J.2_MRRC_B_SOW_dated_10.22.2018.pdf

STATEMENT OF WORK

RISK ADJUSTMENT DATA VALIDATION MEDICAL RECORD REVIEW

CONTRACTOR B

I. SCOPE

Medicare Advantage (MA) (formerly known as Medicare + Choice) risk adjusted payments are calculated using the Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) model. The Part C CMS-HCC payment model is prospective in that it uses Medicare fee-for-service (FFS) diagnosis data and Risk Adjustment Processing Systems (RAPS) data in a base year to predict health service expenditures in the subsequent year. Beginning with diagnoses with dates of service 2014, Encounter Data System (EDS) data will also be used in risk adjustment. Centers for Medicare & Medicaid Services (CMS) uses a mean predictive expenditure to calculate relative ratios and assign relative risk scores for the managed care population. Medicare Advantage Organizations (MAOs) are required to submit relevant diagnoses that comprise the CMS-HCC model and other risk adjustment enrollee demographic data to CMS for payments. MAOs submit risk adjustment data from acceptable hospital inpatient, hospital outpatient and physician sources. Accurate risk adjusted payments to MAOs are primarily dependent upon the accuracy of relevant diagnosis codes. This data reflects the health status of MA enrollees; thus inaccurate and incomplete data may lead to incorrect risk adjusted payments to MAOs.

A. Purpose of Contract

The purpose of Risk Adjustment Data Validation (RADV) is to measure the extent to which inaccurate diagnosis codes impact HCC assignments and the associated payment for MA beneficiaries. The RADV process involves the evaluation and analysis of the risk adjustment data via medical record review.

CMS conducts two (2) major RADV projects: the National sample and the Contract-Level sample (the term sample is synonymous in this context with audit).* The National sample is used to compute an error estimate for the Medicare Part C Program. The Contract-Level sample is used to estimate extrapolated payment adjustments at the MA Contract-Level based on medical record review findings. The Part C payment error estimate and the MA Contract-level extrapolated payment adjustments represent CMS’s response to provisions set forth in the Improper Payments Information Act (IPIA) of 2002 as amended by the Improper Payments Elimination and Recovery Act (IPERA) of 2010 and the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012.

The Contractor shall function as a Medical Record Review Contractor (MRRC) and conduct medical record review for various projects including the RADV projects and Ad Hoc Studies.

The purpose of this task order is to:

1. Conduct Medical Record Focused Reviews;

2. Conduct Medical Record Abstraction;

3. Perform Operational Analysis;

4. Perform Business Intelligence and Post audit review Analyses;

5. Perform Medical Record Intake;

6. Conduct Evaluation of MAOs Appeals Submissions; and

7. Perform Project Management.

This Contractor shall use Quality Improvement Organization (QIO) equivalent principles to identify ICD-9/ICD-10-CM (and blended HCC model) (International Classification of Diseases, Ninth & Tenth Revision, And Clinical Modification) discrepancies that affect future risk adjusted payments to MAOs. Specifically, for all coding related tasks (medical record focused review, medical record abstraction, appeals support, medical record intake and ad hoc projects), the Contractor must have ICD-9/ICD-10-CM (and blended HCC model) certified coders. See section III for coder qualification requirements.

B. Background

1. Description of Risk Adjustment

With the Balanced Budget Act (BBA) of 1997 Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans instead of the original Medicare plan (i.e., Parts A and B). These programs were known as Medicare+Choice or Part C plans. The subsequent passage of the Medicare Prescription Drug and Modernization Act (MMA) of 2003 changed the compensation and business practices for these private health insurance plans and “Medicare+Choice” plans became known as MA plans or MAOs. As a result of MMA of 2003, the BBA of 1997 impacted both managed care organizations (MCO) and MAOs, in that it mandated that payments to MCOs and MAOs be based on the health status of their enrollees. By implementing risk adjustment, MAOs have been paid more accurately based on the health status of their enrollees. Full risk adjusted payment to MAOs was phased in over a period of years; since 2007, payment has been made on a 100% risk adjusted basis. Since risk adjusted payment is based on enrollee health status, MAOs have been provided with an incentive to enroll and treat less healthy Medicare beneficiaries.

To receive risk adjusted payments, MAOs submit diagnostic data to CMS. Part C Risk Adjustment Data Collection refers to data submitted in two formats: data in abbreviated formats (often referred to as RAPS data) and comprehensive data equivalent to Medicare FFS claims data (often referred to as encounter data).

RAPS data. For submission on RAPS records, MAOs are required to submit an occurrence of a model-relevant diagnosis only once during the data collection year, even though a beneficiary may have several service dates in a data collection year associated with a given diagnosis. The data elements collected are: Health Insurance Claim (HIC) Number; Provider type (Hospital Inpatient, Hospital Outpatient, or Physician); Service from date; Service through date; and ICD-9/ICD-10-CM (and blended CMS-HCC model) codes at the level of specificity required to trigger an HCC in the model.

