J.1_RVC_SOW_12-07-17.docx

RVC SOW

Statement of Work (SOW) for the Recovery Auditor Validation Contractor

Table of Contents

Statement of Work (SOW) for the Recovery Auditor Validation Contractor

Purpose

The primary purpose of the RAC Validation Contractor (RVC) is to review RAC claim determinations on Medicare claims that were paid under part A or B of title XVIII of the Social Security Act, and to ensure that the Recovery Audit Contractors (RAC) are not unnecessarily denying Medicare claims that were properly paid. This Statement of Work includes the following tasks, which are further defined in subsequent sections of this contract:

· The RVC shall review a random sample of claims on which the RAC has made improper payment determinations. The RVC shall also review any written correspondence sent to the providers for clarity and accuracy. The RVC shall submit reports to the Centers for Medicare and Medicaid Services (CMS) that outline recommendations and findings.

· The RVC shall conduct special studies upon request from CMS and will submit an analysis of their recommendations and findings.

· The RVC shall review proposed and approved New Issue concepts.

· The RVC shall meet and communicate with CMS and the RACs about their review findings, as well as developing public relations material upon CMS’ request.

· The RVC shall ensure compliance with all SOW and CMS system requirements, including Information Technology (IT) systems security policies, procedures and practices. This includes participating in the necessary security testing to obtain an Authority to Operate (ATO).

This contract focuses on the accuracy of the RACs’ improper payment determinations. This typically includes the review of improper payments to determine if the determination was accurate. At CMS’ discretion, the RVC shall also review no finding claims to assess the accuracy of those determinations.

Background

Section 302 and 1893(h) of the Tax Relief and Health Care Act of 2006 required CMS to make the RAC program permanent and nationwide by 2010. The Recovery Audit Program’s mission is to reduce Medicare improper payments through the efficient detection and correction of improper payments. Since inception of the permanent program, CMS has tasked the RVC with measuring the accuracy of the claim review determinations made by the RACs, as well as conducting special study reports of RAC identification. The CMS will continue these tasks with the RAC Validation Contractor in the RAC program.

To gain additional knowledge potential bidders may research the following documents:

· Medicare Fee-for-Service (FFS) Recovery Audit Report to Congress (see https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-RTC-FY2014.pdf)

· Permanent RAC Statement of Work

· Region 1-4 Statement of Work (see https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/New_RAC-SOW-Regions-1-4-clean.pdf)

· Region 5 Statement of Work (see https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/New_RAC-SOW-Region-5-clean.pdf)

· National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) (see https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx)

· The Financial Management Manual, Claim Processing Manual, Benefit Policy Manual and the Program Integrity Manual (PIM) (see https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html, published by CMS for use by CMS contractors)

· CERT Reports (see https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html?redirect=/cert/) Requirements

The RVC shall seek ways to complete their tasks in a timely and efficient way.

General Requirements

Independently, and not as an agent of the Government, the RVC shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government, as needed to perform the requirements of this Statement of Work (SOW). The contractor shall perform these services in accordance with the standards defined in this document.

The CMS will provide minimum administrative support, which may include assistance communicating with Medicare contractors, policy interpretations, and other support deemed necessary by CMS to allow the RVC to perform its tasks efficiently. The CMS will support changes it determines as necessary but is not bound to any timeframe. The RAC program is constantly improving systems to provide higher levels of efficiency; these changes could result in other administrative tasks assigned to the RVC. These administrative tasks will not extend from the tasks in this contract and the RVC is required to comply with changes that CMS deems necessary to improve the RAC Program. All changes initiated will be applicable to the accuracy and validation of RAC improper payment claims.

At a minimum CMS will conduct an annual review of the RVC clinical review functions and business practices. The contractor shall consider the first month of the contract a pilot of all RVC processes and procedures. Official reporting will not begin until 30 days following the initial receipt of the accuracy samples.

Initial Meeting

The RVC project staff (including key personnel, the Project Manager and Medical Director) shall meet at CMS in Baltimore, Maryland with the CMS Contracting Officer Representative (COR) and appropriate staff within fourteen (14) business days of the date of award to discuss the project plan. The specific focus will be to discuss the timeframes for the tasks outlined below. Within seven (7) business days of this meeting, the RVC shall submit a formal project plan outlining the resources and timeframe for completing the work outlined. The CMS must approve the initial project plan and any subsequent updates prior to implementation.

