36C77622R0090_1.docx

36C77622R0090

GENERAL INFORMATION

SET-ASIDE

PCAC-ST. LOUIS

1 Jefferson Barracks Dr., Bldg 56 Saint Louis MO 63125

POINT OF CONTACT*

Contract Specialist Haley Huff Haley.Huff@va.gov

PLACE OF PERFORMANCE

POSTAL CODE

ADDITIONAL INFORMATION

DESCRIPTION

Payer Relations and Services Support

This is a Synopsis of Proposed Contract Action in accordance with FAR Part 5.2

The government anticipates awarding a Firm Fixed Price (FFP), Single Award, Indefinite Delivery – Indefinite Quantity (IDIQ) contract resulting from this proposed action. The incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2022-06, effective 05/26/2022.

The contract is anticipated to have a base year plus 4 option year.

· Anticipated Minimum Guarantee: $2,500.00

· Anticipated Minimum Order: $2,500.00

· Anticipated Contract Ceiling: $25,000,000.00

The associated North American Industrial Classification System (NAICS) code for this procurement is 541611 with a small business size standard of $21.5 Million. The solicitation is anticipated to be Full and Open.

Synopsis Synopsis All interested companies are encouraged to review the Performance Work Statement and other provided documents to begin preparing proposals for the upcoming solicitation, which will be posted approximately 7 days after the post date of this synopsis.

Synopsis

A.1 PERFORMANCE WORK STATEMENT

Title of Project: Payer Relations and Services Support Contract

The Payer Relations and Services (PR&S) department, within the Office of Finance, Revenue Operations, provides detailed analytical support to review reimbursement rates paid or proposed by Third-Party Payers (TPPs) and Pharmacy Benefit Managers (PBMs) to determine whether payments meet federal payment requirements. PR&S is also responsible for the implementation of VA’s rates and charges billed to TPPs and other entities.

Scope of Work: The Contractor shall provide subject matter expertise sufficient to support PR&S in areas to include Electronic Health Record Modernization (EHRM) implementation, development of rates and charges, changing payer reimbursement models, rate verifications, expanding analytical needs, and program/project support.

Specifically, the contractor shall support PR&S with the following:

· Overall PR&S program support to include project management, Standard Operating Procedure (SOP) and Guidebook development, special project support, business and strategic analysis of PR&S operations, development of executive presentations, and facilitation of executive briefings

· Planning, development, calculation and implementation of VA Rates and Charges for inpatient admissions, skilled nursing admissions, outpatient services, professional services, supplies, and drugs; encompassing all medical services for over 1500 VA hospitals/clinics in over 700 geographic areas

· Provision of national rates and charges to the specific geographic adjusted charge for stations in production with the VA’s new Electronic Health Record (EHR).

· Administration of TPP Rate Verification activities

· Key Performance Indicator (KPI) monitoring and risk mitigation under Electronic Health Record Modernization (ERHM) Charge Services (CS) and Charge Description Master (CDM) governance

· Net Collection Ratio (NCR) analysis, review, and recommendations

· Provide assessments of current state to industry best practices

· Development and stand up of a robust revenue integrity program that aligns revenue and workload components across Consolidated Patient Account Centers (CPACs), Veterans Integrated Services Networks (VISNs), and Veterans Affairs Medicals Centers (VAMCs).

· Support PR&S and regional Payer Relations Managers (PRMs) with activities relating to value-base care (VBC) arrangements

· Analysis of annual charge master updates that assesses the impact of variances in charge amounts, unit dosage changes, and VA utilization changes from the prior year

· Training, mentoring and education support of PR&S staff and PRMs

· Ad Hoc analyses, studies, or assessments

· TPP agreement review and recommendations

· Financial impact analysis related to rate verification with commercial payers

2. Background: Title 38 USC Section 1729 and Title 38 CFR Part 17.101 and Part 17.106 is the authority that permits VA to seek reimbursement from TPPs and PBMs for the cost of non-service-connected medical care furnished to eligible Veterans who have commercial insurance coverage. Under this authority TPPs are required to pay VA billed charges, or the amount they can demonstrate to the satisfaction of the Secretary of VA that they pay non-government providers in the same geographic area as a VA Medical Center (VAMC). The money collected from TPPs and PBMs is revenue anticipated in the President’s budget and helps to offset VA imposed cost sharing for world class medical care provided to our nations Veterans.

PR&S established a process to verify whether or not a TPP or PBM is reimbursing VA per the authority noted above and has worked with a number of TPPs to develop regional and national payer agreements and rates. The goal of this process is to ensure TPP compliance with this authority and to identify and maximize revenue and operational opportunities.

VA is committed to delivering world-class service to Veterans and their families. To adequately fund world-class health care services, VA needs to collect funds from private health insurers and, where permitted by law, public health insurance.

