36C10G20R0014-003.xlsx
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- Solicitation number
- 36C10G20R0014
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This document contains a performance work statement and quality assurance surveillance plan for a Community Care Network contract in Region 5 Alaska. The contractor will establish and maintain a provider network to deliver various healthcare services to eligible Veterans throughout Alaska. Key performance objectives address network adequacy, appointment availability, claims processing, formulary compliance, and customer service. The quality assurance plan outlines quarterly and annual metrics for objectives like geographic access standards, timeliness of care, and credentialing. Incentives and disincentives ranging from 1-4% of the PMPM payment amount are tied to performance on these metrics. The contract type will be firm-fixed price IDIQ with a nine-month base and seven one-year options. The solicitation is expected to be posted on May 11th with proposals due June 1st.
This federal contract opportunity notice indicates the Department of Veterans Affairs intends to issue a request for proposal around May 11th for a Community Care Network contractor serving Alaska. The anticipated period of performance is a nine-month base period with seven one-year options. Proposals will be due on or around June 1st under full and open competition. The goal is to provide eligible Veterans access to necessary medical care from licensed providers when services are unavailable at VA facilities or inaccessible due to distance.
36C10G20R0014 CCN Region 5 Attachment BA - QASP Performance Requirement Summary.xlsx
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Performance Standards
| PWS Paragraph | Performance Objective / Elements | Acceptable Quality Level (AQL) | Inspection | Incentive / Disincentive | |||
| What | How/ Steps (ST) | When/ Freq | |||||
| 3.1 CCN Healthcare Services Contractor Network Adequacy Performance Objective 1 (PO 1) | Outstanding - 97% and above Very Good -96.9% - 95% Good - 94.99% - 90% Marginal - 89.9% and below | Disbursed payment claim data Network adequacy Corrective Action Plan (CAP) submitted by contractor | ST1-Region 5 network adequacy assessment (PE1*25%+PE2*25%+PE3*25%+PE4*25%) = overall network adequacy ST3 - Corrective Action Plan (CAP) adjustment PE5 (applied to Quarterly and Annually only); each VA Facility (identified in the CAP) will receive a 1.0% reduction per month to their overall regional cumulative percentage. Example: VA Facility on CAP for 7 months will receive a total adjustment of -7.0%) | ||||
| ST4 - Total cumulative regional percentage after CAP adjustment divided by total number of VA Facility in the region = Regional rating | Random Sampling | Yes | |||||
| 25% | PE 1 for PO1 (Geographic Accessibility (Veteran) - Performance Percentage / Average Drive time) Primary care, Mental Health and Extended Care | 30 minutes | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1 - Gather data Per VA Facility |
ST2 - Monthly Claim data (opportunities = active veterans 1st DOS claim paid in a specific month) Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for GEO accessibility
| ST3 - Urban total successes divided by opportunities = Percent of urban success ST4 - Rural/Highly Rural total successes divided by opportunities = Percent of rural success ST5 - Overall assessment Per VA Facility = ST3 Urban *50%+ ST4 Rural/Highly Rural *50 = overall VA Facility assessment | Random Sampling | Yes | |||
| 25% | PE 2 for PO1 (Geographic Accessibility (Veteran) - Performance Percentage / Average Drive time) Specialty care | 60 minutes | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1 - Gather data Per VA Facility |
ST2 - Monthly Claim data (opportunities = active veterans 1st DOS claim paid in a specific month) Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for GEO accessibility ST3 - Urban total successes divided by opportunities = Percent of urban success
| ST4 - Rural/Highly Rural total successes divided by opportunities = Percent of rural success ST5 - Overall assessment Per VA Facility = ST3 Urban *50%+ ST4 Rural/Highly Rural *50 = overall VA Facility assessment | Random Sampling | Yes |
| 25% | PE 3 for PO1 (Appointment availability Percentage / Average) Specialty Care |
| 28 days | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1- Gather data Per VA Facility | |||||
| ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for timeliness standards; Veterans who no-show or reschedule. Performance is measured from date referral sent to provider to date of 1st completed DOS in episode of care ST3 - Total success divided by total opportunities = Percent of success | Random Sampling | Yes | |||||
