Air Ambulance QA Revised 7-30-24.pdf

Pre‐Solicita on No ce

36C26024R0088 DRAFT RFP

Ques ons and Responses

Ques on 1: Prior to issuing this pre‐solicita on, did the VA engage with industry stakeholders on the viability of its proposed brokerage model? If so, can you please detail which en es the VA engaged with and on what dates?

VA Response: Yes, prior to the pre‐solicita on the VA did engage with the industry stakeholders. The following is a list of several engagements, which have occurred, between VHA and air ambulance leaders/industry points of contact. In addi on to the list below, VA senior leaders have also had separate conversa ons with companies.

o Industry Day 1: May 25, 2023 o Industry Day 2: July 20, 2023 o Industry Day 3: August 30, 2023 o Interview conducted by VHA Procurement and Logis cs Office: (Large Business) January 31, 2024 o Interview conducted by VHA Procurement and Logis cs Office: (Large Business) January 31, 2024 o Interview conducted by VHA Procurement and Logis cs Office: (Large Business) February 1, 2024 o Interview conducted by VHA Procurement and Logis cs Office: (Large Business) February 6, 2024 o Women‐Owned Small Business Industry Day: March 20, 2024

Ques on 2: Does the pre‐solicita on and thus the RFP cover provisions for Veterans of emergency air ambulance transports?

VA Response: No. The pre‐solicita on does not cover provisions for Veterans of non‐VA ini ated emergency air ambulance transports. However, it does cover “on‐demand” transport if it is ini ated by the VA. The VA has two categories of VA‐ini ated, prescheduled air ambulance transports: 1. Standard and 2.

On‐demand (STAT). These are the only transports that are ini ated by the VA under this solicita on.

Ques on 3: Is the pre‐solicita on and thus the RFP limited to only cover provisions for Veterans of scheduled air ambulance transports?

VA Response: Yes.

Ques on 4: Can the VA provide clear and simple informa on and references that answer whether if the pre‐solicita on and thus the RFP does not cover provisions for Veterans of emergency air ambulance transports, has the VA determined that it does not have statutory authority to contract for these emergency, unscheduled transports, which the VA did not ini ate?

VA Response: The RFP does not cover non‐VA ini ated emergency air ambulance transports.

Ques on 5: If the pre‐solicita on and thus the RFP covers provisions for Veterans of emergency air ambulance transports, how will this (and the use of VetRide) work with the widespread use of the 911 system, which is also used to request emergency transports for Veterans? Or will the VA insert a broker to dispatch 911 requests for Veterans? If the la er, how will 911 determine in advance that the pa ent is a Veteran?

VA Response: The RFP does not cover non‐VA ini ated emergency transporta on.

Ques on 6: If the pre‐solicita on and thus the RFP cover provisions for Veterans of emergency air ambulance transports, has the VA determined the 911 system is inadequate for Veterans?

VA Response: No. The RFP does not cover non‐VA ini ated emergency transporta on.

Ques ons and Responses

Ques on 7: Does the VA plan to replace the 911 system with VetRide? If so, how will rural physicians and first responders know to use VetRide to request a transport of a Veteran requiring transport?

VA Response: No.

Ques on 8: Did the VA determine whether there are exis ng small businesses capable of serving as air transporta on brokers for life‐saving flights, whether emergency or non‐emergency, before limi ng the planned RFP to small businesses? If no small businesses qualify under the RFP for a region, will it be opened to larger business concerns?

VA Response: Yes, the VA did extensive market research including mul ple RFIs and determined that there were adequate Small Businesses within that market. If the requisite number of awards cannot be made to small businesses, addi onal contracts will be solicited for those regions that are not covered under a contract.

Ques on 9: Will Federal Acquisi on Regula on (FAR) 52.225‐1 apply to this solicita on?

VA Response: The Buy American Act does not apply to this acquisi on..

Ques on 10: If so, is this restricted to the equipment used for opera ng the brokerage, or for all of the prime contractor's helicopters and other equipment used in providing transports?