Encounter data. MAOs are required to submit all encounters for dates of service beginning in January 1, 2012. In the FY 2009 IPPS Rule (73 FR 48650), published August 2008, CMS amended 42 CFR § 422.310 to authorize the collection of data from MAOs and other entities regarding each item and service provided to an enrollee. The collection of encounter data gives CMS information on both the utilization and cost of services at the MA plan enrollee level and will allow CMS to further refine the CMS–HCC risk adjustment models to reflect patterns of diagnoses and expenditures in the MA program.

Risk Adjusted payment is based on the CMS-HCC model. The CMS-HCC model (in its current form) uses disease groups (referred to as HCCs) and is made up of ICD-9/ICD-10- CM (and blended HCC model) codes in determining Part C risk adjusted payments. The CMS-HCC model is additive, and includes most body systems (that is, multiple chronic diseases are incorporated into the risk factor for an enrollee). In some cases, however, a diagnosis that is included in the model does not trigger additional payment because a more severe diagnosis supersedes the less serious one; these are considered hierarchy cases.

The CMS-HCC model uses diagnoses from multiple sites of care: physician, hospital inpatient and hospital outpatient. The model is site neutral, which means that the model does not distinguish payment amounts based on the site of care where the diagnosis was generated (i.e., hospital inpatient, hospital outpatient or physician setting).

The model is divided into segments with associated coefficients that define the relative mean predicted expenditure based on place of residence for the Medicare FFS population -community versus long- term institutional. These segments are applied to all enrollees with twelve (12) months of Medicare Part B enrollment during the data collection period (i.e., full risk enrollees). The community model is used to calculate Part C payment risk scores for enrollees who spent less than ninety (90) days in an institution (i.e., community enrollees).

The institutional model is used to calculate payment risk scores for enrollees who spent ninety (90) days or greater in an institution during the payment year (i.e., institutional enrollees). Additionally, there is a new enrollee segment that applies to beneficiaries who are new to Medicare, and also, beneficiaries with less than twelve (12) months of Medicare Part B enrollment during the data collection period.

The CMS-HCC model is periodically re-calibrated to reflect newer treatment and coding patterns in Medicare FFS; thus updating the coefficients for all segments (community, long-term institutional and new enrollee). In annual payment notices, CMS proposes changes to the disease groupings, draft coefficients, and the disease hierarchies for the model. The final coefficients for each of the segments are provided in the specific calendar year’s Announcement of MA Capitation Rates and Payment Policies.

2. Description of Medicare Advantage Risk Adjustment Data Validation Activities

CMS conducts annual MA RADV activities for the purpose of ensuring the accuracy of risk adjustment data and MA risk adjusted payments. The focus of RADV is on reviewing medical record documentation to verify diagnoses submitted by MAOs for payment under Medicare Part C.

The Contract-Level RADV project includes the following processes:

Sampling. For Contract-Level RADV, CMS uses defined criteria by which to select statistically valid samples of enrollees for the purpose of estimating payment error.

Medical Record Request. CMS notifies MAOs of their selection for RADV and requests points of contact who will be responsible for facilitating the RADV process on behalf of the MAOs. CMS then sends each selected MA contract a medical record request for submission of medical records to support the CMS-HCCs for each enrollee in the MA contract’s sample.

Medical Record Submission and Receipt. MAOs are required to submit the requested enrollee’s medical records to CMS via the Central Data Abstraction Tool (CDAT) or another system as specified by CMS†.

Medical Record Review. Certified and independent medical record ICD-9/ICD-10-CM (and blended CMS-HCC model) coders review the medical records submitted by the MAOs, and abstract diagnoses in accordance with the ICD-9/ICD-10-CM (and blended CMS-HCC model) coding guidelines.

Continuous Plan Feedback Report. CMS generates and provides sends this report to the MAOs in the RADV samples.

RADV Audit Report. CMS generates audit report findings based upon the coders’ review of the medical records. These findings are used to develop payment error results for each sampled enrollee. Once the report is generated, CMS provides this report to each MA contract in the Contract-Level RADV samples detailing the medical record review results for their sampled enrollees.

RADV Administrative Appeals Process. In accordance with 42 C.F.R. §422.311, CMS provides MAOs in the Contract-Level RADV samples an opportunity to request a Medical Record Review Determination appeal and/or a Payment Error Calculation appeal.

Post-Appeal RADV Audit Report. An audit report generated pursuant 42 C.F.R. § 422.311(c) (7) (ix) (2014) corrects payment errors based on the results of the administrative appeals process, and provides instructions for the next phase of the appeals process.

Payment recovery amounts are established based on CMS’ policies for the Contract-Level audit.