VA implemented the reasonable charges methodology to set charges for medical care services and updates them on an annual basis. This methodology sets VA charges at the 80th percentile of nationwide charges. This methodology has been employed since 1999. VA requires Contractor support to assist in the development of rates and charges for a variety of services, in addition to providing support in evaluating opportunities to improve revenue.

3. Performance Period: The period of performance shall be one year from the date of award for a base period. The contract will also include four (4) 12-month option years.

There are eleven (11) Federal holidays set by law (U.S.C. Title 5 Section 6103):

Under current definitions, five are set by date:

If any of the above falls on a Saturday, then Friday shall be observed as a holiday. Similarly, if it falls on a Sunday, then Monday shall be observed as a holiday.

The other six are set by a day of the week and month:

Work at the government site shall not take place on Federal holidays or weekends unless directed by the Contracting Officer (CO).

4. Place of Performance: The Contractor shall support this effort at the Contractor facilities within the continental United States. Under no circumstances can any of the services be provided by contractor employees outside of the United States.

5. Type of Contract: The Government will award a Firm Fixed Price, Indefinite Delivery, Indefinite Quantity (IDIQ) contract for this requirement.

6. APPLICABLE DOCUMENTS:

Documents referenced or germane to this PWS are listed below. The Contractor shall be guided by the information contained in the documents in performance of this PWS. The documents are:

a. 38 Code of Federal Regulations (CFR), 17.101, 17.100, 17.102 and 17.106

b. Title 38 USC Section 1729

c. Center of Medicare and Medicaid Services (CMS) guidelines

d. Center of Medicare and Medicaid Services (CMS) Databases

e. Data reports to mirror those described in 38 CFR 17.101

f. The Health Insurance Portability and Accountability Act of 1996 (HIPAA – all existing and revised statutes)

g. Federal Information Security Management Act (FISMA)

h. VHA Policy

In addition, all work and products executed and provided to VHA Office of Finance/Revenue Operations PR&S shall be formatted and/or structured to be compatible (e.g., data structures/input/output must execute without error and reports/documents shall be formatted to comply with established guidance) with the following established protocols:

· Structured Query Language (SQL)

· My SOL, Workbench, Oracle Discoverer and Oracle Business

· VHA Intelligence tools (Power+, mPower, Power BI (Oracle Business Intelligence); Payer Compliance Tool; Tableau or Spotfire

· Project Management Institutes Body of Knowledge (PMBOK)

· MS Office

B1. GENERAL REQUIREMENTS:

General Requirements:

a. All written deliverables will be phrased in layperson language. Statistical and other technical terminology will not be used without providing a glossary of terms.

b. All CMS mandated regulations relating to billing, rates, and charges shall be incorporated into the rate development task identified in tasks 3 through 5.

c. All VA Reasonable Charge methodology as identified in 38 CFR 17.101 (including data sources and calculations) shall be followed.

The Contractor team shall have knowledge of Current Procedural Terminology (CPT)/Diagnostic Related Group (DRG)/Healthcare Common Procedure Coding System (HCPCS) codes. In addition, possess knowledge of technical concepts and training in preparing analytic reports and economic analysis using VA data which is Billed and Charge data by month, to do trend analysis and projections on estimated revenue impact on charge updates. Also, the contractor shall have the medical health care expertise in making sound judgement calls on the data that is being used to develop charges. This is a critical necessity to have as a contractor due to the sensitivity of the work. The contractor shall possess and demonstrate the following knowledge:

a) 3rd Party Coding and Billing – updating codes, modifiers and charges based on CMS regulations and effective dates.

b) A CMS Bundling rules –understanding some codes are not billable.

c) A Bundling regulations for admin codes.

d) A Status indicator knowledge – understanding what codes are used for Inpatient, Outpatient and SNF billing.

e) A VA IT Host files preparation – working with staff and IT patch developer staff to provide proper charge assignments.

f) VA Reasonable Charges Regulations in 38 CFR 17.101 (pages of calculations) for each area of billing.

g) CMS Regulations relating to billing, rates, and charges.

h) Developing charges at the 80th Percentile of nationwide charges.

i) Itemized vs per diem inpatient billing.

j) Extensive knowledge of Medicare Severity Diagnostic Related Groups (MS-DRGs) – which began in 2008 with Complications and Comorbidities (CC) and Major Complications and Comorbidities (MCC’s).

k) Developing Room & Board (R&B), Ancillary, Intensive Care Unit (ICU) services – most data received nationwide is based on itemized billing.

l) Working knowledge of APC Groupings – Medicare APC pricing has to be adjusted to conform to VA’s rates at the 80th percentile.

m) Working with outlier claims and the correlation for developing charges – some charges should not be used because they skew the outcome of the charge development and are out of the norm.

n) Use of medical and non-medical CPI-U, Medicare geographic practice cost expense and all urban consumers.