System Requirements and Data Accessibility

The RVC shall possess appropriate hardware, software, and telecommunications equipment to undertake this task order. Following award of the contract, the RVC shall only establish connections over the secure Medicare Data Communications Network (MDCN) and Multiprotocol Label Switching (MPLS) connectivity. At CMS discretion, this connectivity will be used to access a system for sending Protected Health Information (PHI) over the secure MDCN/MPLS network, and for communicating analysis findings electronically to CMS. The RVC shall test the system with all affected entities (including subcontractors) that the system can successfully pick up, process, and return PHI back to CMS. If the described format for CMS changes, the RVC will be required to comply.

The Contractor shall include this requirement in any subcontract awarded under this prime contract. If this SOW requires the Contractor to (1) process, (2) store, (3) facilitate transport, or (4) host/maintain Federal information; the Contractor agrees to comply with the Federal, Health and Human Services (HHS), and CMS Information Systems Security and Privacy Policy (IS2P2) and the CMS Business Partners System Security Manual (BPSSM). The CMS security requirements, policies, procedures, standards, and guidelines are located at CMS Information Security and Privacy “Virtual Handbook” at: http://www.cms.gov/InformationSecurity as well as the Information Security and Privacy Library at: https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html.

This SOW is subject to Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. 794d) as amended by the workforce Investment Act of 1998 (P.L. 105-220). Specifically, subsection 508 (a)(1) requires that when the Federal Government procures Electronic and Information Technology (EIT), the EIT must allow Federal employees and individuals of the public with disabilities comparable access to and use of information and data that is provided to Federal employees and individuals of the public without disabilities. For additional information, please refer to the HHS Section 508 Accessibility Checklist (https://www.hhs.gov/web/section-508/making-files-accessible/checklist).

Specific Tasks to Be Performed

Task 1: Project Plan

The RVC shall develop a project plan outlining the administrative activities associated with the contract. A post-award conference will be required after contract award to discuss the project plan. The specific focus will be to discuss the timelines for the tasks outlined below. Within seven (7) business days of this meeting, the RVC shall submit a formal project plan outlining the resources and timeframe for completing the work outlined. After the project plan is submitted, reviewed, and accepted by CMS, any changes or updates in regards to the project plan will be noted in the RVC Operations Manual.

Task 2: RVC Operations Manual

The RVC shall develop and maintain an approved RVC Operations Manual. The Contracting Officer’s Representative (COR) will approve the design and layout of this manual. The draft manual shall be submitted to the CMS COR no later than thirty (30) calendar days after contract award and quarterly thereafter. If no comments are received from the CMS COR within thirty (30) days of submission of a draft manual change, the RVC shall submit the final document within ten (10) calendar days after the comment period ends.

The RVC Operations Manual is a living document and may be updated without contract modification. The contractor shall provide written comments to the CMS COR on changes, updates or corrections to the manual on a continual basis so that it will be kept current to accommodate workload and other changes in the RVC processes as necessary. Changes identified in revisions to the review manual are to be acted upon only if they fall within the general scope of the contract. The RVC manual documents the various processes that the RVC follows in its daily operations, including the process for obtaining, processing and reviewing medical records and claims, reporting procedures, and other processes and business rules as necessary.

Task 3: Accuracy Reviews

The RVC shall measure the accuracy rate for each RAC by reviewing a randomly selected sample of claims on which the RAC has made an improper payment determination. The CMS will provide up to 1,000 randomly selected claims per month to send to the RVC. The type of claims selected will be comparative to the provider types that the RACs review (inpatient hospital, inpatient rehabilitation facility, outpatient hospital, skilled nursing facility, physician, lab/ambulance/other carrier, home health, and DME). The CMS will notify the RACs which claims were selected for review and the RACs will forward the claim information to the RVC within seven (7) business days or unless otherwise specified by CMS. The accuracy reviews begin once the RVC receives claim detail information from the RAC.

The RVC shall review each submitted claim, claim selection criteria, associated medical record (for complex reviews only), New Issue Review Form (NIRF), review guidelines (for complex reviews only), edit parameters, improper payment finding, reviewer rationale, communication to provider, error type and subtype, and beneficiary liability finding. The RVC will also review all correspondence sent to the provider communicating the improper payment finding and compare the letter to denial options in the New Issue Form and review guidelines for each review. The RVC shall develop a standardized checklist to assist in this review unless CMS provides checklists to the RVC on specific topics. The RVC shall review and compare each submitted claim to the RAC Data Warehouse (RACDW) for accuracy and consistency. The RVC will identify any discrepancy between claim information from the RAC and the information in the RACDW.

The RVC shall document the following findings for each claim in the study:

· Whether the RACs used the CMS-approved ADR Letter template

· Whether the RAC’s edit parameters/review guidelines are supported by CMS policy or evidence -based medical research when policy does not exist or is silent

· Did the RAC use the appropriate edit parameters/review guidelines when reviewing the claim?