| 25% | PE 4 for PO1 (Appointment availability Percentage / Average) - Primary Care, Mental Health and Extended Care | 20 days | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1- Gather data Per VA Facility | |||
| ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for timeliness standards; Veterans who no-show or reschedule. Performance is measured from date referral sent to provider to date of 1st completed DOS in episode of care ST3 - Total success divided by total opportunities = Percent of success | Random Sampling | Yes | |||||
| -1.0% after regional cumulative percentage calculated | PE 5 for PO1 (Network Adequacy Corrective Action Plan (CAP) | Submitted within 10 days of discovery | Disbursed payment claim data; 1st DOS in claim; Per referral contractor network adequacy Corrective Action plan - submission | ST1 - Subtract 1.0% from the cumulative regional percentage for each VA Facility identified in the contractor network adequacy CAP report as not meeting standards within the quarter | Audit Quarterly | Yes | |
| 3.2.2: Complementary and Integrative Healthcare Services Contractor Network Adequacy Performance Objective 2 (PO 2) | Outstanding - 97% and above Very Good -96.9% - 95% Good - 94.99% - 90% Marginal - 89.9% and below | Disbursed payment claim data Network Adequacy CAP submitted by contractor | ST1- Individual VA Facility network adequacy assessment (PE1*50%+PE2*50%) = individual VA Facility network adequacy score ST2- Sum of all individual VA Facility network adequacy assessments in the region = Regional network adequacy cumulative percentage |
ST3 - CAP adjustment PE3 (applied to Quarterly and Annually only); each VA Facility (identified in the CAP) will receive a 1.0% reduction per month to their overall regional cumulative percentage. Example: VA Facility on CAP for 7 months will receive a total adjustment of -7.0%)
| ST4 - Total regional cumulative percentage after CAP adjustment divided by total number of VA Facility in the region = Regional rating | Random Sampling | Yes | |||
| 50% | PE1 for PO2 (Geographic Accessibility (Veteran) Percentage / Average Drive time) | 30 minutes | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1 - Gather data Per VA Facility |
ST2 - Monthly Claim data opportunities = active veterans 1st DOS claim paid in a specific month. Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for GEO accessibility ST3 - Urban total successes divided by opportunities = Percent of urban success
| ST4 - Rural/Highly Rural total successes divided by opportunities = Percent of rural success ST5 - overall assessment Per VA Facility = ST3 Urban *50%+ ST4 Rural/Highly Rural *50 = overall VA Facility assessment | Random Sampling | ||
| 50% | PE2 for PO2 (Appointment availability Percentage / Average) Specialty | ||
| 28 days | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1- Gather data per VA Facility |
ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for timeliness standards; Veterans who no-show or reschedule. Performance is measured from date referral sent to provider to date of 1st completed DOS in episode of care ST3 - Overall appointment availability within 30 days ST4 - 70% of ST3 = Total Success
| ST5 - Total success divided by total opportunities = Percent of success | Random Sampling | Yes | |||||
| -1% after regional cumulative percentage calculated | PE3 for PO2 (Network Adequacy Corrective Action Plan (CAP) | Submitted within 10 days of discovery | Disbursed payment claim data; 1st DOS in claim; Per referral contractor network adequacy Corrective Action plan - submission | ST1 - subtract 1.0% from the cumulative regional percentage for each VA Facility identified in the contractor network adequacy CAP report as not meeting standards within the quarter | Audit Quarterly | Yes | |
| 17.1 Dental Contractor Network Adequacy Performance Objective 3 (PO 3) | Outstanding - 97% and above Very Good -96.9% - 95% Good - 94.99% - 90% Marginal - 89.9% and below | Disbursed payment claim date Network adequacy Corrective Action Plan (CAP) submitted by contractor | ST1- Individual VA Facility network adequacy assessment (PE1*20%+PE2*20%+PE3*20%+PE4*20%+PE5*20%+PE6) = individual VA Facility network adequacy percentage ST2- Sum of all individual VA Facility network adequacy assessment in the region = Regional network adequacy cumulative percentage |
ST3 -CAP adjustment PE6 (applied to Quarterly and Annually only); each VA Facility (identified in the CAP) will receive a 1.0% reduction per month to their overall regional cumulative percentage. Example: VA Facility on CAP for 7 months will receive a total adjustment of -7.0%) .
