60RRBH21R0011 Attachment J.6 Award Fee Plan Template.docx

RFP 60RRBH21R0011 Attachment J.6 RRB SMAC Award Fee Plan

RFP 60RRBH21R0011 Attachment J.6 RRB SMAC Award Fee Plan

Award Fee Plan for RRB Part B Specialty Medicare Administrative SMAC

Nationwide Jurisdiction

Effective Date

TBD

Contract Period of Performance

TBD

Award Fee Evaluation Period

TBD

I. OVERVIEW

This document provides the Award Fee Evaluation Plan for the RRB Medicare Part B Specialty Medicare Administrative SMAC (RRB SMAC) contract awarded to SMAC X. The performance criteria contained within this plan will be used, along with other performance related information, to determine the amount of award fee earned by the SMAC.

The purpose of utilizing the award fee process is to motivate and reward SMAC excellence in the performance of contract requirements critical to program success, while the SMAC meets at least minimum acceptable performance levels in all other areas.

The maximum award fee will be based on evaluated performance exceeding minimum contract requirements, and may be awarded in whole, in part, or not at all.

II. THE AWARD FEE PLAN

The award fee plan describes how the SMAC will be evaluated and how the award fee will be administered. This plan identifies the criteria to be used to evaluate the SMAC’s performance as it relates to the award fee metrics for the performance period. This plan also identifies the roles and responsibilities of those who will participate in the evaluations.

The Award Fee Plan:

· Is approved by the RRB Contracting Officer (CO), the Performance Evaluation Board (PEB), and the Fee Determining Official (FDO);

· Allocates the fee pool among performance categories;

· Specifies the evaluation cycle;

· Identifies the roles and responsibilities of those who will participate in the evaluation; and

· Describes criteria for evaluating the SMAC’s performance.

The FDO may unilaterally change the award fee plan prior to the beginning of an evaluation period. The SMAC will be notified of changes to the plan by the CO, in writing, before the start of the affected evaluation period. Changes to this plan that are applicable to a current evaluation period will be incorporated by mutual consent of both parties.

1.0 Fee Arrangement

The fee arrangement is negotiated based on the total estimated cost of the contract. There are regulatory limitations on total fee (cumulative base fee and award fee) for a cost plus award fee contract. The fee consists of two parts, the base fee and the award fee.

1.1 Base Fee: The base fee (which may be zero) can be viewed as the minimum compensation for the resources a SMAC uses or the investment it may undertake in order to perform the contract.

1.2 Award Fee: The award fee is the amount of fee set aside in the contract that is available to be earned by the SMAC for exceeding minimum contract requirements. The SMAC is not guaranteed a minimum amount of award fee. Consequently, some, none, or the entire maximum available award fee may be earned. The amount of the fee awarded to the SMAC is unilaterally determined by the Government’s evaluation of SMAC performance exceeding contract requirements.

1.3 Prerequisite for Eligibility for Award Fee: In order to qualify for any award fee as described in this document, the SMAC must obtain at least a minimum score of “Green – Satisfactory” in each individual perspective/evaluation criterion for the most recent SMAC Performance Assessment Reporting System (CPARS) evaluation during the evaluation period.

2.0 Performance Evaluation Periods

Please note however, that the base year evaluation period begins with the first full month, and ends with the last full month of the contract year, unless otherwise specified. The final determination of the fee earned will be accomplished within 90 days after the end of the contract year.

3.0 Organizational Structure for Award Fee Administration

The award fee organizational structure is established for administering the award fee provisions of this contract. The organization consists of the following:

Fee Determining Official (FDO). The FDO is the Director of the RRB’s Unemployment and Support Programs Division; The responsibilities of the FDO are to:

· Approve the award fee plan and any significant changes;

· Review the Performance Evaluation Board (PEB) report, SMAC input, and other pertinent performance data; and,

· Make a final determination of award fee earned and payable for each evaluation period.

Performance Evaluation Board (PEB). The PEB is comprised of the Contracting Officer (CO); the Contracting Officer’s Representative (COR), the Senior Medicare Contract Operations Specialist (SMCOS), and the Medicare Contract Specialist (MCS). The responsibilities of the PEB are to:

· Review Performance Monitors’ evaluation of the SMAC’s performance;

· Consider all evaluation information from pertinent sources;

· Prepare a report to the FDO on the recommendation of an award fee to be earned by the SMAC; and,

· Substantiate the recommended award fee to the FDO.

