36C10X25R0021_1.docx

SUBJECT*

VHA OFFICE OF FINANCE (OF) – RECOVERY AUDIT SERVICES

GENERAL INFORMATION

SET-ASIDE

POSTAL CODE

COUNTRY

CONTACT INFORMATION

Department of Veterans Affairs

5202 Presidents Court, Suite 103 Frederick MD 21703

POINT OF CONTACT*

Contract Specialist Mr. LaShawn Knight lashawn.knight@va.gov

ADDITIONAL INFORMATION

Presolicitation Notice Presolicitation Notice

DESCRIPTION

Presolicitation Notice

THIS IS NOT A REQUEST FOR COMPETITIVE OFFERS

Recovery Audit (RA) Services This is a Pre-Solicitation Notice for The Department of Veterans Affairs (VA), VHA Office of Finance (OF) has a requirement for up to 3 highly skilled contractor(s) to conduct Recovery Audit (RA) activities of healthcare claim payments made for a variety of VHA Community Care programs, as described below. Automated reviews occur at the system level while complex reviews require a qualified individual to review the medical record. Each program has specific payment methodologies as defined by VA regulations. In general, the audit will review various types of paid healthcare claim data with specific dates and criteria included in the description of each auditing scenario.

OBJECTIVES

Key objectives of the RA contract are to receive access to paid Community Care healthcare claims data; audit that data for potential overpayments to providers based on laws, regulations, policies and industry standard practices (e.g., medical coding) using RAC’s technology solutions and validated by qualified individuals employed by RAC; verify overpayments through a defined dispute process by qualified individuals employed by RAC; and report results to VA. The contractor shall also identify root causes or trends for potential reduction of improper payments. Another key objective of the contract is to manage and perform all provider communications and interactions through the entire lifecycle of each claim’s audit and recovery process, which includes announcements of RAs for new audit topics (e.g., claim types, programs) on a provider portal established and operated by the RAC; receiving ml documentation from providers (e.g., via RAC’s provider portal); notifying providers of audit findings; communicating findings from the defined dispute process; establishing and operating a Customer Service Center (CSC) for addressing questions from providers.

The auditing of various VA Community Care Programs has been organized into mandatory and optional tasks with any exclusions noted in the task descriptions. Each of the auditing tasks has criteria for the specific data set for that scenario. The contractor shall review 100% of the supplied paid claim data in accordance with their approved audit plan, unless otherwise directed by VA, and report results to OF, who will validate findings and perform collection processes once contractor- managed dispute process is exhausted. The contractor shall be paid a percentage of the recovered funds. VA may elect to name another VA organization, another government entity, or a separate contractor to perform the collections on its behalf.

VA will use filters and algorithms to restrict the data provided the contractor to claims data the contractor is required to audit. However, some claim data not required to be audited under this contract may still find its way past those filters and algorithms and become comingled with the required data. The contractor shall not take any action on that data and the contractor shall treat all data in their possession in accordance with Appendix C.

TASK AREAS

Tasks Associated with Contract Requirements:

In addition to auditing the broad spectrum of program-specific data, the contractor also has non- auditing contract requirements to meet. These tasks are further defined in Section III, Specific Tasks.

Task 3

Public Website Establish and maintain a public website for posting of audit plans and receipt of public comments

Task 5

Audit Documentation Obtain access to VA systems and secure documentation required for the audit

providers and the public

Task 7

Auditing VA Paid Claim Data Audit paid claims with qualified individuals supplemented by ready- made technology platforms under authorities in which claims were paid, including request of medical records to verify findings and first level disputes of said findings.

Task 7 Associated with Auditing VA Paid Claim Data:

The Task 7 auditing scenarios listed in the table below (Tasks 7a – 7g) show the VA Programs that could potentially be audited through mutual agreement between the parties, and the authorities under which the claims were paid. The fiscal year ranges identified below refer to Dates of Service (DOS); actual claims payment dates may vary.

Task 7a

(FY15 – June 6, 2019) then PL115 – 182 “MISSION Act of 2018” (June 6, 2019 and forward)

Task 7b VACC Emergency Care for Non-Service Connected Veterans

(FY22 – FY29)

38 U.S.C. § 1725

Veterans (FY22 – FY29) 38 U.S.C. § 1728

FY29)

38 U.S.C. 1720J

Task 7e Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

(FY24 – FY29)

38 U.S.C. § 1781, 38 C.F.R. § 17.270 – 17.278

Task 7f

PL 110-387,

PL 108-183,

38 C.F.R. § 17.900 – 17.905

(FY22 – FY29)

38 U.S.C. § 8153

TYPE OF CONTRACT CONTEMPLATED

OF intends to award up to 3 no cost (contractor is paid out of recovered funds only) contract(s), to provide healthcare claims recovery auditing services. The Government’s obligation to make payments to the contractor under this contract is contingent upon both the contractor’s correct identification of valid overpayments and the Government’s subsequent recovery of overpayments, or portion of overpayments. The contractor shall bear the burden of costs of performing the task associated with the RA and will be compensated only on a percentage of the actual funds recovered.

The full solicitation will be posted on the Contract Opportunities website at www.sam.gov on or about August 1, 2025.

The full solicitation will be conducted as a total small business set-aside. The North American Industry Classification System (NAICS) for this procurement is 541219 –Other accounting services; the size standard is $25 Million.

Potential offerors are responsible for monitoring this site for the release of the solicitation package and any other pertinent information and for downloading their own copy of the solicitation package. Any amendments issued to this solicitation will ONLY be available on this site. Offerors are advised that they are responsible for obtaining all amendments. All questions must be submitted in writing to the Contract Specialist, LaShawn Knight at lashawn.knight@va.gov and Contracting Officer, Jacky Jean-Jacques Jacky.Jean-Jacques@va.gov.

No telephone inquiries will be accepted.

This notice does not obligate the Government to award a contract neither does it obligate the Government to pay for any quotes or proposal preparation costs. The Government is not obligated to issue a solicitation because of this notice. No other information is available until issuance of the solicitation. All interested parties must be registered in System for Award Management (SAM) pursuant to applicable regulations and guidelines prior to award. Registration information can be found at www.sam.gov.

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