VA Response: N/A

Ques on 11: It appears that sec on 3.2.7 bases payment for air ambulance services based on a price/block hour rate. Why is the VA devia ng from the Medicare, Medicaid, and commercial industry standard of base rate and miles traveled reimbursement?

VA Response: The price/block rate language is being removed from 3.2.7. The price schedule reflects a mileage rate that is higher than Medicare/Medicaid reimbursement rates.

Ques on 12: Under a price/block rate, how will rural air ambulance transports be appropriately compensated for transports over long distances? What provisions are made for transports origina ng in one region and ending in another, such as from Mississippi to Alabama and vice versa?

VA Response: VA is not using a price block rate. Rural air ambulance transports shall be compensated on a base rate/mileage rate basis.

Emergency vs. non‐emergency transports (emergency transports originate from physicians and emergency responders, NOT the VA):

Ques on 13: Does the pre‐solicita on and thus the RFP cover provision for Veterans of emergency air ambulance transports, scheduled air ambulance transports, or both? Note that:

a. Section 2.2.1 requires a 60‐minute response time for urgent and STAT transports, which is much longer than the industry standard for emergent transports. Note also that STAT in medicine is an abbreviation for the Latin word statim, which means immediately.

Ques ons and Responses

b. The Pre‐solicitation Notice Description in Part A refers to AP89 for special modes of transportation, which includes emergency services.

VA Response: The RFP only covers scheduled air ambulance transports. See answer to ques on 2.

Ques on 14: If the pre‐solicita on and thus the RFP does not cover provision for Veterans of emergency air ambulance transports, has the VA determined that it does not have statutory authority to contract for these emergency, unscheduled transports, which the VA did not ini ate?

a. If the pre‐solicitation and thus the RFP does not cover provision for Veterans of emergency air ambulance transports, how does VA intend to obtain and pay for emergency, unscheduled transports, which the VA did not initiate?

VA Response: The VA has determined that non‐VA ini ated emergency air transports will not be covered under this acquisi on. Unscheduled transports will be reimbursed under VA’s applicable regula ons.

Ques on 15: Can the VA provide clear and simple informa on and references that answer whether this RFP will apply to Veteran transports not ini ated by the VA?

a. Note that section 2.2 provides that response times are measured from the time VA places an order.

VA Response: No, this RFP will not apply to Veteran transports not ini ated by the VA.

Ques on 16: If the pre‐solicita on and thus the RFP covers provision for Veterans of emergency air ambulance transports, is it intended to replace the 911 system for Veterans?

a. Or to insert a broker to dispatch 911 requests for Veterans?

b. If the latter, how will 911 determine in advance that the patient is a Veteran?

VA Response: The RFP does not cover non‐VA ini ated emergency air ambulance transports.

Ques on 17: If the pre‐solicita on and thus the RFP cover provision for Veterans of emergency air ambulance transports, what is it about the 911 system that is inadequate for Veterans?

VA Response: The RFP does not cover non‐VA ini ated emergency air ambulance transports.

Ques on 18: How will rural physicians and first responders know to use VetRide to request a transport of a Veteran requiring transport? See 3.2.1

VA Response: Non‐VA personnel are not authorized to use VetRide to request transport.

Ques on 19: Will all providers, even those outside the VA, be required and able to submit requests for transporta on through VetRide?

Ques ons and Responses

VA Response: VetRide is a VA internal system that will be used to manage veterans’ transport. Non‐VA personnel are not authorized to use VetRide to request a transport.

Ques on 20: Will the contractor be able to retroac vely enter informa on into VetRide for these transports, and will the air ambulance organiza on receive prompt payment (will the Prompt Payment Act apply)? Sec on 4.5 appears to indicate that these unscheduled transports will require further review and that “private agencies” like non‐VA hospitals are not “considered authorized to place transporta on requests.”

VA Response: Contracted vendors will have 30 days from date of transport to enter informa on into VetRide of authorized transports. Yes, the Prompt Payment Act will apply.

Ques on 21: Will the VA work with facili es and providers to ensure they have the training, technology, and capabili es in place to ini ate VetRide?

VA Response: Yes, contractors will be trained on the use of VetRide..

