Attachment J.1 SOO.docx

Attachment J.1 Section C – Statement of Objectives (SOO)

Project Title: Comprehensive Cost Avoidance, Coordination of Benefits, and Recovery Program

Project Office: World Trade Center Health (WTC) Health Program Division National Institute for Occupational Safety and Health (NIOSH) Centers for Disease Control and Prevention (CDC) Purpose:

The World Trade Center (WTC) Health Program intends to improve efficiency and control health care costs. Our purpose is to establish a comprehensive cost avoidance, coordination of benefit, and recovery program by implementing a comprehensive cost avoidance and recovery platform from pre- to post-payment processes.

This requirement includes the deployment of a robust and near real-time primary insurance identification system and database, validation and facilitation of the Coordination of Benefit (COB), recovery of incorrectly or inappropriately paid claims from private insurance, participation in New York State (NYS) Workers’ Compensation Board (WCB)’s Health Insurance Matching Program (HIMP) to identify individuals who are eligible for WC benefits and to seek reimbursement from WC’s insurers, identification of deceased members, and providing performance metrics, quality assurance and payment integrity services.

The purpose of this Statement of Objective (SOO) is to establish a comprehensive cost avoidance, coordination of benefit, and recovery program that will facilitate the ability of the WTC Health Program to improve efficiency and control health care costs without compromising quality of care.

I. Scope:

This SOO describes the requirements, services, and expected performance for efficiency and controlling of health care costs.

1. The contractor shall propose CLINs and payment structure in accordance with the Federal Acquisition Regulations for each performance objective listed in the SOO.

2. The insurance identification system must be robust and near real-time with a database allowing for updates with insurance changes and data exchanges with WTC Health Program and its contractors.

3. The contractor shall deploy proven strategies, capacity and capabilities to maximize successes with private and WC insurance identification and recovery of paid payment.

4. The contractor shall collect and distribute comprehensive, up-to-date and accurate COB information to WTC Health Program claim adjudicator for pre-payment adjudication within the WTC Health Program’s Timely Filing Limits (TFLs).

5. The contractor shall work with the program to establish an agreement with NYS WCB to act on behalf of the WTC Health Program to recover payment from their insurers through the HIMP and be able to meet a series of legal recovery timelines.

6. The contractor shall seek as many death records as possible to perform diseased member identification without social security number (SSN), such as the Death Master File (DMF).

7. The contractor shall establish performance metrics, quality assurance and payment integrity services and provide solutions for cost control and administrative cost reductions from pre- and post-payment processes.

II. Period of Performance:

One base year of 12 months with four 12-month options. Estimated dates below

III. Place of Performance:

The contractor work shall take place at the Contractor’s facility (100%) offsite. At least four trips are anticipated, including the kickoff meeting. Trips may be to travel to meetings in Washington Metro Area, Cincinnati, Atlanta or New York City.

IV. Background:

On January 2, 2011, the President signed into law the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Act established within the Department of Health and Human Services a program to be known as the World Trade Center (WTC) Health Program. The WTC Health Program provides medical monitoring, screening, and treatment for responders and survivors of the 9/11 terrorist attacks. The statute authorizing these services directs the WTC Health Program to recover monies from workers’ compensation (WC) insurers for medical treatment (including pharmaceuticals) when the responder or survivor who is treated by WTC Health Program is also eligible for workers’ compensation benefits. The New York State (NYS) Workers’ Compensation Board (WCB) has established a Health Insurance Matching Program (HIMP) that permits health plans, such as the WTC Health Program, to identify individuals who are eligible for workers’ compensation benefits and to seek reimbursement from workers’ compensation insurers for treatment-related costs paid by the health plan.

The overarching aim of this contract is to improve efficiency and control health care costs by establishing a comprehensive cost avoidance, coordination of benefit and recovery program from pre- to post-payment processes.

The four primary objectives and one optional objective are:

1. Identify primary health insurance and maintain database;

2. Validate and facilitate COB;

3. Recoup incorrectly or inappropriately paid claims from private insurance and NYS WCB’s insurers through HIMP

4. Identify deceased members.

5. (Optional) Provide quality assurance payment integrity services

The contractor must have substantial experience in providing financial services to a federal health care program with comprehensive, scalable platforms and agile methodologies for pre- to post- payment of medical and pharmacy benefits claims.

This requirement includes the deployment of a robust and near real-time primary insurance identification system and maintaining a database, validating and facilitating the COB, recovery of incorrectly or inappropriately paid claims, participating in NYS WCB HIMP to identify individuals who are eligible for WC benefits and to seek reimbursement from WC’s insurers, and identifying deceased members.

Objective 1. Identify primary health insurance and maintain database

1.1. Deploy a robust and near real-time health insurance identification platform to support pre- and post-payment activities

1.2. Establish and maintain an interoperable database to capture updates of insurance changes, and secured data exchanges with ability to intake and correlate data from multiple sources in varying formats

Objective 2. Validate and facilitate COB

2.1 Validate primary health insurance information and Explanation of Benefits (EOBs)

2.2. Facilitate COB for pharmacy and medical benefits claims adjudication process by coordination with the Pharmacy Benefit Manager (PBM), Health Program Support (HPS) and other contractors

2.3. Provide COB information to WTC Health Program claim adjudicator for pre-payment adjudication within WTC Health Program’s TFLs and protocols

2.4. Reconcile member records and COB database for pre- and post-payment claims analytics

Objective 3. Recoup incorrectly or inappropriately paid claims from private insurance and NYS WCB HIMP

3.1. Expedite recovery and negotiation for maximum payment possible and dispute resolution options

3.2. Recoup maximum possible amount from incorrectly or inappropriately paid claims from private insurance

3.3. Recoup maximum possible amount from incorrectly or inappropriately paid claims from NYS WCB’s insurers through HIMP

3.4. Reconcile payment and recoupment for reporting and deposit to WTC Health Program’s account.

Objective 4: Identify deceased members

4.1. Identify deceased members without SSN in various sources such as the Death Master File (DMF) and other databases.

4.2. Reconcile and provide deceased members database to the WTC Health Program.

Objective 5: Provide quality assurance payment integrity services

5.1 Provide performance metrics, quality assurance and surveillance plan (QASP) Review claims, COB information, death records, recoupment records and other databases for errors and potential FWA, and create claim-level breakdowns of improper billing issues for instant compliance verification and overpayment protection.