· Whether the criteria for automated review was met (or whether the RAC should have performed a complex review instead)

· Whether the RVC agrees or disagrees with the RAC’s claim improper payment determination (full overpayment, partial overpayment, underpayment, etc)

· For each disagree, indicate the correct determination. At CMS’ discretion the RVC may be requested to recode and re-price claims (the RVC will be responsible for purchasing all pricers and groupers needed for the reviews)

· For each claim, the RVC shall indicate if they agree with the improper payment type and amount.

· Whether the RVC agrees or disagrees with the RAC’s error type (no documentation, insufficient documentation, medically unnecessary, incorrectly coded, or other) and subtype (to be provided by CMS) for the claim determination

· For each disagree, indicate the correct denial type and subtype

· Whether the RVC believes the language used by the RAC to communicate findings to the provider was clear and accurate based on the approved New Issue concept

· Did the RAC use the CMS-approved Review Results Letter or Demand Letter template?

· Does the Review Results Letter clearly describe all findings?

· Whether the RVC believes that the RAC appropriately communicated to the provider the clinical evidence contained in the medical record that justifies their determination

· Whether the RVC agrees or disagrees with the RAC’s beneficiary liability determination

· Whether the information the RAC submitted matches the information found in the RACDW

Prepayment Reviews

Claims for these types of reviews may be assigned at CMS discretion, but will only be assigned when CMS has the authority to use Recovery Auditors to conduct prepayment review.

Accuracy Report

The RVC shall submit to CMS one report per RAC discussing accuracy. The 508-complaint report shall be delivered within 30 calendar days after the RVC’s receipt of the monthly accuracy sample. The report shall include a narrative section with information about patterns of inappropriate determinations that can be seen from the data as well as recommendations to CMS. The RVC shall only provide a brief explanation/rationale for disagree claims that have the wrong error type, the wrong improper payment amount, and the wrong information found within the RACDW. In these rationales, the RVC shall include what findings were documented in the medical record and what CMS policy was used to support the review determination, if there is a beneficiary liability issue with the review concept, and if the RAC followed their approved edit parameters and review guidelines. It is important for the RVC to provide a rationale or explanations of inconsistencies seen in the review so CMS can implement corrective actions for the RAC to follow.

A standardized 508 compliant format for this document is required. Please note that the COR will approve the design and layout of this report and may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

Recommendations

New Issue and Policy Recommendations

Upon delivery of the Accuracy Report, the RVC shall provide a separate report each month for each RAC region that addresses New Issue and Policy Recommendations. The RVC shall write a clear and articulate analysis highlighting the key policy and other possible vulnerabilities that can positively or negatively affect the integrity of the program. The report shall include corrective actions that CMS (i.e. LCD change, system edit, etc), the Division of Recovery Audit Operations (DRAO) Review Plan Team, and RAC should undertake (i.e. update a new issue concept). Specifically, the RVC shall provide recommendations on how CMS can further assist the RAC to effectively and efficiently improve the submitted new issue.

Furthermore, the RVC shall make recommendations based on issues/concerns identified during accuracy reviews of approved New Issues (NI). These recommendations include but are not limited to broader issues that are, or can become, problematic and issues that may affect medical review, such as patterns of, or consistent mistakes seen with the RAC’s reviews, egregious errors that need to be addressed regardless of patterns or trends, policy vulnerability issues, and identification of outdated policy.

In addition to providing recommendations for each monthly accuracy report, the RVC shall be responsible for performing a monthly quality assurance (QA) check on all NI concepts being reviewed within the accuracy sample. The RVC is to research the entire NI package, which includes but is not limited to the New Issue Review Form (NIRF), edit parameters, review guidelines, and good cause language. In addition to reviewing all documents, the RVC shall review all references that are a part of the NI concept. With the review of references, the RVC shall research and check all regulations and/or policy (SSA, CFR, NCD, CMS policy, etc.) to ensure that references are valid and up to date. Additionally, the RVC will be required to inform CMS of all policy changes and how it affects the NI concept.

This review will determine if there are any changes in policy and or if there needs to be an update to the approved concept under review. This QA check will involve verifying policies in place at the Date of Service (DOS) to ensure correct application of policy as it relates to the RAC’s review guidelines/edit parameters. Even though this report will include notification of recent changes to policy to the NI under review, if applicable, the RVC shall note that the information provided may not affect the specific claims under review. The RVC is solely responsible for monitoring policy changes and if there is a need to update or change a NI concept, this needs to be discussed in the New Issues Policy and Recommendations report.