An trust concerns created by the RFP:

Ques on 22: Will the Government, including the Department of Veterans Affairs and the Department of Jus ce, hold air ambulance providers harmless for any and all an trust and compe on law viola ons or liability, for the sharing of price data that is inherent in a prime contractor opera ng the brokerage with flights performed by other air ambulance providers?

VA Response: No.

Brokerage‐specific ques ons:

Ques on 23: Will air transporta on brokers be required to follow the regula ons for air charter brokers under 14 CFR Part 295?

VA Response: Yes, an Air Ambulance broker does not meet the exemp on of sub‐part B; however, the contract will take precedence where the clauses of the contract related to the health care aspect of the requirement conflict with the requirements of 14 CFR 295.

Ques on 24: Did the VA determine whether there are exis ng small businesses capable of serving as air transporta on brokers for life‐saving flights, whether emergency or non‐emergency, before limi ng the planned RFP to small businesses? Please explain the methodology used to make this determina on, if applicable.

VA Response: Yes, prior to the pre‐solicita on the VA engaged with the industry stakeholders and conducted market research before making the set‐aside determina on.

Ques on 25: If no small businesses qualify under the RFP for a region, will it be opened to larger business concerns?

Ques ons and Responses

VA Response: The VA did extensive market research including mul ple RFIs and determined that there were adequate Small Businesses within that market. If the requisite number of awards cannot be made to small businesses, the requirement will be resolicited for those regions that are not covered under a contract.

Ques on 26: Sec on 1.1 states that prime contractors with large operator networks qualify for this contract. How does being a provider with a large operator network reconcile with being a small business?

VA Response: An operator network refers to access to mul ple operators either through formal business rela onships or by other means such as access to data lis ngs. Having access to a large operator network does not require a broker to have operators on staff.

Ques on 27: For prime contractors ac ng as a broker and using their own air ambulance services, the number would be one. Will this diminish the prime contractor's evalua on for this criterion? Should the ques on instead be how many fully staffed and opera onal air ambulances are in your network? Part

5.1.4.5 is also inapplicable to contractors providing the air ambulance services directly.

VA Response: The dra solicita on calls for a capability statement showing how interested offerors plan to meet the requirement and includes a requirement for informa on such as evidence of staff to operate 24/7, evidence of access to adequate medical staff and equipment, the number of air ambulance providers in the network, how addi onal providers are ve ed, and the management tools being used to communicate with providers to arrange services. None of these requirements limits your ability to reference a fleet wholly owned and operated by the broker.

Ques on 28: Will Federal Acquisi on Regula on (FAR) 52.225‐1 apply to this solicita on?

VA Response: The Buy American Act does not apply to this acquisi on.

Ques on 29: If so, is this restricted to the equipment used for opera ng the brokerage, or for all of the prime contractor's helicopters and other equipment used in providing transports?

VA Response: N/A

Contract payment ques ons

Ques on 30: It appears that sec on 3.2.7 bases payment for air ambulance services based on a price/block hour rate. Why is the VA devia ng from the Medicare, Medicaid, and commercial industry standard of base rate and miles traveled reimbursement?

VA Response: The price/block rate language is being removed from 3.2.7. The price schedule reflects a mileage rate that is higher than Medicare/Medicaid reimbursement rates.

Ques on 31: Under a price/block rate, how will rural air ambulance transports be appropriately compensated for transports over long distances?

Ques ons and Responses

VA Response: VA is not using a price block rate. Rural air ambulance transports shall be compensated on a base rate/mileage rate basis.

Transport specific ques ons

Ques on 32: Sec on 3.2.4 states that no devia on from the order can be made by the contractor but must instead be made by the ordering officer. How does this account for unforeseen circumstances while in flight?

VA Response: Unforeseen circumstances will require no fying the VA of the situa on at its earliest convenience.

Ques on 33: How many individuals will be delegated by the Administra ve Contrac ng Officers as Ordering Officers? How are the Ordering Officers selected? How will the Ordering Officers communicate with providers outside the VA system?

