J.1_MRAC_SOW_Updated.docx

MEDICAL REVIEW ACCURACY CONTRACTOR

STATEMENT OF WORK

I. Scope

A. Purpose

The Center for Program Integrity (CPI) and other areas of the Centers for Medicare & Medicaid Services (CMS) are seeking to collaborate to monitor the accuracy of the Medicare and Medicaid Medical Review Contractors (MRCs) medical review decision making, the ability to implement Medicare coverage, coding, payment, and billing policies and the identification of potential fraud, waste, or abuse. MRCs are defined as the Medicare Administrative Contractor (MAC), Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing contractor (CERT), Zone Program Integrity Contractor (ZPIC)/Unified Program Integrity Contractor (UPIC), Medicare Drug Integrity Contractor (MEDIC), Medicaid Integrity Contractor (MIC), Qualified Independent Contractor (QIC) and Beneficiary and Family Centered Care - Qualified Independent Contractor (QIC) and Quality Improvement Organization Contractor (QIO). To fulfill this, CPI and other areas of CMS are seeking to obtain a Medical Review Accuracy Contractor (MRAC), to review a specified amount of claims medically reviewed by each MRC per month. The claim reviews require, at a minimum, the use of clinical review judgment in the evaluation of medical records and related documents to determine whether Medicare and Medicaid MRCs made accurate claim decisions in compliance with coverage, coding, payment, and billing policies, and medical review for program integrity purposes focusing on situations of potential fraud, waste and abuse in the Medicare and Medicaid programs. The MRAC will measure the accuracy rate for each MRC by medically reviewing a representative sample of claims that each MRC has reviewed. Medical review shall be conducted in accordance the MRC-specific requirements in the CMS Internet Only Manuals and the Medicaid State Manuals.

B. Background

The CPI’s Division of Medical Review and Education (DMRE) is accountable for the evaluation of medical records and related documents to determine whether Medicare claims were billed in compliance with Medicare’s coverage, coding, payment, and billing policies. As part of this oversight, CPI and other areas of CMS are seeking to monitor the accuracy of the MRCs medical review decision making and ability to implement Medicare coverage, coding, payment and billing polices. Specific work related to the DMRE hereafter will be referred to as “Standard”.

The CPI’s Division of Contractor Performance Assessment (DCPA) is accountable for the evaluation of medical records and related documents to determine whether Medicare and Medicaid claims were billed in compliance with Medicare’s and Medicaid’s coverage, coding, payment, and billing policies and the identification of patterns and/or trends which may support an allegation of potential fraud, waste or abuse. Specific work related to the DCPA hereafter will be referred to as “Program Integrity”.

The statutory and regulatory authority for the medical review of Medicare and Medicaid claims is referenced in the following:

· Social Security Act Section 1833(e) which states, in part, “….no payment shall be made to any provider…unless there has been furnished such information as may be necessary in order to determine the amounts due such provider…;’

· Social Security Act Section 1862(a)(1) states no Medicare payment shall be made for expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

· Social Security Act Section 1936: Medicaid Integrity Program

· 42 CFR 421.4 for the Medicare Administrative Contractors (MACs)

· 42 USC 1396u-6: Medicaid Integrity Program

· 42 CFR 455- Program Integrity: Medicaid

· Social Security Act, Title XI Part B and Title XVIII – BFCC-QIOs

NOTE: Although this contract vehicle combines work in support of Standard and Program Integrity medical reviews, each are governed under separate and distinct funding appropriations. The MRAC must track all costs incurred under each workload stream and bill to the appropriate contract line item number (CLIN) under this contract.

II. Requirements

A. General Requirements

· Independently, and not as an agent of the Government, the MRAC 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). CPI and other areas of CMS will provide administrative support which may include help communicating with Medicare contractors, policy interpretations, and other support deemed necessary by CPI to allow the MRAC to perform its tasks efficiently.

· Assumptions and Constraints The following identifies the basic assumptions and constraints concerning this effort.

· The MRAC shall furnish the Information Technology (IT) environment and any equipment required by its personnel to complete the medical review project/tasks and reports. CPI/CMS is not acquiring the Contractor’s facilities or IT systems (hardware or software) used to support performance of the work.

· The MRAC shall present and maintain a Quality Control plan for this assessment/training of medical review personnel.

· The MRAC’s training plan and maintenance of training materials shall take into account changes in CPI/CMS regulations, guidance, manuals, or forms.