o) Working knowledge of developing Geographical Area Adjustment Factors (GAAF’s) to develop charges for different areas of the country. Understand COLA (Cost of Living Allowances), wage indexes and non-wage indexes which all play a part in COLA/GAAF’s. Labor/non-labor components.

p) A Working knowledge of Med Par files, Market Scan and Fair-Health databases.

q) Working knowledge of creating DME, Medical and Lab Fee Schedules.

r) Working knowledge of the development of Professional conversion factors.

s) How payers in the private sector apply discounts on reimbursement of billed charges.

t) Working knowledge and experience with creating an economic analysis - very critical to projection of future revenue generation.

u) And hands-on experience making the tables 508 compliant using Adobe XI PRO or applicable VA required software for web-posting

v) The contractor shall possess an understanding of conversion of drug dosages from Milliliters to Milligrams to properly set charge rates for drugs.

w) To analyze large claim database extracts (up to 100,000,000 rows or lines of data) of sensitive information in accordance with FISMA from both the VA and external TPP systems and provide a relevant data analysis of both the VA claims data and TPP claims data to determine if reimbursement rates paid or proposed by TPPs or PBM meet federal payment requirements.

x) To complete market and data analysis related to emerging TPP alternative payment methodologies in order to provide the financial impact of emerging payment methodologies in the insurance industry.

y) To be able to complete an annual analysis of VA Annual Charge Master updates that analyzes impact of variances in charge amounts, unit dosage changes, and VA Utilization changes from the previous year.

It is an integral requirement of this contract that the contractor shall provide staff experienced in healthcare consulting including a comprehensive knowledge and understanding of common reimbursement methodologies and payment practices for Medicare and other third-party payers. Key personnel demonstrating an understanding of the federal regulatory process as well as the VA charge methodology detailed in 38 CFR 17.101 is required.

A member of the Contractor team shall be a member of the American College of Healthcare Executives (ACHE), American Association of Healthcare Administration Management (AAHAM), Healthcare Financial Management Association (HFMA), the American Health Information Management Association (AHIMA) or similar healthcare administration industry organization.

Key Personnel: The Contractor shall provide staff experienced in healthcare consulting, including development of charges using a variety of methods for both Medicare and commercial insurance billing. This includes a comprehensive knowledge and understanding of common payment practices for Medicare and other third-party payers. The Contractor shall be able to develop rates and charges based on the published VA methodology and perform an economic analysis on the expected changes in the rates and charges. The Contractor shall be able to demonstrate extensive experience in the following categories: actuarial experience, healthcare billing experience, and exhibit comprehensive knowledge and understanding of common payment practices for Medicare and other third-party payers. The Contractor shall demonstrate an understanding of the federal regulatory process as well as the VA charge methodology detailed in 38 CFR 17.101. The Contractor shall be experienced in evaluating payment rates and methodologies made by TPPs and have a comprehensive knowledge and understand of common reimbursement methodologies and payment practices. In meeting the requirements of this contract, the individuals listed below are considered essential to successful performance and are “Key Personnel” who must possess, at a minimum, the following experience and background:

Partner/Principal – Must possess a Bachelor’s degree and Actuary Certification

Must possess a minimum of ten (10) years actuarial experience in the health insurance industry particularly with respect to facility and professional rate development, charge description master maintenance and evaluation of rates in relationship to Medicare Fee Schedules and payer agreements. The Contractor shall have at least one principal/partner with current professional actuarial certification and be a member of an actuarial society in good-standing (e.g., Fellow of the Society of Actuaries (FSA), Associate of the Society of Actuaries (ASA), Member of the American Academy of Actuaries (MAAA)). Previous experience and working knowledge of Centers for Medicare and Medicaid Services (CMS) regulations and development of actuarial models based on Medicare Provider Analysis and Review file (MedPAR), MarketScan, Essential Resource-Based Relative Value Scale (RBRVS), FAIR Health databases, Medicare Ambulatory Payment Classification (APC), Medicare Geographic Practice Cost Index for both practice and work expense, Medicare Durable Medical Equipment (DME), Medicare Lab Fee Schedule and Medicare Conversion Factors. Additionally, experience working with Consumer Price Index – All Urban Consumers (CPI)-U in applied situations for statistical modeling.

Project Manager – Must possess a Bachelor’s degree and Project Management Professional (PMP) Certification

Must have a minimum of seven (7) years’ experience as a Project Manager and Health Care Reimbursement subject matter expert.