The PEB report shall be delivered to the FDO no later than 75 days after the end of the evaluation period.

Performance Monitors. Performance Monitors are RRB staff who maintains written records of the SMAC performance so that a fair and accurate evaluation is obtained. Performance Monitors will review and consolidate periodic monitoring information for inclusion in their performance monitor reports, which are due to the PEB no later than 45 days after the end of the evaluation period

SMAC Input. The SMAC shall provide a written award fee performance evaluation self-assessment to the CO and COR within 30 calendar days of completion of the award fee evaluation period. The SMAC shall provide as much detail as is necessary to assist the evaluators in making their final determination; however, the written self-assessment shall not exceed 20 pages in length and shall be submitted in Microsoft Word. When preparing the self-assessment, the SMAC shall use the attached Award Fee Self Assessment template (see Attachment A).

Notification to the SMAC. The SMAC shall receive written notification of the award fee determination within 150 days of the end of the contract year.

III. AWARD FEE CATEGORIES - SCORING

1.0 Operations

The RRB will assess SMAC performance against stated metrics in the following areas:

· Program Improvement and Collaboration

· Provider Customer Service Program – Online Portal User Sessions

· Appeals – Medicare Redetermination Notice (MRN) Timeliness

· System Security

· Provider Enrollment (PE) – Written Correspondence Timeliness

· Benefit Integrity – Increase in Total Savings Dollars

· Medical Review (MR) – Edit Effectiveness

· Beneficiary Customer Service – Written Inquiries Timeliness

· Beneficiary Customer Service – Average Speed of Answer (ASA)

· Beneficiary Customer Service – Quality Call Monitoring (QCM)

· Beneficiary Customer Service – Quality Written Correspondence Monitoring (QWCM)

The FDO will consider any other information available which relates to the SMAC’s performance of all other contract requirements in the final determination of fee earned.

2.0 Distribution of Award Fee Pool

The award fee will be distributed in the following manner for the operational period:

TBD

In the event that an award fee metric is no longer applicable, RRB reserves the right to reallocate the award fee pool associated with that metric among the remaining award fee criteria and disperse accordingly.

In addition, RRB will determine an overall adjectival rating for the SMAC’s award fee performance based on the percentage of award fee earned in compliance with the chart below. If the SMAC does not earn award fee because it is ineligible due to its CPARS rating(s), the overall award fee adjectival rating will automatically be “Unsatisfactory.”

3.0 Award Fee Process

At the end of the award fee evaluation period, the COR reviews the work performed during the period. The COR and the SMCOS evaluate the SMAC’s performance in accordance with the performance metrics and the Statement of Work (SOW). The COR and the SMCOS make a recommendation to the CO and MCS regarding the percentage of fee to be awarded. This recommendation is subject to the CO’s review of the SMAC’sperformance of the contract.

This recommendation is provided to the FDO. The FDO has the prerogative to overrule the recommendation and independently determine the appropriate award fee. Within 150 days after the end of the contract year, the FDO will make a determination and an official letter will be issued by the CO advising the SMAC of the award fee earned.

4.0 Award Fee Metrics

The SMAC shall be evaluated using the following operational evaluation criteria:

Award Fee Criterion 1: Program Improvement and Collaboration

This award fee criterion measures the SMAC’s ability to propose and implement program improvements that have a tangible or intangible benefit to the government. It also measures the SMAC’s collaboration with other key stakeholders to the benefit of the Medicare program. The COR will consider the items below when evaluating this item. The table below provides illustrative examples of performance for each percentage category. This table is intended to serve as a guide to illustrate how RRB will determine if the SMAC will earn 100 percent, 75 percent, or 50 percent of the award fee pool for this criterion.

· SMAC exhibits contract cost savings. The SMAC must demonstrate and provide documentation showing where and how cost savings were obtained.

· SMAC takes a very active role in reviewing CMS Change Requests; offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS/RRB for how to better facilitate significant changes; provide accurate cost estimates for CRs. SMAC provides feedback during CR testing that alerts CMS/RRB to problems with business requirements and/or potential problems with CR implementation.