| ST4 - Total cumulative percentage divided by number of VA Facility in the region = Regional rating | Random Sampling | Yes | |||
| 33% | PE1 for PO3 (Geographic Accessibility (Veteran) Percentage / Average Drive time) | 30 minutes | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1 - Gather data Per VA Facility |
ST2 - Monthly Claim data opportunities = active veterans 1st DOS claim paid in a specific month. Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for GEO accessibility ST3 - Urban total successes divided by opportunities = Percent of urban success
| ST4 - Rural/Highly Rural total successes divided by opportunities = Percent of rural success ST5 - overall assessment Per VA Facility = ST3 Urban *50%+ ST4 Rural/Highly Rural *50 = overall VA Facility assessment | Random Sampling | Yes | |
| 33% | PE2 for PO3 (Appointment availability Percentage / Average) Primary | ||
| 20 days | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1- Gather data per VA Facility |
ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for timeliness standards; Veterans who no-show or reschedule. Performance is measured from date referral sent to provider to date of 1st completed DOS in episode of care ST3 - Overall appointment availability within 30 days ST4 - 70% of ST3 = Total Success
| ST5 - Total success divided by total opportunities = Percent of success | Random Sampling | Yes | |
| 33% | PE3 for PO3 (Appointment availability Percentage / Average) Specialty | ||
| 28 days | Disbursed payment claim data; 1st DOS in claim; Per referral | ST1- Gather data per VA Facility |
ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) Minus the following opportunities: validated deviation; Veterans who self appoint; Veterans who prefer a provider outside of contract standards for timeliness standards; Veterans who no-show or reschedule. Performance is measured from date referral sent to provider to date of 1st completed DOS in episode of care ST3 - Overall appointment availability within 30 days ST4 - 70% of ST3 = Total Success ST5 - Total success divided by total opportunities = Percent of success
| -1% after regional cumulative percentage calculated | PE4 for PO3 (Network Adequacy Corrective Action Plan (CAP) | submitted within 10 days of discovery | Disbursed payment claim data; 1st DOS in claim; Per referral contractor network adequacy Corrective Action plan - submission | ST1 - subtract 1.0% from the cumulative regional percentage for each VA Facility identified in the contractor network adequacy CAP report as not meeting standards within the quarter | Random Sampling | Yes |
| 15.2 14 Day Fill Perscription Network Adequacy Performance Objective 4 (PO 4) | Outstanding - 97% and above Very Good -96.9% - 95% Good - 94.99% - 90% Marginal - 89.9% and below | Disbursed payment claim data; 1st DOS in claim; Per referral Monthly Electronic Urgent/Emergent Prescription Report |
Monthly Electronic Prior Authorization Report
| ST1- Individual VA Facility network adequacy assessment (PE1*33.3%+PE2*33.3%+PE3*33.3%) = individual VA Facility network adequacy percentage ST2- Sum of all individual VA Facility network adequacy assessment in the region = Regional network adequacy cumulative percentage ST3 - Total Regional network adequacy cumulative percentage divided by number of VA Facility in the region = Regional rating | Random Sampling | Yes | |
| 33.30% | PE1 for PO4 - (Geographic Accessibility (Veteran) Percent / Average Drive time) - Urban beneficiaries have access to network pharmacy within 5 miles of residence | good - 90% and above | Disbursed payment claim data; 1st DOS in claim; Per referral Monthly Electronic Urgent/Emergent Prescription Report |
Monthly Electronic Prior Authorization Report ST1- Per VA Facility ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) -- validated deviations
| ST3 - Total success divided by total opportunities = Percent of success | Random Sampling | Yes | ||
| 33.30% | PE2 for PO4 (Geographic Accessibility (Veteran) Percent / Average Drive time) - Rural beneficiaries have access to network pharmacy within 20 miles of residence | good - 70% and above | 1. Disbursed payment claim data; 1st DOS in claim; Per referral 2. Monthly Electronic Urgent/Emergent Prescription Report |
3. Monthly Electronic Prior Authorization Report ST1- Per VA Facility ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) - validated deviations
| ST3 - Total success divided by total opportunities = Percent of success | Random Sampling | Yes | ||
| 33.30% | PE3 for PO4 (Geographic Accessibility (Veteran) Percent / Average Drive time) - Highly Rural Location beneficiaries have access to network pharmacy within 200 miles of residence | good 70% and above | Disbursed payment claim data; 1st DOS in claim; Per referral Monthly Electronic Urgent/Emergent Prescription Report |
Monthly Electronic Prior Authorization Report ST1- Per VA Facility ST2- Monthly Claim data (opportunities = active veteran 1st DOS claim paid by VA in a specific month) - validated deviations