5.2. Conduct clinical claims review by clinicians to identify improper coding, location, service and reimbursement.

5.3. Provide solutions for cost control and administrative cost reduction

5.4. Provide FWA analytics platforms with ease of access, interface and report.

V. Deliverables

The offeror’s proposal shall include how and when deliverables will be provided with objective data for the government to make informed decisions and to reflect the work being performed. The deliverables table below includes suggested deliverables. The list is not intended to be final.

When a timeframe for completion is specified (for example, “within 45 days”), “days” refers to calendar days unless otherwise stated. If the deadline calculated in this way falls on a weekend or a federally recognized holiday, the contractor may comply with the deadline on the next business day, unless otherwise stated.

The QASP should include the process for conducting internal audits and results of internal audits are to be provided semi-annually within forty-five (45) calendar days after the beginning of each six-month period.

Staffing Matrix

Provide a draft staffing plan that describes organizational structure, assignment, management and oversight to ensure highly qualified personnels are availble to implement contract requirements.

The plan should describe how risks are assessed and managed at all stages of operation from the implementation and throughout operationalized phase. Tests should be conducted during the initial implementation phases and corrected accordingly. The offeror shall describe approaches to address failed tests or less than optimal results.

Subcontracting Plan Request for Consent to Subcontract per FAR 44.2 In accordance with FAR 44.2, submit a request for consent to subcontract to the CO and COR for prior approval before entering into a new subcontract. Submit as applicable.

Contractor will be provided with security welcome packet that we provide to those that need to go through the Security Assessment and Authorization (SA&A) process to be authorized has other timelines as far as specific items in the package. Contractor may be subjected to additional report upon authorization.

VI. Reporting Requirements

The proposed SOW should provide a description of reporting to inform the government of contractor’s implemantion of the requirement and how it meets performance standards. The frequency of reporting may include monthly, quarterly, semi-annually and / or annually.

VII. HIPAA Compliance and Business Associate Agreement

The WTC Health Program is a Covered Entity for purposes of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).[footnoteRef:1] The successful applicant will be required to become a Business Associate[footnoteRef:2] of the WTC Health Program for purposes of HIPAA compliance. To the extent that the successful applicant performs functions or activities on behalf of, or provides certain services to, the WTC Health Program where the successful applicant creates, receives, maintains, or transmits “protected health information” (PHI), the following “HIPAA provisions” apply: the Health Insurance Portability and Accountability Act of 1996 (HIPAA)(Pub. L. 104-191; 42 U.S.C. § 1320d); the Health Information Technology for Economic and Clinical Health (HITECH) Act (Pub. L. 111-5; 42 U.S.C. §§ 300jj et seq.); the HIPAA Privacy, Security, Breach Notification and Enforcement Rules (45 C.F.R. pts. 160, 162, and 164); and HHS HIPAA policies. [1: Pub. L. 104–191; 42 U.S.C. § 1320d, as modified, and the corresponding implementing regulations, including the Privacy, Security, Breach Notification, and Enforcement Rules (45 C.F.R. pts. 160, 162, and 164). HHS is a hybrid entity under HIPAA because it is a covered entity conducting business activities that include both covered and non-covered functions. 45 C.F.R. § 164.103. As a hybrid entity, HHS must designate any component that would “meet the definition of a covered entity or business associate if it were a separate legal entity” as a health care component; a health care component also may include a component only to the extent that it performs covered functions. 45 C.F.R. § 164.105(a)(2)(iii)(D). Accordingly, HHS has designated the WTC Health Program as a health care component of HHS and must comply with all requirements applicable to a covered entity under HIPAA.] [2: “Business Associate” is defined in the HIPAA Privacy, Security, Breach Notification, and Enforcement Rules (45 C.F.R. pts. 160, 162, and 164).]

The successful applicant shall require that any and all agents and subcontractors comply with all applicable provisions of HIPAA and shall document in writing the policies and procedures that will be used to meet such obligations. A WTC Health Program Business Associate Agreement is attached to this statement of objectives; it describes the detailed legal obligations and requirements of the Business Associate and the Covered Entity, including reporting of potential breaches. Any potential offeror shall submit an executed Business Associate Agreement with their proposal. This document shall later be incorporated into the successful awardees’ subsequent contract.

As a Business Associate of the WTC Health Program, the successful applicant will be directly liable under HIPAA for the following violations: Impermissible uses and disclosures of PHI; failure to provide breach notification to the WTC Health Program; failure to provide access to a copy of electronic PHI to either the WTC Health Program, the individual, or the individual’s designee, as specified in the Business Associate Agreement; failure to disclose PHI where required by the Secretary of HHS to investigate or determine the Business Associate’s compliance with HIPAA; failure to provide an accounting of disclosures; and failure to comply with the requirements of the Security Rule.

The proposal should include a detailed description of the processes that will be used to ensure compliance with HIPAA and the security of protected health information.