3.1 - Draft Fraud Defense Contracts Statement of Objectives.pdf

FRAUD DEFENSE CONTRACTS: STATEMENT OF OBJECTIVES

I. Purpose

The Centers for Medicare & Medicaid Services (CMS) seeks contractor support to protect the integrity of the Medicare program by preventing, detecting, and addressing fraud and abuse.

The purpose of this contract is to support CMS by investigating suspected fraud and abuse, protecting CMS programs, and supporting timely, consistent, and defensible administrative, civil, and criminal enforcement actions. The contractor will provide the investigative expertise, clinical and analytical capabilities, management practices, and other support necessary to address evolving fraud schemes and advance CMS’ program integrity priorities.

CMS seeks an outcome-focused approach that promotes timely and consistent action, effective coordination with Federal, State, and private program integrity partners, appropriate use of data and technology, and meaningful results in the prevention, detection, and disruption of fraud.

CMS will establish program integrity priorities, assign and prioritize investigations, and retain authority over Government decisions and actions requiring CMS approval. Within those parameters, the contractor shall be responsible for planning, managing, and executing the investigative activities necessary to develop assigned matters efficiently and to support appropriate program integrity and enforcement outcomes.

Offerors shall propose the approach, staffing, tools, quality controls, performance measures, and management practices necessary to perform the work described in this Statement of Objectives.

II. Scope or Mission

The contractor shall provide program integrity support within its assigned jurisdiction by:

• Receiving and working CMS-assigned fraud investigations in accordance with CMS-established priorities.

• Conducting the CMS directed investigative activities, including claims and other authorized data analysis, targeted pre-payment and/or post-payment medical review, onsite or boots-on-the-ground activities, provider/supplier/beneficiary interviews and retrieval of attestations, document and evidence collection, and other appropriate investigative actions directed by CMS.

• Identifying, developing, recommending, and supporting appropriate administrative actions, including payment suspensions, revocations, and other available program integrity remedies, subject to applicable CMS approval and direction.

• Developing and supporting law enforcement referrals and other criminal, civil, and administrative enforcement activities.

• Providing assigned law enforcement and external stakeholder support, including requests for information or assistance related to active and/or historical cases, DRAFT medical review, data support, testimony, litigation support, and other assistance as applicable and directed by CMS.

• Coordinating with other CMS program integrity stakeholders to avoid unnecessary duplication, identify overlapping activities, and prevent investigative or administrative actions from interfering with other matters.

• As capacity allows, identifying and developing potential leads and submitting them to CMS for review, prioritization, applicable law enforcement vetting, and direction before opening an investigation. Reporting findings and outcomes throughout the investigative process and obtaining CMS direction on next steps as needed.

• Maintaining complete and accurate investigative documentation and evidence in CMS-designated systems of record.

• Compiling investigative reports as directed/requested by CMS.

• Providing sufficient and appropriate staffing, expertise, and surge capability to respond to changing CMS priorities and urgent investigative needs.

• Proposing practical technology, analytical, quality, policy/regulatory and process improvements for CMS approval.

III. Period and Place of Performance

The contractor shall perform work throughout the assigned jurisdiction during the period specified in the Task Order.

Performance shall include collaboration with CMS, Medicare Administrative Contractors (MACs), U.S. Department of Health and Human Services Office of Inspector General, Department of Justice, Federal Bureau of Investigation, and other Federal, State, and local partners as appropriate.

The contractor shall maintain the ability to respond to changing workload demands, emerging fraud schemes, urgent CMS assignments, and law enforcement needs throughout the period of performance.

The contractor shall support orderly transition-in and transition-out activities, including the transfer of historical (as applicable) and active investigations, investigative records, evidence, pending administrative and enforcement actions, and other relevant institutional knowledge, as directed by CMS. Transition activities shall minimize disruption to ongoing investigations and enforcement actions.

IV. Background

CMS will serve as the primary driver of proactive data analysis, lead generation, prioritization, and law enforcement vetting. Approved investigations will be referred for contractor investigation following CMS review and applicable law enforcement vetting.

Once an investigation is assigned, the contractor's primary role is to develop the investigation per CMS’ direction, with the focus of supporting the administrative or enforcement actions warranted by the facts. As capacity allows and at the approval of CMS, the contractor may also identify potential leads through authorized data sources.

Contractor-developed leads shall be submitted to CMS for review, prioritization, applicable law enforcement vetting, and direction before the contractor opens an investigation.

CMS may establish or modify priorities based on emerging fraud schemes, program risk, law enforcement interest, financial exposure, beneficiary impact, statutory or regulatory changes, or other program integrity considerations. The contractor shall manage its workload accordingly and promptly identify resource constraints, competing priorities, or other barriers that may affect timely and quality performance.

V. Performance Objectives

Objective 1 - Conduct and Develop CMS-Assigned Investigations

Receive CMS-assigned investigations and perform the investigative work needed to develop the investigation efficiently, thoroughly, and consistently.