The RVC is expected to review all NI concepts within the monthly sample, in addition to validating all concepts under review. The RVC shall only submit a report to CMS if there are policy updates or recommendations noted. This report shall be no more than three (3) pages. A standardized 508 compliant format for this document is required. However, CMS may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, borders, margins, etc. Please note, the RVC can request that the report extend the 3-page requirement. For this request to be reviewed, the RVC needs to provide an anticipated page amount and the reason for the extension. This page extension request will be reviewed and CMS will determine if an extension will be granted.

Please note that the COR will approve the design and layout of this report and may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

Error Code Recommendations

If the RAC receives a “Disagree” on their assigned error code, the RVC will include a recommendation with in the accuracy report. In this recommendation, the RVC will discuss why there was a disagreement.

Please note that the COR will approve the design and layout of this section found in the accuracy report and may dictate the formatting of report. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

Error Code Decision Table

RAC: Can update RACDW with correct error code RVC: Update AR report

RAC: Dispute eligible only if the content of the RRL is correct.

RAC: Dispute eligible

RAC: If the RVC disagrees, the dispute is not eligible.

RAC: Dispute eligible

Recovery Audit Data Warehouse (RACDW)

The CMS will provide the RVC with access to the Recovery Audit Data Warehouse (RACDW). The Data Warehouse is a web-based application that houses data related to all RAC improper payment identifications and corrections (overpayment collections and returned underpayments). The RVC shall upload each RAC region’s monthly accuracy report on the same day each RAC region’s monthly accuracy report is submitted to CMS. For more information, please refer to Task 3: Accuracy Reviews, Section 2- Accuracy Report.

The RVC will also be responsible for editing information if changes in the report occur.

The RVC is responsible for creating a upload file (.txt file) for uploading claims in the RACDW. A standardized 508 compliant format for RACDW uploads will be required. Please note that the COR will approve the design and layout of this file and may dictate the formatting of this document.

Task 4: RAC Disputes/Disagrees

When the RVC disagrees with a RAC improper payment determination in an accuracy review, the RAC may submit a dispute. To submit a dispute, the RAC shall complete a dispute form (DF- Appendix B) and submit to their RAC COR within thirty (30) calendar days of the accuracy report. Once the form is submitted by the RAC COR, the RVC COR will be responsible for forwarding the dispute to the RVC. The RVC shall review the dispute and submit a response to CMS within ten (10) calendar days. There is no limit on the amount of disputes each RAC can submit per month. If an automated review is disputed, the RAC shall place multiple claims under the same new issue on the dispute form, as long as the dispute has the same denial reason; this dispute will count as one billable item. Each complex review is counted separately as one billable item since this review requires the RVC to perform a second review of the entire medical record. This process may be subject to change at CMS’ request.

RVC Overturns

After reviewing the RAC dispute, the RVC shall submit a completed dispute form outlining a rationale for the overturn, an updated Accuracy Report, and a corrective action plan that includes the summary of error(s), root cause analysis, plan of action for correction(s), and an estimated time frame for resolving the error(s). The RVC shall also identify any lessons learned and provide instructions to strengthen future accuracy reviews. The RVC shall assume that corrective action plans are required on all overturns unless otherwise specified by CMS. The RVC shall also be required to update information in the RACDW when the Accuracy Report is updated.

RVC Upholds

If the RVC upholds their original decision, CMS will make the final decision. The CMS is not held to a timeline for review of the dispute, and once the decision is reached, this final decision is not open to further dispute.

If CMS disagrees with the RVC’s decision, CMS will provide its decision and rationale to the RVC. Upon receipt of the final decision, the RVC has two (2) business days to provide an updated accuracy report and corrective action plan that includes the summary of error(s), root cause analysis, plan of action for correction(s), and an estimated time frame for resolving the error(s). The RVC shall also identify any lessons learned and provide instructions to strengthen future accuracy reviews. The RVC shall assume that corrective action plans are required on all overturns unless otherwise specified by CMS. The RVC shall also be required to update information in the RACDW if CMS overturns the RVC decision.

Please note that special studies are not eligible for disputes.

Task 5: Special Studies

In addition to Accuracy Reviews, the RVC shall review 500 claims per year for special studies at CMS’ request. Special studies are conducted to inform CMS management of specific topics or areas of interest. This task does not affect the RAC’s overall accuracy and the results do not have to be shared with the RACs. The RVC shall review the entire special study package including the NIRF, edit parameters/review guidelines, claim samples, associated medical records, improper payment finding, reviewer rationale, etc. The RVC will also review all correspondence sent to the provider communicating the improper payment finding and compare the letter to denial options in the New Issue Review Form and review guidelines for each review. The RVC shall develop a standardized checklist to assist in this review unless otherwise directed by CMS. Not every special study package may include all items as mentioned above.

