23MC-SA022_RFI_-_Medical_Survey_Consultant_Support.pdf

Gavin Newsom, Governor State of California

Health and Human Services Agency

DEPARTMENT OF MANAGED HEALTH

CARE

980 9th Street, Suite 500 Sacramento, CA 95814

Phone: 916-324-8176 | Fax: 916-255-5241 www.HealthHelp.ca.gov

DEPARTMENT OF MANAGED HEALTH CARE (DMHC)

REQUEST FOR INFORMATION (RFI)

Medical Survey Consultant Support

23MC-SA022

Date: April 10, 2024

RESPONSE DUE DATE: April 30, 2024 @ 4:00 p.m. Pacific Daylight Time (PDT)

The DMHC invites interested parties (Participants) to review and respond to this non-binding RFI. The DMHC is gathering information from Participants to establish a vendor pool for health plan medical survey and clinical consulting services to support its monitoring and oversight of health plans’ regulatory compliance with the Knox-Keene Health Care Service Plan Act of 1975 (KKA).

For more information about the DMHC, please refer to www.HealthHelp.ca.gov.

Please read this document carefully and thoroughly. For Participants planning to respond to this RFI, the DMHC requests that the Participant refer to Section 6, Response Content and submit a comprehensive written response. Please refer to Section 3, Key Action Dates and Times and submit responses no later than 4:00 p.m. on April 30, 2024.

Responses received after the submission deadline may not be considered. The DMHC shall not be responsible for any delays, missed deliveries or transmission errors.

Please submit RFI responses to the contact listed in Section 5, Response Requirements.

Please direct questions pertaining to this RFI to the following contact:

Procurement Official:

Lesya Vorobets

Department of Managed Health Care Contracts Unit

Lesya.Vorobets@dmhc.ca.gov mailto:Lesya.Vorobets@dmhc.ca.gov

Department of Managed Health Care Medical Survey Consultant Support

RFI No. 23MC-SA022

General Information

1. PURPOSE

The DMHC’s Office of Plan Monitoring (OPM) seeks information from interested Participants with the ability to perform the services outlined in Section 4, Proposed Contracted Services, to better understand the marketplace and identify a potential vendor pool for health plan medical survey and clinical consulting services, including:

• Assessing, analyzing and making recommendations to the DMHC regarding compliance with the KKA, as amended.

• Providing input regarding clinical consulting to better understand the types of services they provide, their strategy, processes, qualifications and cost structure.

This RFI is issued solely for information and planning purposes. This RFI shall not be construed in any manner to create an obligation on the part of the DMHC to enter into any contract or serve as a basis for any claim whatsoever for reimbursement of costs for efforts expended.

Furthermore, the scope of this RFI may be revised, withdrawn, or cancelled, at any time by the DMHC.

The DMHC reserves the right to waive formalities and to add, modify, or delete the DMHC requirements, terms, or conditions prior to making an award whenever it is deemed to be in the DMHC’s best interest.

Notwithstanding any other provision of this RFI, Participants are hereby specifically advised that this RFI is a request for information only and is not intended to be, nor is it to be construed as, engaging in formal competitive bidding pursuant to any statute, code, ordinance, rule, or regulation. Therefore, the DMHC shall not be obligated by any responses received by the DMHC or by any statements or representations, whether oral or written, that may be made by the DMHC, and the DMHC reserves the unqualified right to reject any or all information submitted hereunder for any reason whatsoever. The DMHC shall be held free from any liability resulting from the use or implied use of the information submitted in any response to this RFI. Submission of response shall constitute the Participant's acknowledgment of this notice and the Participant's acceptance of this disclaimer.

The DMHC reserves the right to verify all information provided by a Participant via direct contact with the Participant's prior clients and personnel. If required, the Participant agrees to provide and release necessary authorizations for the DMHC to verify any of the Participant's previous work and qualifications to perform this work.

The DMHC reserves the right to amend the schedule of RFI activities as the DMHC deems necessary.

Any costs the Participant incurs in preparation of a response to this RFI will not be reimbursed by the DMHC.

2. BACKGROUND

The DMHC’s mission is to protect consumer health care rights and ensure a stable health care delivery system. The DMHC regulates health plans in California under the provision of the KKA. The DMHC regulates approximately 96 percent of commercial and public health enrollment, which includes approximately 29.7 million Californians.