· The MRAC shall provide individuals who are completely trained and capable of doing all tasks pertinent to their job function. It is the responsibility of the Contractor to ensure their employees are current on all licenses/certifications/necessary training that relates to the execution of services under this contract.

· The base year of this contract will be limited to the review of the MACs, SMRC, CERT, BFCC-QIOs, QIC and ZPICs/UPICs. The additional contractor types will be integrated into the workload after the evaluation of the base year of work and at the direction of CPI/CMS.

· CPI/CMS anticipates that the Standard MR workload required in Task 4 below will be based on 2,000 Part A and 3,300 Part B Standard claims in the Base Year and 2,600 Part A and 4,600 Part B Standard claims in the Option Years to be reviewed by the MRAC.

· CPI/CMS anticipates that the Program Integrity MR workload required in Task 4 below will be based on 1,450 Medicare Part A, 4,100 Medicare Part B, and 50 Medicaid Program Integrity claims in the Base Year and 1900 Medicare Part A, 6,000 Medicare Part B, and 100 Medicaid Program Integrity claims in the Option Years to be reviewed by the MRAC.

· At the discretion of CMS, additional Standard MR workload may be required in Task 4.1.1 below based on approximately 650 Part A and 2,000 Part B Standard claims in the Base Year and Option Years.

· During the transition period, the Standard MR workload will be 23 Part A, and 7 Part B Standard claims to be reviewed by the MRAC.

· During the transition period, the Program Integrity MR workload will be 23 Medicare Part A, 6 Medicare Part B, and 1 Medicaid Program Integrity claims to be reviewed by the MRAC.

· The MRAC travel requirements only pertain to Key Personnel in support of Task 1.1 for the Kick-off meeting and Task 3.4 for the annual CPI/CMS Medical Review Operational meeting.

· The MRAC shall establish a JOA for the purpose of facilitating efficient processes for communication between the MRAC and MRC. These processes shall include a procedure for obtaining the required information/documents for the medical review of the MRC’s Medicare claims, for Standard and Medicare and Medicaid claims for Program Integrity.

· Section 508 Compliance All contract deliverables are subject to these 508 standards as applicable. Regardless of format, all Web content or communications materials produced, including text, audio or video shall conform to applicable Section 508 standards to allow federal employees and members of the public with disabilities to access information that is comparable to information provided to persons without disabilities. All Contractors (including subcontractors) or consultants responsible for preparing or posting content shall comply with applicable Section 508 accessibility standards, and where applicable, those set forth in the referenced policy or standards documents stated in this section. Remediation of any materials that do not comply with the applicable provisions of 36 CFR Part 1194 as set forth in the SOW, shall be the responsibility of the Contractor or consultant. The following Section 508 provisions apply to the content or communications material identified in this SOW:

• 36 CFR Part 1194.22 a – j, l – p

• 36 CFR Part 1194.41 a – c

· Systems Requirements The MRAC shall possess appropriate hardware, software, and telecommunications equipment to meet the requirements in this SOW.

As required the MRAC shall (1) process, (2) store, (3) facilitate transport of, or (4) host/maintain Federal information; the MRAC shall comply with the Federal, HHS, and CMS Information Security Program Policies and the CMS Business Partners System Security Manual (BPSSM). The CMS security requirements, policies, procedures, standards, guidelines are located at CMS Information Security “Virtual Handbook” at: http://www.cms.gov/InformationSecurity ).

The MRAC shall include this requirement in any subcontract awarded under this prime contract.

B. Specific Requirements

Note: This section has requirements that will apply to standard and/or program integrity (PI) medical review. Some of the sub-tasks below apply to both, but some sub-tasks may only apply to standard or program integrity medical review, respectively. All tasks that only apply to a specific division will be clearly marked as such. (e.g. “Standard medical reviews shall include the medical review of MAC, SMRC, CERT, QIC and BFCC-QIO claims. Program Integrity medical reviews shall include the medical review of ZPIC/UPIC and MEDIC, and MIC Contractor claims.”)

Task 1 – Administrative Requirements

Task 1.1 – Contract Kick-off Meeting

The MRAC shall conduct a contract Kick-off meeting within seven (7) business days after contract award. The MRAC shall prepare the agenda and take meeting minutes.