VA Response: Each Medical facility will have a list of 10‐15 Ordering Officers. Ordering Officers will not communicate with outside providers. They will communicate only with the Air Ambulance broker and the Contrac ng Officer for any concerns.

Ques on 34: What provisions are made for transports origina ng in one region and ending in another, such as from Mississippi to Alabama and vice versa?

VA Response: Each region will transport within the iden fied area of responsibility to the maximum extent possible. Where it is deemed that transport must cross regions, the contract of origina ng region will govern.

Ques on 35: Were some states deliberately put in mul ple regions, such as Virginia and West Virginia – and if so, why? In such cases, which air transporta on broker or prime contractor will be responsible for origina ng transport?

VA Response: In the final RFP states will be in only one region.

Ques on 36: Does the pre‐solicita on apply to emergent air medical transports, to non‐emergent (i.e.

scheduled) air medical transports, or to both? Given the nature of emergent transports, the delay a broker model creates can significantly increase uncertainty and delay as well as lead to undesirable outcomes.

VA Response: The solicita on applies to preauthorized On‐Demand transports as defined in the RFP, not non‐VA ini ated emergency transports. See ques on 2.

Ques on 37: If this pre‐solicita on applies to emergent air medical transports, does it apply only to transports origina ng at a VA facility, or does it apply to transports that are not origina ng at a VA facility (which is the vast majority of transports of veterans)?

Ques ons and Responses

VA Response: The RFP does not apply to non‐VA ini ated emergency transports. On‐Demand transport may originate from other than a VA facility.

Ques on 38: Consistent with FAR Part 33, we would like for our outside counsel to address Air Methods’ concerns with the Agency. Would you please provide us with the contact informa on for Agency counsel assigned to this procurement?

VA Response: Air Method's concerns should be presented to the Contrac ng Officer in wri ng. The contrac ng officer will consult with agency counsel on any legal ma ers presented.

Ques on 39: It is unclear what types of air ambulance transports are covered by the PWS. The language of the PWS appears to be primarily aimed at non‐emergent and pre‐scheduled air ambulance transports from or to a VA facility. It is unclear whether the PWS covers emergent transports not involving a VA facility, which cons tute the vast majority – more than 93% – of Air Methods’ transports of veterans.

VA Response: This requirement applies to VA ini ated transports only.

Ques on 40: Regardless of the types of transports the PWS covers, the opera onal and reimbursement requirements in the PWS do not align with commercial industry prac ces, making the PWS unworkable from an opera onal and administra ve standpoint. For example:

VA Response: No example was provided so VA does not know where the PWS may not align with commercial prac ces.

Ques on 41: The only air ambulance providers capable of providing these na onwide air ambulance brokerage services are unable to bid, as none of them – Air Methods included – meet the required small business size of fewer than 1,500 employees. Any company awarded a contract under the PWS will need to build a large, na onwide, non‐exclusive subcontractor network, as we do not believe a broker can be successful without contrac ng with every air ambulance company throughout the country. This simply cannot be accomplished by February 1, 2024.

VA Response: According to the brokers we interviewed, there is a substan al database of operators that is in use throughout the industry and available to brokers. A subcontractor network is not required.

Ques on 42: The 30‐minute and 60‐minute response me requirements create safety concerns.

Response me requirements are viewed by the Federal Avia on Administra on as crea ng pressure to fly, which can poten ally result in safety issues. Air ambulance transports, and par cularly emergent transports, typically respond to requests much more quickly than as required under the PWS, but there should never be response me requirements in air ambulance contracts.

VA Response: The 30‐minute meframe is being amended. See ques on 49. The requirement is for flight arrangements to me made within this meframe. VA does not expect the flight to take place within this meframe. The RFP does not cover non‐VA ini ated emergency air ambulance transports.

Ques ons and Responses

Ques on 43: Sec on 3.3.7 indicates that the PWS covers emergency transporta on and requires no fica on to the VA within 72 hours following transport. This me frame is en rely unworkable and not industry standard. For example, Medicare requires that claims for transports of eligible beneficiaries be submi ed within 365 days a er transport. Air ambulance companies o en have no knowledge of a pa ent’s healthcare coverage for weeks following an emergent transport.