The RVC shall document the following findings for each claim in the study:

· Whether the RACs used the CMS-approved ADR Letter template

· Whether the RAC’s edit parameters/review guidelines are supported by CMS policy or evidence-based medical research when policy does not exist or is silent

· Did the RAC use the appropriate edit parameters/review guidelines when reviewing the claim?

· Whether the criteria for automated review was met (or whether the RAC should have performed a complex review instead)

· Whether the RVC agrees or disagrees with the RAC’s claim improper payment determination (full overpayment, partial overpayment, underpayment, etc)

· For each disagree, indicate the correct determination. At CMS’ discretion the RVC may be requested to recode and re-price claims (the RVC will be responsible for purchasing all pricers and groupers needed for the reviews)

· For each claim, the RVC shall indicate if they agree with the improper payment type and amount.

· Whether the RVC agrees or disagrees with the RAC’s error type (no documentation, insufficient documentation, medically unnecessary, incorrectly coded, or other) and subtype (to be provided by CMS) for the claim determination

· For each disagree, indicate the correct denial type and subtype

· Whether the RVC believes the language used by the RAC to communicate findings to the provider was clear and accurate based on the approved New Issue concept

· Did the RAC use CMS-approved Review Results Letter or Demand Letter template?

· Does the Review Results Letter clearly describe all findings?

· Whether the RVC believes that the RAC appropriately communicated to the provider the clinical evidence contained in the medical record that justifies their determination

· Whether the RVC agrees or disagrees with the RAC’s beneficiary liability determination

· Whether the information the RAC submitted matches the information found in the RACDW

Special Study Report

For each special study, the RVC shall submit to CMS a report including accuracy rates, a narrative section with information about patterns of inappropriate denials that can be seen from the data. The 508-complaint report shall be delivered within 30 calendar days after the RVC’s receipt of the documents for the special study sample. The RVC shall only provide a brief explanation/rationale for disagree claims that have the wrong error type, the wrong improper payment amount, and the wrong information found within the RACDW. In these rationales, the RVC shall include what findings were documented in the medical record and what CMS policy was used to support the review determination, if there is a beneficiary liability issue with the review concept, and if the RAC followed their approved edit parameters and review guidelines. It is important for the RVC to provide a rationale or explanations of inconsistencies seen in the review so CMS can implement corrective actions for the RAC to follow.

The special study report shall also include recommendations and corrective actions for any policy(s) during the review and include any additional reference that may be applicable to the analysis finding. The report shall be delivered by the 30th calendar day, following the RVC’s receipt of the special study package or unless otherwise directed by CMS. A standardized 508 compliant format for this document is required. Please note that the COR will approve the design and layout of this report and may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

Recovery Audit Data Warehouse

The RVC shall upload each special study report on the same day that each RAC region’s monthly accuracy report is submitted to CMS. For more information, please refer to Task 3: Accuracy Reviews, Section 2- Accuracy Report. A standardized 508 compliant format for RACDW uploads will be required.

Task 6: New Issue Review

The RVC will be tasked with reviewing proposed and approved New Issue concepts. The Recovery Audit Contractor (RAC) program performs post payment review to identify Medicare claims that contain improper payments (overpayments or underpayments), which were made under Part A or Part B of Title XVIII of the Social Security Act. This includes review of all Medicare claim and provider types and a review of claims/providers that have a high propensity for error based on the Comprehensive Error Rate Testing (CERT) program and other CMS analysis.

These improper payments are identified both by automated review which utilize edit parameters to capture claims as well as by complex medical review which use edit parameters and detailed review guidelines to select claims for detailed medical record review by clinicians and certified coders.

New Issue Proposal Review

The RVC shall review the new issues that a RAC wishes to pursue for potential improper payments. In order for new issue proposals to be reviewed, the RAC must submit a new issue proposal package to CMS. The proposals submitted will be either automated or complex review concepts. Proposals must contain:

· New Issue Review Form with detailed references

· References include the Social Security Act, Code of Federal Regulations, CMS rulings, and National Coverage Determinations (NCDs).

· Other acceptable references include: CMS interpretive manuals, CMS coding policies, CMS technical direction, Local Coverage Determinations (LCDs), and coding clinics.

· That RAC has been instructed to refrain from including references such as MAC Manuals, OIG reports, Medicare Learning Network articles, etc.