Task 1.2 – Key Personnel

The MRAC shall provide appropriate personnel who shall be designated as “key” personnel. The following project positions are hereby designated as key and as such require the COR’s approval before the personnel are assigned to or removed from this contract. All proposed substitutions must be submitted, in writing, to the Contracting Officer at least thirty (30) days prior to the proposed substitution or as soon as reasonably known. Each request shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume and any other information required by CPI/CMS. All proposed substitutions must have qualifications equal to or greater than the person(s) being replaced. All personnel employed must also meet the requirement of never having been sanctioned or excluded from the Medicare or Medicaid Program. CPI/CMS shall also consider any current or prior licensure restrictions and/or disciplinary actions when reviewing/approving all proposed key personnel. Unless otherwise approved by the Contracting Officer, the key personnel noted below shall possess the following minimum work experience and educational requirements and be a full-time employee on the contract.

The following are key personnel positions for this contract:

· Project Manager

The Contractor shall dedicate a Project Manager whose roles and responsibilities shall be defined by this contract’s technical approach and management plan. The project manager’s roles and responsibilities include day to day contact with the CPI/CMS COR, Standard Business Function Lead (BFL) and Program Integrity BFL, and the general oversight of the contract performance including obtaining and maintaining the staff necessary to conduct MRAC work.

· Experience: A minimum of five (5) years of professional experience with at least three (3) years as a manager responsible for managing complex systems and work flow. Prior work experience in the Medicare and Medicaid programs, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines. Medical review experience is also required in the area of Program Integrity investigation of fraud, waste, and abuse.

· Education: A master’s degree from an accredited institution or substitution with a bachelor’s degree from an accredited institution with four (4) additional years of related work experience in lieu of the master’s degree.

· Contract Medical Director (CMD)

CMD shall be either a Doctor of Medicine or a Doctor of Osteopathy.

· Experience: Prior work experience in the Medicare and Medicare programs, a utilization review firm, or another health care claims processing organizations in a role that involved developing coverage or medical necessity policies and guidelines; extensive knowledge of the Medicare and Medicaid programs, particularly the coverage and payment rules and clinical review judgment experience; public relations experience such as working with physician groups, beneficiary organizations, and/or congressional offices is preferred. Medical review experience is also required in the area of Medicare and Medicaid Program Integrity investigation of fraud, waste, and abuse.

· See IOM, 100-8, PIM 1.4 for further Medical Director Requirements.

· Medical Review Managers

The Medical Review Managers shall work collaboratively with the CMD to plan, implement and evaluate the medical review program and quality assurance processes.

· Standard MR Manager– Shall have primary responsibility for the development, oversight and implementation of the medical review program and related quality assurance processes of MACs, SMRC, CERT, QICs and BFCC-QIOs. In addition, the Medical Review Manager shall have the primary responsibility for ensuring the timely submission of Standard required reports.

· Experience: A minimum of five (5) years of clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice; A minimum of two years of supervisory experience; extensive Task specific knowledge of the Medicare program, particularly the coverage and payment rules; extensive knowledge of medical terminology; experience in the analysis and processing of Medicare claims and clinical review judgment is required; at least one year of experience in the medical review processes of MACs, SMRC, CERT, QICs and BFCC-QIOs.

· Education/Licenses: Board Certified in Nursing and licensed to practice nursing in the United States. Both the Standard Medical Review Manager and the Program Integrity Medical Review Manager shall be a currently licensed registered nurse.

· Program Integrity MR Manager – Shall have primary responsibility for the development, oversight and implementation of the medical review program and related quality assurance processes of ZPICs/UPICs/MEDICs/MICs. In addition, the Medical Review Manager shall have the primary responsibility for ensuring the timely submission of Program Integrity required reports.

· Experience: A minimum of five (5) years of clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice; A minimum of two years of supervisory experience; extensive Task specific knowledge of the Medicare and Medicaid programs, particularly the coverage and payment rules; extensive knowledge of medical terminology; experience in the analysis and processing of Medicare and/or Medicaid claims and clinical review judgment is required;

· Standard – at least one year of experience in the medical review processes of MACs, SMRC, CERT, QICs and BFCC-QIOs.

· Program Integrity – at least one year of medical review experience in Medicare and Medicaid Program Integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions in support of allegations of fraud, waste or abuse; at least one year of experience in the medical review processes of ZPICs/UPICs/MEDICs/MICs.

· Education/Licenses: Board Certified in Nursing and licensed to practice nursing in the United States. Both the Standard Medical Review Manager and the Program Integrity Medical Review Manager shall be a currently licensed registered nurse.

