Tuskegee

STATEMENT OF WORK

Title of Project: Case Management and Auditing Services Contract for Tuskegee Health Benefit Program

C.1 Background and Need –

The Tuskegee Health Benefit Program (THBP) is a congressionally mandated program which provides comprehensive lifetime medical and health benefits to the affected wives/widows and offspring of participants in the Tuskegee Syphilis Study. Currently, there are 15 THBP clients located in six states (Alabama, Georgia, Florida, Illinois, New York, and Ohio) participating in the program.

From FY04-FY10, the THBP was engaged in several contractual agreements for case management and auditing services. These agreements produced significant savings for the government as well as provided high quality services for the THBP clients in the form of detailed case management services yielding positive health out-comes for THBP clients. There is a need to reestablish a contract for these services for FY12.

C.2 Project Objective –

The Tuskegee Health Benefit Program seeks to obtain case management services and audits of hospital and physician invoices for services rendered to enrolled clients. The proposed contract will ensure that THBP clients receive clinically appropriate, medically necessary, and cost-effective services.

C.3 Scope of Work –

The Project Officer will routinely review and forward for audit all hospital and provider bills exceeding $5000.00. Additionally other questionable bills will be forwarded for audit. Concurrently, contractor’s case management services shall ensure that the each THBP client receives healthcare that is both clinically appropriate and medically necessary.

C.4 Technical Requirements –

Task 1: Kick-off – Within two weeks of the award, meet for the kick-off meeting with the CDC Project Officer (PO) This meeting shall take place via teleconference call. The contractor shall provide meeting minutes no later than two days after the meeting.

Task 2: The contractor shall participate in quarterly telephone calls with the CDC Project Officer to discuss current Activities (Tasks 3 and 4 including subtasks), problems encountered, and procedures. As individual case management dictates, the contractor will contact the CDC Project Officer as needed to provide updates and address issues as they arise.

Task 3: Case Management Services

Subtask 3.1: Conduct monthly telephone calls with each of the 15 clients. The contractor shall provide the Project Officer with a written monthly summary of each THBP client treatment plan and progress. Contractor shall immediately contact CDC project officer by phone or email when a THBP client’s healthcare needs warrant emergency response.

Subtask 3.2: Client Assessment

3.2.1: The contractor shall visit each THBP client annually, notating any changes to the biopsychosocial assessment, e.g. family dynamics, housing, health status etc. currently in the client file maintained by the contractor. The assessment will provide the case manager with the data necessary to perform patient-centered and cost-effective case management services. The contractor shall inform the client of all treatment alternatives/referral services available to the client, as well as the location of such alternative treatments. The contractor shall provide a trip report summarizing the visit.

3.2.2: The contractor shall provide and maintain a toll-free number for the THBP clients and healthcare providers to contact the contractor case manager. The contractor shall also assist primary healthcare providers in identifying appropriate treatment alternatives/referral services for THBP clients following discharge.

Subtask 3.3: Healthcare Provider Network

The contractor shall contact current and past healthcare providers and/or facilities to set-up a healthcare provider network capable of delivering necessary care and treatment for each THBP client. This healthcare provider network profile shall be maintained by the contractor and made available to the THBP clients as need dictates.

Subtask 3.4: Treatment Programs

When a THBP client enters an inpatient treatment program, health or medical care with a new health professional, the contractor shall conduct an initial treatment plan review with the program and/or health professional. The contractor shall conduct monthly telephonic updates of treatment programs with healthcare professionals providing inpatient care to THBP clients.

Subtask 3.5: On-site Reviews

The contractor shall provide quarterly on-site reviews to all THBP clients requiring extended inpatient treatment to monitor and document client’s progress toward meeting client treatment goals. Any recommended changes to the treatment plan must be reviewed and accepted by the Project Officer before proceeding with changes. This ensures that the proposed treatment is medically necessary. The contractor shall provide a trip report summarizing the on-site review.

Task 4: Auditing Services

Subtask 4.1 Clients’ invoices greater than $5,000.00 will be forwarded by the Project Officer to the contractor for prescreen auditing services. Invoices less than $5,000.00 found to be questionable by the Project Officer, will be forwarded to the contractor for prescreen auditing services. The contractor shall determine if the amount charged for billed services is within a reasonable rate range, determine the accuracy of charges, verify the delivery of billed services, and will document and report any unjustified charges to the Project Officer within seven business days from the time of receipt. Invoices requiring adjustments will not be processed until corrections are made by the healthcare provider.