3. Contractors Involved in Risk Adjustment Data Validation

Various contractors are involved in the RADV process. As part of the overall RADV projects, this Contractor will collaborate with, coordinate with, and receive support from the following contractors:

Lead Analytic Contractor (LAC): Will coordinate the overall analytic approach and process for the medical record activities. This will involve sampling, analysis, developing reports, calculating initial and final payment error estimates, working with the Medical Record Review Contractors (MRRCs) to conduct requests, and managing project data.

CDAT Contractor: Will develop and maintain a centralized tool (CDAT) to support the RADV processes. The CDAT contractor will provide functionality to CDAT end users to allow for RADV communications with MAOs, collection and processing of all RADV data and medical records, medical record abstraction and lastly RADV data management across all RADV processes. The CDAT contractor will also work with CDAT end-users to assure that the operational and analytic functions for the overall RADV Project are met. The CDAT contractor will also train end-users on the use of CDAT for their specific roles on the RADV project.

Independent Coding Consultant (ICC): May provide expert coding support for the medical

† Throughout this Statement of Work, all mentions of “CDAT” are understood to mean “CDAT or any other system as specified by CMS.”

record reviews for RADV projects. ICC may conduct coder training; and develop written communication, guidance and briefing materials to document and assist CMS in making decisions.

Technical Data Procession Support (TDPS) Contractor: Will provide support for managing project data for the LAC and MRRCs. This Contractor will also be used for internal quality assurance (QA) support of the project data.

Independent Statistical Consultant (ISC): Performs payment error recalculations where required.

Independent Verification & Validation (IV&V) Contractor: Conducts all User Acceptance Testing (UAT) to verify and confirm that the CDAT system meets mutually agreed-upon requirements. UAT is one of the final stages of validation of the system and often occurs before a client or customer accepts the new system or modification to an existing system.

RADV Communication and Quality Control (C&QC) Contractor: Transmits RADV communications to MAOs and RADV contractors on behalf of CMS. The RADV C&QC also captures RADV communications from all communication sources and reports to CMS and RADV contractors, and tracks communications until closure.

Appeals Support Contractor: Provides an array of support for payment error calculation and medical record review determination disputes during the RADV Reconsideration and appeals processes.

4. Recovery Audit Contractor Program Payment Error Estimate Calculation

Methodology

Under the 2010 Patient Protection and Affordable Care Act (ACA) legislation enacted in March 2010, CMS is required to expand the RAC Program to the Medicare Part C (Medicare Advantage) and Part D (Prescription Drug Benefit) programs. Section 6411 (b) of the ACA provides CMS with general authority to enter into contracts to conduct RAC audits in Medicare Part C and Part D. The Medicare Part C and Part D RAC is to identify targeted overpayments associated with diagnoses submitted to CMS for risk adjustment purposes.

II. GENERAL REQUIREMENTS

For all coding related tasks (medical record focused review, medical record abstraction, medical record intake, appeals support and ad hoc projects), the Contractor must have ICD-9/ICD-10-CM (and blended HCC model) certified coders.

The Contractor shall be able to access CDAT, hosted by the CDAT contractor, attend training on CDAT, utilize CDAT for all tasks related to RADV, and provide constructive evaluation that could result in further refinement of CDAT throughout the project. The Contractor shall launch a web-based encoder, to assist in coding medical records. In addition, the Contractor shall develop training materials and provide training on CDAT to new Contractor personnel processing medical records via CDAT. The Contractor shall have sufficient qualified staff to query data within CDAT in order to address potential issues which may impact medical record review findings for individual MAOs. The Contractor shall demonstrate the ability to comply with all requirements for security and user authentication as set forth by CMS. When necessary, the Contractor shall collaborate with the LAC to reconcile inconsistencies and coordinate strategies for alleviating inconsistencies. To propose or request changes to CDAT, the Contractor shall adhere to a change request protocol established by CMS. When CDAT is changed or modified to impact the systems for intake, medical record review, reporting, or appeals, the Contractor shall test, validate, and implement system requirements.

All written and scripted materials referenced in this Statement of Work (SOW) shall be submitted in draft form, revised as directed by CMS, and produced in final format at the discretion of CMS. Final versions of all materials shall be included in the Contractor’s Process Plan as supporting elements of the Standard Operating Procedures. The Contractor shall conform to all requirements for confidentiality of beneficiary and MA organization level data (paper and electronic). The Contractor shall develop a Process Plan, and participate in teleconferences/in-person meetings to contribute to the comprehensive RADV Standard Operating Procedures.

In each task, the Contractor shall conduct additional analyses of alternative approaches as needed and as directed by the Contracting Officer’s Representative (COR).

A. Assumptions and Constraints

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

1. CMS shall provide guidance in the form of standards, policies, procedures and oversight of this contract.

2. The prime Contractor and any subcontractors shall sign a CMS Data Use Agreement

(DUA) in order to protect confidential data.