Pursuant to California Health and Safety Code Section 1380, the DMHC must conduct an onsite medical survey of each licensed full service and specialty health plan not less than once every three years. The DMHC may also perform an investigative medical survey as often as deemed necessary by the DMHC's Director. The DMHC’s OPM is responsible for assessing and monitoring health plans’ care and delivery systems for compliance with state law. The focus of the surveys is to evaluate health plan operations to improve health care delivery systems, ensure transparency in health plan performance and empower Californians to get the care they need, when they need it.

The medical survey is a comprehensive evaluation of the plan's compliance with the law in the following health plan program areas:

• Quality Assurance

• Grievances and Appeals

• Access and Availability of Services

• Utilization Management

• Continuity of Care

• Emergency Services and Care

• Prescription Drug Coverage

• Behavioral Health

• Language Assistance

The DMHC utilizes Technical Assistance Guides (TAGs) and other tools to serve as foundational information for survey staff to conduct medical surveys. The TAGs and tools are available on the DMHC’s website under Health Plan Compliance Medical Surveys.

https://dmhc.ca.gov/LicensingReporting/HealthPlanComplianceMedicalSurvey.aspx https://dmhc.ca.gov/LicensingReporting/HealthPlanComplianceMedicalSurvey.aspx

When the survey is complete, the DMHC issues a Final Report that is publicly available. The DMHC may perform a Follow-Up Survey within 18 months of the Final Report for any uncorrected deficiencies.

California law requires surveys be conducted onsite by a panel of qualified health professionals experienced in evaluating the delivery of prepaid health care and authorizes the DMHC to contract with professional organizations or outside personnel to conduct medical surveys. The DMHC requires clinical consulting services and managed care expertise to conduct medical surveys.

3. KEY ACTION DATES AND TIMES

Action Item Anticipated Date Release of RFI April 10, 2024 Participant Questions Due April 16, 2024, at 4:00 p.m. PDT

DMHC Responses to Questions April 23, 2024

Participant Responses Due April 30, 2024, at 4:00 p.m. PDT

4. PROPOSED CONTRACTED SERVICES

The DMHC anticipates the following activities would be required to support the OPM’s medical surveys:

A. Develop a work plan and timeline, including a description of how resources will be allocated.

B. Provide qualified and knowledgeable clinical and non-clinical professionals to assess health plan compliance in the following areas: Quality Assurance, Grievance Systems, Access and Availability of Services, Utilization Management, Continuity of Care, Emergency Services, Prescription Drug Coverage, Behavioral Health Services, and Language Assistance.

C. Make recommendations to the DMHC regarding medical survey strategy including approaches to surveying the areas listed under Item 4.B above to help improve enrollee access to timely and appropriate health care services.

D. Assist with implementing changes to the medical survey process, including assisting with the revision or development of survey assessment tools, such as TAGs, health plan document and data requests, and file audit tools (i.e., File Review Worksheets), and participating in DMHC workgroups to revise and develop TAGs.

E. Complete assigned pre-onsite survey work, including reviewing and analyzing health plan documents, information, systems, data and case files to assess compliance with applicable laws and regulations, and complete file audit tools.

F. Participate in pre-onsite survey conference call(s), as needed, to discuss survey strategies and findings.

G. Conduct and complete all onsite survey work in accordance with assignment and survey agenda, including assigned TAG work papers, interviews with health plan staff, and review of applicable reports and case files.

H. Participate in post-survey conference call(s), as needed, to discuss survey findings and impressions.

I. Draft a Preliminary Report using DMHC template(s), outlining the consultants’ findings and deficiencies identified in a manner consistent with the formatting requirements of DMHC survey reports.

J. Identify and allocate a professional technical writer and/or editor position to serve as the primary technical writer and/or editor for all reports and written survey findings that are to be submitted to the DMHC.

K. Respond to all DMHC inquiries related to the health plan’s response to the Preliminary Report.

L. Assess health plan response or Corrective Action Plan and complete a draft Final Report, at the request of the DMHC.

M. Conduct Follow-Up Survey work and complete a draft Follow-Up Report, at the request of the DMHC.

N. Conduct non-routine survey work and complete a draft Non-Routine Survey Report, at the request of the DMHC.

O. Conduct special investigation work and complete a draft findings report, at the request of the DMHC.

P. Perform quality control review of all deliverables prior to submitting to the

DMHC.