Auditing services may include the following services:

Auditing and Bill Review

C.5 Reporting Schedule –

Monthly Progress Reports

30 days after contract award date, the Contractor shall submit an electronic copy of a monthly progress report of work performed in the previous month. Thereafter, a monthly report of work performed is due by the fifteenth day of each month. Each monthly report shall consist of:

1. Cover Page containing;

a. Contract number and title;

b. Period of performance being reported;

c. Author(s); and

d. Date of submission.

2. Summary of work performed during reporting period including:

a. Name of task(s) as identified in the SOW (tasks 2 through 4 including subtasks);

b. Description of work completed, plans for the next month including anticipated travel and estimated funds remaining;

c. Deliverables as identified in SOW.

d. List of all contractor’s staff, administrative personnel, and their roles in completing project tasks.

e. Description of current technical or administrative problems encountered, and their resolution or proposed corrective actions.

Trip Reports

Contents and format will be as follows:

· Maximum number of pages: 2

· Font size: 12 point unreduced, Times New Roman

· Double spaced

· Page margin size: One inch

· Number all narrative pages; not to exceed the maximum number of pages.

The trip report must include the following items:

· Date of trip

· Names of traveler (s)Address where visit occurred

· Purpose of Trip (Client annual visit, meeting with healthcare provider, etc.)

· Summary of trip Clearly describe observations, accomplishments, recommendations, as they pertain to the purpose of the trip.

Audit Reports

Contents and format will be as follows:

· Maximum number of pages: 2

· Font size: 12 point unreduced, Times New Roman

· Double spaced

· Page margin size: One inch

· Number all narrative pages; not to exceed the maximum number of pages.

The audit report must include the following items:

· Date of audit

· Healthcare Provider Name (s)

· Healthcare Provider Address

· Indentify THBP Client Receiving Services

· Purpose of Audit

· Summary of Audit

Clearly describe observations, results and recommendations as they pertain to the purpose of the audit.

Final Evaluation Report

Contents and format will be as follows:

· Maximum number of pages: 25

· Font size: 12 point unreduced, Times New Roman

· Double spaced

· Page margin size: One inch

· Number all narrative pages; not to exceed the maximum number of pages.

The Final Evaluation Report must include the following items:

· Cover Page containing:

· Contract number title

· Period of performance being reported

· Author (s); and

· Date of submission.

· Summary of Work performed during the reporting period including:

· Name of task(s) as identified in the SOW;

· Description of work completed;

· Detailed financial status report;

· Description of technical and administrative problems encountered and resolutions or corrective actions; and

· Recommendations for THBP administration regarding future case management and bill auditing.

C.6 Special Considerations –

The contractor must meet each of the following technical requirements.

1. Medical Case Management and administrative service coordination must be overseen by a current Certified Case Manager (CCM). CCM certification is through The Commission for Case Manager Certification, which is the largest nationally accredited organization that certifies case managers.

2. Medical and/or Provider Bill Review Services must be overseen by a current Certified Medical Audit Specialist (CMAS). CMAS certification is through the American Association of Medical Audit Specialist (AAMAS).

3. Any review for medical necessity and/or appropriateness of services should be rendered by a professional with experience in utilization review with certification as a Certified Professional in Utilization Review (CPUR) preferred. Certification is through McKesson.

4. The selected contractor must be a current company member with the Case Management Society of America (CMSA). The person performing direct case management services must be a member of CMSA. CMAS is a national association providing professional collaboration in the field of case management.

5. The selected contractor must be a current member of the American Association of Medical Audit Specialists (AAMAS). AAMAS is a national organization that provides CMAS certification and is composed of healthcare professionals from the areas such as case management, hospital bill audit, compliance, utilization review and quality assurance.

C.7 Government Furnished Property

No government furnished property is a part of this contract.

C.8 References – None

C.9 Deliverables –

Item Description

Task 4

Task 4

C.10 Period of Performance

The period of performance shall commence upon the award of a contract and shall continue for twelve months (Base Period) with two (2) twelve (12) month Options.