3.2 - Request for Information – Interested Vendor Response.pdf

Request for Information (RFI) - Fraud Defense Contracts

RFI Questions - Response Form

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The Centers for Medicare & Medicaid Services (CMS) works diligently to crush fraud in federal health care programs, including Medicare and Medicaid. A cornerstone of CMS' program integrity (PI) strategy is focused on using advanced analytics and other investigative techniques to identify potentially problematic actors and stopping them in their tracks. CMS has traditionally contracted with private entities to bolster our investigative capabilities and take appropriate administrative action, including imposing payment suspensions, revoking Medicare billing privileges, and referring potential fraud cases to states and appropriate law enforcement entities. Through this

Request for Information (RFI), we are seeking creative ideas and solutions as to how a contractor might best address the draft Statement of Objectives (SOO). The draft SOO reflects the direction of the proposed future operating model, including a greater CMS role in lead development, prioritization, and direction of investigations.

We encourage commenters to recommend innovative approaches for accomplishing the objectives within that framework and to identify where the framework creates risk. Within that framework, responses should not be constrained by traditional policies and processes, such as those in the current Unified Program Integrity

Contractor (UPIC) Statements of Work or the Medicare Program Integrity Manual. We have also developed a list of specific questions for which we are seeking input; however, all ideas are welcome.

Each question appears on its own page. Type your response in the box below the question. Responses are limited to 4,000 characters (including spaces); text will scroll within the box if it exceeds the visible area.

RFI Questions - Fraud Defense Contracts Page 1

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 1

1. What defines a successful PI model in 2026 and beyond? Provide examples of activities, technology, or other innovations that should be included in a new PI model focused on crushing fraud. How is this different or similar to the traditional investigative roles of the UPICs and predecessor contractors, such as the Zone Program Integrity Contractors (ZPICs)?

Response - character limit: 4,000 characters (including spaces). Text scrolls if longer.

RFI Questions - Fraud Defense Contracts Page 2

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 2

2. CMS is considering centralizing some compliance-related tasks currently assigned to the individual PI contractors. What impacts (positive, negative, and risks) will the approach have on the PI contractors supporting payment suspensions, revocations, law enforcement referrals, etc.?

RFI Questions - Fraud Defense Contracts Page 3

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 2a

2a. Medical Review (MR) - how should CMS distinguish MR performed in support of fraud investigations from compliance-focused MR, and what type and level of MR capability should remain with PI contractors? How should investigative MR, including targeted prepayment and post-payment reviews, be scoped to produce reliable findings without unnecessary review volume?

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INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 2b

2b. Requests for information and requests for assistance from law enforcement and other partners -should CMS centralize this work, with whom, and what would be gained or lost in responsiveness and investigative value?

RFI Questions - Fraud Defense Contracts Page 5

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 2c

2c. Site Verifications - should site verifications be centralized or performed by a separate contractor, and how should CMS coordinate them with PI contractor onsite activities?

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INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 2d

2d. What other current functions performed by PI contractors could be centralized to allow the PI contractors to focus on crushing fraud?

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INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 3

3. What are the advantages and disadvantages of specialty contractors for specific provider types for national functions?

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INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 4

4. What jurisdictional structure and office or field presence would best support timely and effective investigations under the proposed PI model, including cases that may cross geographic boundaries?

RFI Questions - Fraud Defense Contracts Page 9

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 5

5. Where do handoffs among PI contractors, Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), the Supplemental Medical Review Contractor (SMRC), and other CMS contractors delay or weaken administrative actions? How should responsibilities be redrawn under the proposed PI model?

RFI Questions - Fraud Defense Contracts Page 10

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 6

6. Should investigations involving Medicare Advantage (Part C) and Part D be integrated with fee-for-service investigations or remain with a separate contractor? What capabilities do Part C and Part D investigations require that fee-for-service investigations do not?