Q. Develop and maintain a deficiency database to support deficiency trend analysis. Utilize the deficiency database to develop template findings and/or standard language for recurring deficiencies to be used in the survey reports. Develop a process to obtain DMHC approval on each template finding and/or language.

R. Assist the DMHC in identifying opportunities for business process improvements to improve efficiency of the survey process.

S. Assist the DMHC in maintaining training tools, protocols and conduct training for the Contractor and DMHC staff, as needed.

5. RESPONSE REQUIREMENTS

The interested Participant must submit one copy of its RFI response to the DMHC in an electronic format to the email address below. Vendors currently contracted with the DMHC for medical surveys and clinical consulting services are not required but may submit a response to this RFI.

Department Contact:

Lesya Vorobets

Department of Managed Health Care Contracts Unit

Lesya.Vorobets@dmhc.ca.gov

In the email subject line, include: RFI No. 23MC-SA022 Medical Survey Consultant Support.

6. RESPONSE CONTENT

The information provided in response to this RFI may be no more than ten pages, 12-point, Arial font. Resumes and sample work product are not included in this page count.

The following outline is the expected format and content to be provided by the organization:

A. A cover memo with the entity or organization name, type of organization or institute (e.g., corporation, nonprofit, etc.), and contact information for a specific person within the entity or organization able to answer questions regarding documents submitted in response to this RFI.

B. A brief description of the organization’s history and general business experience as relevant to the subject matter of this RFI, to include:

i. A description of the organization’s experience with providing clinical consulting services, including any experience working with governmental health care purchasers, regulators and managed health care organizations;

ii. A description of the organization’s experience with and knowledge of the managed care health care delivery system in California;

mailto:Lesya.Vorobets@dmhc.ca.gov

iii. A description of the organization’s experience with conducting onsite inspections or audits for compliance with federal and state health care laws or regulations;

iv. A description of the organization’s experience with developing survey assessment or audit tools, including guides, checklists, policies and procedures, and health plan document and data requests. Examples must be attached;

v. Years of operation;

vi. Operating budget; and

vii. Total number of staff

C. A brief description of the organization’s qualifications, describing knowledge and experience for the services listed in Section 4, Proposed Contracted Services.

D. A description of what the organization’s approach would be for pre-onsite preparation, onsite work, and determining and writing up deficiency findings for a medical survey.

E. A high-level work plan outlining activities, tasks, assignment of tasks, data collection, estimated timeframe for delivery of services and personnel resources to complete a medical survey and follow-up activities.

F. A description of how the organization will perform quality control review of all deliverables prior to delivering to the DMHC and how it will address and incorporate performance feedback from the DMHC.

G. A description of experience working on multi-partner projects (e.g., experience working with stakeholders, government and/or other partners concurrently) and the organization’s ability to integrate feedback from a client and/or stakeholder who may have varied priorities and needs.

H. A cost proposal or outline of cost structure for the services you are providing information on as described in Section 4, Proposed Contracted Services.

I. Provide resumes and/or Curriculum Vitae (CV) for all proposed key staff who may provide services. Resumes and/or CVs should include any medical consulting experience, preferably in the California health care industry and licensure status, if applicable.

J. Identify and provide resumes and/or CVs for staff member(s) who will serve as the primary technical writer and/or editor for all reports and written survey findings submitted to the DMHC. Resumes and/or CVs should include relevant education and experience related to writing and editing. If the organization does not currently have a professional writer and/or editor on staff, describe the organization’s plan for staffing this position.

K. Three references for which the organization has provided similar services as described in this RFI, including names of entity, total budget, timeline of work and outcome(s) of work.

7. NEWS RELEASE AND SOCIAL MEDIA

Organizations must obtain prior written approval from the DMHC before issuing any news release, statement to the news media or social media post(s) pertaining to this RFI.

8. EXECUTIVE ORDER N-6-22 – RUSSIA SANCTIONS

On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 regarding Economic Sanctions against Russia and Russian entities and individuals. “Economic Sanctions” refers to sanctions imposed by the U.S.

government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. By submitting a bid or proposal, Contractor represents that it is not a target of Economic Sanctions. Should the State determine Contractor is a target of Economic Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for rejection of the Contractor’s bid/proposal any time prior to contract execution, or, if determined after contract execution, shall be grounds for termination by the State.

https://www.gov.ca.gov/wp-content/uploads/2022/03/3.4.22-Russia-Ukraine-Executive-Order.pdf