· SMAC consistently collaborates with other entities without RRB prompting.

· SMAC has established and maintained excellent working relationships with all other entities.

· Works well at addressing RRB requests without additional coordination/follow up.

· SMAC works within proposed contract funding.

· SMAC takes an active role in reviewing CMS Change Requests; offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS/RRB for how to better facilitate significant changes; provide accurate cost estimates for CRs.

· SMAC often collaborates with other entities without RRB prompting.

· SMAC has established and maintained excellent working relationships with a majority of other entities.

· Works well at addressing RRB requests and requires minimal RRB coordination/follow up.

50%

· SMAC occasionally takes an active role in reviewing CMS Change Requests; offering constructive feedback when additional information or clearer direction is needed; making suggestions to CM/RRB for how to better facilitate significant changes; provide accurate cost estimates for CRs.

· SMAC proposes process improvements or innovations that may provide tangible or intangible benefit to the government.

· SMAC occasionally collaborates with other entities without RRB prompting.

· SMAC has established and maintained good working relationships with many other entities.

· Works well at addressing RRB requests but it requires RRB coordination/follow up as well.

The data source for this metric is the CO and the COR who will evaluate on an ongoing basis.

Award Fee Criterion 2: Provider Customer Service Program – Online Portal User Sessions

This criterion measures the SMAC’s ability to increase the number of user sessions in the SMAC’s online portal. The SMAC shall include online portal user session statistics in its monthly status reports.

In order to earn award fee dollars, the SMAC must show an increase in the number of online portal user sessions in the award fee evaluation period by 3,000. Award fee will be earned based on the increase in the number of online portal user sessions in the last month of the award fee evaluation compared to the baseline. The baseline is the monthly average of online portal user sessions for the last six months of the prior option year (B). The comparison score is based on the monthly average of online portal user sessions for the last six months of the evaluation period (A). The increase or decrease in online portal user sessions will be calculated by subtracting the baseline score (B) from the comparison score (A).

The SMAC will earn award fee according to the following table:

Award Fee Criterion 3: Appeals – Medicare Redetermination Notice (MRN) Timeliness

This criterion measures the SMAC’s timeliness in processing and sending 100 percent of redetermination notices within 60 calendar days of receipt during the award fee evaluation period.

In order to be eligible for any award fee under this criterion, the SMAC shall process at least 90% of redetermination cases within 60 calendar days of receipt for each month of the award fee evaluation period. If the SMAC has one or more months during the period in which the SMAC does not successfully process and send 90% or more redeterminations within 60 calendar days then the SMAC is not eligible for any award fee under this criterion.

The award fee for this criterion will be earned based on the number of months the SMAC achieves a 100 percent performance level during the award fee evaluation period. The percentage of award fee earned will be calculated by dividing the number of months that the 100% timeliness standard was met by the total number of months in the evaluation period. For example, if there are twelve (12) months in the operational period and the SMAC achieves the 100% rate for four (4) of the twelve (12) months, the SMAC would earn 33% of the award fee for this metric.

The data source for this metric is the CROWD, CMS-2592 Appeals Workload Report and data submitted in the monthly report. Redetermination timeliness is calculated by dividing the sum of redeterminations cleared in 60 days (line 15) by the total cleared (lines 15 + 16). For validation purposes, the sum of lines 15 + 16 should equal line 6 (requests cleared) – line 7 (requested cleared where evidence is submitted after request). Redeterminations subject to the 74-day processing timeframe, because documentation is submitted later in the process (as reported on lines 7, 18, 19, and 20), are not to be included in the calculation for this metric

For this criterion, timeliness is calculated to two decimal places, with a hundredth value of five and above rounded up, and hundredth value of four and below rounded down. Therefore, a value of 99.95% or above would be rounded to 100%, and a value of 99.94% would be rounded to 99.9%.

Award Fee Criterion 4: System Security

This criterion measures the SMAC’s compliance with CMS’ system security standards. The following chart displays risk rankings on any applicable Section 912 evaluation which will be used by RRB to determine award fee earned for the SMAC.

The rating methodology used by RRB is as follows:

*If any of the findings (i.e., any medium or high risk) are a repeat from a prior year, then this percentage amount will be reduced by 15%.