Senior Staff – Must possess a Bachelor’s degree and Actuary Certification

Must possess a minimum of Five (5) years actuarial experience in the health insurance industry particularly with respect to facility and professional rate development, charge description master maintenance and evaluation of rates in relationship to Medicare Fee Schedules and payer agreements. The Contractor shall have at least one senior staff member with current professional actuarial certification and be a member of an actuarial society in good-standing (e.g., Fellow of the Society of Actuaries (FSA), Associate of the Society of Actuaries (ASA), Member of the American Academy of Actuaries (MAAA)). Must have previous experience and working knowledge of CMS regulations and development of actuarial models based on MedPAR, MarketScan, Essential RBRVS, FAIR Health databases, Medicare APC, Medicare Geographic Practice Cost Index for both practice and work expense, Medicare DME, Medicare Lab Fee Schedule and Medicare Conversion Factors. Additionally, experience working with CPI-U in applied situations for statistical modeling.

Substitution of Key Personnel. All Contractor requests for approval of substitutions hereunder shall be submitted in writing to the COR and the Contracting Officer at least (30) calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the Contracting Officer necessary to vet the proposed substitution. Substitute key personnel shall not commence work until all necessary security requirements have been fulfilled and resumes provided and personnel accepted by the Contracting Officer. The COR and the Contracting Officer will evaluate such requests and promptly notify the Contractor of approval or disapproval in writing. All substitutions must demonstrate via resume the minimum requirements listed in this section.

B2. SPECIFIC MANDATORY TASKS AND ASSOCIATED DELIVERABLES

Description of tasks and Associated Deliverables: The Contractor shall provide the specific deliverables described below. See the schedule of deliverables for the specific dates.

Task 1: Project Management. The Contractor shall establish an initial kick-off conference call/virtual meeting with the PR&S project team. The Contractor shall provide a detailed project management plan and briefing for the PR&S project team, which presents the Contractor’s plan for completing the task order. The Contractor’s plan shall be responsive to this PWS and describe, in further detail, the approach to be used for each aspect of the task order as defined in the technical proposal. At a minimum, the project management plan shall include the risk, quality, and technical management approach, detailed schedule, cost requirements and proposed personnel. The Contractor shall keep the project management plan up to date throughout the period of performance. The Contractor shall establish a recurring conference call/virtual meeting with PR&S project team monthly and provide meeting minutes documenting attendance, discussions, decisions, actions, and next steps within 5 calendar days following the meeting.

Deliverable 1:

· 1a: Initial Kick-off meeting established within 7 calendar days of contract award.

· 1b: Project Management Plan within 30 calendar days of contract award.

· 1c: Monthly Project Status meeting established within 30 calendar days of contract award.

· 1d. Meeting minutes provided within 5 calendar days following the meeting.

· 1e. Monthly status report providing work in-progress or completed, as well as any issues or risks that need to be communicated to the COR. The report will be delivered on the fourth Wednesday of each month.

Task 2. Program Support. The Contractor shall meet with the PR&S project team in person at the PR&S Offices in the Mid-Atlantic Consolidated Patient Account Center (MACPAC) building located at 128 Bingham Road, Asheville NC 28801 within 30 calendar days of contract award. The Contractor shall provide a staff member skilled in project management and meeting facilitation as well as a senior healthcare consultant. This meeting will plan out the program support needs for the period of performance to include:

· Standard Operating Procedure (SOP) development or updates

· Guidebook development and/or updates

· Key Performance Indicator monitoring

· Business and strategic analysis

· Other program support needs determined during the initial meeting.

Monthly program support meetings will be scheduled, facilitated, and recorded by the Contractor.

Deliverable 2:

· 2a - Contractor shall provide a detailed project plan to meet the objectives identified in the Program Support meeting within 15 calendar days following the meeting.

· 2b – Monthly meeting minutes and project plan updates shall be provided within 5 calendar days following the monthly meeting.

Task 3. Inpatient Update. The Contractor shall submit the draft and final inpatient economic analysis to VA PR&S project team to include existing and new MS-DRGs (for inpatient and Skilled Nursing Facility (SNF) updates) based on the CMS regulations published each fiscal year. The Contractor will identify any new MS DRG codes and provide to the PR&S team within 15 days of the codes being published by the Standard Development Organization (SDO). The Contractor will assist VA on how to set up the EHR billing system for the new codes, as necessary. The Contractor shall facilitate a virtual meeting to review the findings and address any rate outliers. The Contractor shall submit draft Host Files and Federal Register tables to the PR&S project team for review. The Contractor shall provide updated final Host File and Federal Register tables related to the inpatient charge update upon PR&S project team approval of draft documents. The Contractor shall review methodologies used previously in accordance with 38 CFR 17.101 and ensure that regulations are followed while developing the Inpatient and SNF tables and charges. The rate updates must include updated tables based on CMS regulations published each fiscal year. The tables must be in the format used by VA for Federal Register publication and the Host file tables must be developed based on VA format (Excel spreadsheet) and reviewed by Office of Information Technology staff prior to acceptance. The contractor will provide the annual DRG and SNF EHR Data Collection Workbook (DCW) with geographically adjusted per diem prices for all medical centers currently implemented with the Cerner Millennium system or those that have been identified by VA as being in the testing phases of a future implementation. VA will provide a current list of facilities for the period of performance that have implemented the new EHR or are in the testing phase on a monthly basis by the 1st Tuesday of each month. The Contractor shall provide a final project binder describing the methodology used for the MS-DRG rate update, a copy of the host files and federal register tables, as well as detailed reports showing the variance in rates per MS-DRG year over year. The Contractor shall participate as needed on rate development conference calls and respond to questions directed to them within two business days of the receipt of the question.