Task 1.3 – Monthly Costs Report

· The MRAC shall submit monthly workload reports outlining all work accomplished during the previous month by Task.

· These workload numbers shall be reconciled with the monthly invoice submitted for payment for each Task. The MRAC shall submit monthly costs report for the Optional Tasks 4.1.

· In addition to required contractual responsibilities for invoicing, the MRAC shall provide detailed documentation to support invoice payment which shall include, but is not limited to:

· All optional task incurred costs and invoices including current and cumulative budgetary status to date for the period of contract performance;

· All contract tasks related travel invoices and receipts including current and cumulative budgetary status to date for the period of contract performance; and

· The MRAC shall provide the percentage of work completed for each task in this SOW, by period of contract performance. The MRAC shall provide the percentage of work completed and expenditures for each task under the optional task 4.1.1.

Task 2 - Transition Period

There shall be a 90-day ramp up period initiated at the time of contract award. During this ramp-up period it is expected that:

· All positions for all labor categories shall be fulfilled to meet the requirements of this SOW for the MACs and ZPICs/UPICs by the end of the 90-day ramp up period

· Accuracy reviews shall be initiated in modified quantities as directed by CPI within 30 days of contract award and increased to the full requirements of this SOW for the MACs, CERT, SMRC, and BFCC-QIOs and ZPICs/UPICs by the end of the 90-day ramp-up period

· It is expected that the Joint Operating Agreements (JOA) with the MACs, CERT, SMRC, BFCC-QIOs and ZPICs/UPICs will be initiated and completed by the end of the 90 day ramp-up period. The JOAs with the additional contractor types will be integrated into the workload after the evaluation of the base year of work and at the direction of CPI/CMS.

Task 2.1 – Joint Operating Agreement (JOA)

The MRAC shall execute a JOA with the MRCs that delineates the roles and responsibilities of the MRAC and facilitates efficient processes for communication between the MRAC and MRCs related to the medical review of the MRC’s Medicare claims, for Standard and Program Integrity. This JOA is designed to establish guidelines and shared expectations within which the MRAC and the MRCs will conduct operations. This JOA is designed to be a “living document” that can be revised as needed. The JOA shall be executed within 90 days from the date on which the MRAC work is placed on contract

Task 2.2 - Project Plan

The MRAC shall develop a detailed project plan to include the steps illustrating how the tasks described in this SOW shall be implemented and accomplished. Standard medical reviews shall include the medical review of MAC, SMRC, CERT, QIC and BFCC-QIO Medicare claims. Program Integrity medical reviews shall include the medical review of ZPIC/UPIC and MEDIC and MIC Contractor Medicare and Medicaid claims. The project plan shall include, at a minimum:

· Detailed timetables

· Identification of resources and staffing

· Detailed approach towards meeting the deliverables

· Project milestones

The MRAC shall submit a draft project plan explaining how they will execute the requirements in this SOW within seven (7) business days after contract award. The draft project plan will be submitted and discussed at the kick-off meeting. The Contract Officer Representative (COR) shall respond with comments or proposed revisions to the MRAC within seven (7) business days of the kick-off meeting. When a COR response is received, the draft project plan shall be modified by the MRAC, incorporating the COR’s comments and recommendations, if any. A final project plan is to be submitted for COR approval within five (5) business days after receipt of comments.

Task 2.3 – IT Systems Project Plan

The MRAC shall develop a draft IT Systems Project plan no later than ten (10) business days after the kick-off meeting. The IT Systems Project plan should include:

· Identification of resources

· Identification of the required hardware, software and telecommunications equipment to undertake this task order

· Documentation of any and all mainframe and server systems, modules, and programs utilized for the Contractor’s work pertaining to this contract

· Capability to produce reports and read and write them to CD ROMs with encryption

· Capability to securely receive and utilize data from CMS

· The capability to back-up all data on a weekly basis (at a minimum) and maintain old reports

The COR shall respond with comments or proposed revisions to the MRAC within seven (7) business days. When COR response is received, the draft IT Systems Project Plan shall be modified by the MRAC, incorporating the COR’s comments and recommendations and a final IT Systems Project Plan to be submitted within five (5) business days.

Task 2.4 – Quality Control/Quality Assurance Plan

Quality assurance activities shall ensure that each element is being performed consistently and accurately.