| ST3 - Total success divided by total opportunities = Percent of success | Random Sampling | Yes | ||
| 15.2.1:14 Day fill prescriptions meet VA prescription Performance Objective 5 (PO5) | overall conformance with VA Urgent/Emergent Formulary for CCN providers | Outstanding - 97.5% and above Very Good - 97.49% - 96.0% Good - 95.99% - 95.0% Marginal - 94.9% and below | 1. Disbursed payment claim data; 1st DOS in claim; Per referral 2. Monthly Electronic Urgent/Emergent Prescription Report |
3. Monthly Electronic Prior Authorization Report
| ST1- Monthly Claim data (opportunities = active veteran claim paid by VA in a specific month) | ||||
| ST2 - Total number of Urgent / Emergent prescriptions paid in the quarter ST3 - Success total number of Urgent / Emergent formulary conformance reviewing claims and monthly prescription report ST4 - Total Success / Total opportunities = Percent of Success | Sampling / Inspection and Audit Quarterly | Yes | ||
| 15.2.1: 14 Day Fill prescriptions meet VA prescription Performance Objective 6 (PO6) | overall conformance with generic dispensing for VA Urgent/Emergent prescriptions for CCN Providers | Outstanding - 97.5% and above Very Good - 97.49% - 96.0% Good - 95.99% - 90.0% Marginal - 89.9% and below | Disbursed payment claim data; 1st DOS in claim; Per referral Monthly Electronic Urgent/Emergent Prescription Report |
Monthly Electronic Prior Authorization Report ST1- Monthly Claim data (opportunities = active veteran claim paid by VA in a specific month) ST2 - Total number of Urgent / Emergent prescriptions paid in the quarter
| ST3 - Success total number of Urgent / Emergent generic formulary conformance reviewing claims and monthly prescription report ST4 - Total Success / Total opportunities = Percent of Success | Sampling / Inspection and Audit Quarterly | Yes | |||||
| 3.7.1: Network Credentialing Requirements upon Accreditation Performance Objective 7 (PO7) | All network services, facilities, and providers shall be credentialed in accordance with a nationally-recognized accrediting body | 98% compliance at any given time | Network provider file (deliverable) | ST1 - Sampling of providers and facilities to verify licensing, accreditation, credentialing and licensing records ST2 - Sample size success divided by opportunities = percent of success | Sampling / Inspection / Audits Continuous Annual review of accreditation and credentialing | No | |
| 6.5: Complaints and Grievances Procedure Performance Objective 8 (PO8) | The Contractor shall forward all Veteran Complaints and Grievances received to VA within three (2) business days of receipt. | 98% | 1. contractor call center operations / customer service technology report | ||||
| 2. VA call center data | ST1 - Total opportunities is determined based upon the date the Veteran complaint was received by the contractor in a given month |
ST2 - Total success is measured from the date the contractor received the Veteran complaint to the date the contractor submits to the VA (date forwarded to VA is < 2 business days)
| ST3 - Total success divided by total requested cards in a given month = success percent | Random Sampling | No | ||
| 6.6: VA and Congressional Inquiries Performance Objective 9 (PO9) | The Contractor must establish a point of contact (POC) for Congressional inquiries and VA inquiries. The Contractor shall forward to VA all inquiries received directly by the Contractor from a Congressional office, and a copy of the full written response back to the Congressional office, within five (5) business days of an inquiry. | |||
| VA reserves the right to request information relating to customer service at any time. When VA requests supplemental information from the Contractor, the Contractor shall confirm receipt of the request within one (1) business day. Notification of receipt can be accomplished electronically via an agreed-upon mechanism with VA. The Contractor shall provide the full written response within five (5) business days of VA’s request. | 95% | 1. contractor call center operations / customer service technology report | ||
| 2. VA call center data | ST1- (PE1 * 25.0% + PE2 * 25.0% + PE3 * 25.0% + PE4 * 25.0%) = overall congressional inquiry performance | Random Sampling | No | |
| 25.00% | PE1 of PO9 The Contractor shall forward all inquiries received directly by the Contractor or one of the CCN Providers from a Congressional office that is associated with services under this contract to VA within five (5) business day of receipt | 95% | 1. contractor call center operations / customer service technology report | |
| 2. VA call center data | ST1 - Total opportunities is determined based upon the date the contractor or CCN provider receives a congressional inquiry in a given month |
ST2 - Success the number of opportunities which the contractor meet standards:
| ST3: Date inquiry received measured against date contractor submits to VA is less than 5 business days ST4 - total success divided by total opportunities in a given month = success percent | Random Sampling | No | ||