RFI Questions - Fraud Defense Contracts Page 11

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 7

7. If CMS takes a greater role in lead development, prioritization, and direction of investigations, what decision timelines, data and systems access, and approvals must CMS commit to so that contractors can meet their performance standards?

RFI Questions - Fraud Defense Contracts Page 12

INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 8

8. How should CMS transition in-flight investigations, active payment suspensions, open law enforcement matters, and case files to the new model without losing cases or institutional knowledge?

What transition timeline is realistic?

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INVESTIGATIVE WORK AND OPERATING MODEL • QUESTION 9

9. What investigator, clinical, and data science qualifications should CMS require of PI contractor staff, and how do those requirements affect pricing and the ability to staff quickly?

RFI Questions - Fraud Defense Contracts Page 14

MEDICAID PROGRAM INTEGRITY • QUESTION 10

10. What concerns or benefits arise from separating Medicare and Medicaid lead development and investigations, including the effect of reduced cross-program data visibility? What did the unified UPIC model gain or lose compared with separate Medicare and Medicaid contractors, and what evidence supports that view?

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MEDICAID PROGRAM INTEGRITY • QUESTION 11

11. The draft SOO focuses on Medicare PI. CMS is considering the future Medicaid PI strategy and is interested in feedback on the following to frame an effective approach:

Please respond to items 11a-11e on the following pages.

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MEDICAID PROGRAM INTEGRITY • QUESTION 11a

11a. What functions should the CMS PI contractor perform and which functions should be led by CMS, State Medicaid Agencies (SMAs), Medicaid Fraud Control Units (MFCUs), etc.?

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MEDICAID PROGRAM INTEGRITY • QUESTION 11b

11b. What is most important to maximize effective coordination among CMS PI contractors, CMS, SMAs, MFCUs, law enforcement?

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MEDICAID PROGRAM INTEGRITY • QUESTION 11c

11c. What contractor capabilities should CMS solicit to effectively investigate fraud and abuse involving Medicaid managed care organizations, providers, subcontractors, and encounter data?

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MEDICAID PROGRAM INTEGRITY • QUESTION 11d

11d. What role should contractors have in identifying, recommending, developing, or supporting Medicaid administrative actions? Which actions require SMA involvement or approval?

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MEDICAID PROGRAM INTEGRITY • QUESTION 11e

11e. What measures would best assess contractor performance in Medicaid without creating incentives for unnecessary investigations, referrals, or administrative actions?

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LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 12

12. What tools, data sources, analytics, artificial intelligence (AI), modeling, structured query language (SQL)/query methods, open-source intelligence (OSINT), or workflow technologies should CMS use for lead development and investigations? Which capabilities are not currently available through CMS systems that could improve quality or efficiency?

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LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 13

13. How should CMS govern contractor use of AI and analytics, including explainability, human review before any action is taken, and validation of model accuracy? Who should own the models, tools, and work products developed under the contract, and how should CMS ensure they remain portable at contract end?

RFI Questions - Fraud Defense Contracts Page 23

LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 14

14. Based on your experience with fraud and abuse complaint and referral intake, what complaint and referral sources should CMS consider as part of a centralized intake process? What volume and format considerations should CMS account for, and what types of submissions typically require rerouting?

What intake gatekeeping, routing, and immediate-escalation criteria would you recommend?

RFI Questions - Fraud Defense Contracts Page 24

LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 15

15. How should CMS associate, aggregate, and prioritize repeated complaints or referrals involving the same provider, beneficiary, or scheme over time?

RFI Questions - Fraud Defense Contracts Page 25

LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 16

16. What improvements could expedite law enforcement vetting while ensuring all relevant subjects are vetted?

RFI Questions - Fraud Defense Contracts Page 26

LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 17

17. How should contractor proactive data analysis, conducted as capacity allows and with CMS approval, be governed, tracked, and evaluated, including Fraud Prevention System (FPS) access, CMS review, source attribution, and contractor credit?