· Edit Parameters

· The edit parameters will identify, step by step, how claims are identified as improper payments (for automated review), or selected for documentation requests (for complex reviews).

· These parameters will indicate the look-back period, and any/all claim exclusions.

· Review Guidelines (for complex reviews)

· The review guidelines shall include all applicable exclusions including modifiers, codes, types of bill, etc.

· Coding lists with long descriptors

· Potential dollar amount of improper payment

· Good cause language for claim review

· Improper payment rationale

· Claim samples

· Sample correspondence the RAC would send to the provider if an improper payment were identified

Once CMS receives the new issue proposal package and determines that the entire proposal package is complete, CMS will submit the proposal to the RVC for review. The DRAO Review Plan Team is responsible for performing a quality assurance check before sending any proposals to the RVC COR.

Since the RACs may submit New Issue Proposal packages at any time during the month, the RVC will not receive proposals by a specific date. Even though this is a fluid and ongoing process, the RVC will only review a maximum of thirty (30) proposals a month.

New Issue Proposal Vulnerability Report

The New Issue Proposal Vulnerability Report for each individual proposal is deliverable to CMS by the 10th business day following the RVC’s receipt of the proposal. The RVC shall submit to CMS a report no more than three (3) pages per new issue proposal.

In this document, the RVC shall include if the New Issue proposal is ready for submission to the CMS Review Plan Team, the strengths and weaknesses of the review, and if this review could possibly increase appeals. In addition to the above document requirements, the RVC shall state if there is a true basis for denial based on policy or regulation. If so, the report should state or describe what the basis of denial would be.

For each proposal, the RVC shall write a clear and articulate analysis highlighting the key policy and other possible vulnerabilities that may positively or negatively affect overall program integrity. The vulnerability report shall include corrective actions that CMS (i.e. LCD change, system edit, etc), the Division of Recovery Audit Operations (DRAO) Review Plan Team, and RAC should undertake (i.e. update a new issue concept). Specifically, the RVC shall provide recommendations on how CMS can further assist the RAC to effectively and efficiently improve the submitted new issue. The RVC shall proceed with submission to the CMS Review Plan Team and note if the proposal submitted was correct based on current policy and regulations. Additionally, the RVC should provide, if appropriate, any additional reference(s) that may be applicable to the review.

A standardized 508 compliant format for this document is required. The COR will approve the design and layout of this report and may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

Please note, the RVC can request that the report extend the 3-page requirement. For this request to be reviewed, the RVC needs to provide an anticipated page amount and the reason for the extension. This page extension request will be reviewed and CMS will determine if an extension can be granted.

New Issue Quality Assurance (QA) Review

In addition to review and QA check of NI concepts during the monthly Accuracy Review, the RVC shall review all approved New Issues Packages, which includes but is not limited to the New Issue Review Form (NIRF), edit parameters, review guidelines, and good cause language. In addition to reviewing all documents the RVC shall review all references that are a part of the NI concept. With the review of references, the RVC shall research and check all regulations and/or policy (SSA, CFR, NCD, CMS policy, etc.) to ensure that references are valid and up to date. Additionally, the RVC will be required to inform CMS of all policy changes and how it affects the NI concept.

The DRAO Review Plan Team will submit the NI package to the RVC COR. The DRAO Review Plan Team will provide the RVC COR up to thirty (30) New Issue Packages monthly. Once delivered to the RVC, the RVC shall provide updates if appropriate within fifteen (15) business days. It will be expected that the RVC will update the entire package with track changes or inform CMS that there are no changes noted in the package. With submission of updated packages, the RVC shall provide a tracker for the concepts reviewed to confirm that the QA check was performed. The information (format and substance) located within the tracker may be dictated by CMS. The RVC is required to keep an internal tracker of all New Issues that have been reviewed for a QA check. This internal tracker is a living document and should be updated by the RVC, and supplied to CMS upon request. In addition to supplying CMS with this tracker upon request, the RVC shall include a list of approved New Issues where a QA check was performed in the annual report. This admission in the report shall also include the number of NI updated and a brief overview of updates that address significant program vulnerabilities. For more information, please refer to Task 9: Annual Reports.

The DRAO Review Plan Team has the right to submit any approved NI concept for review, but the priority will be given to NI that are not currently being reviewed by the RAC to ensure review concepts remain up to date. At their discretion, The DRAO Review Plan Team may also submit to the RVC COR approved concepts that have high appeals rates.