| 25.00% | PE 2 for PO9 When VA requests information from the Contractor, the Contractor shall confirm receipt of the request within one (1) business day | 95% | 1. contractor call center operations / customer service technology report | |
| 2. VA call center data | ST1 - Total opportunities is determined based upon the date the VA submits a request to the contractor on a congressional inquiry in a given month |
ST2 - Success the number of opportunities which the contractor meet standards 1 business day
| ST3: Date VA submitted inquiry measured against date contractor confirms receipt is 1 business days or les ST4 - total success divided by total opportunities in a given month = success percent | Random Sampling | No | ||
| 25.00% | PE3 for PO9 The contactor must always provide VA relevant background information regarding Congressional inquiry within (3) business day of notification | 95% | 1. contractor call center operations / customer service technology report | |
| 2. VA call center data | ST1 - total opportunities is determined based upon VA data requesting congressional background information within a given month. | |||
| ST2 - Success the number of opportunities which the contractor meets standards within 3 business day ST3 date VA submitted notification to measure against date contractor returns background information to VA ST4 - total success divided by total opportunities in a given month = success percent | Random Sampling | No | ||
| 25.00% | PE 4 for PO9: The Contractor shall provide the full written response within five (5) business days | 95% | 1. contractor call center operations / customer service technology report | |
| 2. VA call center data | ST1 - Total opportunities is determined based upon the date the VA submits a request to the contractor on a congressional inquiry in a given month |
ST2 - Success the number of opportunities which the contractor meet standards of providing a full written response back to VA in 5 business days or less ST3: Date VA submitted inquiry measured against date contractor submits full written response back to VA in 5 business days or less
| ST4 - total success divided by total opportunities in a given month = success percent | Random Sampling | No | |||||
| 6.8: Call Center Operational Performance Measures Performance Objective 10 (PO10) | Outstanding - 97% and above Very Good -96.9% - 95% good - 94.99% - 90% Marginal - 89.9% and below | 1. Contractor Call center Operations Customer Service technology monthly report | PE1*20% + PE2*30%+PE3*25%+PE4*25% = overall assessment | Random Sampling | No | ||
| 20% | PE 1 for PO 10: Blockage rate | less than 5% | Contractor Call center Operations Customer Service technology monthly report | ST1 - total opportunities = total number of calls in a given month ST 2 - success number of calls not receiving a fast busy signal in a given month ST3 - success divided by total opportunities = success percentage | Random Sampling | No | |
| 30% | PE 2 for PO 10: Call abandonment rates | 5% or less | Contractor Call center Operations Customer Service technology monthly report | ST1- the Percentage of contacts that spend time waiting to speak to an agent and then hung-up or otherwise exited the system before being offered to an agent (call is not resolved in the IVR | Random Sampling | No | |
| 25% | PE 3 for PO 10 : Average speed of answer | 30 seconds or less | Contractor Call center Operations Customer Service technology monthly report | ST1- the average speed to answer Total time / number of calls | Random Sampling | No | |
| 25% | PE 4 for PO 10 : first call resolution (between Contractor and VA) | 85% or higher | Contractor Call center Operations Customer Service technology monthly report Contractor CRM Data | ST1 - total calls answered / number of annotated 1st call resolutions ** NO FURTHER FOLLOW UP REQUIRED*** | Random Sampling | No | |
| 6.5 Complaints and Grievances Performance Objective 11 (PO11) | |||||||
| Any Veteran Complaint or Grievances VA forwarded to the Contractor on behalf of a Veteran shall be resolved within three (3) business days. | 98% compliance | contractor call center operations / customer service technology report | ST1 - Total opportunities is determined based upon the date the VA submits Veteran complaint to the contractor in a given month |
ST2 - Total success is measured from the date the VA submits to the contractor to the date the contractor submits the resolved response to the VA
| ST3 - Total success resolutions divided by total opportunities in a given month = success percent | Random Sampling | No | |||||
| 7.1: Notification of Emergency Care Performance Objective 12 (PO12) | The Contractor shall instruct CCN providers to notify VA of all emergency admissions of Veterans to a community hospital or behavioral health care facility within seventy-two (72) hours following an emergent admission. | 90% | Table 7.3 Process for Transmitting Referrals from a CCN Provider | ST1 - Total opportunities is determined by the number of 278 transactions submitted by the Contractor / provider for emergency care (date and time of 278 transaction) in a given month ST2 - Success is measured by the number of emergency 278 submissions by the contractor / provider to VA in 72 hours or less (278 date /time of emergency admission to date on 278 submission to VA) ST3 - overall performance - total success divided by total opportunities in a given month = success percent | Random Sampling | No | |