Within fifteen (15) business days of kick-off meeting, the MRAC shall provide a quality control/quality assurance plan to include:

· Procedures and processes used to perform quality control and assurance functions to include specific measures for reporting and resolving corrective actions

· Delineation of specific personnel responsibilities to perform this function

· An objective process to assign staff to review projects, ensuring that the correct level of expertise is available

· Rate and frequency by which quality control functions are performed

· Procedures and processes used to disseminate information to MRAC personnel of policy and procedures changes as well as systematic issues identified during quality control reviews

· A process to address how MRAC will monitor and maintain accuracy in decision-making (inter-reviewer reliability)

Training methods shall be in place to familiarize MRAC medical reviewers/support staff with techniques and procedures for completing the process of medical review, to include knowledge of Medicare and/or Medicaid statutory/regulatory requirements/guidance required to make a claim payment decision and the identification of potential fraud, waste, or abuse based on medical review.

Task 3 – Meetings/Conference Calls

Teleconference is an acceptable format for all meetings. The Government reserves the right to exercise the option of requiring two (2) contract employees to meet face to face with CPI staff. The Government reserves the right to conduct site visits at the MRAC’s location at any time. The meeting schedule shall be flexible and can change as needed. The MRAC shall provide phone lines for all scheduled calls. The MRAC shall attend the following conference calls:

Task 3.1 – Bi-weekly Status Meeting: The MRAC shall arrange and facilitate a meeting that occurs twice a month with the COR, BFLs and other CPI/CMS staff as deemed necessary by CPI/CMS. The MRAC shall collaborate with the COR regarding the meeting time and agenda. Key Personnel, the CMD, MR Managers and Project Manager shall participate in the calls. The MRAC shall provide a summary of the previous activities and provide comments relating to procedural matters and policy clarifications. CPI/CMS reserves the right to decide if and how to act upon these recommendations. The MRAC shall prepare the agenda and take meeting minutes for each meeting. The meeting minutes shall be distributed to the COR and BFLs within two (2) business days after the meeting for review and approval.

Task 3.2 – Medical Review Manager’s Conference Call: The MRAC CMD and Medical Review Managers shall participate in the Medical Review Manager’s conference call hosted by CPI on a monthly basis. Meeting appointments and times will be sent to the MRAC upon award of this contract.

Task 3.3 – AB/DME Collaboration Conference Calls: The MRAC shall participate in the AB Collaboration, AB Inter Rater Reliability (IRR), DME Collaboration and DME IRR conference calls unless otherwise directed by the COR. Key personnel, the CMD, Standard Medical Review Manager, or both shall attend these meetings. These conference calls occur four (4) to six (6) times per year. Conference call information will be provided after contract award.

Task 3.4 – CPI/CMS Program Integrity Continuum of Compliance Meeting: The MRAC shall participate by attending as directed by the COR. The Medical Review Operational Meeting is anticipated to be held annually at the CMS central office, pending CMS Administrative approval each year. The CMD and Medical Review Managers shall attend.

Task 3.5 – Ad hoc Conference Calls: The MRAC shall participate in ad hoc conference calls as directed by CPI/CMS. An example of an ad hoc conference call would be a meeting with CPI/CMS, MRAC and a MRC to discuss particular MRC’s accuracy reviews. The CMD and appropriate Task MR Manager shall attend the ad hoc meetings.

Task 3.6 – Communication: The MRAC shall be available for phone calls and email request from the COR and BFLs in regards to findings, reports, or medical review procedures concerning assigned projects on an as needed basis.

Task 4 – Accuracy Reviews

The Contractor shall ensure the following:

· Complex reviews for the purpose of making coverage determinations are performed by registered nurses (RNs) or physicians licensed to practice medicine in the United States. During a complex review, nurse and physician reviewers may call upon other health care professionals (e.g., dieticians, therapists, or physician specialists) for advice.

· Services reviewed by other licensed health care professionals are within their scope of practice and that their project-specific medical review strategy supports the need for their specialized expertise in the review of a particular claim type (i.e., speech therapy claim, physical therapy).

· Complex reviews for the purpose of reviewing accurate coding determinations are performed by certified professional coders or clinicians with approved coding credentials.

· Employ clinical personnel that possess critical thinking skills that can be applied when rendering clinical review judgment based on their clinical expertise.

· Shall only review the specific line(s)/purpose that the claim was reviewed by the specific MRCs.

· Shall maintain references to support medical review determinations.