3. The Contractor shall follow the current CMS Security policies and guidelines.

4. All Contractor personnel shall participate in CMS Information Security Awareness

Training.

5. The Contractor shall establish connectivity to CMS, in order to perform required tasks.

6. There may be times when the Contractor shall be required to have staff at the CMS complex, as requested by CMS.

7. The Contractor shall use the current CMS standard desktop suite versions for all deliverables.

8. All deliverables developed by the Contractor shall be made accessible in accordance with Section 508 of the Rehabilitation Act of 1973, as applicable.

9. Work on medical record review may not be evenly distributed across the period of performance. The Contractor will process medical records through review on a rolling basis as they are submitted by MAOs. From past experience, MAOs tend to submit the majority of records late in the “submission window;” accordingly, for each RADV project the Contractor should expect the volume of medical record review work to be low early in the submission window.

10. All products, including software, data, and all utilities developed to support the activities and deliverables of this contract, are the property of CMS. The Contractor shall deliver all products, including software, data, utilities, and deliverables of this contract at the request of CMS or upon termination of this contract. The Contractor shall provide the Government with interim and final files, and file documentation upon request by the COR. The Contractor shall provide software and licenses for software as required by

CMS.

11. The Contractor shall be responsible for purchasing any hardware needed to accomplish their tasks.

12. The Contractor shall not design, implement, or maintain any customized or proprietary utilities without prior approval in writing from the COR.

13. CMS shall provide training to Contractor staff on CMS unique software and tools that is required for this contract.

14. The Contractor shall update and maintain all documentation and deliverables in this contract.

B. Key Personnel

The Project Director, the Physician Reviewer, and the Senior Analyst will be key personnel for this contract. CMS expects that key and additional personnel listed below will comprise an adequate structure to account for the different review types and Information Technology (IT) responsibilities.

The Contractor shall designate and identify the below key personnel positions. Unless otherwise approved by the COR, the identified key personnel shall be responsible for the following activities and possess the minimum work experience and educational requirements.

Project Director

The Project Director shall be responsible for the oversight and overall operations of the contract requirements. In addition, the Project Director shall oversee the coordination of activities to include, but not limited to the following:

• Staffing is appropriate;

• Effective lines of communication are established and maintained with internal staff and external stakeholders;

• Contract requirements are met including quality, cost control, timeliness and business relations;

• Assure an adequate QA program and processes are in place and strictly adhered to for all tasks;

• Develop, execute, and maintain a Risk Management Program;

• Monthly cost reports are submitted timely and accurately, including a plan to correct any cost variances;

• Timely and quality submission of deliverables and ad hoc requests; and

• Maintain superior business relations with CMS and all other stakeholders and partners.

The Project Director is a key personnel on this project and must be approved by CMS.

Work Experience: Eight or more years of professional experience with and knowledge of health care insurance, including Medicare, Medicaid, or a related private insurance field.

The Project Director shall be experienced in the management and direction of CMS Part C RADV medical record data abstraction and managed care data systems, claims processing, and analysis of large health care data sets respectively. The Project Director shall be capable of effectively communicating with individuals representing various professional disciplines and service providers and providing technical assistance as required at every stage of medical record acquisition, transmittal, processing, evaluation, and maintenance. At least five (5) years of experience in a progressive management capacity with responsibility for managing complex systems and workflows.

Educational Requirements: A master’s degree from an accredited institution or a bachelor’s degree from an accredited institution plus an additional three (3) years of related professional experience.

Physician Reviewer

The Physician Reviewer must have experience in experience in clinical documentation, internal medicine, geriatrics, and/or related experience. The Physician Reviewer, or a designated alternate, must be available to resolve ambiguity in clinical guidelines and to participate in the QA panel meetings. The Physician Reviewer is a key personnel on this project and must be approved by CMS.

Work Experience: The Physician Reviewer shall have experience in clinical documentation, internal medicine, geriatrics, and/or related experience. Experience practicing medicine for a minimum of five (5) years as a licensed and board-certified doctor of medicine or osteopathy. Prior work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing or reviewing coverage or medical necessity policies and guidelines.

Extensive knowledge of the Medicare and Medicaid programs, particularly the coverage and payment rules, as well as experience related to the specific workload of the individual task order is required.

Public relations experience such as working with physician groups, beneficiary organizations, and/or congressional offices is preferred.

Educational Requirements: The Physician Reviewer must be a board certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties. The Physician Reviewer must have been board certified for at least three (3) years. The Physician Reviewer must have an active valid and unrestricted license must be currently licensed to practice in at least one US state.

Senior Analyst

The Senior Analyst shall be experienced in analyzing Medicare claims data, RADV medical record abstraction procedures and applying methods for CMS Part C RADV. The senior analyst shall further be knowledgeable about managed care and health plans and have experience in management information systems, claims processing, statistical analysis and report writing.

