E.3 - Assumptions_Amendment 1.docx
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- Solicitation number
- 260656J
About this file
This is an assumptions and workload projections document for the Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC) program, which supports Amendment 1 of solicitation 75FCMC26R0041. The document outlines estimated workload volumes for a 12-month period (applicable to both Base and Option Years) that the contractor must budget for and staff accordingly. The projections are subject to a variance of +/- 10% due to factors such as audit scheduling and medical record submission volumes.
The workload projections encompass multiple categories: Parts C and D audits (including self-audits, PI audits, and ad hoc audits ranging from 4 to 22 annually); audit appeals with reconsiderations (57 in Base Year, 115 in Option Year) and CMS support requests (100 in Base Year, 200 in Option Year); recurring and discrete reports for plan sponsor releases (ranging from 2 to 18 quarterly releases); internal reports including ROI reports, status reports, audit activity logs, and workload/cost reports (monthly, quarterly, or annual frequency); meetings with CMS (26 biweekly contractor meetings, 26 biweekly collaboration calls, 92 PI Data User Group meetings, 12 monthly IDR and DASG calls, and 4 quarterly meetings); and presentations/conferences including fraud, waste, and abuse training, outreach missions, and external conferences. Additional deliverables include audit protocols (1 Part C and 1 Part D annually), 2 Part C and 2 Part D data analysis projects, 250 ad hoc deliverables, 4 model development feedback items, 2 vulnerabilities assessments, approximately 15,000 Part D and 200 Part C correspondence mailbox items, plan sponsor alerts, RFIs/investigations, OIG recommendation requests, congressional inquiries, and FOIA requests. The document assumes virtual meetings unless otherwise noted and travel to CMS headquarters in Woodlawn, Maryland for onsite PI audits.
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Exhibit E.3 – Assumptions_Amendment 1 75FCMC26R0041
Assumptions: Workload Projections
For budgeting purposes, the PPI MEDIC workload projections for a 12 month period (Base and Option Year) are as follows. Note: The workload projections are subject to change based on an anticipated variance of +/- 10% for the base and option years due to when audits will start, how many medical records are submitted for audits, etc.
The workload projections for Audits, Recurring/Discrete Reports, Internal Reports, Meetings, and Presentations/Conferences for a 12-month period are as follows:
Audits- Part C
12-Month Period (Base & Option Years)
Self-Audits – Exploratory (to include preliminary data analysis, any data/non-data assignments or meetings related to the audit)
PI Audits (to include preliminary data analysis, any data/non-data assignments or meetings related to the audit) Ad hoc Audits (to include preliminary data analysis, any data/non-data assignments or meetings related to the audit)
| 4 |
| 4† |
| 22* |
Audits-Part D
12-Month Period (Base & Option Year)
| National Audits (to include preliminary data analysis, any data/non-data assignments or meetings related to the audit) |
| Self-Audits (to include preliminary data analysis, any data/non-data assignments or meetings related to the audit) |
| PI Audits (to include preliminary data analysis, any data/non-data assignments or meetings related to the audit) |
| 6 |
| 6 |
| 4† |
Audit- Appeals
12-Month Period (Base)**
| Reconsiderations |
| CMS Support Requests (first, second and third level) |
| 57 |
| 100 |
12-Month Period (Option Year)
| Reconsiderations |
| CMS Support Requests (first, second and third level) |
| 115 |
| 200 |
Recurring/Discrete Reports for Plan Sponsor Release -Part C
12-Month Period (Base & Option Year)
| Total Releases |
| Quarterly (separate reports) |
| Discrete |
| 10 |
| 2 |
| 2 |
Recurring/Discrete Reports for Plan Sponsor Release -Part D
12-Month Period (Base & Option Year)
| Releases |
| Quarterly (separate reports) |
| Discrete |
| 18 |
| 4 |
| 2 |
Recurring Internal Reports
12-Month Period (Base & Option Year)
| ROI Reports |
| Status Report |
| Audit Activity Project Management |
| Audit Issues Logs |
| Self-Assessment Report |
| Workload and Costs Reports |
| Medicare Prescription Payment Plan (M3P) Report |
| 4 (Quarterly) |
| 12 (Monthly) |
| 1 |
| 4 (Quarterly) |
| 1 (Annual) |
| 12 (Monthly) |
| 1 (One time report, may repeat at CMS discretion) |
Meetings (All meetings are anticipated to be 60 minutes in duration and take place virtually unless indicated differently below)
12-Month Period (Base & Option Year)
| Project Contractor Meeting with CMS |
| PAR |
| Ad-Hoc (as needed) |
| PPI MEDIC/ IMEDIC Collaboration |
| PIDUG (PI Data User Group) |
| IDR (Integrated Data Repository) User Group |
| CMS DASG (Division of Analytics and Systems Group), PIMASC and PPI MEDIC Collaboration Calls |
| 26 (Biweekly) |
| 26 (Biweekly) |
| 90 Virtual; 2 In-person |
| 12 (Monthly) |
| 12 (Monthly) |
| 12 (Monthly) |
| 4 (Quarterly) |
Presentations/Conferences (assume travel is required for all)
12-Month Period (Base & Option Year)
| Fraud Waste and Abuse (FWA) Parts C & D Training |
| Outreach and Education Missions |
| Conferences Outside of CMS Hosted Events (may include, but not limited to: PIAM, NHCAA and Durable Medical Equipment (DME) Coordination Meeting (DCM)) |
| 1 |
| 3 |
| 4 |
Additional workload projections for other PPI MEDIC activities for a 12-month period are noted in the following table:
Audit Protocols (to include protocols for each type of audit conducted under the program)
12-Month Period (Base & Option Year)
1 Part C Audit Protocol 1 Part D Audit Protocol
Data Analysis Project – PAR Projects
12-Month Period (Base & Option Year)
2 Part C PAR Projects 2 Part D PAR Projects
Ad Hoc Deliverables as Requested by CMS (Data and non-data analysis including but not limited to: special studies, UAT testing, SWIFT Requests, ligation holds, and HPMS memos outside of audits)
12-Month Period (Base & Option Year)
Model Development (Feedback on AICE-FWA models)
12-Month Period (Base & Option Year)
Vulnerabilities
12-Month Period (Base & Option Year)
Part D Correspondence Mailbox
12-Month Period (Base & Option Year)
15,000
Part C Correspondence Mailbox
12-Month Period (Base & Option Year)
Plan Sponsor Alerts
12-Month Period (Base & Option Year)
RFIs, investigations, complaints, and referrals
12-Month Period (Base & Option Year)
OIG Recommendation Requests***
12-Month Period (Base & Option Year)
Congressional Inquiries
12-Month Period (Base & Option Year)
FOIA Requests
12-Month Period (Base & Option Year)
* 20 of the 22 audits require no data analysis but will include follow-up and communications with plan sponsors.
**Once CMS has approved the contractor to proceed, the appeal reconsiderations and support requests would not begin until January 1, 2027.
***Many OIG recommendations are included in audits and reports.
† Assume two onsite and two virtual PI audits for each contract year. For estimating purposes, assume travel to CMS headquarters in Woodlawn, MD for each onsite audit.
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