· Shall reference the CMS Internet Only Manuals and the State Medicaid manuals for MR requirements specific to the type of MRC being reviewed

This SOW provides a specified quantity of Medicare Part A and Part B and Medicaid MRs to be conducted during each period of performance. When there is a need for additional Medicare Part A or Part B or Medicaid MRs that exceeds the current period of performance limits, upon discussion with the COR and BFL(s) and a written approval from the COR, MRs may be exchanged based on the dollar conversion value identified at time of contract award (example: 100 Part A and 100 Part B MRs required in the base year. In month 11 of the base year, the MRAC completed 100 Part A MRs and 70 Part B MRs, but CMS need 10 additional Part A MRs. The COR can approve the MRAC to convert 10 of the remaining 30 Part B MRs to Part A MRs using the dollar conversion value identified at time of contract award).

Accuracy Review Process

The MRAC will receive a claims universe from the Standard and Program Integrity MRCs specified by CPI/CMSand generate a random representative sample of claims to be reviewed. Once the random representative sample of claims is received by the MRC, the MRC shall put the claims on an encrypted CD. The MRC’s shall send the encrypted CD to the MRAC with email notification to the MRAC COR and BFLs. The MRC shall have seven (7) business days from receipt of the random representative sample of claims from the MRAC to send encrypted CDs to the MRAC. The MRAC shall notify the COR and BFLs if they have not received CDs from the MRC within the timeframes specified.

Upon receipt of the CDs, the MRAC shall complete the medical review of the claims within twenty (20) business days unless specified by CPI/CMS on a case by case basis. The MRAC shall review the claims and determine if the Standard and Program Integrity MRCs made accurate medical review claim decisions in compliance with Medicare’s and Medicaid’s coverage, coding, payment, and billing policies and in addition for Program Integrity, whether claims contain patterns and/or trends which may support an allegation of potential fraud, waste or abuse. For claims in which the MRAC does not agree with the MRC’s decision, the MRAC shall follow the Disagreement Process outlined below in Task 5.

Task 4.1 – Standard – Accuracy Reviews for MACs, SMRC, CERT, QICs and BFCC-QIOs.

The MRAC shall review and measure the accuracy rate for claims that have been reviewed by the MRCs. The claim reviews require, at a minimum, the use of clinical review judgment in the evaluation of medical records and related documents to determine whether Medicare’s MRCs made accurate claim decisions in compliance with coverage, coding, payment, and billing policies. The MRAC shall measure the accuracy rate for each MRC by medically reviewing a representative sample of claims that each MRC has previously reviewed. The MRAC shall only review the specific line(s)/purpose that the claim was reviewed by the MRCs. The MRAC shall review each claim and determine whether the MRC’s payment decision was correct. If the claim was a full or partial denial, the MRAC shall review the MRC’s reviewer’s rationale and error type and subtype to determine if the correct rationale and error type was provided. If the accuracy contractor detects there is potential fraud, waste or abuse during the review of records for any of the Standard MRCs and the MRC didn’t refer the provider to the ZPIC/UPIC, in accordance with the PIM requirements and contractor-specific SOWs, this shall be documented as an observation in the review summary and communicated to the Standard MR BFL to be reviewed..

With assistance from the BFL, the COR will assign the MRAC Standard medical reviews to be conducted under this task. The MRAC shall perform Standard medical reviews that total 2,000 for Part A claims and 3,300 for Part B claims in the Base Year; and 2,600 for Part A claims and 4,600 for Part B claims each Option Year period of performance of this contract.

Optional Task 4.1.1 – Standard – Accuracy Reviews for MACs, SMRC, CERT, QICs and BFCC-QIOs.

At the discretion of CMS, the MRAC shall perform additional Standard medical reviews in accordance with the process outlined in Task 4.1 above. This optional task will only be initiated in cases where the MRAC has completed the quantity of Standard medical reviews identified in Task 4.1 before the end of the period of performance. All work initiated under this optional task shall be completed by the end of the period of performance of when it was assigned. All work shall be tracked separately in all applicable reports and billed separately under the assigned Contract Line Item Number (CLIN).

With assistance from the BFL, the COR will assign the MRAC additional Standard medical reviews to be conducted under this optional task. The MRAC shall perform Standard medical reviews that total approximately 650 for Part A claims and approximately 2,000 for Part B claims in each period of performance of this contract.