The Contractor shall:

3a. Provide a draft economic analysis in Excel spreadsheet format by the first week in July, annually. The economic analysis must include a detailed estimate of increase in revenue based on VA’s prior year methodology used for calculating this economic impact analysis, as well as take prior year billing and expected collections into account. It must be developed using VA’s collection data and take into account the components of the VA Reasonable Charges methodology. The economic analysis must include worksheets that show the trend forward calculation using the medical CPI tables. An internal peer review must be conducted by the contractor prior to submission to PR&S project team. A final analysis is due within 3 business days after PR&S project team review and approval of the draft economic analysis.

3b. Provide the draft Federal Register and Host file rate update tables (Table A – Acute Inpatient Facility Nationwide Per Diem Charges by MS-DRG, and Table B – Skilled Nursing Facility/Sub-Acute Inpatient Facility Nationwide Per Diem Charge) and conduct a virtual review with the PR&S project team of the draft tables by the second week in August. After government review, the Contractor shall revise the tables and Data Source tables and provide the final Federal Register data tables to the PR&S project team and the Host Files to the IT Developer for final review. The final tables are due no later than the first week in September. The final Federal Register tables must be 508 compliant and provided in both an MS Excel format and an image PDF copy.

3c. Provide a summary outlining the changes (variances from year to year) in rates for each rate increase and shall provide a detailed Excel spreadsheet listing each code and the rate increase. Detailed charge development review will be required for each MS-DRG subjected to significant change from the previous year. This information shall be provided within two weeks of the finalization of the rates for publication in the Federal Register.

3d. Attend weekly and ad hoc development calls and participate as requested. The Contractor shall provide detailed responses via email to questions on rates and charges, describing specific methodology used for charge calculations, within two business days of the receipt of the question.

3e. Provide an Inpatient final project binder describing the methodology and data used in the rate update. This Inpatient binder should consist of at least three sections. Section one should include “Scope of Project” with the Economic Impact analysis and supporting documentation. Section two should include all final Federal register and host file tables; including detailed schedules developed to show how the rates were calculated as well as the variance tables to show the difference from year to year. Section three should have all Appendices to show Federal Register regulations, final and proposed tables, final supplementary data source tables as documented in the regulations. This final project binder shall be provided within four weeks of the finalization of the Federal Register rates.

3f. Provide annual and periodic EHR Host files (Master Data Collection Workbook (DCW) formatted file) by station number and zip code as sites are implemented under the Cerner System. The GAAF Adjusted EHR annual Inpatient Host file is due no later than the second week in September for all stations under the EHR System. The tables will include charge data for all Inpatient services and provides pricing by Station numbers, and associated Zip codes. This Master DCW is to include columns for pricing for all MS-DRG’s by Station Numbers by names/suffixes and zip codes and all related charges for all zip codes as facilities become live in the EHR System.

3g. Provide charge validation on the charges loaded to Cerner Millennium from the master DCW to confirm the correct VA charge for the specific location was loaded. VA will provide the extract from Cerner Millennium showing the charge detail information.

Deliverable 3:

· 3a – Draft economic analysis due first week in July annually – final analysis due within 3 days of receipt of PR&S project team input

· 3b – Draft Federal Register Notice and Host File Rate Update Tables due the second week in August – final tables due the first week in September

· 3c – Rate Change Summary due within two weeks of the finalization of rates for publication

· 3d – Responses to ad hoc e-mails and questions within two business days of receipt

· 3e – Inpatient final project binder due within 4 weeks following the finalization of the Federal Register notice of rate updates

· 3f – Data Collection Workbook (DCW) file for all Facilities implemented with Cerner Millennium due the second week in September

· 3g. Charge validation to be completed with errors identified or comments provided no later than 3 business days from receipt of the Cerner extract from VA.

Task 4. Geographic Area Adjustment Factor (GAAF) Updates. The Contractor shall analyze the existing Reasonable Charge rates and provide an update to all of the Inpatient, Outpatient, Professional, and SNF Geographic Area Adjustment Factors tables included in the VA reasonable charge files, as outlined by the Reasonable Charges methodology. The Contractor shall provide their assistance to VA on how to set up the EHR charge tables for new locations in various stages of the testing and implementation phases of the new EHR as provided by the VA monthly to determine the best approach for loading rate tables by zip code.