VA Response: This requirement applies only to VA‐ini ated transports. The 72‐hour requirement has been removed.

Ques on 44: Air ambulance transports are billed to Medicare and Medicaid, and to substan ally all other payers, based on two codes: a base/li code, and a mileage code. This is industry standard and applies to both rotor and fixed‐wing emergent transports. The VA’s price per block hour reimbursement structure is en rely outside the norm and would lead to administra ve challenges for providers.

VA Response: This is incorrect. VA's pricing schedule includes a base rate and a milage rate and is aligned with the way Medicare pays for transport.

Ques on 45: Each company awarded a broker contract under the PWS will need to contract with every other air ambulance company in the na on in order to leverage mul ple assets na onwide, which is the stated goal of the PWS. Sharing transport volume and pricing informa on between air ambulance providers could be perceived as an ‐compe ve behavior, and more clarity is needed from the VA in this regard.

VA Response: N/A

Ques on 46: More clarity is needed regarding the $98,100,000 maximum aggregate value of orders. The VA has repeatedly stated that it intends to pay a fair and reasonable rate for air ambulance transports, but it is unclear how the VA has determined that $98.1 million over five years is a fair and reasonable maximum contract amount. Our internal review suggests that this alloca on will fail to cover basic opera ng costs and will lead to dras c underpayment for air ambulance services. As Air Methods and others in our industry have explained to the VA, the failure to receive a fair and reasonable payment for air ambulance transports of veterans will almost certainly lead to the closure of air ambulance bases throughout the country, thereby jeopardizing care to veterans.

VA Response: The solicita on does not iden fy a maximum aggregate value of orders. The RFP will iden fy contract ceiling amounts for each of the five contracts.

Ques on 47: Is the RFP solicita on specifically for emergent transporta on? If non‐emergent, how does an emergent air ambulance provider contract for services for sustainable reimbursement, being that Medicare reimbursement does not cover cost?

VA Response: This requirement applies to VA ini ated transports only.

Ques on 48: What is an ‘authorized facility’? Does this solicita on include non‐VA to non‐VA transports, or is it intended for VA‐VA scheduled transfers?

VA Response: This requirement applies to VA ini ated transports only. It can apply to both situa ons, so long as VA places the order.

Ques ons and Responses

Ques on 49: In sec ons 2.2.1 On Demand Response and 2.2.2 Standard Response me, it states that the required response me is 60 minutes and 90 minutes respec vely. But, within the Quality Assurance Surveillance Plan, the response mes show 30 minutes for On Demand Response and 60 minutes for the Standard Response. What are the accurate response mes?

VA Response: The correct response mes are 60 and 90 minutes respec vely. The Quality Assurance Surveillance Plan will be corrected, and the VA thanks you for the assistance.

Ques on 50: In cases of emergent situa ons, how does the VA plan to streamline transport approval processes when the pa ent's VA insurance status is uncertain? For instance, in scenarios where a veteran sustains injuries and local protocols recommend the use of the nearest air ambulance. How will this process work for inter‐facility transfers as well?

VA Response: This RFP does not cover non‐VA ini ated emergency transports.

Ques on 51: What con ngency plans are in place if contracted air ambulance service is unavailable or lacks sufficient coverage in a par cular region?

VA Response: VA has the op on of contrac ng directly with any provider for a specific transport.

Ques on 52: How does the VA plan to compensate brokerages for the addi onal infrastructure required to onboard subcontractors, manage dispatch resources, monitor performance, and provide repor ng?

Currently, GMR is known for having this level of infrastructure through the FEMA brokerage contract, but it's important to note that this is situa on‐specific and not for immediate, on‐demand needs.

VA Response: The VA will pay the broker in accordance with the price schedule. There will be no cost‐ based line items.

Ques on 53: What measures will the VA implement to ensure that brokerages maintain robust networks and do not engage in opportunis c prac ces? Is there a framework in place to guide how brokerages establish and adjust pricing structures?

VA Response: The VA will pay the broker in accordance with the price schedule. There will be no cost‐based line items.