Task 4.2 – Program Integrity – Accuracy Reviews for ZPIC/UPIC and MEDIC and MIC Contractor

The MRAC shall review and measure the accuracy rate for claims that have been reviewed by the ZPICs/UPICs, MEDIC, and MIC Contractor. The claim reviews require, at a minimum, the use of clinical review judgment in the evaluation of medical records and related documents to determine whether the ZPICs/UPICs, MEDIC, and MIC Contractors made accurate claim decisions in compliance with Medicare and Medicaid coverage, coding, payment, and billing policies and noted whether Medicare and Medicaid claims contain patterns and/or trends which may support an allegation of potential fraud, waste or abuse. The MRAC shall measure the accuracy rate for each ZPIC/UPIC, MEDIC, and MIC Contractor by medically reviewing a representative sample of claims that each ZPIC/UPIC, MEDIC, and MIC Contractor has previously reviewed. The MRAC shall review each claim in the representative sample and determine whether the ZPIC/UPIC, MEDIC, and MIC Contractor’s, payment decision was correct and whether claims contain patterns and/or trends which may support an allegation of potential fraud, waste or abuse, such as, evidence of alterations including, but not limited to: obliterated sections, missing pages, inserted pages, white out, and excessive late entries. If the claim was a full or partial denial, the MRAC shall review the ZPIC/UPIC, MEDIC, and MIC Contractor reviewer’s rationale and error type and subtype to determine if the correct rationale and error type was provided. If the MRAC detects patterns and/or trends which may support an allegation of potential fraud, waste or abuse during the review of records for any of the ZPICs/UPICs, MEDIC, and MIC Contractor that was not recognized/documented by them, this will be documented as a finding for the ZPIC/UPIC, MEDIC, and MIC Contractor and referred back to the COR/BFL for review/follow up with the specific ZPIC/UPIC, MEDIC, and MIC Contractor.

With assistance from the BFL, the COR will assign the MRAC Program Integrity medical reviews to be conducted under this task. The MRAC shall perform Program Integrity medical reviews that total 1,450 For Part A claims and 4,100 for Part B and 50 Medicaid claims in the Base Year; and 1,900 for Part A claims and 6,000 for Part B claims, and 100 Medicaid claims in each Option Year period of performance of this contract.

Task 5 – Disagreement Process

The MRAC shall develop an Accuracy Review Disagreement Worksheet-Template. The Accuracy Review Disagreement Worksheet –Template shall be submitted for review within fifteen (15) business days from contract award. The Accuracy Review Disagreement Worksheet shall include the following information:

· Clearly identified review findings

· Detailed rationale for the disagreement including CMS policy citations

· Claim number and date

· MRAC determination

· Claim type

· Name of MRC

· A section for the MRC disagreement rebuttal rationale

When the MRAC disagrees with the MRC’s payment decision on a claim, or identifies unaddressed patterns and/or trends which may support an allegation of potential fraud, waste or abuse, the MRAC shall fill out the Accuracy Review Disagreement Worksheet. The MRAC shall provide regulatory/manual citations current for the period during which the service being billed was provided to support the denial rationale. The MRAC shall complete an Accuracy Review Disagreement Worksheet for each individual claim disagreement. Upon completion of accuracy reviews, the MRAC shall send, via encrypted CD, all Accuracy Review Disagreement Worksheet(s) and associated claim documentation to COR and BFL within five (5) business days.

The COR with assistance from the BFL shall the final decision in the disagreement process which will require CPI/CMS to review a representative sample of claim documentation.

The MRAC shall track and report the number of disagreements that were sent to CPI/CMS on a monthly basis. The MRAC shall comply with the reporting requirements outlined in the reporting requirements section below.

Task 6 – Status Reports

The MRAC shall comply with the following reporting requirements. Each report shall be submitted to the COR and BFLs via email.

Task 6.1 – Claim by Claim Monthly Report:

The MRAC shall submit a claim by claim monthly report for each MRC. The MRAC shall submit this report to the COR by the fifteenth (15) business day of each month. This report shall include:

· Name of MRC reviewed;

· Month the reviews were completed by the MRC;

· Total number of claims reviewed;

· Total number of agreements;

· Total number of disagreements; to include unaddressed patterns and/or trends which may support an allegation of potential fraud, waste or abuse

· Agreement/accuracy rate; and

· Claim by claim detail

· Whether the MRAC agrees or disagrees with the MRC’s final determination. The MRAC shall include rationale for each claim decision, to include the identification of patterns and/or trends which may support an allegation of potential fraud, waste or abuse.