Work Experience: The Senior Analyst shall be experienced in both practical and theoretical backgrounds in information systems, computer hardware, software, interfacing, networking, design, and data security. Other qualifications include: experience in complex data analysis, data manipulation and statistical analysis; and proficiency in utilizing software to perform analysis and reporting. The Senior Analyst shall be capable of effectively communicating with individuals representing various professional disciplines and service providers.

Educational Requirements: Bachelor’s Degree in Information systems or a related discipline from an accredited institution.

C. Section 508 – Accessibility of Electronic and Information Technology

This contract 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.

The EIT accessibility standards 36 CFR Part 1194, were developed by the Architectural and Transportation Barriers Compliance Board (“Access Board”) and apply to contracts and task/delivery orders awarded under indefinite quantity contracts on or after June 25, 2001.

Each EIT product or service furnished under this contract shall, at a minimum, comply with the EIT Accessibility Standards 36 CFR 1194, as specified in the contract. If the Contracting Officer determines any furnished product or service is not in compliance with the contract, the Contracting Officer will promptly inform the Contractor in writing. The Contractor shall, without charge to the government, repair or replace the non-compliant products or services within the period of time to be specified by the government in writing.

If such repair or replacement is not completed within the time specified, the government shall have the following recourses:

1. Cancellation of the contract, delivery, purchase, or line item without termination liabilities, or

2. In the case of custom EIT being developed by a Contractor, the government shall have the right to have any necessary changes made or repairs performed by itself or by another firm for the noncompliant EIT, with the Contractor liable for reimbursement to the government for any expenses incurred thereby.

The Contractor shall ensure that all EIT products that are less than fully compliant with the accessibility standards are provided pursuant to extensive market research and are the most current compliant products or services available to satisfy the contract requirements.

For every EIT product or service accepted under this contact by the government that does not comply with 36 CFR 1194, the Contractor shall, at the government’s discretion, make every effort to replace or upgrade it with a compliant equivalent product or service, if commercially available and cost-neutral, on either a contract-specified refresh cycle for the product or service, or on a contract-effective option/renewal date—whichever occurs first.

Section 508 Compliance for Communications The Contractor shall comply with the following standards, policies, and procedures. In the event of conflicts between the referenced documents and this contract, the contract shall take precedence.

Rehabilitation Act, Section 508 Accessibility Standards

1. 29 U.S.C. 794d (Rehabilitation Act as amended)

2. 36 CFR 1194 (508 Standards)

3. http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards (508 standards)

4. Federal Acquisition Regulations (FAR) 39.2 (Section 508)

5. CMS/Department of Health and Human Services (HHS) standards, policies, and procedures (Section 508) In addition, 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, must 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 http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards

(including subcontractors) or consultants responsible for preparing or posting content must comply with applicable Section 508 accessibility standards and, where applicable, those set forth in the referenced policy or standards documents above. Remediation of any materials that do not comply with the applicable provisions of 36 CFR Part 1194, as set forth in the contract, shall be the responsibility of the Contractor or consultant.

The following Section 508 provisions apply to the content or communications material identified in this contract:

1. 36 CFR Part 1194.21 a – l

2. 36 CFR Part 1194.22 a – p

3. 36 CFR Part 1194.31 a – f

4. 36 CFR Part 1194.41 a – c

The Contractor shall provide a completed Section 508 Product Assessment Template and the Contractor shall state exactly how proposed EIT deliverable(s) meet or does not meet the applicable standards.

For software development, the Contractor/Developer/Vendor shall comply with the following standards, policies, and procedures:

Rehabilitation Act, Section 508, Accessibility Standards

1. 29 U.S.C. 794d (Rehabilitation Act as amended)

2. 36 CFR 1194 (508 Standards)

• 36 CFR Part 1194.21 (a – l)

• 36 CFR Part 1194.31 (a – f)

• 36 CFR Part 1194.41 (a – c)

3. http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards (508 Standards)

4. FAR 39.2 (Section 508)

5. CMS/HHS Standards, policies and procedures (Section 508)

Information Technology – General Information (http://www.cms.gov/Research- Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html)

For web-based applications, the Contractor shall comply with the following standards, policies, and procedures:

Rehabilitation Act, Section 508, Accessibility Standards

1. 29 U.S.C. 794d (Rehabilitation Act as amended)

2. 36 CFR 1194 (508 Standards)

• 36 CFR Part 1194.22 (a – p)

• 36 CFR Part 1194.41 (a – c)

3. http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards (508 Standards)

4. FAR 39.2 (Section 508)

5. CMS/HHS Standards, policies and procedures (Section 508)

• Information Technology – General Information (http://www.cms.gov/Research- Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html)

