliance requirements not mentioned in the SOO? Requires further discussion.

42 Are there any OWCP-specific security requirements beyond standard HIPAA and FISMA compliance? Yes.

43 What is the process for security clearance for contractor personnel? The requirement for contractor-performed background investigation is located at 5.1.16.6. Federal background investigation will be required for any personnel that is given access to federal equipment, systems and/or facilities.

A SOC 1 report is due annually to address internal controls over financial reporting. The Office of the Inspector General also performs FISMA audits and Adhoc audits such as but not limited to data integrity.

Staffing and Operations:

45 Are there any specific staffing level requirements, especially for the call center? This is a performance based contract. Offerors shall determine appropriate resources to support their proposed solution, including identifying any proposed key personnel positions.

46 Are there language requirements for customer service beyond English? The Government requires the capablility to handle Spanish speaking callers.

47 What are the expected hours of operation for different services? TBD at contract award.

Performance Metrics:

48 For metrics with percentages, what are the baseline volumes these percentages apply to? All volume projections will be provided as an attachment to the solicitation.

How will performance be measured and reported?

The SOO includes information on the governments objective for performance reporting by the contractor. The frequency of reporting is listed in 6.2 Performance Metrics and Service Level Agreements. OWCP also anticipates that the vendor would propose a appropriate performance metrics, measurements and reporting schedule, based on industry best practices. All performance measures and reporting shall be in accordance with the offerors quality control plan and governments quality assurance surveillance plan.

50 Are there any financial incentives or penalties tied to performance metrics?

OWCP anticipates that the vendor would propose appropriate incentives related to performance metrics, based on industry best practices.

51 Can you provide historical data on current performance levels for key metrics? The requested information is business/vendor sensitive and cannot be shared. Defer to OSPE 52 How frequently will performance be evaluated? The government will evaluate performance on a monthly basis.

Financial Model and Pricing:

53 Can you provide more details on the expected pricing model for:

53a)

- In-network provider services

"OWCP anticipates two separate sources of revenue for the vendor for standard operations (bill processing, mailroom, call center):

For services performed by in-network providers, the vendor's revenue would come from the spread between what OWCP's fee schedule pays the vendor for a medical service rendered and what the vendor pays its network provider for that same service.

For services performed by out-of-network providers, the vendor's revenue would come from a fixed administrative fee that the vendor bills and OWCP pays for medical service rendered by out-of-network providers.

OWCP anticipates customization and enhancements outside of industry standards may be billed separately under unique, program-specific CLINs."

53b) - Out-of-network provider services see response to 53a above Administrative fees

How often are compliance audits conducted, and what is their scope?

54 How are current fee schedules structured for each program?

OWCP fee schedule utilized by each of the Programs is made up of the Physician or Medical Fee Schedule, which covers facility and non-facility medical services delivered by physicians, and other healthcare providers. Other components of OWCP fee schedule includes Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Ambulatory Surgical Center (ASC) fee schedule, Anesthesia fee schedule, Pharmacy fee schedule, Dental services fee schedule, Pharmacy fee schedule, and the fee schedule for Durable Medical Equipment (DME), Prosthetics, Orthotics, and Supplies (POS).

Various elements that go into the determination of OWCP fee schedule are either sourced from the Centers for Medicaid and Medicare Services (CMS) or other industry sources. These elements include facility and non -facility relative value units (RVUs), geographic practice cost indexes (GPCIs), Medicare wage indexes, Medical Economic Index, etc., obtained from CMS. For elements that are not available from CMS, OWCP uses on other sources such as the states workers’ compensation programs, the Department of Veterans’ Affairs (VA) Fee Schedule, and industry vendors, etc.

For additional insight into the composition, structure, and determination of OWCP fee schedule, see the following Read Me First Link: OWCPFeeSchedule-ReadMeFirstDocumentversion2024-08-19.pdf

55 What is the historical claims cost data for each program? See response to 23a above 56 Can you provide more details on how the separation of medical payments and administrative fees will be operationalized? See response to 53a above

57 Are there any restrictions on pricing models for administrative fees? The Government envisions a fixed fee per non-PPO bill processed, that shall be the sole revenue generated to the Contractor for services on non-PPO provider transactions.

Authorization Process:

54 Can you provide more details on the current authorization process and expected improvements? Requires discussion at contract award.