· For disagreements, the MRAC shall include disagreement rationale and indicate the correct determination.

· The MRAC shall provide information on claims that are in the Disagreement process.

· The report shall include a narrative summary as well as a bar graph depicting the accuracy rates of each MRC comparatively. This bar graph shall depict current month data compared to cumulative year to date data for each of the MRC’s accuracy rates.

Task 6.2 – Annual Report

· The MRAC shall submit a cumulative report of the accuracy rates for the MRCs. The MRAC shall submit this report to the COR and BFLs within fifteen (15) business days from the end of the period of performance. The report, at a minimum, shall include the following:

· Overall accuracy rates for each MRC

· Narrative section with information about patterns of inappropriate denials and documentation of observations made during the accuracy medical review of the MRCs claims

· Total number of claims reviewed per MRC, total number of agrees and disagrees per MRC, to include the identification of patterns and/or trends which may support an allegation of potential fraud, waste, or abuse

· Total number of Disagreement Packages sent to CPI/CMS

· Comments to CPI/CMS regarding policy issues based on trends identified during review

III. Performance Standards

The MRAC shall participate in a semiannual (twice a year) performance evaluation to be completed by CPI/CMS. These will be referred to as the mid-year and end of year performance evaluations. The objective of the performance evaluation is to provide a systematic, quality assurance approach for monitoring and/or evaluating the requirements and standards set forth in the SOW. Effective use of the performance evaluation, along with the MRAC’s Quality Control/Quality Assurance Program, will help to ensure that the MRAC performs in accordance with all of the requirements set forth in the contract documents, that the Government receives the quality of services called for in the contract and the Government pays only for acceptable levels of services and products received. The evaluation will be conducted for MRAC’s performance purposes only and documented in the Contractor Performance Assessment and Reporting System (CPARS) at the end of each Period of Performance.

The evaluation will include all of the SOW requirements. With CPI/CMS approval, the COR, and the BFLs will conduct the mid-year performance evaluation as a desk review and the end of year performance evaluation as a site visit to the contractor’s primary office location.

Standard – Performance Metrics

· Shall document the rationale for disagreement and include the basis for it in 100% of the reviews.

· Coverage/medical necessity determinations are made by RNs or therapists and that coding determinations are made by certified coders or clinicians with approved coding credentials in 100% of the reviews.

· MR decisions are consistent with national and local coverage determinations, statutory coverage provisions, and sound clinical judgment. The review should include reference to CFR, IOMs, and LCDs in 100% of the reviews.

· Determine if patterns and/or trends exist in the medical record which may demonstrate potential patient harm in 100% of the reviews.

· Identification of patterns and/or trends which may support an allegation of potential fraud, waste, or abuse and were not referred to the ZPIC/UPIC

· CPI/CMS will concur with a representative sample of MRAC accuracy review disagreements in 95% of the reviews.

Program Integrity – Performance Metrics

· Shall document the rationale for disagreement and include the basis for it in 100% of the reviews.

· Coverage/medical necessity determinations are made by RNs or therapists and that coding determinations are made by certified coders or clinicians with approved coding credentials in 100% of the reviews.

· Medical review considered all allegations identified in the complaint/investigation that could be validated through the review of medical records in 100% of the reviews.

· MR decisions are consistent with national and local coverage determinations, statutory coverage provisions, and sound clinical judgment. The review should include reference to CFR, IOMs, LCDs and State Medicaid Manuals, in 100% of the reviews.

· Determine if patterns and/or trends exist in the medical record which may indicate potential fraud, waste or abuse or demonstrate potential patient harm in 100% of the reviews.

· Determine if patterns and/or trends exist in the medical record which may indicate potential fraud, waste, or abuse that was not addressed by the MRC in 100% of the reviews.

· Evaluate the medical record for evidence of alterations in 100% of the reviews.

· For Medicaid medical review, the parameters surrounding the medical review are based upon state protocols in 100% of the reviews.

· CPI/CMS will concur with a representative sample of MRAC accuracy review disagreements in 95% of the reviews.

IV. Deliverable Schedule

The contractor shall submit all deliverables via secured email to the COR until CPI/CMS- provided IT systems become available, in accordance with the following schedule. If the deliverable or other required information is scheduled for a Saturday, Sunday, or Federal holiday, the contractor shall have until 11am EST the next business day to submit the deliverable.