The Contractor shall provide the following GAAF Tables: Acute Inpatient Facility Charges GAAFs, Skilled Nursing Facility/Sub-Acute Inpatient Facility Charges GAAFs by Zip Code, Outpatient Facility Charges GAAFs by Zip Code, Durable Medical Equipment, Supplies, Vision and Hearing Hardware Charges GAAFs by Zip Code, and the Outpatient Dental Professional Charges GAAFs by Zip Code and Professional Services Relative Unit (RVU) and Conversion Factor GAAFs by Zip Code. Additionally, the Contractor shall provide a variance table that compares the GAAFs from year to year for every impacted VA Medical Center. The draft GAAF tables will be provided to VA no later than the 2nd week of October and the final GAAF tables will be provided no later than the 2nd week of November.

Deliverable 4. Draft GAAF Tables provided no later than the 2nd week of October and Final GAAF Tables provided no later than the 2nd week of November.

Task 5. Outpatient Update: The Contractor shall develop the economic analysis for the rate updates for each existing and new Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes (for facility and professional charge updates) based on the CMS regulations published for each fiscal year. The Contractor shall submit the draft and final inpatient economic analysis to PR&S project team to include existing and new CPT/HCPCS codes based on the CMS regulations published each fiscal year.

The rate updates must include updated tables based on CMS regulations published each fiscal year. The tables must be in the format used by VA for Federal Register publication and the Host file tables must be developed based on VA’s format (Excel spreadsheet) and presented for review by Office of Information Technology staff prior to acceptance. The Contractor shall provide a final project binder describing the methodology used for the CPT/HCPCS rate update, as well as detailed reports showing the variance in CPT/HCPCS rates by code year over year.

The Contractor shall participate as needed on rate development conference calls and respond to questions directed to them within two business days of receipt of the question. The Contractor shall also develop the quarterly National Interim Charge rate. The updates are based on VA’s rate methodology for the development of charges when no charges exist from our standard source data. The quarterly National Interim charge table should include charges for new CPT and HCPCS codes published by CMS on a quarterly basis as well as charges for old CPT and HCPCS codes without charges.

The Contractor shall provide an annual and periodic EHR Host file (Master DCW formatted file) by station number and zip code as sites are implemented under the EHR System. The GAAF Adjusted files are to include, Outpatient and Professional Medical services priced by facility, zip code, bill type/provider type, provider based/non-provider based, modifier 50, and other applicable modifiers. This Master DCW is to include columns for pricing for all CPT’s, HCPCS codes, Modifier, Station Numbers by names/suffixes and zip codes and all related charges and zip codes as facilities become live in the EHR System.

The Contractor shall:

5a. Provide a draft economic analysis in Excel spreadsheet format by the first week in October, annually. The economic analysis must include a detailed estimate of increase in revenue based on VA’s prior year methodology used for calculating this economic impact analysis, as well as take prior year billing and expected collections into account. It must be developed using VA’s collection data and take into account the components of the VA Reasonable Charges methodology. The economic analysis must include worksheets that show the trend forward calculation using the medical CPI tables. An internal peer review must be conducted by the contractor prior to submission to Government. A final analysis is due within three days after Government review and approval of the draft economic analysis.

5b. Provide the draft Federal Register and Host file rate updates for the following categories: partial hospitalization facility charges, outpatient facility charges, physician and other professional charges and relative value units (RVU), including base units and professional charges for anesthesia services and dental services, charges for pathology and laboratory services, observation care facility charges, ambulance and other emergency transportation charges, and Professional Services Relative Unit (RVU) and Conversion Factor GAAFs by Zip Code tables and charges for durable medical equipment, drugs, injectable, and other medical services, items, and supplies identified by Healthcare Common Procedure Coding System (HCPCS) Level II codes. The Contractor shall conduct an on-site review of the draft tables by the second week in November at the location designated by the PR&S project team. Virtual options will be considered. After Government review, the Contractor shall revise the tables and Data Source tables and provide the final Federal Register data tables to the PR&S project team and the Host Files to the IT Developer for final review. The final tables are due no later than the first week in December. The final Federal Register tables must be 508 compliant and provided in both an MS Excel format and a PDF copy. Additionally, the Contractor shall provide, along with the draft and final Federal Register and Host File tables, the Professional Service conversion Factors table and Charge Adjustment Factors for Professional Services Charge Modifiers table.

5c. Provide summary outlining the changes (variances from year to year) in rates for each rate increase and shall provide a detailed Excel spreadsheet listing each code and the rate increase. Detailed charge development review will be required for each CPT/HCPCS Code subjected to significant change from the previous year. This information shall be provided within two weeks of the finalization of the rates for publication in the Federal Register.

5d. Attend weekly and ad hoc development calls and participate as requested. The Contractor shall provide detailed responses via email to questions on rates and charges, describing specific methodology used for charge calculations, within two business days of the receipt of the question.