Award Fee Criterion 5: Provider Enrollment – Correspondence Timeliness

This criterion measures the SMAC’s timeliness in responding to all provider enrollment correspondence within 35 calendar days of receipt during the award fee evaluation period.

The data source for this metric is the Monthly Status Report.

In order to be eligible for an award fee under this criterion, the SMAC shall respond to provider enrollment correspondence within 35 calendar days for 100% of provider enrollment correspondence.

Award fee for this criterion will be earned based on the number of months the SMAC achieves a 100% performance level. The percentage of award fee earned will be calculated by dividing the number of months that the 100% timeliness standard was met by the total number of months in the evaluation period. For example, if there are twelve (12) months in the operational period and the SMAC achieves the 100% rate for seven (7) of the twelve (12) months, the SMAC would earn 58% of the award fee for this metric.

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 79.5% would be rounded to 80% and values of 79.4% would be rounded to 79%.

Award Fee Criterion 6: Benefit Integrity –Increase in Total Savings Dollars

This criterion measures the SMAC’s ability to increase the total savings dollars based on the proactive investigations completed monthly. In order to earn award fee for this metric, the SMAC will have to increase their total savings dollars in overpayments demanded from providers. The SMAC shall include all overpayment savings dollars in its monthly status reports.

In order to earn award fee dollars, the SMAC must show an increased total savings dollars in overpayments demanded from providers at the end of the current award fee evaluation period compared to the average total savings dollars in overpayments demanded from providers for the award fee evaluation period for Option Years # and #. The savings dollars in overpayments demanded from providers is defined as the number of accounts receivables established by the SMAC related to proactive investigations. The percentage increase in savings dollars will be calculated by subtracting the average of total savings dollars for Option Years # and # (B) from the total savings dollars for all months in the current award fee evaluation period (A) and dividing this result by the average of total savings dollars for Option Years # and # (B).

Percentage Increase = (A-B)/B.

For this criterion, timeliness is calculated to two decimal places, with a hundredth value of five and above rounded up, and hundredth value of four and below rounded down. Therefore, a value of 9.95% or above would be rounded to 10%, and a value of 9.94% would be rounded to 9.9%.

The SMAC will earn award fee according to the following table:

Award Fee Criterion 7: Medical Review– Edit Effectiveness

This metric will measure the SMAC’s ability to decrease the average initial charge denial rate for prepayment widespread service specific and provider specific reviews based on vulnerabilities identified in the Improper Payment Reduction Strategy (IPRS) and the Statistical Analysis Report (SAR) that have at least six months of data.

In order to earn award fee dollars, the SMAC must show a decrease in the average initial charge denial rate in the award fee evaluation period by the % identified for each vulnerability reported in the IPRS and SAR that have at least six months of data.

The average initial charge denial rate for each vulnerability will be measured by the total dollar amount of initial denied charges as determined by Medical Review divided by the total dollar amount of allowable charges for services medically reviewed for all vulnerabilities identified in the IPRS and SAR that have at least six months of data.

For vulnerabilities that are carried over from the prior option year, the baseline for the average initial charge denial rate will be calculated by using the total initial denied amount and total initial allowed amount from the prior option year.

Award fee will be based on the percentage change (decrease or increase) for each vulnerability in initial charge denial rate by subtracting the comparison score (A) from the baseline score (B), then multiplying the result by the baseline score (B), and then multiplying by 100.

For example, (using a CDR % of 3%) if the baseline CDR is 62.6% (B) and the comparison score is 58.7% (A); the % decrease would be 6.23% and the SMAC would achieve the % reduction in CDR.

Example: (62.6% - 58.7%) / 62.6% * 100 = 6.23%

The percentage of award fee earned will be calculated by the number of vulnerabilities identified in the IPRS and SAR that have at least six months of data that achieved the % charge denial rate divided by the total number of vulnerabilities identified in the IPRS and SAR that have at least six months of data.

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 3.6% would be rounded to 4 and a value of 3.4% would be rounded to 3%.

The data source for this metric will be the SMAC submitted IPRS and SAR.

Award Fee Criterion 8: Beneficiary Customer Service – Written Inquiries Timeliness

This criterion measures the SMAC’s timeliness in responding to all beneficiary written inquiries within 35 business days of receipt during the award fee evaluation period.