A standardized 508 compliant format for this document is required. Please note that the COR will approve the design and layout of this tracker and may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

New Issue Support Services

At times, the DRAO Review Plan Team creates New Issue Proposals based on recommendations from various stakeholders. To assist with this task, the RVC shall support the DRAO Review Plan Team as needed through educational activities or in-services, which can be completed remotely in regards to, but not limited to:

· Medicare coverage guidelines and medical review program requirements;

· NCD, LCD, and policy articles including how these are developed, how to identify if updates need to be made, and steps involved with revision;

· CPT, HCPCS, ICD 9/10, Coding and MS-DRG rules and guidelines

Task 7: Contractor Quality Assurance

The RVC shall develop a quality assurance (QA) plan to be approved by the CMS COR. The plan shall include, at a minimum, a review of 30% of all claims reviewed (accuracy reviews and special studies). The RVC shall spend 8-10 hours per week on activities aimed at ensuring the consistency of accuracy reviews (i.e. random quality checks, staff in-services, QA Meetings). The Contractor Medical Director (CMD) and the Medical Review (MR) Manager shall provide oversight of all RVC medical review activities for quality assurance. If needed the Program Manager can assist with QA and will collaborate with the CMD and the MR Manager to ensure the services and deliverables required in this SOW align with contractual and regulatory requirements.

Please note that the COR shall review and approve all training/education before initiated. At times, the COR and other CMS stakeholders will be present at the trainings being provided.

Potential Contractor Quality Problems

The RVC shall report potential quality assurance issues immediately to the CMS COR.

Task 8: Monthly Progress Reports

The RVC shall submit monthly administrative progress reports outlining all work accomplished during the previous month. The report shall include but not limited to the following for the current month and/or contract year:

· Number of accuracy claims reviewed and agreement rate (current month and contract year)

· Number of special study claims reviewed and a summary of study (current month)

· Number of identified CMS policy vulnerabilities and a summary of each vulnerability (current month)

· Cumulative number of special study claims reviewed incurred (contract year)

· Contractor Quality Assurance activities (current month)

· RVC Corrective Actions (current month)

· Complications completing any task (current month)

· RAC communication through monthly RVC/RAC calls (current month)

· Communication with all other RAC Supporting Contractors (current month)

· Communication with subcontractor if applicable (current month)

· Action Items (current month and contract year)

· Major Findings identified from accuracy and special study reviews and RAC monthly calls (current month)

· A complete list of New Issue Proposals reviewed (current month)

· A complete list of the updated approved New Issue Packages that have been checked for Quality Assurance purposes (current month)

Each monthly report shall be submitted by the close of business on the 10th calendar day of the month for the previous month’s effort. A standardized 508 compliant format for this document is required. Please note that the COR will approve the design and layout of this report and may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc. Each report shall be submitted by email to the CMS COR and one copy accompanying the contractor’s voucher that is sent to the CMS accounting office.

Task 9: Annual Reports

The RVC shall provide an annual report of contract activities sixty (60) calendar days after the end of the fiscal year (September 30th). The report shall include but not limited to the following findings from the past fiscal year:

· Overall accuracy rates and the number of agrees vs. disagrees for each RAC

· A narrative section with information about patterns of inappropriate denials

· A list of New Issue proposals reviewed in the past fiscal year

· A list of approved New Issues where a QA check was performed in the past fiscal year

· Overall Contractor Quality Assurance activities for the fiscal year

· RVC corrective actions in the past fiscal year

· Future enhancements and recommendations section to highlight noteworthy vulnerabilities or trends identified during the previous fiscal year

· Corrective actions the agency should undertake to remedy documented vulnerabilities

The report shall be no more than twenty (20) pages. Please note, the RVC can request that the report extend the 20-page requirement. For this request to be reviewed, the RVC needs to provide an anticipated page amount and the reason for the extension. This page extension request will be reviewed and CMS will determine if an extension can be granted.

A standardized 508 compliant format for this document is required. Please note that the COR will approve the design and layout of this report and may dictate the formatting of this document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

Task 10: Meetings and Conference Calls

The CMS and the RVC shall meet weekly via conference call to discuss any process issues. In lieu of a cancelled meeting, the RVC shall send an RVC contract update that outlines the workload for that week.

In addition to the weekly conference call, the RVC shall meet with each RAC via conference call on a monthly basis, at a minimum. The RVC shall schedule one meeting per week. If necessary, the RVC shall meet with CMS and all of the RACs to discuss any outstanding issues and status updates. The meeting schedule shall be flexible and can change as needed.

The RVC shall have additional conference calls with CMS upon request. During this meeting it may be required that the RVC CMD, Project Manager, and Medical Review (MR) team consult with DRAO staff for any issues (policy, coding issue, etc) related to RAC review. The discussion shall include trends and concerns for individual RACs or the program as a whole and any corrective actions the agency should undertake when the RVC has identified a consistent pattern during accuracy reviews.