| 18.2: Continuity of Operations Performance Objective 14 (PO14) | Contractor meets the operational availability, and recovery time objectives (RTO) requirements stated in the PWS 18.2. | 99.9% | Continuity of Operations Report | ST1 - Unscheduled downtime occurs for more than one (1) cumulative hour in any given twenty-four (24) hour period | Random Sampling | No | |
| 12.4: Claims Submission and Processing Timeframes (accuracy of submission) Performance Objective 15 (PO15) | Process CCN Provider Clean and Resubmission Claims within thirty (30) days | 98% | 1. EDI 835 Transaction File 2, Weekly Claims Processing Reports | ST1- Total opportunities = number of clean provider claims submitted to the contractor in a given month (date of original claim submission to contractor) and claim resubmissions | |||
| ST2 - Success = the number of clean provider claims processed in 30 day or less by the contractor measured from date of receipt to adjudication and resubmission claims from date of resubmission to adjudication ST3 - Overall performance = total success divided by total opportunities | Random Sampling | No | |||||
| 14.2: Clinical Quality Issues Identification Performance Objective 16 (PO16) | Process to completion potential quality issues within 90 and 180 days | 90% in 90 Days 99% in 180 days | 1. Quarterly Clinical Quality Issues Report | ST1- Total opportunities = number of reported potential quality issues identified in a 90 day period ST2 - Success = the number of potential quality issues resolved in a 90 and 180 day period (date identified to date resolved) | |||
| ST3 - Overall performance = total success divided by total opportunities | Sampling / Inspection and Audit Quarterly | No |
Incentive disincentive factors
| CCN increase/ decrease Factor (IDF) | Contractor Major Responsibility | PWS Authority | QASP Performance Objective | increase/ decrease logic | Increase | Disincentive | Frequency of calculation and payment | |||
| Benefits | Positive Outcome | Indicator of Outcome | Negative Outcome | Indicator of Outcome | ||||||
| IDF1 | Building provider network | High Performing Network | N/A | Step 1: total number of institutional providers identified as high performing (CoE) divided by total number of institutional providers not designated as high performing (CoE) = overall percentage Step 2: total number of group practice providers identified as high performing divided by total number of group practice providers not designated as high performing = overall percentage Step 3: total number of individual providers identified as high performing divided by total number of individual providers not designated as high performing = overall percentage Step 4: overall percentage of institutional providers meeting high performing (CoE) designation multiplied by 33.3% + overall percentage of group providers meeting high performing designation multiplied by 33.3% + overall percentage of individual providers meeting high performing designation multiplied by 33.3% = overall percentage of network provider meeting the high performing designation | This incentive is designed to encourage the Contractors to educate and encourage providers in the network to submit the quality performance metrics that will allow them to be designated as high performing providers. Providers who achieve High Performing status will get higher priority in referrals. Quantitative data regarding this new approach is not available at this time. However, having the provider's quality data allows VA and Veterans to seek the highest caliber of care available in a particular area when the service is not available in VA. | Increased participation in the high performer ratings | Increase is applied to PMPM Tiered performance. 2% increase for performance equal to or greater than15.0% of CCN Network Providers earning earning high performing designation 1% increase for Performance equal to 12.0% and less than 15.0% of CCN Network Providers earning earning high performing designation No increase/ decrease for performance below 12.0% | N/A | N/A | Semi-annually |