The data source for this metric is the Monthly Status Report.

In order to be eligible for an award fee under this criterion, the SMAC shall respond to beneficiary written inquiries within 35 business days for 100% of written inquiries.

Award fee for this criterion will be earned based on the number of months the SMAC achieves a 100% performance level. The percentage of award fee earned will be calculated by dividing the number of months that the 100% timeliness standard was met by the total number of months in the evaluation period. For example, if there are twelve (12) months in the operational period and the SMAC achieves the 100% rate for seven (7) of the twelve (12) months, the SMAC would earn 58% of the award fee for this metric.

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 79.5% would be rounded to 80% and values of 79.4% would be rounded to 79%.

Award Fee Criterion 9: Beneficiary Customer Service – Average Speed of Answer (ASA)

This criterion measures the SMAC’s average speed of answer in answering beneficiary telephone inquiries. In order to be eligible for an award fee under this criterion, the SMAC shall have an average speed of answer of 50 seconds or less during the award fee evaluation period. This data is summarized on monthly statistical phone data reports.

The data source for this metric is provided by the CMS designated Network Service Provider, currently Verizon Networx Universal Customer Center (NUCC).

The award fee for this criterion will be based on the number of months in the award fee period that the SMAC’s beneficiary average speed to answer is equal to or less than 50 seconds. The percentage of award fee earned will be calculated by dividing the number of months the SMAC achieved the performance level by the number of months in the award fee period. For example, if there are 12 months in the award fee period and the SMAC achieves the 50 second or less average speed to answer rate for seven of the 12 months, the SMAC would earn 58% of the award fee for this metric.

Award Fee Criterion 10: Beneficiary Customer Service – Quality Call Monitoring (QCM)

This criterion measures the quality (Knowledge Skills, Customer Skills, Adherence to Privacy Act, and Administrative Procedures) of SMAC Customer Service Representative (CSR) responses to beneficiary telephone calls each month.

In order for the SMAC to earn the award fee for this criterion, the percent of calls scoring as “Achieves Expectations” or higher for Knowledge Skills, Customer Skills, Adherence to Privacy Act, and Administrative Procedures using the QCM tool shall be no less than 95% each month during the award fee evaluation period.

The award fee for this criterion will be earned based on the number of months the SMAC achieves a 95 percent performance level for Knowledge Skills, Customer Skills, Adherence to Privacy Act, and Administrative Procedures during the award fee evaluation period. The 95% performance level must be met for each measure (Knowledge Skills, Customer Skills, Adherence to Privacy Act, and Administrative Procedures) to be eligible to earn award fee. The percentage of award fee earned will be calculated by dividing the number of months that the 95% standard was met by the total number of months in the evaluation period. For example, if there are twelve (12) months in the operational period and the SMAC achieves the 100% rate for four (4) of the twelve (12) months, the SMAC would earn 33% of the award fee for this metric.

The data source for this criterion is the QCM database.

Award Fee Criterion 11: Beneficiary Customer Service – Quality Written Correspondence Monitoring (QWCM)

This criterion measures the quality (Knowledge Skills, Customer Skills and Adherence to Privacy Act) of SMAC Customer Service Representative (CSR) responses to general beneficiary written inquiries each month. This criterion does not include responses to complex beneficiary or congressional inquiries.

In order for the SMAC to earn the award fee for this criterion, the percent of written responses scoring as “Achieves Expectations” or higher for Knowledge Skills, Customer Skills and Adherence to Privacy Act using the QWCM tool shall be no less than 95% each month during the award fee evaluation period.

The award fee for this criterion will be earned based on the number of months the SMAC achieves a 95 percent performance level for Knowledge Skills, Customer Skills and Adherence to Privacy Act during the award fee evaluation period. The 95% performance level must be met for each measure (Knowledge Skills, Customer Skills and Adherence to Privacy Act) to be eligible to earn award fee. The percentage of award fee earned will be calculated by dividing the number of months that the 95% standard was met by the total number of months in the evaluation period. For example, if there are twelve (12) months in the operational period and the SMAC achieves the 100% rate for four (4) of the twelve (12) months, the SMAC would earn 33% of the award fee for this metric.

The data source for this criterion is the QWCM database.