III. SPECIFIC REQUIREMENTS

Task 1: Transition

The MRRC B shall work with the outgoing MRRC B contractor to transition all medical record focused review, medical record abstraction, operational analysis, business intelligence analysis, medical record intake, appeals submission evaluation, project management activities. As part of the transition period, the MRRC B shall conduct a kick-off meeting and submit deliverables http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards http://www.access-board.gov/guidelines-and-standards/communications-and-it/about-the-section-508-standards/section-508-standards http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html in accordance with the SOW requirements. The MRRC B shall lead regular transition meetings with CMS, the outgoing MRRC B and all appropriate contractors and maintain minutes from those meetings. Meeting minutes shall be provided to CMS within two (2) business days of the meeting date. Work performed as the MRRC B shall occur in two phases: transition and fully operational. The day after the MRRC B award is the first day of the transition period. The transition period will last no longer than fourteen (14) calendar days. At the conclusion of the transition period, the fully operational period begins.

Task 2: Conduct Medical Record Focused Reviews

The Contractor shall use CDAT to facilitate medical record review of medical records in accordance with CMS’s requirements. This task shall include, but is not limited to:

• Conducting the medical record review phase of the RADV projects utilizing trained and certified coders according to CMS guidelines and instruction;

• Conducting medical record review on MAOs hospital inpatient, hospital outpatient and physician risk adjustment data submitted for the payment year(s) defined by CMS;

• Reviewing medical record documentation submitted by MAOs in CDAT to determine whether CMS-HCC(s) are present;

• Implementing quality control protocols for confirming discrepant and additional CMS-

HCCs;

• Implementing initial inter-rater reliability (IRR) evaluations and quality control protocols for achieving IRR of medical records reviewed;

• Documenting all medical record abstraction data reviewed within CDAT;

• Applying coding guidelines based on dates of service and provider types indicated by the

MAOs;

• Performing medical record reviews consistently to assure appropriate confirmation of CMS-

HCC(s);

• Assisting in the generating reports and communications to MAOs;

• Reporting to CMS on areas of discrepancies/ inconsistencies when performing medical record review, and being prepared to discuss/resolve with other RADV Contractors, if applicable; and

• Reporting to CMS on status of work on a regular basis as determined by CMS.

The Contractor shall include in the medical record review process participation of an adequate number of trained and certified coders to complete medical record review based on the type of RADV project and the number of medical records, as determined by CMS. RADV projects are performed concurrently. The Contractor shall be prepared to perform medical record review on up to one hundred thousand (100,000) medical records. All medical record review reports and documentation of operational decisions related to medical record review shall be included in the Process Plan.

Where this SOW only references to ICD-9-CM codes, ICD-10-CM and blended HCC model codes shall also be applicable, to the degree that this classification has been implemented and is appropriate for application for a given sample. ICD-9/ICD-10 (and blended HCC model) codes will be year-specific for the dates of service in each increment, based on timeframes to be established by CMS. The Contractor shall evidence ability to apply appropriate coding clinics and ICD-9/ICD-10 (and blended HCC model) guidelines according to medical record dates of service under review.

The Contractor shall provide sufficient, qualified coding staff to complete all aspects of RADV projects, within the timeframes defined by CMS. All coders must have experience in abstracting and ICD-9/ICD-10 (blended HCC model) coding, and have one or more of the following certifications: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or CCS (Certified Coding Specialist). Coders must be able to code all provider medical record types: hospital inpatient, hospital outpatient, and physician. Senior coders must have a minimum of 5 year experience. All coders must be fully qualified, certified, at minimum as detailed in this SOW, and able to code all provider medical record types: hospital inpatient, hospital outpatient, and physician. Coders should be familiar with the 3M Encoder Tool, which is presently used in RADV projects. The 3M Encoder Tool is embedded within CDAT. For RADV projects, the Contractor’s coders shall abstract all diagnoses from specified medical record date(s) of service as agreed to by CMS. All diagnoses shall be abstracted in accordance with the ICD-9/ICD-10-CM (and blended HCC model) coding guidelines for the respective settings (hospital inpatient, hospital outpatient and physician medical record types), and for the appropriate year of service, without knowledge of what was abstracted by any prior coder for each record. All data abstraction shall be performed within the CDAT using established protocols. The Contractor shall also provide staff that is capable of interpreting medical records information submitted in a foreign language for purposes of assigning ICD-9/ICD-10-CM (and blended HCC model) codes as needed for each RADV project.

The Contractor shall also provide the use of a physician reviewer to make determinations as needed. Physician reviewers are not required to be ICD-9/ICD-10-CM (and blended HCC model) coders; these clinicians inform coding activities by providing a clinical basis for rendering specific diagnoses. Coders typically use information from physician reviewers to better inform ICD-9/ICD-10-CM (and blended HCC model) coding decisions. The Contractor shall properly staff for at least one (1) Senior Coder and at least one (1) Physician Reviewer to serve on the RADV project-specific QA panel. The QA panel is a resource for coders to escalate coding cases to when the case cannot be resolved at the senior coder level. The Contractor shall attend and participate in discussions with CMS and other RADV contractors as determined by CMS regarding areas of disagreement or inconsistency on medical record review outcomes.