| IDF2 | Building provider network | Network Usage | N/A | Step 1: total opportunities = total number of medical service invoice claims submitted by the contractor and non-network providers claims providing services through the contract, which were reimbursed by the VA in a given month (minus out of network emergency and Mental Health Veteran Self-scheduling) Step 2: Success = total number of claims with approved referrals number paid by the contractor to network providers Step 3: success divided by opportunities = Percentage of claims submitted by network providers | The incentive and disincentive is designed to encourage the contractors to develop, maintain and exceed the network adequacy standards in the PWS to meet the demand of Veterans who require community care. It is also designed to encourage the recruitment of hospital based specialists, such as radiologists, anesthesiologists, pathologists, emergency medicine and hospitalists who are in must be used by patients of the hospital, yet who resist network participation with almost all commercial and government beneficiary networks. This incentive and disincentive is designed to limit the volume of out-of-network (OON) services by encouraging the contractor to make all efforts to recruit providers that address every aspect of the continuum of care to join the community care network. | 92% of all claims submitted will be network provider claims | Increase is applied to PMPM Tiered performance 2% increase when performance is greater than or equal to 92.0%; No increase for performance greater than 90.0% and less than 92.0% | 8% or more of all claims submitted by out-of-network providers | Deduction applied to total out of network claims paid for services authorized through the contractor Tiered performance 2% decrease when performance is less than 90% | Monthly |
| IDF3 | Maintain provider network | Maintain Network Adequacy | PO 1-4 | Step 1: QASP PO1 1st Quarter regional assessment * 12.5% + QASP PO1 2nd Quarter Regional Assessment *12.5% = QASP PO1 semi-annual overall rating percentage Step 2: QASP PO2 1st Quarter regional assessment * 12.5% + QASP PO2 2nd Quarter Regional Assessment *12.5% = QASP PO2 semi-annual overall rating percentage Step 3: QASP PO3 1st Quarter regional assessment * 12.5% + QASP PO3 2nd Quarter Regional Assessment *12.5% = QASP PO3 semi-annual overall rating percentage Step 4: QASP PO4 1st Quarter regional assessment * 12.5% + QASP PO4 2nd Quarter Regional Assessment *12.5% = QASP PO4 semi-annual overall rating percentage Step 5: QASP PO1 Semi-annual percentage + QASP PO2 semi-annual percentage + QASP PO3 Semi-annual percentage + QASP PO4 semi-annual percentage = overall increase/ decrease success percentage | The contract requires that vendors maintain a sufficient network to meet VA’s referral needs, but health care is a dynamic service complicated by changing patient care requirements, changes in VA capabilities, changing reimbursement environments and the existing and projected shortfalls of physicians. This incentive/disincentive is designed to emphasize the importance of not only an initial robust network, but also a network tailored to the ongoing referral requirements of Veterans. This incentive will encourage the Contractors to keep physicians in the network and to work with VAMCs to identify future needs and meet them. Like IDF2, the disincentive component is the stronger financial impact to encourage meeting at least minimum standards as outlined in the PWS. | Network supports VA referral needs | Increase is applied to PMPM Tiered performance. 2% increase for performance greater than or equal to 97.0% 1% increase for performance greater than or equal to 95.0% and less than 97.0% No increase for performance greater than or equal to 90.0% and less than 95.0% | Network cannot support VA's referral needs | Deduction applied to PMPM Tiered performance 2% deduction when performance is greater than or equal to 87.0% and less than 90.0% 4% deduction when performance is less than 87.0% | Semi-annually |
| IDF4 | Provider Education and Claims Payment | Claims Submission and Processing Timeframe | N/A | Data source: claims reports submitted to VA Step 1: total opportunities = total number of claims submitted to the contractor by CCN providers during a given 180 day period (-) Minus Emergency care, Mental health and front end rejected EDI claims submitted to the contractor from providers Step 2: success = total number of claims processed by the contractor as clean claims step 3: total successes divided by opportunities = percent of success | The VA benefits from this incentive by increasing CCN network provider satisfaction on the timeliness of reimbursement, access to contractor training materials and resources to increase the percentage of clean claims submitted to the contractor for reimbursement. The monetary incentive / disincentive on the contractor will drive the contractor to increase this provider satisfaction element and decrease the number of direct complaints submitted to the VA by providers who are not satisfied with the level of service they receive from contractors administering the CCN network. Ultimately the VA and Veterans will benefit with increased access to care through the contractor’s CCN network | Timely claims processing | Increase is applied to PMPM Claims received by the Contractor will be clean claims and processed on the first pass 1% Increase for performance equal to or greater than 90.0% | Not recommending any disincentive | n/a | Semi-annually |