Depending on the investigation and CMS’ direction, this may include claims and other authorized data analysis, targeted pre-payment and/or post-payment medical review, onsite investigative activities, provider/supplier/beneficiary or other relevant interviews and retrieval of attestations, document and evidence collection, referrals to or coordination with other program integrity stakeholders, and other investigative steps. These actions shall be thoroughly documented and recorded in CMS-designated systems.

CMS-assigned work will take priority. As capacity allows, the contractor may conduct limited proactive analysis or identify potential leads through FPS alerts, investigative observations, site-visit information, regional knowledge, or other approved sources. Potential contractor-developed leads shall be submitted to CMS for review, approval, and direction before the contractor opens an investigation.

The contractor shall report investigative findings to CMS throughout the investigative process and carry out additional actions as directed.

The contractor shall maintain personnel with the investigative, analytical, clinical, program integrity, and other expertise necessary to develop assigned investigations. The contractor shall also alert CMS to any resource constraints or other barriers that may affect timely, high-quality performance.

Desired outcomes include:

• Timely development and completion of CMS-assigned actions and investigations.

• Investigative activity aligned with CMS’ direction.

• Clear investigative findings supported by relevant evidence and data.

• Appropriate coordination and referrals to other program integrity and law enforcement partners.

• Timely reporting of findings and outcomes to CMS to support decisions and next steps.

• Potential contractor-developed leads, when pursued, submitted through the CMS review process.

• Prompt escalation of resource constraints or barriers to CMS.

Offerors should describe how they will staff and manage investigations, use data and technology, provide appropriate clinical and subject-matter expertise, coordinate with CMS and other program integrity and law enforcement partners, respond to workload surges, and maintain investigative quality, consistency, and timeliness.

Objective 2 - Develop and Support Administrative and Enforcement Actions

Use investigative findings to identify, develop, recommend, and support the administrative, civil, or criminal actions appropriate to the facts of the investigation and CMS’ direction.

Work may include:

• Payment suspension development and support

• Revocation referrals and support

• Law-enforcement referrals and support

• Rebuttal, appeal, and hearing support

• Witness testimony and other litigation support

• Requests for information or assistance related to active and/or historical cases

• Evidence and document preparation

• Analytical and medical-review support

• Other assigned administrative or enforcement activities

Desired outcomes include:

• Timely, consistent, and defensible administrative action recommendations and supporting materials.

• Complete, high-quality, actionable law enforcement referral packages and investigative products.

• Timely action to prevent continued fraudulent payments and removal of fraudulent providers or suppliers when warranted.

• Consistent support for active criminal, civil, and administrative proceedings.

• Clear reporting of action results and outcomes to CMS.

Offerors shall describe how they will move assigned investigations from investigation through appropriate administrative or enforcement actions, coordinate with CMS and other program integrity and law enforcement partners, and produce complete, accurate, timely, and defensible work products.

Objective 3 - Innovation and Continuous Improvement

Identify and propose practical improvements to investigative processes, analytics, technology, policy/regulations, quality assurance, and performance measurement. New technologies and material process changes shall be implemented only after appropriate CMS review and approval and shall comply with applicable CMS requirements.

The contractor shall use operational experience, performance data, investigative outcomes, quality-review findings, emerging fraud trends, and lessons learned to identify opportunities for improvement.

Proposed improvements shall include, as appropriate, an explanation of the problem addressed, anticipated benefit, implementation requirements, risks, proposed performance measures, and methods for evaluating effectiveness.

Desired outcomes include:

• Improved investigative quality, accuracy, and consistency.

• Reduced time between CMS assignment, investigative activity, and appropriate action.

• Better use of analytics, automation, and other technology where they provide a measurable benefit.

• Reduction of unnecessary manual effort or duplication.

• Outcome-based performance measures and lessons learned that improve future work.

Offerors shall describe how they will identify, test, measure, and implement CMS-approved improvements while continuing to meet investigative workload and CMS security, privacy, and system requirements.

VI. Operating Constraints

The contractor shall perform all work consistent with applicable Federal statutes, regulations, CMS manuals, and program integrity authorities, contract requirements, and CMS direction.

The contractor shall:

• Give CMS-assigned work priority and obtain CMS review and direction before opening an investigation based on a contractor-developed potential lead.

• Protect CMS information and systems and maintain applicable security, privacy, records-management, and evidentiary safeguards.

• Coordinate activities with CMS and designated Federal, State, MAC, and law enforcement partners.

• Use CMS-designated systems of record for official documentation.

• Comply with applicable CMS information-security and privacy requirements.

• Obtain CMS approval before using non-approved tools, external data resources, artificial intelligence, automation, or material process changes in performing contract work.

• Maintain appropriately qualified investigative, analytical, clinical, technical, and management personnel.

• Maintain continuity of operations and support orderly transition of active matters when required.

• Remain adaptable to evolving fraud schemes, authorities, workload priorities, law enforcement needs, and CMS direction.

Offerors are encouraged to recommend practical methods, technologies, organizational approaches, analytical capabilities, performance measures, and business processes that improve the Government's ability to achieve these objectives, subject to applicable CMS approval and oversight.