5e. Provide an Outpatient final project binder describing the methodology and data used in the rate update. This Outpatient final project binder should consist of at least three sections. Section one should include Scope of Project and the Economic Impact analysis and supporting documentation. Section two should include all final Federal Register and host file tables; including detailed schedules developed to show how the rates were calculated as well as the variance tables to show the difference from year to year. Section three should have all Appendices to show Federal Register regulations, final and proposed tables, final supplementary data source tables as documented in the regulations. This Outpatient final project binder shall be provided within four weeks of the finalization of the Federal Register rates.

5f. Provide a draft National Interim Charge table utilizing VA’s current format, no later than two weeks after the end of each Government quarter unless the code update coincides with the outpatient annual update. The purpose of this table is to provide nationwide procedure charges for billing on an interim basis until charges are provided through the annual Outpatient Reasonable Charge update. A new table of these National Interim Charges will be posted on a quarterly basis when new codes are released and published by CMS. This table will provide national charges for newly released codes as well as existing codes that did not have a charge. The Government quarters end in December (1st Qtr.), March (2nd Qtr.), June (3rd Qtr.) and September (4th Qtr.). A final table is due within two days after Government review. The final tables must be 508 compliant and provided in both an excel format and a PDF copy.

5g. Provide an annual and periodic EHR Host file (Master DCW formatted file) by station number and zip code as sites are implemented under the EHR System. The GAAF Adjusted files are to include, Outpatient and Professional Medical services priced by facility, zip code, bill type/provider type, provider based/non-provider based, modifier 50, and other applicable modifiers. This Master DCW is to include columns for pricing for all CPT’s, HCPCS codes, Modifier, Station Numbers by names/suffixes and zip codes and all related charges and zip codes as facilities become live in the EHR System The formatted file shall be provided no later than the last week of November. After government review, the final document is due the first week in December.

5h. Provide charge validation for VAMCs in production or testing with Cerner Millennium based on the Master DCW provided to Cerner. VA will provide the extract from Cerner Millennium showing the new charge updates and associated charge details.

Deliverable 5.

· 5a – Draft economic analysis due the first week in October. Final analysis due three business days after PR&S project team approval

· 5b. Draft Federal Register Notice and Host File Updates with a face-to-face review of the updates by the second week in November. Final notice and tables due no later than the first week in December.

· 5c. Rate change summary due within two weeks of the finalization of rates for publication

· 5d. Responses to ad hoc e-mails and questions within two business days of receipt

· 5e. Outpatient final project binder due within 4 weeks following the finalization of the Federal Register notice of rate updates

· 5f. Quarterly National Interim Charge Draft Tables provided within two calendar weeks following the end of each Government quarter ending December, March, June, and September. Final tables provided within two business days following PR&S project team review.

· 5g. Annual EHR DCW for professional/outpatient services due no later than the 1st week in December.

· 5h. Charge validation of new outpatient/professional charges loaded to Cerner Millennium within 3 business days of receipt of the charge details from VA.

Task 6. The Contractor shall provide their assistance to VA on how to set up the EHR billing system to replicate VistA processes currently established and described in the detailed calculation data tables. Attendance at meetings will be required to provide advice on making system changes to the EHR’s format to accommodate the existing VistA data calculation tables and formulas that provide individual code pricing. Contractor recommendation following the meetings shall be provided to the PR&S project team within 5 calendar days following the meeting. Estimate four (4) meetings for discussion regarding charge tables per option period.

Deliverable 6.

Contractor recommendations shall be provided within 5 calendar days following subject meetings.

Task 7. Third Party Payer Rate Verification. 38 CFR 17.101 affords VA the right to verify rates paid by TPPs. It is anticipated that between four to seven (4-7) Rate Verification engagements with TPPs or PBMs may be executed during a period of performance. Rate Verification engagements need to take into account the VA’s charge structure outlined in the regulation. The intent of the Rate Verification is to ensure VA is being paid the same amount as a non-VA provider for the same service in the same geographic area. The amount charged by non-VA providers in comparison to the amount charge by the VA must also be considered, along with upcoming VA rate changes.

Task 7a. The Contractor shall conduct large database extracts (up to 100,000,000 rows or lines of data), provide secure data transfer capabilities to receive or transmit large database extracts (up to 100,000,000 rows or lines data), using Contractor resources and systems, of sensitive information in accordance with FISMA from both the VA and external sources, perform rate verifications, and provide analytical support for PR&S to determine if reimbursement rates paid or proposed by TPPs or PBMs meet federal payment requirements by processing the extracted data into a standardized data set that can be used in conducting multiple analyses. The deliverables listed below shall be assigned by the COR as optional tasks (small, medium, or large) based on the number of VA medical centers covered by the payer selected for verification.