| IDF5 | IPERA | Adjudication and Payment Rules | N/A | Step 1: VA Publishes Annual Universe of healthcare services Accuracy of Performance Thresholds to Reduce Improper Payments (IPERA) by individual quater assessments Step 2: Incentive / Disincenive plan updated by contracting and published by contracting Step 3: Contractor submits quartelry independent third party audit statistical projections of improper payment / accuracy performance Step 4: VA reviews and provides acceptance / rejection of independent 3rd party audit results: confirms statistical projection of improper payments / accuracy of payment by quarter | Increased accuracy of universe of healthcare claims pricing ensures claims are only looked at once (decreases rework costs) and supports Annual reduction of improper payments and recovery of improper payments | Increased accuracy of claims pricing ensures claims are only looked at once (decreases rework costs) | Increase is applied to PMPM Tiered performance 2% increase for performance equal to or greater than 97.0% 1% increase for performance greater than or equal to 96.0% and less than greater than 97.0% No increase for performance greater than or equal to 95.0% and less than 96.0% | Decreased accuracy of claims pricing results in claims being looked at multiple times (increases rework costs) | Deduction applied to PMPM Tiered performance 2% deduction when performance is greater than or equal to 94.0% and less than or equal to 95.0% 4% deduction when performance is equal to or less than 94.0% | Quarterly |
| IDF6 | Formulary adherence | 14 Day prescription fills | PO5 / PO6 | Step 1: QASP PO5 Quarterly Assessment Multiplied by 50% + QASP PO6 Quarterly assessment multiplied by 50% = overall success for increase/ decrease calculation | Pharmacy Service’s incentive and disincentive program is designed to influence the CCN providers’ prescribing pattern through the Contractor to mirror VA providers’ prescribing pattern. Pharmacy Service has worked collaboratively with our VA providers to achieve a 95% or better conformance to the VA National Formulary and generic drug utilization. These achievements have led to significant medication cost savings, or avoidance, via established national contracts for generic drugs and blanket purchase agreements with brand manufacturers. Maintaining or surpassing 95%, will result in opportunities to further reduce pharmaceutical costs nationally while maintaining the highest standard of medicinal care for our Veterans. Payment shall apply to the total pharmacy PMPM (CLINXX11AC) paid amounts within a period of 3 months, quarterly. | Compliance with Urgent/Emergent Formulary | Increase is applied to PMPM Tiered performance 3% increase for performance equal to or greater than 97.5% 1% increase for performance greater than or equal to 96.0% and less than 97.5% No increase for performance greater than or equal to 95.0% and less than 96.0% | Compliance with VA utilization of the urgent/emergent formulary contract | Deduction is applied to PMPM Tiered performance 1% deduction When performance is greater than or equal to 90.0% and less than 95.0% 3% deduction When performance is less than 90.0% | Quarterly |
Table 1 Incentive factors
| CCN Incentive / Disincentive Factor (IDF) | Contractor Major Responsibility | PWS Authority | QASP Performance Objective | Frequency of calculation and payment | Maximum Incentive (%) | Maximum Disincentive (%) |
| IDF 1 | Building provider network | High Performing Network | N/A | Semi-annually | 2% | 0 |
| IDF 2 | Building provider network | Network Usage | N/A | Monthly | 2% | 2% |
| IDF 3 | Maintain provider network | Maintain Network Adequacy | PO 1-4 | Semi-annually | 2% | 4% |
| IDF 4 | Provider Education and Claims Payment | Claims Submission Accuracy | N/A | Semi-annually | 1% | 0 |
| IDF 5 | IPERA | Ajudication and Payment Rules | N/A | Quarterly | 2% | 4% |
| IDF 6 | Formulary adherence | urgent/emergent prescription fills | PO5 / PO6 | Quarterly | 3% | 3% |
Table 2 CCN Anl Max Incen Value
| CCN Incentive / Disincentive Factor (IDF) | Contractor Major Responsibility | PWS Authority | Frequency of payment | Region 5 Estimated Maximum Incentive Annual Value | Region 5 Estimated Maximum Disincentive Annual Value | ||
| IDF 1 | Building provider network | High Performing Network | Semi-annually | 2% | $ 158,437.46 | 0 | $ - 0 |
| IDF 2 | Building provider network | Network Usage | Monthly | 2% | $ 158,437.46 | 2% | $ 158,437.46 |
| IDF 3 | Maintain provider network | Maintain Network Adequacy | Semi-annually | 2% | $ 158,437.46 | 4% | $ 316,874.91 |
| IDF 4 | Provider Education and Claims Payment | Claims Submission Accuracy | Semi-annually | 1% | $ 79,218.73 | 0 | $ - 0 |
| IDF 5 | IPERA | Ajudication and Payment Rules | Quarterly | 2% | $ 158,437.46 | 4% | $ 316,874.91 |
| IDF 6 | Formulary adherence | 14 Day prescription fills | Quarterly | 3% | $ 870.73 | 3% | $ 870.73 |
| CCN Annual Maximum Incentive Value | $ 713,839.29 | $ 793,058.02 | |||||
| Please note: the above maximum incentive and disincentive values are estimates. The actual maximum incentives and disincentives will be based on the final contract value for PMPM and active Veteran volume. |
File details come from the government source that posted it. Updated .