74BAI-S3470 SOW.docx

SCOPE OF WORK

Benchmarking Analysis

The vendor shall:

Conduct a comparative, frequency-weighted benchmarking analysis using the following data sources:

Medicare rates Paid, allowed, and billed amounts from Nevada workers’ compensation claims Group health data, if available

Clearly define “paid,” “allowed,” and “billed” within the methodology Disclose all data sources, sample sizes, and explain data interpretation methods Provide benchmarking across all CPT code ranges:

Anesthesia (00000–99999) Surgery (10000–69999) Radiology (70000–79999) Pathology & Laboratory (80000–89999) Medicine & E/M (90000–99999)

Identify and justify the top 100 cost driver codes, including selection methodology Ensure recommended fees:

Do not exceed usual and customary billed and paid amounts in Nevada Are not unfairly discriminatory among legally qualified providers

Conversion Factor Recommendations

Using the Resource-Based Relative Value Scale (RBRVS) and national benchmarks, the vendor shall recommend updated conversion factors for:

Anesthesia Surgery Radiology Pathology & Laboratory General Medicine E/M

Base recommendations on a cost impact analysis comparing:

Current 2025 Nevada Medical Fee Schedule (NV MFS) rates:

Anesthesia: $99.01 Surgery: $283.69 Radiology: $51.37 Pathology: $30.48 General Medicine: $13.31

Medicare and national benchmarks

Recommend a CPI-based update using the CPI Medical Care Component, per NRS 616C.260(2).

Align with the most current editions of the Relative Values for Physicians and the Relative Value Guide of the American Society of Anesthesiologists.

Relative Value Units (RVUs)

Recommend RVUs for services or codes not currently represented in the RBRVS or NV MFS.

Hospital and Inpatient Services

Review and recommend maximum allowable payments for inpatient care , including:

Medical-Surgical: $3,733.97

ICU: $6,139.88

Step-Down: $4,936.92 Skilled Nursing: $2,559.01 Observation (>23 hrs ): $3,733.97 Observation (≤23 hrs ): $155.58/hr Psychiatric & Rehab: $2,559.01 Rehabilitation: $2,559.01

Clarify bundled services and professional vs. facility billing distinctions.

Dental Services

Review and recommend maximum allowable payments for dental using CPT and ADA codes (e.g., D0120 to D9223). For unlisted codes, establish usual and customary pricing benchmarks.

Ambulatory Surgery Centers (ASC)

Using the ASC Hospital Outpatient Group List 2016, recommend reimbursement rates for surgical codes grouped 1-9, as currently reimbursed under the 2025 NV MFS (e.g., Group 1: $1,160.97- Group 9: $3,733.97). Address unlisted CPT codes reimbursed at $3,468.99 and provide methodology for rate assignment.

Bundling and Global Service Editing

Evaluate the feasibility of adopting nationally recognized bundling edits (e.g., Medicare NCCI) and global periods, and recommend adoption, modification, or continued exclusion based on impact and practicality.

Miscellaneous Services

Recommend maximum allowable payments for the following:

Telemedicine

Telemedicine services as defined by services provided to an injured employee at an originating site, rural healthcare facility by a consulting physician or chiropractor located at a distant site in another rural healthcare facility or in an urban healthcare facility and medical information is communicated between the injured employee and consulting physician or chiropractor in real-time with the use of simultaneous interactive audio and video communication equipment.

Originating Site Fee (NV00250): $266.37 Services to be billed with GT modifier, using standard CPT codes

Emergency Department Facility Fees

First Hour (NV00100): $311.18 Each Additional Hour (NV00101): $155.58 Trauma Activation Fee (NV00150): $4,486.82

Ambulance Services

Include ground and air ambulance transportation rates

Pharmaceuticals

Average Wholesale Price + $13.31 dispensing fee or Usual & Customary (U&C), whichever is lower Compound medications must list all ingredients with valid National Drug Codes (NDCs) Prior authorization required for compound prescriptions

Drug and Alcohol Testing

Appropriate CPT codes and reimbursement rates

Home Health Care

Skilled Care (per visit, NV90170): $148.52 CNA Care (per visit, NV90130): $72.37 Hourly rates: Skilled $74.24; CNA $36.19

Durable Medical Equipment (DME), including custom DME

Reimbursed at actual cost + 20% markup with invoice

Custom Orthotics and Prosthetics

Reimbursed at 140% of Medicare allowable for Nevada

Permanent Partial Disability (PPD) Evaluations

Review records, testing, evaluation, and report (includes evaluation of up to two body parts) (NV01000): $980.57 Review of medical records and evaluation of each additional body part in excess of initial two body parts (NV01004): $327.49 Organization of medical records in chronological order based on the date of service per 50 pages (NV01005) $55.23 Failure of an injured employee to appear for appointment (NV01001): $327.49 Review of records and report (NV01006) $489.31

Independent Medical Evaluations (IMEs)

Review of medical records (up to 50 pages) (NV02001): $2,022.43 Review of each additional 100 pages of medical records (NV02002): $505.61 Evaluation of each additional body part in excess of initial two body parts (NV02003): $379.21 Organization of medical records in chronological order based on date of service per 50 pages (NV02004): $55.23 Failure of an injured employee to appear for appointment (NV02000): $758.40

Functional Capacity Evaluations (FCEs)

Evaluation (NV99060): $308.43/hr No-show (NV99061): $327.49

Work Hardening Programs

Propose methodology and rate structure

Back School (NV97115)

Reimbursed at $108.55/hr

Consultation Services

Provide up to 15 hours of virtual consultation with DIR for clarification and interpretation of deliverables Provide up to 6 hours of in-person consultation with DIR upon request.

Statutory and Regulatory Compliance

Ensure all recommendations comply with NRS 616C.260 and meet the following criteria:

Reflect Nevada-specific billing trends Align with AMA CPT coding standards Avoid discrimination among qualified providers Include documentation and interpretation support for DIR Propose compliance monitoring methods Support competitive bidding and vendor designation Present findings in a format suitable for annual schedule updates Recommend appropriate frequency for comprehensive fee schedule reviews