31786-00180.pdf

STATE OF TENNESSEE

DEPARTMENT OF FINANCE AND ADMINISTRATION,

DIVISION OF BENEFITS ADMINISTRATION

REQUEST FOR INFORMATION

FOR

MEDICAL CLAIMS PAYMENT INTEGRITY SERVICES

RFI # 31786-00180

May 29, 2024

1. STATEMENT OF PURPOSE:

The State of Tennessee, Department of Finance and Administration, Division of Benefits Administration (“State”) issues this Request for Information (“RFI”) for the purpose of soliciting information on best practices for on-going medical claim payment integrity services and the companies which provide these services. The State is interested in receiving information from companies with experience providing these services to large employers. The State manages benefits for three self-insured risk pools serving state, higher education, local education, and local education employees, retirees, and their dependents. We currently have over 290,000 members that we serve in these medical plans. We appreciate your input and participation in this process.

The State, under authority of the State Insurance Committee, is conducting a study of these options. This market research is not a competition. No evaluation of participating vendors will occur and your participation is not a promise of future business with the State. Responding or not responding to the RFI does not preclude the Vendor from submitting a proposal to any future solicitations/requests for proposals issued by the State. The State is NOT requesting specific pricing for any components or services addressed in this RFI. Instead, the State is seeking price ranges and structures for programs in order to determine approximately, what these types of programs sought by the State will cost. Do NOT provide specific pricing amounts in response to this RFI. Should responses from this RFI generate additional questions from the State all vendors responding to this request will receive the additional questions.

2. BACKGROUND:

The State recognizes that the current national health care system has issues with payment integrity, including billing errors, waste, and inefficiencies. The information provided will assist the State in comparing emerging strategies to detect and correct these issues. The State has a current contractor who provides random sample auditing, pre and post implementation audits, operational audits, and targeted audits. The State’s goal with this RFI is to identify opportunities to enhance already existing processes to ensure payment integrity.

3. COMMUNICATIONS:

3.1. Please submit your response to this RFI by uploading your documents to a specific file sharing link listed below.

https://tncloud.tn.gov/owncloud/index.php/s/HcEfQTBLxcCatzv Integrity24!

3.2. Please feel free to contact the Department of Finance and Administration, Division of Benefits Administration with any questions regarding this RFI. The main point of contact will be:

Heather Pease Department of Finance and Administration, Division of Benefits Administration 312 Rosa L. Parks Avenue, 19th Floor WRS TN Tower Nashville, TN 37243 Phone: (615) 253-1652 Heather.pease@tn.gov

3.3. Please reference RFI # 31786-00180 with all communications to this RFI.

4. RFI SCHEDULE OF EVENTS:

EVENT

TIME

(Central Time Zone)

DATE

(all dates are State business days)

1. RFI Issued May 29, 2024

2. RFI Response Deadline 2 p.m. June 24, 2024

3. Scheduling of webinar meetings July 9-10, 2024

4. Webinar meetings 9 a.m. to 4 p.m.

July 31 – August 2, https://tncloud.tn.gov/owncloud/index.php/s/HcEfQTBLxcCatzv mailto:Heather.pease@tn.gov

5. GENERAL INFORMATION:

5.1. Please note that responding to this RFI is not a prerequisite for responding to any future solicitations related to this project and a response to this RFI will not create any contract rights. Responses to this RFI will become property of the State.

5.2. The information gathered during this RFI is part of an ongoing procurement. In order to prevent an unfair advantage among potential respondents, the RFI responses will not be available until after the completion of evaluation of any responses, proposals, or bids resulting from a Request for Qualifications, Request for Proposals, Invitation to Bid or other procurement method. In the event that the state chooses not to go further in the procurement process and responses are never evaluated, the responses to the procurement including the responses to the RFI, will be considered confidential by the State.

5.3. The State will not pay for any costs associated with responding to this RFI.

6. INFORMATIONAL FORMS:

The State is requesting the following information from all interested parties. Please fill out the following forms:

RFI #31786-00180

TECHNICAL INFORMATIONAL FORM

1. RESPONDENT LEGAL ENTITY NAME:

2. RESPONDENT CONTACT PERSON:

Name, Title:

Address:

Phone Number:

Email:

3. Please provide a brief description of your company’s experience providing the services described herein.

4. Describe your three largest clients including the organization type and services offered.

5. What are the newest developments in the medical claims payment integrity arena that a large, self-insured plan such as the State Group Insurance Program (SGIP) should be aware of as we consider whether to draft a procurement for these services?

What would you most want to make us aware of?

6. Please list in detail the specific types of services your company provides and recommends for our plans.

7. Does your company perform pre-payment payment integrity services? If so, please describe this process. Please include, at a minimum:

• The focus areas of testing,

• Frequency of testing,

• Impact on timely claims processing,

• Whether you are testing 100% of claims or a sample of claims, and

• If testing a sample of claims, how is that sample determined?

8. Does your company perform post-payment payment integrity services? If so, please describe this process. Please include, at a minimum:

• The focus areas of testing,

• Frequency of testing,

• Whether you are testing 100% of claims or a sample of claims,

• If testing a sample of claims, please describe how the sample is determined, and

• Any interaction you have with the member, or updates you provide to them, on the status of the claim(s) under review.

9. Do your services include reviews for duplicate claims, high-cost claimants, denied claims, pended claims, and provider appeals? If so, please describe.

10. Do your services include reviews for high-cost services, such as high-cost facility claims? If so, please describe.

11. Does your company integrate features of the plan sponsor’s plan document, e.g., coverage and exclusion criteria, into the reviews?

12. Does your company provide reconciliation services showing the amounts paid for claims vs other services provided by the TPA(s) i.e., imbedding fees within claims?

13. What data elements are required to perform the engagement and how does the company normally obtain the data? Please include data source, frequency, timing, etc.

14. Please describe in detail the expectations, processes, and timelines from both the client and the TPA(s). Please be specific for each.

15. Our contracted TPA(s) have independent contractor(s) who perform payment integrity services. How would your services coordinate with the initiatives already in place?

16. When claims are identified as having potential improper payments or errors, how does your company verify these are indeed improper payments?

17. How does your company communicate potential improper payments or errors to the TPA, the client, and the member (when appropriate)? What data elements does your company report? Please provide examples of reports used to communicate and track issues identified.

18. Once the potential improper payments or errors are confirmed as such, what steps does your company perform to remedy the issue?

19. What percentage of identified improper payments or errors were validated as being such? What percentage were actually collected or corrected? Please provide a breakout if the answer varies between post payment and pre-payment engagements.

20. Has your company conducted repeat engagements with the same client? If so, have the number of recoupments or corrections increased, decreased, or stayed about the same?

21. What is the average return on investment for clients of a similar size population (over 2 million claims and over 290,000 members) and how it is calculated?

22. What is a typical timeline from contract award date to services start date?

COST INFORMATIONAL FORM

1. Describe what pricing structure you typically utilize for similar engagements (e.g. per member per month, per employee per month, per engagement, contingency fee based on collection, etc).

2. Describe the typical price range for similar engagements (assume one plan year with over 2,000,000 claims and over 290,000 members).

ADDITIONAL CONSIDERATIONS

1. Please provide input on alternative approaches or additional considerations that might benefit the State.