The Contractor shall implement an initial IRR evaluation of each coder at the beginning of each RADV project in accordance with CMS guidelines. Medical record checks and coding consistency checks are ongoing throughout the RADV projects. CMS may provide IRR reports to the Contractor to assist with this evaluation. In the event that a coder achieves less than 95% IRR proficiency, the Contractor shall provide education to the coder, observing particular issues or diagnosis codes that the coder did not abstract correctly. The Contractor shall continue to monitor IRR of all coders and provide appropriate remediation, if applicable according to CMS instruction. The Contractor shall also submit to CMS a plan for addressing coding quality issues evidenced by IRR and be prepared to discuss IRR findings with CMS and other RADV contractors.

The Contractor shall document all medical record abstraction data reviewed within CDAT and work with CMS and other RADV contractors to identify and access medical record files, document abstraction data, and view data within CDAT. The Contractor shall be prepared to discuss with CMS and other RADV contractors all data findings pertaining to medical record review and IRR outcomes.

The complete medical record includes all documentation requested from and submitted by MAOs for the purposes of these RADV projects, including but not limited to a medical record, an attestation, and a coversheet (CMS document describing individual CMS-HCCs for individual beneficiaries).

Task 3: Conduct Medical Record Abstraction

The contractor shall perform medical record abstraction activities, the general process of which has been outlined above, for activities beyond focused review. This may include the discrepant confirmation step in the RADV process or other ad hoc studies, such as a review of the impact of the transition to ICD-10 (from ICD-9) on coding. The Contractor shall be prepared to perform medical record review up to one hundred thousand (100,000) medical records for each twelve (12) month period. MRRC B will perform up to thirty thousand (30,000) post audit medical record reviews and will lead up to ten (10) ad hoc studies related to post audit reviews as directed by CMS.

Task 4: Perform Operational Analysis

The contractor shall perform analyses related to medical record review operations. The purpose of the analysis will be to identify and report coding efficiencies and practices. Examples of such analyses include examination of agreements between coders, length of time it takes to code records, and differences between outpatient and inpatient records. Up to five (5) such analyses may be requested. Results of the analyses will be reported to CMS in the Monthly Status and Costs Report.

Task 5: Perform Business Intelligence and Post audit review Analyses

The RADV program has implemented a business intelligence solution to perform analysis around the project. The basis of the system is a data warehouse. The business intelligence system is accessed through CDAT.

CDAT provides reports and dashboards that provide CMS, its contractors, and MAOs with reliable and timely information about the progress of medical record request, submission, intake, review, and appeals processes. Reports will be cross-checked by the Contractor and the LAC and maintained in CDAT. The Contractor shall quality assure the reports to assure consistency of the information. The Contractor shall also track and conduct ongoing independent checks against reports generated from CDAT to assure that all appropriate information was captured by CDAT.

The Contractor shall utilize these reports. At the direction of the COR, the Contractor shall contribute to the overall design and implementation of new reports. The Contractor shall submit comments to the COR and shall allow sufficient time for CMS review and edits.

The Contractor shall also access the reports, and business intelligence environment, as directed, to perform additional analysis on coder performance and intake/abstraction findings. As directed, the Contractor shall utilize the data warehouse to conduct analyses.

As directed by CMS, MRRC B will design, lead, and prepare up to ten (10) reports on post audit review topics. MRRC B shall collaborate with CMS and its contractors to develop the parameters and methodology for these analyses.

Task 6: Perform Medical Record Intake

The Contractor shall receive and access all medical record files submitted by MAOs within CDAT. The Contractor shall use CDAT to facilitate medical record intake evaluation on medical records in accordance with CMS’s requirements. This task shall include, but is not limited to:

• Conducting the intake phase of the RADV projects according to CMS guidelines and instruction;

• Developing and supporting tools to improve the intake process and MAO experience. This activity should be limited to innovations that preclude any modification to CDAT or established RADV review processes;

• Providing technical assistance relating to medical record submissions (if applicable);

• Providing technical assistance via teleconference and individual contact with MAOs (if applicable);

• Evaluating all submitted documentation upon receipt;

• Evaluating and processing, within CDAT, provider-completed CMS-generated attestations relating to missing provider signatures and credentials;

• Utilizing Senior Coders to establish medical record submission validity;

• Utilizing Senior Coders to resolve medical record and coversheet inconsistencies;

• Confirming date of service and provider type associated with each CMS-HCC based on the

MAOs submission of medical records and attestations;

• Completing the review of the medical records and CMS-generated attestations submitted;

• Documenting non-compliance medical records received, and tracking other non-compliance events captured within CDAT pertaining to CMS RADV instructions for medical record submission;

• Assisting in generating reports and communications to MAOs;

• Uploading related documentation into CDAT as needed, including hardcopy, electronic media, and faxed materials (if applicable); and

• Reporting to CMS on status of work on a regular basis as determined by CMS.

