Attachment H QASP Rev Final.docx

?.## ATTACHMENT H QUALITY ASSURANCE PLAN

This document does not get incorporated into the contract/ORDER; it is used by government representatives to monitor performance and the government has the right to change its method of surveillance at any time. The CO/COR should provide a copy to the contractor through correspondence.

Quality Assurance Surveillance Plan For: Electronic Data Interchange (EDI) and Paper-Based Health Clams and Associated Medical Documentation (P2E) Services

Contract/Order Number: TBD

Contract/Order Description:

1. This is a services contract for a Healthcare Clearing House (HCCH) contractor to support the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Community Care (OCC) with Electronic Data Interchange (EDI) transactions and paper-based Health claims and associated medical documentation.

2. VHA/OCC, uses a HCCH to provide connectivity for incoming and outgoing EDI transactions to support the payment for services provided by community providers to Veterans and Veteran Families. The Payer EDI program provides interfaces to both external and internal systems to facilitate the reimbursement processes. As a payer OCC accepts both paper and electronic submissions for health claims and for supporting documentation (i.e. attachments). Current programs are as follows:

* Veteran:

o Non-VA Medical Care Program (NNPO-legacy name VA Fee Basis) o Non-VA Medical Care Dialysis National Contracts (DNC) o Patient-Centered Community Care (PCCC) o Indian Health Service and Tribal Health Program (IHS/THP) o Community Care Network (CCN) o CHOICE o VA Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION)

* Veteran Families:

o Camp Lejeune Family Member Program (CLFMP) o Civilian Health and Medical Program VA (CHAMPVA) o Spina Bifida Health Care Program (SB) o Children of Women Vietnam Veterans (CWVV)

As a Payer, VHA/OCC has initiated multiple projects to increase the volume and overall percentage of electronic transactions versus paper or other manual transactions to comply with legislation and to facilitate administrative simplification. VHA/OCC also employs a HCCH to transmit incoming and outgoing EDI transactions to the over one million medical and dental providers throughout the United States, Puerto Rico, and US Territories. The EDI transactions consist of batch and real-time transfers of Health Information Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12N 5010 transactions. VHA/OCC also supports several hosted real-time EDI transactions.

As the HCCH, the contractor must have the capability to interface with VHA/OCC using nationally established standards developed and maintained by ASC X12 providing claim-level views into the claim filing process from claim submission to delivery to the payer organization. The HCCH must have the ability to receive claims, scrub the claims, check for errors and then securely transmit the electronic claims and statuses to VHA/OCC. Additionally, the contractor will support X12 standard payment remittances and the ancillary inquiry/response transactions mandated by HIPAA (eligibility, claim status, authorizations). The contractor must also have the ability to receive, scan, store, and convert paper claims (CMS-1500, UB-04, and American Dental Association (ADA) Dental Forms), and documentation supporting claims from VA community providers (P2E capabilities). The contractor shall provide services capable of receiving a minimum of 500,000 paper claims and 800,000 paper claims’ attachments via postal mail per month in a single location. The following table represents the anticipated number of transactions throughout the life of the contract:

The Contractor shall provide all resources necessary to accomplish the requirements described in this PWS. The Contractor shall also follow all applicable privacy laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104–191, 110 Stat. 1936, enacted August 21, 1996), in the performance of this requirement.

Contractor’s Name: TBD

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to monitor Contractor performance. This QASP describes:

What will be monitored?

How monitoring will take place?

Who will conduct the monitoring?

How monitoring efforts and results will be documented?

Copies of the original QASP and revisions shall be provided to the Contractor and Government officials responsible for surveillance activities. The Government can change the method of surveillance at any time.

1.1 PERFORMANCE MANAGEMENT APPROACH

The PWS sets forth “what” service is required as well as the performance standards associated with that task, as opposed to “how” the Contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by the Office of Financial Healthcare Service to monitor the Contractor’s performance to ensure the expected outcomes or performance standards communicated in the PWS are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates to what extent the expected outcomes for the project are being achieved by the Contractor.

Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the Contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. Required processes are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus by the Government provides the Contractor flexibility to continuously improve and innovate over the course of the contract/order as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

1.2 PERFORMANCE MANAGEMENT STRATEGY

The Contractor is responsible for the quality of all work performed. The Contractor measures that quality through the Contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract/order regardless of whether the work is performed by Contractor employees or by Subcontractors. The Contractor’s QC Program (QCP) will set forth the procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The Contractor will implement a performance management system with processes to assess and report its performance to the designated government representative.

The government representative(s) will monitor performance by the Contractor to determine how the Contractor is performing against performance standards. The Contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively. The Contractor will be monitored and assessed throughout the period of performance of the contract/order as to either meeting or not meeting the performance thresholds stated in the Performance Metrics Section of the PWS. The Contracting Officer’s Representative (COR) will perform monthly assessments. The Performance Based Service Assessment Survey, or other method, may be used to document this assessment. A sample Performance Based Service Assessment Survey is provided at the end of this document. When a Contractor performance issue occurs, the COR will notify the Program Manager and Contracting Officer (CO). The COR/CO will engage the Contractor PM to resolve the discrepancy.

1.2.1 PERFORMANCE FEEDBACK:

At the end of each assessment period, the assessment will be reviewed by the Program Manager and CO. The COR/CO will notify the Contractor of the results no later than 15 working days after the end of the assessment period.

2. Government Roles and Responsibilities

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract/order terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the Contractor receives impartial, fair, and equitable treatment under this contract/order. The CO is ultimately responsible for the final determination of the adequacy of the Contractor’s performance.

Assigned CO: Glenn L. Burton, Jr., Contracting Officer Organization: Department of Veterans Affairs, Office of Acquisition and Logistics, Strategic Acquisition Center

Assigned CS: James Modlin, Contract Specialist Organization: Department of Veterans Affairs, Office of Acquisition and Logistics, Strategic Acquisition Center

b. Contracting Officer’s Representative (COR) - The COR is responsible for technical administration of the contract/order and shall assure proper Government surveillance of the Contractor’s performance. The COR shall keep a quality assurance file. This file shall contain all quality assessment reports. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: Michael Dvorak

c. Other Key Government Personnel – None

3. Contractor Representatives

Program Manager – XXXXX

b. Other Contractor Personnel – XXXXX

4. Performance Standards

The Performance Metrics for Deliverables and Performance Standards are outlined in the Performance Work Statement (PWS). The schedule of deliverables is outlined in Section 5 of the PWS. The table is listed below.

Performance Standards define required performance for specific tasks. The Government performs surveillance to determine if the Contractor exceeds, meets or does not meet these standards (see table of Objectives).

The Government may utilize the Performance Based Service Assessment Survey, provided at the end of this document, or other method to compare Contractor performance to the Acceptable Levels of Performance (ALPs).

5. Methods of QA Surveillance

The Government will evaluate contractor performance and deliverables against the following criteria to determine interim and final acceptance of the services provided:

Quality Level

5.2.2

Exercise of option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

option period and past performance and/or other incentives proposed and accepted by VHA

100% INSPECTION. (Evaluates all outcomes.)

Each month, the COR shall review all of the Contractor’s performance/generated documentation and document your results accordingly.

Validated Customer Complaint or Validated Below Average Acceptable Level of Performance (ALP) in a Specific Area:

Each month, the COR shall review the Contractor’s performance/generated documentation corresponding to a validated customer complaint or validated inability to perform in accordance with the ALP in a specific area and document your results accordingly. This assessment shall be placed in the COR’s QA file.

On-Site Surveillance:

Each month, the COR shall review and document findings from an on-site surveillance and document your results accordingly. This assessment shall be placed in the COR’s QA file.

6. Acceptable Levels Of Performance (ALP)

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and ALP.

The ALPs are included in the Performance Metrics Section of the PWS for Contractor performance and are structured to allow the Contractor to manage how the work is performed, while providing negative incentives for performance shortfalls.

7. Incentives

The Government shall consider the Contractor’s performance when making a determination to exercise any options.

8. Documenting Performance

a. Acceptable Performance

The Government shall document acceptable performance accordingly. Any report may become a part of the supporting documentation for any contractual action.

b. Unacceptable performance

When unacceptable performance occurs, the COR shall inform the CO. This will always be in writing although when circumstances necessitate immediate verbal communication, that communication will be followed in writing. The COR shall document the discussion and place it in the COR file.