The RVC shall provide agendas and phone lines for all scheduled calls. The RVC shall facilitate each call, record the meeting minutes, and distribute meeting minutes after the call. A standardized 508 compliant format for agendas and meeting minutes are required. Please note that the COR will approve the design and layout of the agendas and any presentation that will be used in these conference calls and may dictate the formatting of these document. This includes changing previous format, which includes but is not limited to font, spacing, boarders, margins, etc.

The RVC shall immediately notify CMS of any invitations for the RVC to attend a speaking engagement related to the RAC program. The CMS approval is required to allow the RVC to participate in such engagements. If slides or other written materials are to be used, they must be submitted in advance to CMS for approval. The RVC shall provide meeting, call in information, and other pertinent items in regards to any engagements in reference to the RAC Program. The RVC will also review and provide recommendations on public relation material on the RAC program upon CMS request.

Other Conference Calls

Key personnel are required to be on any call that relates to the RAC Program that CMS directs them to participate in.

Task 11: Travel

The contractor is required to travel to CMS Central Office in Baltimore, Maryland to attend the Program Integrity Annual Meeting and the RAC Operational Meeting.

The CMS will reimburse travel for up to four key personnel (CMD, Back-Up CMD, Program Manager or Vice President, and MR Manager) to attend these events spanning no more than five days. The CMS will only reimburse airfare, gas mileage (if driving), ground transportation, lodging, and meal costs according to the current GSA per diem rate. The CMS will not reimburse FTE hourly rates for travel or attendance. Since this is a firm-fixed price contract, travel costs have been added to the price of the contract and are not broken out separately from the tasks that pertain to travel.

Task 12: Ensuring Compliance with CMS Security Requirements

When using or disclosing protected health Information (PHI), the RVC must comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

The RVC shall conduct an independent evaluation and test of its systems security program in accordance with the CMS Business Partners System Security Manual, 100-17 and the CMS Information Systems Security and Privacy Policy (IS2P2). The Contractor’s first independent evaluation and test of its systems security program shall be completed prior to the Contractor commencing accuracy reviews. Any deficiencies noted because of the independent evaluation and test of its systems security program shall be corrected prior to the initiation of Accuracy Reviews. The RVC shall conduct, at a minimum, annual vulnerability assessment of its systems, programs, and facility in accordance with the CMS Business Partners System Security Manual, 100-17, as well as the CMS Information Systems Security and Privacy Policy (IS2P2) Information Security Continuous Monitoring.

The RVC shall provide annual certification, in accordance with Security Assessment and Authorization (SA&A) procedures, that certifies it has examined the management, operational, and technical controls for its systems supporting RVC function and considers these controls adequate to meet CMS security standards and requirements. The RVC shall ensure security documents are uploaded and security controls are documented timely in the CMS FISMA Control Tracking System (CFACTS). The RVC shall correct any security deficiency, conditions, weaknesses, findings, or gaps identified by all CMS audits, reviews, evaluations, tests, and assessments within the timeframes requested. The RVC shall begin the process to obtain an ATO within sixty (60) days of contract award.

The CMS will take all measures necessary to minimize system security risks, including but not limited to ceasing accuracy reviews, and terminating the RVC contract if necessary.

Administrative and Miscellaneous Topics

Contractor Performance Evaluation

On a regular basis, CMS will perform a contractor performance evaluation by the use of desk audits and/or site visits. Advance notice may or may not be given. During the evaluation, CMS reviewers will work from a prescribed audit protocol, review actual cases, and issue a final report. Any finding from the review will require a corrective action plan.

Unsatisfactory Performance

Failure by the RVC to meet any performance standards, assigned tasks, or otherwise comply with this SOW will result in the RVC being placed on a Performance Improvement Plan. Failure to comply with, or meet the objectives of the Performance Improvement Plan will result in corrective actions by CMS, including limiting the scope of work under the contract and possible contract termination.

Technical Direction

If changes should occur within the program, or clarification is needed regarding a specific issue, CMS will provide the RVC with technical direction through their COR. At times, the RVC may receive informational technical direction letters that may not apply to their internal approach, but is provided to be aware of any changes with claim review or the recovery audit process.

Case Record and File Maintenance

The RVC shall maintain a case file for all claim samples, including documentation review. The case file may be electronic, paper or a combination of both. The RVC shall not destroy any supporting documentation relating to the identification or recovery process. The RVC shall store these cases in such a way that they can be accessed immediately upon request. The RVC shall retain the findings for each claim indefinitely.