55 What percentage of authorizations typically require medical review? It varies.

Fraud Detection:

What specific fraud detection capabilities are required?

OWCP the offerors will propose smart-reporting capabilities such as dashboards, and database tools to conduct trend analyses, identification of outliers, heat maps, scatter plots, network graphs, time series plots, and other relevant analyses.

57 Is there historical data on fraud rates and types? See response to 23a above

58 Can you provide more details on the current fraud detection processes and systems in place?

OWCP utilizes a fraud waste and abuse system provided by the central bill processing vendor that includes tools to monitor and protect bill processing across all OWCP programs, and detects over-utilization, improper utilization, and fraudulent billing practices, while helping prevent future fraud and abuse. FAD provides tools and algorithms to detect, track, and resolve fraud and abuse cases, supporting both scheduled and ad hoc reviews to ensure compliance with Government policies. Additionally, the FAD program incorporates fraud analysis, prevention capabilities, and performance metrics to measure its effectiveness, while maximizing accuracy and minimizing false positives.

Are there specific fraud patterns or issues unique to OWCP programs that we should be aware of?

Common issues experienced on the billing side relate to upcoding, bundling and unbundling, max units, excessive billing and utilization of services. Common issues experienced on the enrollment side relate to proper licensing in geographic areas where providers practice.

Reporting Requirements:

60 Can you provide a comprehensive list of required reports and their frequencies? OWCP anticipates that the vendor would propose appropriate reports and schedules based on the objective and constraints indicated in the SOO, technical solution proposed, and industry best practices.

61 Are there any custom reporting tools or dashboards that need to be developed? See response to 60 above.

Training and Outreach:

62 What are the specific training requirements for government staff? See outreach and training objectives listed at 5.1.15 of the SOO.

63 What provider outreach activities are expected? See response to 62 above 63 What level of training support is expected for OWCP staff on the contractor's systems? See response to 62 above 64 Are there any OWCP-specific training materials that need to be developed for providers? See response to 62 above

Transition Out:

65 What are the specific requirements for transitioning out at the end of the contract? TBD at contract award.

66 How long is the transition-out period expected to be? TBD at contract award.

Contract Structure:

67 What is the expected contract duration? DOL anticipates the contract duration will be one twelve month base period and 4 twelve month option period, with the possibility of two twelve month award terms.

68 Are there any option periods? DOL anticipates a contract that includes at least 4 twelve month option periods.

69 How will price adjustments be handled over the contract duration? This question is unclear the government is unable to respond without further clarification.

Government-Furnished Equipment/Information:

70 Will any equipment or systems be provided by the government? Requires further discussion.

71 What data or information will be provided to support operations? Requires further discussion.

Subcontracting:

72 Are there any limitations or requirements regarding subcontracting? TBD at contract award.

73 Are there any small business subcontracting goals? TBD at contract award.

Innovation:

74 How open is OWCP to innovative approaches that may deviate from current processes? We're open to further discussion.

75 Are there specific areas where innovation is particularly desired? Further discussion required.

Program-Specific Questions:

76 Are there any unique requirements for each program (FECA, Energy, Black Lung, Longshore) not fully detailed in the SOO? Yes. Will discuss at contract award.

77 How do the processes and requirements differ between programs? It varies based on current program policies.

Scalability:

78 Are there any anticipated changes in program size or scope over the contract duration? Requires clarification on question.

79 How flexible does the solution need to be to accommodate potential program changes? Extreme flexibility necessary.

Provider Enrollment:

80 What is the current process for provider enrollment, and how much of this will the contractor be responsible for? TBD at contract award.

81 Are there any OWCP-specific credentialing requirements?

The Contractor must have an established network of providers who are qualified to deliver care to OWCP claimants and ensure that all network providers meet required credentialing standards including compliance with state and federal regulations. At minimum, the vendor must ensure that their network providers are licensed in the states where they provide services in accordance with state and local laws and that medical physicians and specialists are board-certified in their relevant specialties, Offers should propose an approach to managing and credentialing a network to include their credentialing process, recredentialing process, ongoing monitoring of credentials, and ensuring compliance with state and federal regulations. The Contractor should also describe their corrective action approach for addressing credentialing issues or non-compliance among network providers.

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