When the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the Contractor's program manager.

The Contractor shall acknowledge receipt of the CDR in writing to the CO. The CDR will state how long after receipt the Contractor has to take corrective action. The CDR will also specify if the Contractor is required to prepare a corrective action plan to document how the Contractor shall correct the unacceptable performance and avoid a recurrence. The CO shall review the Contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. Frequency of Measurement

a. Frequency of Measurement.

During contract/order performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed, and at a minimum shall be twice a year.

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the Contractor monthly to assess performance and shall provide a written assessment to the CO.

Quality of submission should also be considered. See examples below. Error rates or resubmits for content flaws would be the measures associated with these standards.

Accuracy Work Products shall be accurate in presentation, technical content, and adhere to accepted elements of style.

Clarity Work Products shall be clear and concise. Any/All diagrams shall be easy to understand and be relevant to the supporting narrative.

Consistency to Requirements All work products must satisfy the requirements of this PWS.

File Editing All text and diagrammatic files shall be editable by the VA in Windows-based or Adobe environments/platforms.

Format - Follow specified VA Directives or Manuals and/or best business practices.

Presentations - Presentations shall be clear, concise, executive-focused, and written in plain, clear English with minimal jargon, understandable by lay persons. The quality of deliverables directly contributes to organizational communications.

Project Plan - Project Plan shall be comprehensive; recognize and address authority, perceptions, and concerns of stakeholders; incorporate scope of requisite requirements across the organization and/or agency.

Reports - There shall be no omissions in the reports, documents or functional requirements.

Publications and other documents - Deliverables shall be in formats appropriate to target audiences; user friendly, clear, thorough and comprehensive.

Meeting support - Pre-meeting preparations and logistics; smooth meeting operations; comprehensive post-meeting summaries to include but not limited to: Minutes, Action Items, Attendees, Program Objectives and Milestones and major decision points.

Analyses and Assessments - Analyses and assessments are performed with accuracy, completeness and adherence to industry best practices.

Obtain stakeholder input - Deliverables shall consist of the timely implementation of input mechanisms, and shall consist of an accurate and comprehensive synthesis of results and recommendations. Integration of relevant stakeholder input documented for deliverable.

The following rating definitions can be used as a guide when completing the Performance Based Service Assessment:

Performance Rating Criteria

Below Satisfactory Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

PERFORMANCE BASED SERVICE ASSESSMENT

CONTRACT/ORDER NUMBER/ TITLE:

PERIOD COVERED:

Place an X in the appropriate response

Performance Standards for Assessment

VERY

A. MEETING TECHNICAL NEEDS:

1. What level of understanding does the contractor have of my technical needs and my mission requirements?

2. What level of efficiency and effectiveness does the contractor demonstrate in meeting my requirements?

3. Overall, how well does the contractor meet my technical needs and mission requirements?

B. PROJECT MILESTONES AND SCHEDULE:

1. How well does the contractor meet my established milestones and project dates?

2. How timely are products, reports, and invoices completed, reviewed, and delivered?

3. How would you assess the reasonableness of cost of the services being provided and the accuracy of submitted invoice?

4. How well does the contractor notify me in advance about potential milestones and scheduling problems so that I have enough time to correct them?

C. PROJECT STAFFING:

1. How current is the expertise of those contractors performing requested tasks?

2. Do contractor personnel possess the necessary knowledge, skills and ability to accomplish assigned tasks?

3. Are the staffing levels assigned by contractor appropriate for accomplishing the mission?

D. PERFORMANCE MEASURES:

1. Overall, how well does the contractor meet my established target rates for each claims processing section?

2. How accurately are claims entered into the VA-FSC computer systems?

3. How well does the contractor adhere the VA ICARE values?

4. What overall rating would you give to the contractor's performance?

** Ratings for a Performance Standard are calculated by adding the individual scores under a Performance Standard and dividing it by the number of sub-standards under that Performance Standard.

***Poor and Below Satisfactory ratings must be explained in Section II (Narrative Clarification) below. Must be supportive and objective

II NARRATIVE CLARIFICATION

(USE ADDITIONAL SPACE

AS REQUIRED)

Typed Name And Title of Government Project Lead/ Date