The Contractor shall include in the intake process participation of an adequate number of administrative intake reviewers and certified coders to complete intake evaluation based on the type of RADV project and the number of medical records, as determined by CMS. RADV projects are performed concurrently. The Contractor shall be prepared to perform intake on up to one hundred thousand (100,000) medical records for each of the each twelve (12) month period. Specified under this SOW. All receipt and intake reports, documentation of operational decisions related to intake, and intake validity checklists shall be included in the Process Plan.

The Contractor shall attend and participate in discussions with CMS and other RADV contractors as determined by CMS regarding all data findings pertaining to medical record intake, including areas of disagreement or inconsistency on medical record intake determinations.

The contractor shall use the established coder discussion journal procedure when necessary, i.e., a secure communication method on CDAT between coders, CMS and other RADV contractors that is used primarily to communicate resolution steps of potential Protected Health Information (PHI)/Personally Identifiable Information (PII) cases and initial coversheet/medical record failed items.

Task 7: Conduct Evaluation of MAOs’ Appeals Submissions

The Contractor shall use CDAT to facilitate appeals evaluation in accordance with CMS’s requirements. This task shall include, but is not limited to:

• Supporting the appeals phase of the RADV projects and utilizing trained and certified coders according to CMS guidelines and instruction (during the RADV appeals process, including Reconsideration as needed;

• Conducting appeals evaluation of documentation submitted by MAOs as needed;

• Utilizing Senior Coders to establish medical record validity;

• Utilizing Senior Coders to conduct medical record review of hospital inpatient, hospital outpatient and physician records;

• Collaborating with other CMS contractors in order to evaluate MAO questions and appeals filings relating to the processes of medical record request, medical record submission, medical record intake, and medical record review; and

• Reporting to CMS on status of work on a regular basis as determined by CMS.

The requirements for medical record review described in Tasks 2 & 6 above shall apply to Task 7 as well. The Contractor shall include in the appeals process participation of an adequate number of certified coders to complete appeals evaluation based on the RADV project and the number of medical records, as determined by CMS. RADV projects are performed concurrently. The Contractor shall be prepared to perform appeals evaluation on up to five thousand (5,000) medical records for each twelve (12) month period.

The Contractor shall provide support for appeals, to CMS and other RADV contractors or agencies, on CMS’s behalf by providing relevant information upon request by CMS throughout the administrative appeals process and, where applicable, an appeal to the appropriate Federal court. Support shall, at a minimum, include providing oral justification and written documentation to clarify and explain specific processes that were implemented during the RADV process and providing justifications for different medical record intake and medical record review findings. The Contractor shall provide professional-quality editorial review of all written statements. This review shall ensure structural consistency and editorial quality of all statements. The Contractor shall be prepared to provide appeals support by utilizing CDAT to access materials and upload responses. Upon direction by the CMS, the Contractor shall provide the requested documentation and support.

Task 8: Perform Project Management

The Contractor shall conduct management tasks necessary to facilitate the functions of this SOW including but not limited to:

• Report development, implementation, distribution and delivery;

• Process Plan development, implementation, and delivery;

• Plan, host, and contribute to meetings; and

• Management and destruction of medical records.

Task 8.1: Monthly Status and Costs Report The Contractor shall submit a Monthly Report, which shall explain progress per task each month, including hours spent per task and issues encountered. Each Monthly Report shall:

• Review accomplishments to date, remaining activities to be completed and the status of the project compared with its schedule;

• Detail all accomplishments for the month to support invoice;

• Discuss significant problems encountered or that are anticipated and their impact on the schedule of the project, or if severe enough, on the overall ability to accomplish the project goals;

• Include the Contractor’s plans to deal with any identified significant problem and if appropriate, new delivery or completion dates shall be proposed and revised resource estimates included;

• Include data on planned versus actual expenditures by major task area (discrepancies greater than ten (10) percent shall be noted);

• Include a brief discussion of substantive findings to date;

• Include the monthly financial management report;

• Include a financial graph and narrative depicting budgeted costs, actual costs, and projected costs to completion.

This report shall be submitted to the COR by the Twentieth (20th) of the following month for each month.

Task 8.2: Process Plan

The Contractor shall prepare a Process Plan detailing the Contractor-specific processes around the entire RADV projects. The Contractor shall also be prepared to prepare a Process Plan detailing Contractor-specific processes around any ad hoc studies, at the discretion of the COR.

The Contractor’s Process Plans shall evidence…