RFI Questions - Fraud Defense Contracts Page 27

LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 18

18. What level of information sharing, and what mechanisms, would enable more timely exchange of investigative information among the contractors, CMS, SMAs, MFCUs, law enforcement, and other partners while complying with applicable privacy, security, and disclosure requirements?

RFI Questions - Fraud Defense Contracts Page 28

LEAD DEVELOPMENT, INTAKE, AND TECHNOLOGY • QUESTION 19

19. How should investigative findings feed back into prepayment edits, provider enrollment screening, and policy changes so that identified vulnerabilities are closed?

RFI Questions - Fraud Defense Contracts Page 29

PERFORMANCE, QUALITY, AND OUTCOMES • QUESTION 20

20. What outcome-based measures should CMS use to evaluate contractor performance, including quality, timeliness, adherence to CMS direction, preventable financial loss, and downstream investigative, administrative, and enforcement outcomes? How should CMS define and measure a successful investigation, particularly when contractors are directed to prioritize actions such as payment suspensions, revocations, exclusion referrals to OIG, or law enforcement referrals?

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PERFORMANCE, QUALITY, AND OUTCOMES • QUESTION 21

21. What barriers currently delay or undermine payment suspensions, revocations, exclusion referrals to OIG, or other actions, and what changes should CMS implement to improve timeliness and quality?

RFI Questions - Fraud Defense Contracts Page 31

PERFORMANCE, QUALITY, AND OUTCOMES • QUESTION 22

22. What metrics should CMS use to ensure consistent, complete, and defensible administrative actions and law enforcement referral packages?

RFI Questions - Fraud Defense Contracts Page 32

PERFORMANCE, QUALITY, AND OUTCOMES • QUESTION 23

23. How should CMS plan for and execute surge capabilities and/or shifts in investigative priorities?

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PERFORMANCE, QUALITY, AND OUTCOMES • QUESTION 24

24. How should the PI model limit false positives and unnecessary provider burden, and how should CMS protect beneficiary access to care when a provider is suspended or revoked?

RFI Questions - Fraud Defense Contracts Page 34

FIXED-PRICE CONTRACTING • QUESTION 25

25. In accordance with E.O. 14402, Promoting Efficiency, Accountability, and Performance in Federal Contracting, CMS seeks to identify opportunities to award contracts on a fixed-price basis. To that end, please provide information on the following:

Please respond to items 25a-25c on the following pages.

RFI Questions - Fraud Defense Contracts Page 35

FIXED-PRICE CONTRACTING • QUESTION 25a

25a. Based on the draft SOO, please identify opportunities to create fixed-price, fixed unit price, or hybrid pricing structures and explain your assumptions. What information (workload volume, data and systems access, service level agreements, etc.) would be needed?

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FIXED-PRICE CONTRACTING • QUESTION 25b

25b. What performance standards and incentives should be considered to ensure quality and timely outcomes?

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FIXED-PRICE CONTRACTING • QUESTION 25c

25c. Which tasks in the draft SOO are not well suited to fixed-price contracting, and why? How should fixed unit pricing or performance-based incentives be structured so that they do not reward the volume of investigations, referrals, or administrative actions over their quality?

RFI Questions - Fraud Defense Contracts Page 38

COMPETITION AND CONFLICTS OF INTEREST • QUESTION 26

26. What barriers keep nontraditional vendors, such as commercial special investigations unit (SIU) and analytics firms, from competing for PI work, and how should CMS structure the acquisition to broaden competition?

RFI Questions - Fraud Defense Contracts Page 39

COMPETITION AND CONFLICTS OF INTEREST • QUESTION 27

27. How should CMS identify and mitigate organizational conflicts of interest for firms that also have health plan, provider, or other CMS contractor business?

RFI Questions - Fraud Defense Contracts Page 40

STRUCTURED FEEDBACK / COMMENTS ON THE DRAFT STATEMENT OF OBJECTIVES • QUESTION 28

28. Please provide comments, feedback, and recommendations on the draft SOO. Information should be organized by page number and task area to facilitate a review of the information.

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