The Contractor shall analyze a combination of market-specific (defined as the first three digit zip code of a VAMC) and payer-specific VA claims data along with market-specific/payer-specific claims data provided by a TPP or PBM to determine if reimbursement rates paid or proposed by TPPs or PBMs are supported by the claims data and meet federal payment requirements and develop and provide a report which describes the findings. The Contractor along with the COR or technical representative will determine the adequacy of data received and recommend additional information or clarification needed from the TPP or PBM and participate in teleconferences, as needed, to ask relevant questions about the data received.

The Contractor shall perform various large, medium, and small data analysis utilizing both VA claims data and TPP claims data VA billing and coding regulations and practices, TPP Coding and Reimbursement policies such as MS-DRG, APR-DRG, Per Diem, Case Rates, APC, and EAPG, and VA payment posting regulations and policies, and reconcile the data to determine the appropriate reimbursement rate for the same or similar health care service provided by VA within a geographical area. Data analysis at a minimum should include the following:

1. Analysis methodology (how the analysis was applied, and the data set(s) used);

2. Comparison of paid claims data analysis with Peer Facility contract analysis;

3. Unique attributes of the analysis e.g., geographic area, VA markets, varying payment methodologies within the market; VA charge relativity to the market

4. Process by which the recommended reimbursement data was reconciled from multiple reimbursement methodologies in the data set and Peer Facility contracts;

5. Effect and impact of bundling or prospective payment on the analysis (i.e., Surgical groupers with one code paid and all others denied as included in a paid service);

6. Identify compliance and system/process gaps that impact VA reimbursement from the TPP;

7. Identify strategies to resolve payer issues and provide compliance with guidance described in Governance section of this document;

8. Recommendation whether or not TPP or PBM meets federal payment requirements and whether or not VA should take action to maintain current rates or seek new rates. The results of the analysis shall be delivered to the COR within 15 business days of receipt of TPP claims data and presented in a Microsoft Excel format.

Task 7b. The Contractor shall document rates, outliers, rate methodologies, inflator clauses, stop loss, and other pertinent language provisions related to the amount payable for health care services that are found in non-government TPP hospital, professional, PBM, and/or ancillary contracts. The review of these documents will typically occur on-site (TPP location); each lasting approximately 3-4 days. The Contractor shall ensure that adequate staff resources (generally 2-3 contractor staff) are available to participate in on or off-site visits.

The Contractor shall develop and provide a report which satisfies the tasking described in 7a. above to include at a minimum:

1. Analysis methodology, how the analysis was applied, the data set used

2. Unique attributes of the analysis e.g., geographic area, VA markets

3. Identify compliance and system/process gaps

4. Identify gap resolution strategies which will resolve issues and provide compliance with guidance described in Governance section of this document

5. Number and type of contracts reviewed

6. Types of services analyzed e.g., inpatient, outpatient, professional, ancillary, etc.

The results of the analysis shall be in a Microsoft Excel and/or Word format that includes a descriptive narrative of findings and delivered to the COR within 15 business days upon completion of an on or off-site visit.

Task 7c. Once Deliverables 7a and 7b are deemed completed by the COR, the Contractor shall present a close-out memo summarizing all relevant findings and include recommendations for PR&S to determine the degree to which the TPPs or PBMs reimbursement rates paid or proposed to VA meets or does not meet federal payment requirements and shall include recommendations to describe what changes are necessary to bring the rates into compliance. The close-out memo shall be delivered to the PR&S project team and the COR within 15 business days in a Microsoft Word document.

Task 7d. Financial impact assessment. The Contractor shall review the VA’s charges and potential charge updates (fiscal and calendar year updates) against the proposed payer rate change and identify the financial impact of the rate change. The Contractor shall provide detailed revenue impact analysis that can be utilized for both current and future revenue projections and recommend options to reduce negative impact to the VA and optimize collection results.

Task 7e. VA Agreement Review. Contractor shall complete a review of VA’s contract with the TPP, and a comparison of the VA agreement terms and conditions with industry best practices and make modification recommendations. The results of the review shall include areas of vulnerability and strategies to overcome TPP objections; compliance and system/process gaps of TPP based on VA regulations; and recommended gap resolution strategies to resolve payer issues and bring TPP into compliance with VA regulations. The results of the analysis shall be delivered to the PR&S project team within 15 business days of assignment.

Deliverable 7.

· 7a - Rate Verification data analysis recommendation to be provided in MS Excel format within 15 business days following receipt of TPP or PBM claim data.

· 7b – Rate Verification peer contract review analysis summary report and recommendation to be provided in MS Excel and/or MS Word within 15 business days following on-site contract review

· 7c – Rate Verification close out memo and executive briefing to be provided within 15 business days following finalization of tasks 7a and 7b.

· 7d – Financial Impact Assessment to be provided within 15 business days following the finalization of tasks 7a and 7b, to coincide with the executive briefing

· 7e – VA Agreement Review to be provided within 15 business days of assignment

Task 8 – Net Collection…